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OBJECTIVES: Among older Canadians, we examined the influence of low social support, a weak sense of belonging, and living alone to understand their role on mortality risk in Canada. METHODS: We conducted a retrospective cohort study of older Canadians surveyed in 2001 from the Canadian Community Health Survey and followed up with death events through December 31, 2011 from the Canadian Vital Statistics Database. Analyses were stratified by age: 55–64 and 65 and older. Social support was assessed using measures developed for the Medical Outcomes Study. A sense of belonging, a binary measure, measured community integration. Living alone was a binary measure. Survival analysis was applied using a Cox proportional hazards model, adjusted for age, sex, income, smoking, and frailty. RESULTS: Among respondents 55–64 (n = 6822), low affection (HR = 1.37; 95% CI 1.07, 1.75), low emotional/informational support (HR = 1.36; 95% CI 1.06, 1.74), and low positive social interactions (HR = 1.36; 95% CI 1.06, 1.75) were associated with mortality risk. Among respondents 65 and older (n = 8966), low affection (HR = 1.17; 95% CI 1.04, 1.31), low positive social interactions (HR = 1.20; 95% CI 1.07, 1.34), low emotional/informational support (HR = 1.19; 95% CI 1.06, 1.33), and a weak sense of belonging (HR = 1.13; 95% CI 1.05, 1.22) were associated with mortality risk. CONCLUSION: Low social support and a weak sense of belonging are important risk factors among older Canadians and should be part of the dialogue in Canada about their roles in healthy aging.

Background Sugar-sweetened beverages have obesogenic and diabetogenic effects ascribed to free sugars. These include added sugars and naturally occurring sugars in juices. A meta-analysis indicates that some foods with added sugars are associated with lower type 2 diabetes rates. To expand the evidence relevant to free sugars from solid sources, we examined a young to middle-aged population with respect to overweight and gestational diabetes (GDM) outcomes. Methods We studied female participants (12–50 years old) from the 2004–2005 Canadian Community Health Survey 2.2 (CCHS) with data linked to the hospital Discharge Abstract Database (DAD) until 2017, providing 13 years of follow-up. We estimated free sugars by solid and liquid sources from 24-h dietary recalls as percent total energy intake (TE%), and computed body mass index (BMI). We applied ICD-10 diagnostic codes for deliveries and GDM to DAD. We conducted multivariable logistic regression analyses to evaluate associations between free sugars with overweight at baseline (cross-sectional component) and, in those who delivered, with GDM during follow-up (nested case control component). We compared those with consumption above versus below various thresholds of intake for free sugars, considering solid and liquid sources separately (2.TE%, 5TE%, 10TE% and 15TE% thresholds). Results Among 6305 participants, 2505 (40%) were overweight, defined as BMI ≥ 85th percentile below 18 years and BMI ≥ 25 kg/m2 for adults. Free sugars from solid sources were associated with lower odds of overweight above versus below the 2.5TE% (adjusted odds ratio [adjOR] 0.80, 95%CI 0.70–0.92), 5TE% (adjOR 0.89, 95%CI 0.79–0.99), and 10TE% (adjOR 0.86, 95%CI 0.75–0.97) thresholds. Free sugars from liquid sources were associated with greater odds of overweight across the 2.5TE% (adjOR 1.20, 95%CI 1.07–1.36), 10TE% (adjOR 1.17, 95%CI 1.02–1.34), and 15TE% (adjOR 1.43, 95%CI 1.23–1.67) thresholds. There were 113 cases of GDM among the 1842 women who delivered (6.1%). Free sugars from solid sources were associated with lower odds of GDM above versus below the 5TE% threshold (adjOR 0.56, 95%CI 0.36–0.85). Conclusions Our findings support limiting free sugars from liquid sources, given associations with overweight. We did not identify adverse associations of free sugars from solid sources across any of the thresholds examined.

BACKGROUND: Survivors of acute health events can experience lasting reductions in functional status and quality of life, as well as reduced ability to work and earn income. We aimed to assess the effect of acute myocardial infarction (MI), cardiac arrest and stroke on work and earning among working-age people. METHODS: For this retrospective cohort study, we used the Canadian Hospitalization and Taxation Database, which contains linked hospital and income tax data, from 2005 to 2013 to perform difference-in-difference analyses. We matched patients admitted to hospital for acute MI, cardiac arrest or stroke with controls who were not admitted to hospital for these indications. Participants were aged 40–61 years, worked in the 2 years before the event and were alive 3 years after the event. Patients were matched to controls for 11 variables. The primary outcome was working status 3 years postevent. We also assessed earnings change attributable to the event. We matched 19 129 particpants who were admitted to hospital with acute MI, 1043 with cardiac arrest and 4395 with stroke to 1 820 644, 307 375 and 888 481 controls, respectively. RESULTS: Fewer of the patients who were admitted to hospital were working 3 years postevent than controls for acute MI (by 5.0 percentage points [pp], 95% confidence interval [CI] 4.5–5.5), cardiac arrest (by 12.9 pp, 95% CI 10.4–15.3) and stroke (by 19.8 pp, 95% CI 18.5–23.5). Mean (95% CI) earnings declines attributable to the events were $3834 (95% CI 3346–4323) for acute MI, $11 143 (95% CI 8962–13 324) for cardiac arrest, and $13 278 (95% CI 12 301–14 255) for stroke. The effects on income were greater for patients who had lower baseline earnings, comorbid disease, longer hospital length of stay or needed mechanical ventilation. Sex, marital status or self-employment status did not affect income declines. INTERPRETATION: Acute MI, cardiac arrest and stroke all resulted in substantial loss in employment and earnings that persisted for at least 3 years after the events. These outcomes have consequences for patients, families, employers and governments. Identification of subgroups at high risk for these losses may assist in targeting interventions, policies and legislation to promote return to work.

Importance Traumatic injury disproportionately affects adults of working age. The ability to work and earn income is a key patient-centered outcome. The association of severe injury with work and earnings appears to be unknown. Objective To evaluate the association of severe traumatic injury with subsequent employment and earnings in long-term survivors. Design, Setting, and Participants This is a retrospective, matched, national, population-based cohort study of adults who had employment and were hospitalized with severe traumatic injury in Canada between January 2008 and December 2010. All acute care hospitalizations for severe injury were included if they involved adults aged 30 to 61 years who were hospitalized with severe traumatic injury, working in the 2 years prior to injury, and alive through the third calendar year after their injury. Patients were matched with unexposed control participants based on age, sex, marital status, province of residence, rurality, baseline health characteristics, baseline earnings, self-employment status, union membership, and year of the index event. Data analysis occurred from March 2019 to December 2019. Main Outcomes and Measures Changes in employment status and annual earnings, compared with unexposed control participants, were evaluated in the third calendar year after injury. Weighted multivariable probit regression was used to compare proportions of individuals working between those who survived trauma and control participants. The association of injury with mean yearly earnings was quantified using matched difference-in-difference, ordinary least-squares regression. Results A total of 5167 adults (25.6% female; mean [SD] age, 47.3 [8.8] years) with severe injuries were matched with control participants who were unexposed (25.6% female; mean [SD] age, 47.3 [8.8] years). Three years after trauma, 79.3% of those who survived trauma were working, compared with 91.7% of control participants, a difference of −12.4 (95% CI, −13.5 to −11.4) percentage points. Three years after injury, patients with injuries experienced a mean loss of $9745 (95% CI, −$10 739 to −$8752) in earnings compared with control participants, representing a 19.0% difference in annual earnings. Those who remained employed 3 years after injury experienced a 10.8% loss of earnings compared with control participants (−$6043 [95% CI, −$7101 to −$4986]). Loss of work was proportionately higher in those with lower preinjury income (lowest tercile, −18.5% [95% CI, −20.8% to −16.2%]; middle tercile, −11.5% [95% CI, −13.2% to −9.9%]; highest tercile, −6.0% (95% CI, −7.8% to −4.3%]). Conclusions and Relevance In this study, severe traumatic injury had a significant association with employment and earnings of adults of working age. Those with lower preinjury earnings experienced the greatest relative loss of employment and earnings.

Background Acute health shocks can reduce the ability to work and earn among working-age survivors. The full economic impact includes labor market effects on spouses/partners, but there is a knowledge gap in this area. Objectives The objective of this study was to assess how 3 common health shocks, acute myocardial infarction, stroke, and cardiac arrest, influence work and earnings of spouses aged 35-61 years. Research design This retrospective cohort study of case and control couples used population-based, linked Canadian income tax and hospitalization data from 2005 to 2013. Subjects Case couples comprised 1 partner aged 41-61 years who experienced a health shock in the index year and survived 3 years hence, and a working-age partner. Control couples were matched up to 5:1 on 12 characteristics, with neither experiencing the health shock of interest in the index year. Measures Primary outcome was the change in spousal annual earnings between the year prior and 3 years after the event. Pre-to-post spousal income changes were categorized into 9 levels and compared between case spouses and control spouses by the Pearson χ test. Results There were 11,208 matched case couples for acute myocardial infarction, 622 for cardiac arrest, and 2288 for stroke. Overall, case and control spouses experienced similar distributional changes in preevent to postevent earning (all P≥0.27). Heterogeneity analysis indicated that spouses of more severe stroke sufferers ceased working at a higher rate than for control spouses. Conclusion Beyond assessing average values, detailed analysis of changes in spousal earnings after common cardiovascular health shocks did not demonstrate effects attributable to those health shocks.

OBJECTIVES To estimate the risk of work loss due to illness or disability in a cohort of employed persons with OA compared with matched non-OA individuals. METHODS We performed a population-based cohort analysis using the last six cycles of the Canadian longitudinal National Population Health Survey from 2000 to 2010. OA cases and up to four age- and sex-matched non-OA individuals were selected. Discrete time hazard regression models were used to estimate the hazard of work loss due to illness or disability. To analyse the effect of a self-reported OA measure on the outcome, we performed a sensitivity analyses for case selection. RESULTS From 7273 employed individuals between the ages of 20 and 70 years in the National Population Health Survey, 659 OA cases were selected and matched to 2144 non-OA individuals. The proportion of OA cases who experienced work loss due to illness or disability during the follow-up period was 12.6%, compared with 9.3% for non-OA individuals (P < 0.001). OA cases had a 90% [hazard ratio (HR) 1.90 (95% CI 1.36, 3.23)] higher hazard of work loss due to illness or disability compared with their matched non-OA individuals after adjusting for sociodemographic, health and work-related status. The adjusted HRs were 1.61 (95% CI 1.13, 2.30) and 2.04 (95% CI 1.74, 4.75) for females and males, respectively. CONCLUSION OA is independently associated with an increased risk of work loss due to illness or disability. Given the high prevalence of OA in the population of working age, future research may wish to investigate ways to improve occupational participation among OA patients.

ObjectiveTo evaluate sex-specific and age-specific associations of active living environments (ALEs) with premature cardiometabolic mortality.DesignPopulation-based retrospective cohort study.SettingResidential neighbourhoods (1000-metre circular buffers from the centroids of dissemination areas) across Canada for which the Canadian ALE Measure was derived, based on intersection density, points of interest and dwelling density.Participants249 420 survey respondents from an individual-level record linkage between the Canadian Community Health Survey (2000–2010) and the Canadian Mortality Database until 2011, comprised of older women (65–85 years), older men (65–81 years), middle-aged women (45–64 years) and middle-aged men (45–64 years).Primary outcome measuresPremature cardiometabolic mortality and average daily energy expenditure attributable to walking. Multivariable proportional hazards regression models were adjusted for age, educational attainment, dissemination area-level median income, smoking status, obesity, the presence of chronic conditions, season of survey response and survey cycle.ResultsSurvey respondents contributed a total of 1 451 913 person-years. Greater walking was observed in more favourable ALEs. Walking was associated with lower cardiometabolic death in all groups except for middle-aged men. Favourable ALEs conferred a 22% reduction in death from cardiometabolic causes (HR 0.78, 95% CI 0.63 to 0.97) for older women.ConclusionsOn average, people walk more in favourable ALEs, regardless of sex and age. With the exception of middle-aged men, walking is associated with lower premature cardiometabolic death. Older women living in neighbourhoods that favour active living live longer.

Hospitalizations due to opioid poisonings are increasing. While considerable information is available on the demographic and geographic distribution of opioid-related events, national data on the social and economic circumstances of those experiencing these events are limited. This study uses data from the National Household Survey (2011) linked to the Discharge Abstract Database (2011 to 2016) to provide the first national-level estimates of the socio-economic characteristics of individuals experiencing opioid-related hospitalizations. Results reveal elevated hospitalization rates among people who have lower levels of income and education, are unemployed or out of the labour force, identify as Indigenous, live in lone-parent households, and spend more than 50% of their household income on housing. Understanding the circumstances of individuals who experienced adverse opioid events will help inform policies addressing potential determinants.

National population information about the surgical treatment rate for primary cancers, including breast cancer, has remained a significant data gap in Canada. This gap has implications for cancer care planning and evaluating health system performance. New linkages between the Canadian Cancer Registry and hospital discharge records were conducted by Statistics Canada in 2016. Using already existing, routinely collected health administrative data, these linkages allow viable reporting of surgical cancer treatment for the first time for all provinces and territories (except Quebec).Hospital record information about type and date of surgical treatment of tumours was provided by information from linked data. These linked data reported 50,740 incident primary malignant breast tumours diagnosed between January 1, 2010, and December 31, 2012, among females aged 19 years or older. The unadjusted treatment rate for primary surgical intervention within one year was calculated as the proportion of total tumours that were linkable to hospital records.For three combined years (2010, 2011 and 2012), 88.3% (N=44,780) of patients overall received at least one surgical treatment. Variations to the surgical rate occurred across jurisdictions, with the highest rate at 91-92% for Prince Edward Island, Newfoundland and Labrador, British Columbia and New Brunswick. Generally, there was an inverse gradient between surgical treatment rate and tumour stage.The surgical treatment rate of new primary breast cancers varied across provinces and territories from 2010 to 2012. New linked data could be used to further identify geographic and demographic inequities in terms of receiving surgical cancer treatment and contribute to the evaluation of cancer system performance and outcomes.

BACKGROUND: Routinely collected data from large population health surveys linked to chronic disease outcomes create an opportunity to develop more complex risk-prediction algorithms. We developed a predictive algorithm to estimate 5-year risk of incident cardiovascular disease in the community setting. METHODS: We derived the Cardiovascular Disease Population Risk Tool (CVDPoRT) using prospectively collected data from Ontario respondents of the Canadian Community Health Surveys, representing 98% of the Ontario population (survey years 2001 to 2007; follow-up from 2001 to 2012) linked to hospital admission and vital statistics databases. Predictors included body mass index, hypertension, diabetes, and multiple behavioural, demographic and general health risk factors. The primary outcome was the first major cardiovascular event resulting in hospital admission or death. Death from a noncardiovascular cause was considered a competing risk. RESULTS: We included 104 219 respondents aged 20 to 105 years. There were 3709 cardiovascular events and 818 478 person-years follow-up in the combined derivation and validation cohorts (5-year cumulative incidence function, men: 0.026, 95% confidence interval [CI] 0.025–0.028; women: 0.018, 95% 0.017–0.019). The final CVDPoRT algorithm contained 12 variables, was discriminating (men: C statistic 0.82, 95% CI 0.81–0.83; women: 0.86, 95% CI 0.85–0.87) and was well-calibrated in the overall population (5-year observed cumulative incidence function v. predicted risk, men: 0.28%; women: 0.38%) and in nearly all predefined policy-relevant subgroups (206 of 208 groups). INTERPRETATION: The CVDPoRT algorithm can accurately discriminate cardiovascular disease risk for a wide range of health profiles without the aid of clinical measures. Such algorithms hold potential to support precision medicine for individual or population uses. Study registration: ClinicalTrials.gov, no. NCT02267447

The aging of the Canadian population has increased attention on the future need for nursing home beds. Although current projections rely primarily on age and sex, other factors also contribute to the need for long-term care. This study seeks to identify additional factors to age and sex that contribute to Canadians transitioning from living at home to living in a seniors' residence or nursing home.As part of a larger record linkage project, three cycles of the Canadian Community Health Survey (CCHS) were linked to the 2011 Census of Population: Cycle 3.1 (2005/2006), Cycle 4.1 (2007/2008), and CCHS-Healthy Aging (2008/2009). The sample was limited to successfully linked CCHS respondents who were aged 60 years or older as of Census Day 2011 (May 10, 2011; n=81,411). Sex-specific generalized multinomial logistic regression models were conducted to examine the association between each respondent's characteristics and dwelling location (private dwelling, private dwelling with additional family, nursing home, or seniors' residence) on Census Day.On Census Day, 1.4% of the study sample were living in a nursing home, 1.2% in a seniors' residence, 7.1% in a private dwelling with additional family, and 90.3% in a private dwelling. Women were more likely than men to be living in a nursing home (1.8% of women vs. 0.9% of men) or seniors' residence (1.7% of women vs. 0.7% of men). Regression models showed that, aside from age, there were increased odds of living in a nursing home or seniors' residence among individuals who lost their spouse or who were not married, who did not own their dwelling, who had poor self-rated health, or who had been diagnosed with dementia. The association of other factors with dwelling place differed according to sex and type of dwelling.Although age is strongly associated with living in a nursing home or seniors' residence, other demographic and health factors affect the likelihood of an individual transitioning to an institutional dwelling. Such factors could be considered when planning for the future housing and care needs of the Canadian population.

Hospitalizations for ambulatory care sensitive conditions (ACSCs) are potentially preventable, but may be required if these conditions are not managed well. National-level information about ACSC hospitalizations is available for Canada, but not for Aboriginal groups. This study describes ACSC hospitalizations among urban Métis adults relative to their non-Aboriginal counterparts.The 2006/2007-to-2008/2009 Discharge Abstract Database, which contains hospitalization records from all acute care facilities (excluding Quebec), was linked to the 2006 Census to obtain Aboriginal identity information. Age-standardized ACSC hospitalization rates (ASHRs) per 100,000 population and rate ratios were calculated for Métis aged 18 to 74 relative to non-Aboriginal people of the same ages. Odds of ACSC hospitalizations were estimated using logistic regression models, adjusting for demographic, geographic, and socioeconomic characteristics.The ASHR for ACSCs among urban Métis adults was twice that among non-Aboriginal adults (393 versus 184 per 100,000 population). Even when demographic, geographic, and socioeconomic characteristics were taken into account, Métis had higher odds of ACSC hospitalizations overall (OR 1.5). Most commonly, these hospitalizations were for diabetes (OR 1.8) or chronic obstructive pulmonary disease (OR 1.5). Modelled factors partly reduced differences between Métis and non-Aboriginal adults, but variations between the groups remained after all adjustments.Rates of ACSC hospitalizations were higher among Métis than among non-Aboriginal adults who lived in urban areas. Further research using other data sources is warranted to assess the roles of factors not available for this analysis, such as primary care, co-morbidity, and health behaviours.

Economic immigrants generally, and economic class principal applicants (ECPAs) specifically, tend to have better health than other immigrants. However, health outcomes vary among subcategories within this group, especially by sex.This study examines hospitalization rates among ECPAs aged 25 to 74 who arrived in Canada between 1980 and 2006 as skilled workers, business immigrants, or live-in caregivers. The analysis used two linked databases to estimate age-standardized hospitalization rates (ASHRs) overall and for leading causes by sex. ASHRs of ECPA subcategories were compared with each other and with those of the Canadian-born population. Logistic regression was used to derive odds ratios for hospitalization among ECPAs, by sex.Male and female ECPAs aged 25 to 74 had significantly lower all-cause ASHRs than did the Canadian-born population in the same age range. This pattern prevailed for each ECPA subcategory and for each disease examined. Compared with skilled workers, business immigrants had lower odds of hospitalization; live-in caregivers who arrived after 1992 had higher odds. Adjustment for education, official language proficiency, and world region reduced the strength of or eliminated these associations.Compared with the Canadian-born population, ECPAs generally had low hospitalization rates. Differences were apparent among ECPA subcategories.

Respiratory diseases are among the leading causes of acute care hospitalization for First Nations people. Poor housing conditions are associated with respiratory disorders and may be related to the likelihood of hospitalization. This analysis examines whether First Nations identity is associated with higher odds of hospitalization for respiratory conditions relative to non-Aboriginal persons, and whether such differences in hospitalization rates remain after consideration of housing conditions.Data from the 2006 Census linked to the Discharge Abstract Database were used to analyze differences in hospitalization for respiratory tract infections and asthma between First Nations and non-Aboriginal people when housing conditions were taken into account.Rural on-reserve First Nations people were more likely than non-Aboriginal people to be hospitalized for a respiratory tract infection (1.5% versus 0.5%) or for asthma (0.2% versus 0.1%). For respiratory tract infection hospitalizations, adjustment for housing conditions, household income and residential location reduced differences, but the odds remained nearly three times higher for on-reserve First Nations people (OR = 2.83; CI: 2.69 to 2.99) and two times higher for off-reserve First Nations people (OR = 2.03; CI: 1.87 to 2.21), compared with the non-Aboriginal cohort. For asthma hospitalizations, adjustment for household income reduced the odds more than did adjustment for housing conditions. Even with full adjustment, the odds of asthma hospitalization relative to non-Aboriginal people remained significantly higher for First Nations people.First Nations people are significantly more likely than non-Aboriginal people to be hospitalized for respiratory tract infections and asthma, even when housing conditions, household income and residential location are taken into account. While housing conditions are associated with such hospitalizations, household income may be more important.

Purpose The purpose of this study was to better understand the impact that financial barriers have on patients with diabetes and the strategies that they use to cope with them. Methods A secondary analysis was conducted of 24 interviews with patients who had either type 1 or type 2 diabetes and perceived financial barriers, which were previously undertaken for a larger grounded theory study. Semistructured interviews were undertaken either face-to-face or by telephone. Data analysis was performed by 3 reviewers using inductive thematic analysis. Sampling for the original study continued until data saturation was achieved. Results The predominant aspects of care to which participants described financial barriers were medications, diabetes supplies, and healthy food. A variety of strategies are used by these patients. Participants described that their health care providers had the potential to either play an important supporting role; or alternatively, that they could also worsen the impacts of financial barriers. Conclusions Patients with diabetes experience financial barriers to various aspects of their care. While they use a variety of strategies to overcome their barriers, their health care providers can play a particularly important role in helping them manage these important barriers that impact their care and outcomes. Providers should ask patients about the existence of financial barriers, and employ strategies to mitigate against their impact.

Background There has been limited research exploring socioeconomic inequity in targeted preventive care for acute myocardial infarction (AMI). The objective of this study was to examine socioeconomic disparities in the use of primary and secondary preventive services relevant to the identification and management of heart disease in a cohort of patients with AMI. Methods Preventive services used before the AMI event were examined in a cohort of 30,491 patients with first-time AMI in Ontario, Canada from 2010 to 2012. Using logistic regression, socioeconomic differences in lipid testing, glucose testing, stress testing, electrocardiography (ECG), and echocardiography in middle-aged and older patients were examined. Results For many of the services, there were no differences in the use of primary and secondary preventive services between patients according to socioeconomic status; however, a number of exceptions were found. Controlling for other factors, we found that for primary preventive services, low-income middle-aged patients had 13% (95% confidence interval [CI], 0.790-0.967) and 10% (95% CI, 0.812-0.997) lower odds of receiving lipid and glucose testing, respectively, when compared with high-income middle-aged patients. Controlling for other factors, we found that for secondary preventive services, low-income middle-aged and older patients had 24% (95% CI, 1.087-1.415) and 10% (95% CI, 1.012-1.202) higher odds of receiving echocardiography when compared with their high-income counterparts. Conclusions Socioeconomic disparities in primary and secondary preventive services for patients with AMI could not be demonstrated in many instances. However, inequities in primary preventive care were found in middle-aged patients receiving lipid and glucose testing, which may have implications for Canadian health policy to ensure healthy aging across the age spectrum.

OBJECTIVES: To evaluate the association between percent body fat (%BF) and body mass index (BMI) among BMI-defined non-obese individuals between 40 and 69 years of age using a population-based Canadian sample. DATA AND METHODS: Cross-sectional data from the Canadian Health Measures Survey (2007 and 2009) was used to select all middle-aged individuals with BMI < 30 kg/m 2 ( n = 2,656). %BF was determined from anthropometric skinfolds and categorized according to sex-specific equations. Association of other anthropometry measures and metabolic markers were evaluated across different %BF categories. Significance of proportions was evaluated using chi-squared and Bonferroni-adjusted Wald test. Diagnostic performance measures of BMI-defined overweight categories compared to those defined by %BF were reported. RESULTS: The majority (69%) of the sample was %BF-defined overweight/obese, while 55% were BMI-defined overweight. BMI category was not concordant with %BF classification for 30% of the population. The greatest discordance between %BF and BMI was observed among %BF-defined overweight/obese women (32%). Sensitivity and specificity of BMI-defined overweight compared to %BF-defined overweight/obese were (58%, 94%) among females and (82%, 59%) among males respectively. According to the estimated negative predictive value, if an individual is categorized as BMI-defined non-obese, he/she has a 52% chance of being in the %BF-defined overweight/obese category. CONCLUSION: Middle-aged individuals classified as normal by BMI may be overweight/obese based on measures of %BF. These individuals may be at risk for chronic diseases, but would not be identified as such based on their BMI classification. Quantifying %BF in this group could inform targeted strategies for disease prevention.

Although immigrants tend to be healthier than the Canadian-born population when they arrive, subgroups, notably different immigration categories, may differ in health and health care use. Data limitations have meant the research has seldom focused on category of immigrant-economic, family or refugee. A newly linked database has made it possible to study acute care hospitalization by immigration category and source region.The Immigrant Landing File-Hospital Discharge Abstract Linked Database (n = 2.6 million) was used to derive sex-specific crude and age-standardized hospitalization rates (ASHRs) per 10,000 population for all-cause and leading causes of hospitalization during the 2006/2007-to-2008/2009 period.Economic class immigrants had lower all-cause ASHRs than did their family class or refugee counterparts. Male refugees had high ASHRs overall and for circulatory diseases, digestive diseases, injury, and cancer. Female differences by immigrant class were less pronounced. All-cause ASHRs (excluding pregnancy) rose with years since arrival in Canada for male and female immigrants. Immigrants from East Asia had the lowest ASHRs; those from the United States, the highest.Although hospital use is an imperfect indicator of health status, this study supports an initial healthy immigrant effect and its subsequent decline. Marked differences emerged among immigrant subgroups with some, notably refugees and immigrants from the United States, having significantly higher hospitalization rates overall and for leading causes, compared with other groups.

National data about acute care hospitalization of Aboriginal people are scarce. This study addresses that information gap by describing patterns of hospitalization by Aboriginal identity for leading diagnoses for all provinces and territories except Quebec.The 2006 Census was linked to the 2006/2007-to-2008/2009 Discharge Abstract Database, which contains hospital records from all acute care facilities in Canada (excluding Quebec). With these linked data, hospital records could be examined by Aboriginal identity, as reported to the census. Hospitalizations were grouped by International Classification of Diseases (ICD-10) chapters based on "the most responsible diagnosis." Age-standardized hospitalization rates were calculated per 100,000 population, and rate ratios (RR) were calculated for Aboriginal groups relative to non-Aboriginal people.Hospitalization rates were almost invariably higher for First Nations living on and off reserve, Métis, and Inuit living in Inuit Nunangat than for the non-Aboriginal population, regardless of ICD diagnostic chapter. The ranking of age-standardized hospitalization rates by frequency of diagnoses varied slightly by Aboriginal identity. RRs were highest among First Nations living on reserve, especially for endocrine, nutritional and metabolic diseases (RR = 4.9), mental and behavioural disorders (RR = 3.6), diseases of the respiratory system (RR = 3.3), and injuries (RR = 3.2). As well, the rate for endocrine, nutritional and metabolic diseases was high among First Nations living off reserve (RR = 2.7). RRs were also high among Inuit for mental and behavioural disorders (RR = 3.3) and for diseases of the respiratory system (RR = 2.7).Hospitalization rates varied by Aboriginal identity, and were consistent with recognized health disparities between Aboriginal and non-Aboriginal people. Because many factors besides health affect hospital use, further research is required to understand differences in hospital use by Aboriginal identity. These national data are relevant to health policy formulation and service delivery planning.

Background Behaviours such as smoking, poor diet, physical inactivity, and unhealthy alcohol consumption are leading risk factors for death. We assessed the Canadian burden attributable to these behaviours by developing, validating, and applying a multivariable predictive model for risk of all-cause death. Methods A predictive algorithm for 5 y risk of death—the Mortality Population Risk Tool (MPoRT)—was developed and validated using the 2001 to 2008 Canadian Community Health Surveys. There were approximately 1 million person-years of follow-up and 9,900 deaths in the development and validation datasets. After validation, MPoRT was used to predict future mortality and estimate the burden of smoking, alcohol, physical inactivity, and poor diet in the presence of sociodemographic and other risk factors using the 2010 national survey (approximately 90,000 respondents). Canadian period life tables were generated using predicted risk of death from MPoRT. The burden of behavioural risk factors attributable to life expectancy was estimated using hazard ratios from the MPoRT risk model. Findings The MPoRT 5 y mortality risk algorithms were discriminating (C-statistic: males 0.874 [95% CI: 0.867–0.881]; females 0.875 [0.868–0.882]) and well calibrated in all 58 predefined subgroups. Discrimination was maintained or improved in the validation cohorts. For the 2010 Canadian population, unhealthy behaviour attributable life expectancy lost was 6.0 years for both men and women (for men 95% CI: 5.8 to 6.3 for women 5.8 to 6.2). The Canadian life expectancy associated with health behaviour recommendations was 17.9 years (95% CI: 17.7 to 18.1) greater for people with the most favourable risk profile compared to those with the least favourable risk profile (88.2 years versus 70.3 years). Smoking, by itself, was associated with 32% to 39% of the difference in life expectancy across social groups (by education achieved or neighbourhood deprivation). Conclusions Multivariable predictive algorithms such as MPoRT can be used to assess health burdens for sociodemographic groups or for small changes in population exposure to risks, thereby addressing some limitations of more commonly used measurement approaches. Unhealthy behaviours have a substantial collective burden on the life expectancy of the Canadian population., To address limitations of commonly used burden-of-disease measurement approaches, Douglas G. Manuel and colleagues develop, validate, and apply a multivariable predictive model for all-cause death attributable to unhealthy behaviors., Author Summary Why Was This Study Done? The burden of unhealthy behaviours and other risk factors is commonly calculated using aggregate, indirectly linked data. Amongst other limitations, there are concerns that these data are poorly suited for assessing equity. Increasingly, population health surveys are being linked, at the individual level, to health outcomes. We examined the role of assessing the burden of unhealthy behaviours using individual, as opposed to aggregate, data. What Did the Researchers Do and Find? We generated a multivariable predictive algorithm of health behaviours and mortality (MPoRT) using the Ontario sample of the linked Canadian Community Health Survey (CCHS). There were approximately 1 million person-years of follow-up and 9,900 deaths in the development and validation datasets. Next, the burden of unhealthy behaviours was estimated by applying the MPoRT risk tool to the most current version of the CCHS. For the 2010 Canadian population, 6.0 y of life expectancy lost were attributable to unhealthy behaviours Smoking, by itself, contributed 32% to 39% of the difference in life expectancy across social groups. The Canadian life expectancy for people adhering to health behaviour recommendations was 17.9 y greater than for people with the least favourable risk profile. What Do These Findings Mean? Unhealthy behaviours contribute to a large burden of reduced life expectancy. Linked population health surveys create an opportunity to estimate burden of disease using individual-based data, as in our multivariable predictive approach, and to supplement existing aggregate approaches. Multivariable risk algorithms can be validated and calibrated for potential application in over 100 countries, potentially allowing widespread use of multivariable approaches. Multivariable risk algorithms are more complex than alternative approaches to measure burden from health behaviours, but their use can be facilitated by reporting the algorithm in machine-readable format (https://github.com/Ottawa-mHealth/predictive-algorithms) and/or by providing online calculators (https://www.projectbiglife.ca).

Approximately one-third of Canadians' prescription medication costs are paid directly out-of-pocket. This study attempts to determine if out-of-pocket spending greater than 5% of household income on drugs and pharmaceutical products is associated with cost-related prescription non-adherence among people with cardiovascular-related chronic conditions.The data are from the survey on Barriers to Care for People with Chronic Health Conditions. Three categories of out-of-pocket spending on drugs and pharmaceutical products as a percentage of household income were identified: 0%, more than 0% to less than 5%, and 5% or more. Log-binomial regression was used to investigate associations between category of out-of-pocket spending and cost-related non-adherence.In 2012, about 80% of people aged 40 or older who lived in British Columbia, Alberta, Saskatchewan or Manitoba and had cardiovascular-related chronic conditions reported out-of-pocket spending on drugs and pharmaceutical products; 4.8% reported out-of-pocket spending of at least 5% of their household income. These individuals were significantly older, more often lived in households with incomes less than $30,000, and more often reported multiple morbidities than did people whose out-of-pocket spending on drugs and pharmaceutical products was less than 5% of household income. When the results were adjusted for age and sex, people whose spending amounted to 5% or more of household income were almost three times as likely (prevalence rate ratio = 2.6) to report cost-related prescription non-adherence than were those spending less than 5%.Spending at least 5% of household income on drugs and pharmaceutical products was significantly associated with cost-related prescription non-adherence. Additional data are required to determine if even lower levels of spending put individuals at risk of cost related non-adherence.

While immigrants tend to be healthier especially when they first arrived, this healthy immigrant effect may not apply to vaccine-preventable diseases (VPD) especially among immigrants from countries without vaccination programs. There is therefore an important information gap regarding differential health outcome and hospitalization usage by immigrant status, landing cohort, world region and immigrant category. This study focused on acute-care hospitalization, and used two recently linked population-based databases in Canada, namely, the 2006 Census linked to the Hospital Discharge Abstract (DAD), and the Immigrant Landing File linked to the DAD (ILF-DAD) to estimate crude and age-standardized VPD-related hospitalization rates (ASHR) by the above-mentioned immigrant characteristics to be compared with that for overall Canadian-born reference population. Based on the 2006 Census-DAD linked database, VPD-specific ASHR for overall immigrants was significantly higher than that for the Canadian-born population (1.6, 95% CI, 1.5, 1.6 vs 1.2, 95% CI, 1.1, 1.2, respectively). VPD-specific ASHRs by landing cohorts also increased with years in Canada (e.g. 1.4, 95% CI, 1.3, 1.5 for the 1990-2006 cohort, and 1.6, 95% CI, 1.5, 1.7 for the pre-1980 cohort). Based on the 1980-2006 ILF-DAD, the VPD-specific ASHRs were highest among Southeast and East Asians (e.g. 2.1, 95% CI, 1.9, 2.3 for East Asia). Compared with the Canadian-born, economic class immigrants overall had significantly lower ASHR (1.4, 95% CI 1.2, 1.6), but the low rate was mainly due to the dependants (spouse or children) within this class (0.8, 95% CI 0.6, 1.1). Both family and refugee categories had significantly higher ASHRs (1.3, 95% CI, 1.2, 1.5 and 1.7, 95% CI, 1.4, 2.1, respectively), especially among those refugees assisted by government (2.0, 95% CI, 1.4, 2.6). With increasing immigration, changing source countries and emerging needs for refugee settlements in Canada, these newly linked datasets help to monitor VPD-related hospitalization pattern among Canadian immigrants.

Objectives. We examined income-related inequalities in self-reported health in the United States and Canada and the extent to which they are associated with individual-level risk factors and health care system characteristics. Methods. We estimated income inequalities with concentration indexes and curves derived from comparable survey data from the 2002 to 2003 Joint Canada–US Survey of Health. Inequalities were then decomposed by regression and decomposition analysis to distinguish the contributions of various factors. Results. The distribution of income accounted for close to half of income-related health inequalities in both the United States and Canada. Health care system factors (e.g., unmet needs and health insurance status) and risk factors (e.g., physical inactivity and obesity) contributed more to income-related health inequalities in the United States than to those in Canada. Conclusions. Individual-level health risk factors and health care system characteristics have similar associations with health status in both countries, but they both are far more prevalent and much more concentrated among lower-income groups in the United States than in Canada.

Objectives To obtain patients’ perspectives on acceptable waiting times for hip or knee replacement surgery. Methods A questionnaire with both open- and close-ended items was mailed to 432 consecutive patients who had hip or knee replacement surgery 3–12 months previously in Saskatchewan, Canada. A content analysis was used to analyse the text data from the open-ended questions. Results The sample of 303 (response rate 70%) was 59% female with a mean age of 70 years (SD 11). The median waiting time from the decision date to surgery was 17 weeks. Individuals who rated their waiting time very acceptable (48%) had a median waiting time of 13 weeks compared with a median waiting time of 22 weeks for those who rated it unacceptable (23%). The two most common determinants of acceptability were patient expectations and pain and its impact on patient quality of life. The median maximum acceptable waiting time was 13 weeks and median ideal waiting time, 8.6 weeks. Seventy-nine per cent felt that those in greater need (higher severity) should go before them on the waiting list. Patient ratings of maximum acceptable waiting time were based on: pain and loss of mobility, time needed to prepare for surgery, and severity at the time of seeing the surgeon. In consideration of changing their surgeon to one with a shorter waiting list, 68% would not. Conclusions Patient views on waiting times are not only related to quality of life issues, but also to prior expectations and notions of fairness and priority. Understanding patient views on waiting for surgery has implications for better management of waiting times and experiences for joint replacement.

Immigrants tend to have better health than the Canadian-born. However, the "healthy immigrant" effect diminishes over time and varies by source country. This study examines whether lower hospitalization rates persist from the first (G1) to the second generation (G2) of immigrants, compared with other Canadians (G3+). All-cause and circulatory disease-related hospitalization rates were examined by generation, with special attention to people of Chinese and South Asian descent.Data from the 2006 Census-hospitalization linkage database (which excludes Quebec) were analysed using logistic regression. Age-standardized all-cause (excluding pregnancy) and circulatory disease-related hospitalization rates were derived for the urban population aged 30 or older for the 2006/2007 to 2008/2009 fiscal years.Over the generations, immigrants' all-cause and circulatory disease-related hospitalization rates converged with those of the Canadian population overall. Compared with G3+, the age-adjusted odds of all-cause hospitalization among men were 0.49 (CI = 0.48-0.51) for recent G1 immigrants, 0.78 (CI = 0.77-0.79) for long-term G1 immigrants, and 0.95 (CI = 0.94-0.97) for G2. Adjustments for socioeconomic status reduced the difference, especially between G2 and G3+. For South Asians, rates converged for circulatory disease, notably among men. Hospitalization rates for people of Chinese descent rose across generations, but remained significantly below rates for G3+.The lower circulatory disease-related hospitalization risk experienced by G1 is maintained in G2 among people of Chinese descent, but not among South Asians.

Record linkage is commonly used in health research to fill data gaps. This study summarizes the linkage of the 2006 Census of Population (excluding Quebec) to hospital data from the Discharge Abstract Database (DAD).Hierarchical deterministic exact matching was employed to link 2006 Census and DAD (2006/2007, 2007/2008 and 2008/2009) data, based on linkage keys derived from three variables common to both files-date of birth, postal code and sex. The full census file (short-form; 23.4 million) was used for record linkage; the 20% file (long-form; 4.65 million) representing the study cohort was used for validation. Linked files were compared across jurisdictions, years and other selected covariates in terms of eligibility for linkage, keys linked, and linkage and coverage rates.Overall, 80% of linkage keys identified in the DAD were linked to the 2006 Census. The percentage of long-form census respondents linked to at least one hospital record ranged between 5% and 8% across jurisdictions; linkage rates were higher among known high users of hospital services: older age groups, lower-income individuals, and Aboriginal people. In general, the linked census file represents the majority of hospital events that occurred during the study period. Coverage rates (weighted/unweighted) varied by geography and age group, with lower weighted rates for the territories and some younger age groups.With hierarchical deterministic exact matching, census data can be linked to multiple years of DAD data. Incorporation of updated postal codes from tax files reduced linkage rate attrition over time. Lower coverage rates for the territories and younger age groups suggest that these populations may be underrepresented in the linked files.

The objective of this study was to explore Canadian rural-urban differences in the use of primary and secondary preventive diagnostic services for acute myocardial infarction (AMI)-a condition that is amenable to primary health care prevention efforts.We examined primary and secondary preventive care services utilized 2 years prior to a patient's first AMI in a cohort of 30,491 patients in Ontario, Canada, from 2010 to 2012. Using logistic regression, rural-urban differences in lipid testing, glucose testing, stress testing, electrocardiograms, and echocardiograms in middle-age and senior patients were examined.The odds of rural patients receiving care for primary preventive screening were more than 50% lower than the odds for urban patients, with rural seniors being the most affected. Lipid testing: middle-age OR 0.519 (95% CI, 0.469-0.574), senior OR 0.422 (0.386-0.460); glucose testing: middle-age OR 0.471 (0.426-0.521), senior OR 0.359 (0.328-0.394). The odds of rural patients receiving secondary preventive diagnostic care were also lower than the odds for urban patients, but differences between the age groups were not as apparent. Stress testing: middle-age OR 0.745 (95%CI, 0.642-0.866), senior OR 0.726 (0.643-0.820); electrocardiogram: middle-age OR 0.815 (0.737-0.901), senior OR 0.724 (0.659-0.795); echocardiogram: middle-age OR 0.755 (0.655-0.869), senior OR 0.746 (0.681-0.818).Study results support ongoing concerns related to health care for rural Canadians by demonstrating underutilization of AMI preventive diagnostic care among rural patients. Rural seniors are most at risk. These results have implications for rural health care as well as seniors' health policy in Canada.

As total joint arthroplasty (TJA) rates rise, there is need to ensure appropriate use. Our objective was to elucidate surgeons' perspectives on appropriateness for TJA.Semi-structured telephone interviews were conducted in a sample of orthopaedic surgeons that perform TJA in three Canadian Provinces. Surgeons were asked to discuss their criteria for TJA appropriateness for osteoarthritis; potential value of a decision-support tool to select appropriate candidates; and the role of other stakeholders in assessing appropriateness.Of 17 surgeons approached for participation, 14 completed interviews (12 males; 7 aged50 years; 5 academic; 8 in urban practices). Surgeons agreed that pain and pain impact on patients' quality of life and function were the key criteria to assess appropriateness for TJA, but that these concepts were difficult to assess and not always congruent with structural changes on joint radiography. Some used a wider range of criteria, including their assessments of patient expectations, ability to cope and readiness for surgery. While patient age was not identified as a criterion itself, surgeons did acknowledge that appropriateness criteria may differ for younger versus older patients. Most agreed that a decision-support tool would help ensure that all elements of appropriateness are assessed in a standardized manner, albeit the ultimate decision to offer surgery must be left to the discretion of surgeons, within the context of the doctor-patient relationship.Surgeons recognized the need for a tool to support decision making for TJA, particularly in the context of increasing surgical demand in younger patients with less severe arthritis. The work to develop and test such a decision-support tool is underway.

Objectives Previous patient-level acute myocardial infarction (AMI) research has found higher hospital spending to be associated with improved survival; however, survivor-treatment selection bias traditionally has been overlooked. The purpose of this study was to examine the AMI cost-outcome relationship, taking into account this form of bias. Data Sources Hospital Discharge Abstract data tracked costs for AMI hospitalizations. Ontario Vital Statistics data tracked patient mortality. Study Design A standard Cox survival model was compared to an extended Cox model using hospital costs as a time-varying covariate to examine the impact of cost on 1-year survival in a cohort of 30,939 first-time AMI patients in Ontario, Canada, from 2007 to 2010. Principal Findings Higher patient-level AMI spending decreased the hazard of dying (Standard Model: log-cost hazard ratio: 0.513, 95 percent CI: 0.479–0.549; Extended Model: log-cost hazard ratio: 0.700, 95 percent CI: 0.645–0.758); however, the protective effect was overestimated by 62 percent when survivor-treatment bias was overlooked. In the extended model, a 10 percent increase in spending was associated with a 3.6 percent decrease in hazard of death. Conclusion The findings of this study suggest that if survivor-treatment bias is overlooked, future research may materially overstate the protective effect of patient-level spending on outcomes.

Background Health behaviours, important factors in cardiovascular disease, are increasingly a focus of prevention. We appraised whether stroke risk can be accurately assessed using self-reported information focused on health behaviours. Methods Behavioural, sociodemographic and other risk factors were assessed in a population-based survey of 82 259 Ontarians who were followed for a median of 8.6 years (688 000 person-years follow-up) starting in 2001. Predictive algorithms for 5-year incident stroke resulting in hospitalization were created and then validated in a similar 2007 survey of 28 605 respondents (median 4.2 years follow-up). Results We observed 3 236 incident stroke events (1 551 resulting in hospitalization; 1 685 in the community setting without hospital admission). The final algorithms were discriminating (C-stat: 0.85, men; 0.87, women) and well-calibrated (in 65 of 67 subgroups for men; 61 of 65 for women). An index was developed to summarize cumulative relative risk of incident stroke from health behaviours and stress. For men, each point on the index corresponded to a 12% relative risk increase (180% risk difference, lowest (0) to highest (9) scores). For women, each point corresponded to a 14% relative risk increase (340% difference, lowest (0) to highest (11) scores). Algorithms for secondary stroke outcomes (stroke resulting in death; classified as ischemic; excluding transient ischemic attack; and in the community setting) had similar health behaviour risk hazards. Conclusion Incident stroke can be accurately predicted using self-reported information focused on health behaviours. Risk assessment can be performed with population health surveys to support population health planning or outside of clinical settings to support patient-focused prevention.

Background Some patients with cardiovascular-related chronic diseases such as diabetes and heart disease report financial barriers to achieving optimal health. Previous surveys report that the perception of having a financial barrier is associated with self-reported adverse clinical outcomes. We sought to confirm these findings using linked survey and administrative data to determine, among patients with cardiovascular-related chronic diseases, if there is an association between perceived financial barriers and the outcomes of: (1) disease-related hospitalizations, (2) all-cause mortality and (3) inpatient healthcare costs. Methods We used ten cycles of the nationally representative Canadian Community Health Survey (administered between 2000 and 2011) to identify a cohort of adults aged 45 and older with hypertension, diabetes, heart disease or stroke. Perceived financial barriers to various aspects of chronic disease care and self-management were identified (including medications, healthful food and home care) from the survey questions, using similar questions to those used in previous studies. The cohort was linked to administrative data sources for outcome ascertainment (Discharge Abstract Database, Canadian Mortality Database, Patient Cost Estimator). We utilized Poisson regression techniques, adjusting for potential confounding variables (age, sex, education, multimorbidity, smoking status), to assess for associations between perceived financial barriers and disease-related hospitalization and all-cause mortality. We used gross costing methodology and a variety of modelling approaches to assess the impact of financial barriers on hospital costs. Results We identified a cohort of 120,752 individuals over the age of 45 years with one or more of the following: hypertension, diabetes, heart disease or stroke. One in ten experienced financial barriers to at least one aspect of their care, with the two most common being financial barriers to accessing medications and healthful food. Even after adjustment, those with at least one financial barrier had an increased rate of disease-related hospitalization and mortality compared to those without financial barriers with adjusted incidence rate ratios of 1.36 (95% CI: 1.29–1.44) and 1.24 (1.16–1.32), respectively. Furthermore, having a financial barrier to care was associated with 30% higher inpatient costs compared to those without financial barriers. Discussion This study, using novel linked national survey and administrative data, demonstrates that chronic disease patients with perceived financial barriers have worse outcomes and higher resource utilization, corroborating the findings from prior self-report studies. The overall exposure remained associated with the primary outcome even in spite of adjustment for income. This suggests that a patient’s perception of a financial barrier might be used in clinical and research settings as an additional measure along with standard measures of socioeconomic status (ie. income, education, social status). Conclusions After adjusting for relevant covariates, perceiving a financial barrier was associated with increased rates of hospitalization and mortality and higher hospital costs compared to those without financial barriers. The demonstrable association with adverse outcomes and increased costs seen in this study may provide an impetus for policymakers to seek to invest in interventions which minimize the impact of financial barriers.

OBJECTIVE: To assess the influence of neighbourhood immigrant concentration on cardiovascular-disease-related hospitalizations in Canada (CVDH), while adjusting for individual-level immigrant status and socio-economic indicators at individual and neighbourhood levels. METHODS: Data were from the 2006 Canadian Census linked to the hospital Discharge Abstract Data (DAD) for the province of Ontario. Adults (n=1,459,950) aged ³18 years at baseline and grouped by place of birth (Canada, China, South Asia, Europe, and other) were followed between Census Day May 16, 2006 and March 31, 2008. Information on CVDH was obtained from the DAD, while that on immigration and socio-economic indicators was obtained from the Census. The analysis used multilevel logistic regression. RESULTS: Unadjusted results showed that CVDH was significantly lower among people living in neighbourhoods with medium and high immigrant concentration. Neighbourhood immigrant concentration tended to have no independent effect on CVDH after adjustment for individual-level immigrant status. Immigrants were less likely to experience CVDH irrespective of their country of birth. However, cross-level interaction showed that neighbourhood immigrant concentration provided additional protection to individual-level immigrant status against CVDH for most female immigrant groups, but only for South Asian males. CONCLUSION: This study resulted from the first-ever linkage of census data to hospitalization data in Canada. It is also the first Canadian study to report on neighbourhood variation and the effect of immigrant concentration on CVDH. The study shows that understanding immigrant health requires both individual and neighbourhood approaches, and a consideration of country of origin.

This study compares registry and non-registry approaches to linking 2006 Census of Population data for Manitoba and Ontario to hospital data from the Discharge Abstract Database (DAD).Using a probabilistic linkage, the registry approach linked the census data to provincial health insurance registries, followed by a deterministic linkage to the DAD based on health insurance number (HIN). The non-registry approach used hierarchical deterministic exact matching based on three variables common to both files to link census data to the DAD. The approaches were compared in terms of linkage and coverage rates, sensitivity and specificity, and consistency of HINs on the linked records.Results of the registry and non-registry linkage approaches were similar. In Manitoba, 7% and 6% of census long-form respondents linked to the DAD with the registry and non-registry linkage approaches, respectively; in Ontario, the linkage rate was 5% for both approaches. With the registry approach, the linked census-DAD data represented 84% (weighted) of hospital admissions in the 2006/2007 DAD in both provinces, compared with 82% in Manitoba and Ontario with the non-registry approach.In the absence of access to provincial health insurance registries with which census data can be linked, a non-registry approach can be used to create a research-quality dataset.

The time between symptom onset and physician diagnosis is a period when people with osteoarthritis can make lifestyle changes to reduce pain, improve function and delay disability.This study analyses data for a nationally representative sample of 4,565 Canadians aged 20 or older who responded to the Arthritis component of the 2009 Survey on Living with Chronic Diseases in Canada. Descriptive statistics are used to report the prevalence of hip and knee osteoarthritis; the mean age of symptom onset and diagnosis; medication use; and contacts with health professionals during the previous year.Among people with a physician diagnosis of arthritis, 37% reported osteoarthritis. Of these, 70% experienced pain in the hip(s), knee(s), or hip(s) and knee(s). Close to half (48%) of these people experienced symptoms the same year that they were diagnosed; 42% experienced symptoms at least a year before the diagnosis; and 10% experienced symptoms after the diagnosis. Among those who had symptoms before diagnosis, the average time between symptom onset and diagnosis was 7.7 years.Individuals with osteoarthritis may experience symptoms for several years before they obtain a physician diagnosis.

As rates of total joint arthroplasty (TJA) for osteoarthritis (OA) rise, there is a need to ensure appropriate use. We undertook this study to develop criteria for appropriate use of TJA.In prior work, we used qualitative methods to separately assess OA patients' and arthroplasty surgeons' perceptions regarding appropriateness of patient candidates for TJA. The current study reviewed the appropriateness themes that emerged from each group, and a series of statements were developed to reflect each unique theme or criterion. A group of arthroplasty surgeons then indicated their level of agreement with each statement using electronic voting. Where ≤70% agreed or disagreed, the criterion was discussed and revised, and revoting occurred. In standardized telephone interviews, OA patient focus group participants indicated their level of agreement with each revised criterion.Qualitative research in 58 OA patients and 14 arthroplasty surgeons identified 11 appropriateness criteria. Member-checking in 15 surgeons (including 5 who had participated in the qualitative study) resulted in agreement on 6 revised criteria. These included evidence of arthritis on joint examination, patient-reported symptoms negatively impacting quality of life, an adequate trial of appropriate nonsurgical treatment, realistic patient expectations of surgery, mental and physical readiness of patient for surgery, and patient-surgeon agreement that potential benefits exceed risks. Thirty-six of the original 58 OA patient focus group participants (62.1%) participated in the member-check interviews and endorsed all 6 criteria.Patients and surgeons jointly endorsed 6 criteria for assessment of TJA appropriateness in OA patients. Prospective validation of these criteria (assessed preoperatively) as predictive of postoperative patient-reported outcomes is under way and will inform development of a surgeon-patient decision-support tool for assessment of TJA appropriateness.

Based on data from the 2007 to 2009 and 2009 to 2011 Canadian Health Measures Survey, this article provides national information about prescription medication use among community-dwelling Canadians. An estimated 41% of 6- to 79-year-olds who lived in private households reported taking at least one prescription medication in the past two days (current use). Generally, prescription drug use was higher among females and among people in poorer health, and increased with age. Approximately 11% of 45- to 64-year-olds and 30% of seniors aged 65 to 79 took at least five prescription medications concurrently. For adults aged 25 to 79, the leading prescription medication classes were lipid-lowering agents, ACE-inhibitors, peptic-ulcer and acid-reducers, beta-blockers (men), other analgesics and anti-pyretics (men), anti-depressants (women) and thyroid medication (women). Among children and young adults aged 6 to 24, the leading prescription medications were for attention deficit and hyperactivity disorder (males), depression, and hormonal contraception (females).

People with chronic conditions who do not achieve therapeutic targets have a higher risk of adverse health outcomes. Failure to meet these targets may be due to a variety of barriers. This article examines self-reported financial barriers to health care among people with cardiovascular-related chronic conditions.A population-based survey was administered to western Canadians with cardiovascular-related chronic conditions (n = 1,849). Associations between self-reported financial barriers and statin use, the likelihood of stopping use of prescribed medications, and emergency department visits or hospitalizations were assessed.More than 10% respondents reported general financial barriers (12%) and lack of drug insurance (14%); 4% reported financial barriers to accessing medications. Emergency department visits or hospitalizations were 70% more likely among those reporting a general financial barrier. Those reporting a financial barrier to medications were 50% less likely to take statins and three times more likely to stop using prescribed medications. Individuals without drug insurance were nearly 30% less likely to take statins.In this population, self-reported financial barriers were associated with lower medication use and increased likelihood of emergency department visits or hospitalization.

This analysis explores barriers to the receipt of health care from a primary care physician for management of chronic conditions.A population-based survey was administered to adults in Manitoba, Saskatchewan, Alberta and British Columbia who had hypertension, diabetes, heart disease or stroke (n=1,849). Associations between socio-demographic factors and barriers to receipt of primary care were identified.Most respondents with chronic conditions required care from a primary care physician in the past year and had no difficulty receiving it; about 10% reported a barrier. Barriers were most commonly reported by respondents with diabetes (16%) and were related to initiation of care or waiting too long to get care.A small percentage of adults with chronic conditions report barriers to receiving care from a primary care physician.

Background Management of chronic diseases requires patients to adhere to recommended health behavior change and complete tests for monitoring. While studies have shown an association between low income and lack of adherence, the reasons why people with low income may be less likely to adhere are unclear. We sought to determine the association between household income and receipt of health behavior change advice, adherence to advice, receipt of recommended monitoring tests, and self-reported reasons for non-adherence/non-receipt. Methods We conducted a population-weighted survey, with 1849 respondents with cardiovascular-related chronic diseases (heart disease, hypertension, diabetes, stroke) from Western Canada (n = 1849). We used log-binomial regression to examine the association between household income and the outcome variables of interest: receipt of advice for and adherence to health behavior change (sodium reduction, dietary improvement, increased physical activity, smoking cessation, weight loss), reasons for non-adherence, receipt of recommended monitoring tests (cholesterol, blood glucose, blood pressure), and reasons for non-receipt of tests. Results Behavior change advice was received equally by both low and high income respondents. Low income respondents were more likely than those with high income to not adhere to recommendations regarding smoking cessation (adjusted prevalence rate ratio (PRR): 1.55, 95%CI: 1.09–2.20), and more likely to not receive measurements of blood cholesterol (PRR: 1.72, 95%CI 1.24–2.40) or glucose (PRR: 1.80, 95%CI: 1.26–2.58). Those with low income were less likely to state that non-adherence/non-receipt was due to personal choice, and more likely to state that it was due to an extrinsic factor, such as cost or lack of accessibility. Conclusions There are important income-related differences in the patterns of health behavior change and disease monitoring, as well as reasons for non-adherence or non-receipt. Among those with low income, adherence to health behavior change and monitoring may be improved by addressing modifiable barriers such as cost and access.

Patients with chronic diseases often face financial barriers to optimize their health. These financial barriers may be related to direct healthcare costs such as medications or self-monitoring supplies, or indirect costs such as transportation to medical appointments. No known framework exists to understand how financial barriers impact patients’ lives or their health outcomes. We undertook a grounded theory study to develop such a framework. We used semistructured interviews with a purposive sample of participants with cardiovascular-related chronic disease (hypertension, diabetes, heart disease, or stroke) from Alberta, Canada. Interview transcripts were analyzed in triplicate, and interviews continued until saturation was reached. We interviewed 34 participants. We found that the confluence of 2 events contributed to the perception of having a financial barrier—onset of chronic disease and lack of income or health benefits. The impact of having a perceived financial barrier varied considerably. Protective, predisposing, or modifying of factors determined how impactful a financial barrier would be. An individual's particular set of factors is then shaped by their worldview. This combination of factors and lens determines one's degree of resiliency, which ultimately impacts how well they cope with their disease. The role of financial barriers is complex. How well an individual copes with their financial barriers is intimately tied to resiliency, which is related to the composite of a personal circumstances and their worldview. Our framework for understanding the experience of financial barriers can be used by both researchers and clinicians to better understand patient behavior.

Background: To comprehensively examine the cardiovascular health of Canadians, we developed the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) health index. We analyzed trends in health behaviours and factors to monitor the cardiovascular health of the Canadian population. Methods: We used data from the Canadian Community Health Survey (2003–2011 [excluding 2005]; response rates 70%–81%) to examine trends in the prevalence of 6 cardiovascular health factors and behaviours (smoking, physical activity, fruit and vegetable consumption, overweight/obesity, diabetes and hypertension) among Canadian adults aged 20 or older. We defined ideal criteria for each of the 6 health metrics. The number of ideal metrics was summed to create the CANHEART health index; values range from 0 (worst) to 6 (best or ideal). A separate CANHEART index was developed for youth age 12–19 years; this index included 4 health factors and behaviours (smoking, physical activity, fruit and vegetable consumption and overweight/obesity). We determined the prevalence of ideal cardiovascular health and the mean CANHEART health index score, stratified by age, sex and province. Results: During the study period, physical activity and fruit and vegetable consumption increased and smoking decreased among Canadian adults. The prevalence of overweight/obesity, hypertension and diabetes increased. In 2009–2010, 9.4% of Canadian adults were in ideal cardiovascular health, 53.3% were in intermediate health (4–5 healthy factors or behaviours), and 37.3% were in poor cardiovascular health (0–3 healthy factors or behaviours). Twice as many women as men were in ideal cardiovascular health (12.8% vs. 6.1%). Among youth, the prevalence of smoking decreased and the prevalence of overweight/obesity increased. In 2009–2010, 16.6% of Canadian youth were in ideal cardiovascular health, 33.7% were in intermediate health (3 healthy factors or behaviours), and 49.7% were in poor cardiovascular health (0–2 healthy factors or behaviours). Interpretation: Fewer than 1 in 10 Canadian adults and 1 in 5 Canadian youth were in ideal cardiovascular health from 2003 to 2011. Intensive health promotion activities are needed to meet the Heart and Stroke Foundation of Canada’s goal of improving the cardiovascular health of Canadians by 10% by 2020 as measured by the CANHEART health index.

Background 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. Methods 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. Results 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). Conclusions 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.

Waiting for specialist consultations can represent a substantial component of overall waiting time in the continuum of care. However, relatively little is known about the factors associated with how long patients wait for an initial specialist consultation.The analysis is based on a subsample of 5,515 respondents aged 15 or older to the 2007 Canadian Community Health Survey who had consulted a specialist about a new condition in the previous 12 months and reported a waiting time. Multivariate logistic regression models were used to identify patient- and provider-related factors associated with waiting time.Female patients were less likely than male patients to see a specialist within a month. The nature of the new condition and the source of referral were significantly associated with waiting time. Compared with those referred by a family physician, patients referred by another specialist or a health care provider other than a physician, or who did not require a referral, were more likely to have a shorter waiting time. For men, but not women, household income and immigrant status were associated with waiting time.This analysis suggests that factors beyond medical need are associated with how long patients wait to see a specialist. More research could usefully explore decision-making and communication processes between primary care physicians and specialists to better understand how urgency is assessed, how patients are triaged for specialist consultations, and how these patterns differ among various groups of patients.

Accumulating evidence points to overall improvements in health-related quality of life after joint replacement for osteoarthritis. Some patients, however, do not appear to benefit from joint replacement. This study investigates health outcomes of patients who underwent hip or knee replacement surgery.Linked survey and administrative data were used to compare the health-related quality of life of individuals who underwent surgery (surgical group) with that of their contemporaries who did not (comparison group), adjusting for other determinants of health. Weighted multivariate linear regression analyses were conducted.When the results were adjusted for other covariates known to be associated with health, the surgical group reported lower functional health (post-operative) than did the comparison group. Differences ranged from 6% lower functional health among hip replacement patients diagnosed with osteoarthritis to 21% lower functional health for those with hip fractures. Among surgical patients with osteoarthritis, co-morbid conditions and being underweight were associated with lower post-operative functional health.This study is a unique application of linked data to the study of health outcomes of joint replacement at the population level. Outcomes of joint replacement differed by the initial diagnosis or reason for the surgery. For patients with osteoarthritis, poorer post-operative health outcomes were associated with co-morbidites and with being underweight.

Building on Andersen's behavioral model for the utilization of health care services, we examined factors associated with utilization of physician and hospital services among adults in Canada and the United States, with a focus on socioeconomic status (enabling resources in Andersen's framework).Using the 2002-2003 Joint Canada/United States Survey of Health, we conducted country-specific multivariate logistic regressions predicting doctor contacts/visits and overnight hospitalizations in the past year, controlling for predisposing characteristics, enabling resources, and several factors representing perceived need for health care. All analyses were appropriately weighted to yield nationally representative results.Several measures of socioeconomic status-having a regular medical doctor, education, and, in the US income and insurance coverage-were associated with doctor contacts or visits in both countries, along with various predisposing and need factors. However, these same measures were not associated with hospitalizations in either country. Instead, only the individual's predisposing characteristics (eg, age and sex) and his/her need for health care predicted utilization of hospital services in Canada and the United States. Insurance coverage status in the United States became a significant predictor of hospitalizations when count data were analyzed via Poisson regression.Given our particular outcome measures, adults in Canada and the United States exhibited similar patterns of hospital utilization, and socioeconomic status played no explanatory role. However, relative to Canadian adults, we found disparities in doctor contacts among US adults-between those with more income and those with less, between those with health insurance and those without-after adjusting for health care needs and predisposing characteristics.

In 2005, an estimated 1.3 million Canadians aged 12 or older (4.9% of the population of these ages) reported to the Canadian Community Health Survey (CCHS) that they had been diagnosed with diabetes. The Canadian Diabetes Association has published Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada,which recommend the type of care that should be provided to individuals with diabetes. According to the CCHS, and based on data from six of the provinces/territories (Newfoundland and Labrador, Prince Edward Island, New Brunswick, Ontario, Manitoba and Yukon Territory), almost three-quarters of diabetic respondents aged 18 or older reported having had their hemoglobin A1C checked by a health care professional at least once in the year before the survey, and those who had had the test were close to meeting the recommended frequency of every three months. The majority of diabetic respondents were also meeting the recommendation for eye examinations, but only half had the recommended annual foot examinations. Half the diabetic population reported that they or a family member had checked their glucose level every day.

This article examines recent trends in self-reported unmet health care needs among the household population aged 12 or older, and explores various explanations for the increase observed.The data are from the first half (September 2000 through February 2001) of data collection for cycle 1.1 of the Canadian Community Health Survey and from cross-sectional (1994/95 through 1998/99) household components of the National Population Health Survey.Weighted frequencies and cross-tabulations were used to estimate the proportion of people aged 12 or older who reported that they did not receive health care when they thought they needed it. Estimates were also produced for the type of care sought, and specific reasons for unmet health care needs.The percentage of people reporting unmet health care needs rose gradually between 1994/95 and 1998/99, then doubled (from 6% to over 12%) between 1998/99 and 2000/01. Long waiting time was the reason most frequently reported for unmet needs.

Objective: To investigate relations between labour market income inequality and mortality in North American metropolitan areas. Methods: An ecological cross sectional study of relations between income inequality and working age (25–64 years) mortality in 53 Canadian (1991) and 282 US (1990) metropolitan areas using four measures of income inequality. Two labour market income concepts were used: labour market income for households with non-trivial attachment to the labour market and labour market income for all households, including those with zero and negative incomes. Relations were assessed with weighted and unweighted bivariate and multiple regression analyses. Results: US metropolitan areas were more unequal than their Canadian counterparts, across inequality measures and income concepts. The association between labour market income inequality and working age mortality was robust in the US to both the inequality measure and income concept, but the association was inconsistent in Canada. Three of four inequality measures were significantly related to mortality in Canada when households with zero and negative incomes were included. In North American models, increases in earnings inequality were associated with hypothetical increases in working age mortality rates of between 23 and 33 deaths per 100 000, even after adjustment for median metropolitan incomes. Conclusions: This analysis of labour market inequality provides more evidence regarding the robust nature of the relation between income inequality and mortality in the US. It also provides a more refined understanding of the nature of the relation in Canada, pointing to the role of unemployment in generating Canadian metropolitan level health inequalities.