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Background Antibiotics are frequently prescribed unnecessarily in outpatients with coronavirus disease 2019 (COVID-19). We sought to evaluate factors associated with antibiotic prescribing in outpatients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Methods We performed a population-wide cohort study of outpatients aged ≥66 years with polymerase chain reaction–confirmed SARS-CoV-2 from 1 January 2020 to 31 December 2021 in Ontario, Canada. We determined rates of antibiotic prescribing within 1 week before (prediagnosis) and 1 week after (postdiagnosis) reporting of the positive SARS-CoV-2 result, compared to a self-controlled period (baseline). We evaluated predictors of prescribing, including a primary-series COVID-19 vaccination, in univariate and multivariable analyses. Results We identified 13 529 eligible nursing home residents and 50 885 eligible community-dwelling adults with SARS-CoV-2 infection. Of the nursing home and community residents, 3020 (22%) and 6372 (13%), respectively, received at least 1 antibiotic prescription within 1 week of a SARS-CoV-2 positive result. Antibiotic prescribing in nursing home and community residents occurred, respectively, at 15.0 and 10.5 prescriptions per 1000 person-days prediagnosis and 20.9 and 9.8 per 1000 person-days postdiagnosis, higher than the baseline rates of 4.3 and 2.5 prescriptions per 1000 person-days. COVID-19 vaccination was associated with reduced prescribing in nursing home and community residents, with adjusted postdiagnosis incidence rate ratios (95% confidence interval) of 0.7 (0.4–1) and 0.3 (0.3–0.4), respectively. Conclusions Antibiotic prescribing was high and with little or no decline following SARS-CoV-2 diagnosis but was reduced in COVID-19–vaccinated individuals, highlighting the importance of vaccination and antibiotic stewardship in older adults with COVID-19.

Background Environmental surveillance of SARS-CoV-2 via wastewater has become an invaluable tool for population-level surveillance of COVID-19. More highly resolved environmental sampling approaches may also be useful for surveillance. Built environment sampling may provide a spatially refined approach for surveillance of COVID-19 in congregate living settings. Methods We conducted a prospective study of 10 long-term care homes (LTCHs) in both urban and rural settings in Ontario Canada between September 2021 and April 2022. Floor surfaces were sampled weekly at multiple locations within each building and were analyzed for the presence of SARS-CoV-2 using qPCR. The exposure variable was detection of SARS-CoV-2 on floors. The primary outcome was the presence of a COVID-19 outbreak. We calculated the test characteristics of the presence of SARS-CoV-2 on floors for detection of COVID-19 outbreaks. Results We followed 10 LTCHs for 214 cumulative weeks, and collected 3,219 swabs from 183 unique locations. Overall, 15 COVID-19 outbreaks occurred with 74.9 cumulative weeks of outbreaks. During time periods when there were outbreaks of COVID-19 the proportion of floor swabs positive for SaRS-CoV-2 was 50.8% (95% CI: 47.7-53.9). During time periods where there were no outbreaks of COVID-19 the proportion of floor swabs positive was 15.8% (95% CI:14.3-17.3). Using the proportion of positive floor swabs for SARS-CoV-2 to predict COVID-19 outbreak status for a given week, the area under the receiver operating curve was 0.84 (95% CI: 0.76-0.92). Using thresholds of ≥10%, ≥30%, and ≥50%, the prevalence of floor swabs positive for SARS-CoV-2 yielded positive predictive values for outbreak of 0.52 (0.43-0.61), 0.65 (0.53-0.75), and 0.72 (0.58-0.83) respectively, and negative predictive values of 0.93 (0.86-0.97), 0.85 (0.78-0.91), and 0.80 (0.73-0.86) respectively (Figure 1). 13 outbreaks had floor sampling performed in the week prior to them being identified, and of these 7 (54%) had positive swab proportions exceeding 30% in the week prior to the outbreak. Figure 1.Test characteristics of built environment floor swabs for predicting COVID-19 outbreaks in LTCH. Figure 1. Test characteristics of different thresholds for percentage of floor swabs positive for SARS-CoV-2 at a given LTCH for predicting active COVID-19 outbreak in the same building in the same week. NPV = negative predictive value, PPV = positive predictive value, Sens = sensitivity, Spec = specificity. Conclusion Detection of SARS-CoV-2 on floors is strongly associated with COVID-19 outbreaks in LTCHs. These data suggest a potential role for floor sampling in improving early outbreak detection and management. Disclosures Michael Fralick, MD, ProofDx: Advisor/Consultant Doug Manuel, MD, PhD, World Bank: Advisor/Consultant.

Few studies have described the settings cancer decedents spend their end-of-life stage, with none considering homecare specifically. We describe the different settings of care experienced in the last 100 days of life by individuals with cancer and how settings of care change as they approached death.A retrospective cohort study from January 2013 to December 2017, of decedents whose primary cause of death was cancer, using linked population-level health administrative datasets in Ontario, Canada.Decedents 125,755 were included in our cohort. The average age at death was 73, 46% were female, and 14% resided in rural regions. And 24% died of lung cancer, 7% breast, 7% colorectal, 7% pancreatic, 5% prostate, and 50% other cancers. In the last 100 days of life, decedents spent 25.9 days in institutions, 25.8 days receiving care in the community, and 48.3 days at home without any care. Individuals who died of lung and pancreatic cancers spent the most days at home without any care (52.1 and 52.6 days), while individuals who died of prostate and breast cancer spent the least days at home without any care (41.6 and 45.1 days). Regardless of cancer type, decedents spent fewer days at home and more days in institutions as they approached death, despite established patient preferences for an end-of-life experience at home.In the last 100 days of life, cancer decedents spent most of their time in either institutions or at home without any care. Improving homecare services during the end-of-life may provide people dying of cancer with a preferred dying experience.

BackgroundEnvironmental surveillance of SARS-CoV-2 via wastewater has become an invaluable tool for population-level surveillance of COVID-19. Built environment sampling may provide a more spatially refined approach for surveillance of COVID-19 in congregate living settings and other high risk settings (e.g., schools, daycares).MethodsWe conducted a prospective study in 10 long-term care homes (LTCHs) across three cities in Ontario, Canada between September 2021 and May 2022. Floor surfaces were sampled weekly at multiple locations (range 10 to 24 swabs per building) within each building and analyzed for the presence of SARS-CoV-2 using RT-qPCR. The exposure variable was detection of SARS-CoV-2 on floors. The primary outcome was the presence of a COVID-19 outbreak in the week that floor sampling was performed.ResultsOver the 9-month study period, we collected 3848 swabs at 10 long-term care homes. During the study period, 19 COVID-19 outbreaks occurred with 103 cumulative weeks under outbreak. During outbreak periods, the proportion of floor swabs positive for SARS-CoV-2 was 50% (95% CI: 47-53) with a median quantification cycle of 37.3 (IQR 35.2-38.7). During non-outbreak periods the proportion of floor swabs positive was 18% (95% CI:17-20) with a median quantification cycle of 38.0 (IQR 36.4-39.1). Using the proportion of positive floor swabs for SARS-CoV-2 to predict COVID-19 outbreak status in a given week, the area under the receiver operating curve (AUROC) was 0.85 (95% CI: 0.78-0.92). Using thresholds of ≥10%, ≥30%, and ≥50% of floor swabs positive for SARS-CoV-2 yielded positive predictive values for outbreak of 0.57 (0.49-0.66), 0.73 (0.63-0.81), and 0.73 (0.6-0.83) respectively and negative predictive values of 0.94 (0.87-0.97), 0.85 (0.78-0.9), and 0.75 (0.68-0.81) respectively. Among 8 LTCHs with an outbreak and swabs performed in the antecedent week, 5 had positive floor swabs exceeding 10% at least five days prior to outbreak identification. For 3 of these 5 LTCHs, positivity of floor swabs exceeded 10% more than 10 days before the outbreak being identified.ConclusionsDetection of SARS-CoV-2 on floors is strongly associated with COVID-19 outbreaks in LTCHs. These data suggest a potential role for floor sampling in improving early outbreak identification.

Patients want personalized information before surgery; most do not receive personalized risk estimates. Inadequate information contributes to poor experience and medicolegal complaints. We hypothesized that exposure to the Personalized Risk Evaluation and Decision Making in Preoperative Clinical Assessment (PREDICT) app, a personalized risk communication tool, would improve patient knowledge and satisfaction after anesthesiology consultations compared with standard care. We conducted a prospective clinical study (before-after design) and used patient-reported data to calculate personalized risks of morbidity, mortality, and expected length of stay using a locally calibrated National Surgical Quality Improvement Program risk calculator embedded in the PREDICT app. In the standard care (before) phase, the application’s materials and output were not available to participants; in the PREDICT app (after) phase, personalized risks were communicated. Our primary outcome was knowledge score after the anesthesiology consultation. Secondary outcomes included patient satisfaction, anxiety, feasibility, and acceptability. We included 183 participants (90 before; 93 after). Compared with standard care phase, the PREDICT app phase had higher post-consultation: knowledge of risks (14.3% higher; 95% confidence interval [CI], 6.5 to 22.0; P < 0.001) and satisfaction (0.8 points; 95% CI, 0.1 to 1.4; P = 0.03). Anxiety was unchanged (− 1.9%; 95% CI, − 4.2 to 0.5; P = 0.13). Acceptability was high for patients and anesthesiologists. Exposure to a patient-facing, personalized risk communication app improved knowledge of personalized risk and increased satisfaction for adults before elective inpatient surgery. www.clinicaltrials.gov (NCT03422133); registered 5 February 2018.

Background For both the current and future pandemics, there is a need for high-throughput drug screening methods to identify existing drugs with potential preventive and/or therapeutic activity. Epidemiologic studies could complement laboratory-focused efforts to identify possible therapeutic agents. Methods We performed a pharmacopeia-wide association study (PWAS) to identify commonly prescribed medications and medication classes that are associated with the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in older individuals (≥65 years) in long-term care homes (LTCHs) and the community, between 15 January 2020 and 31 December 2020, across the province of Ontario, Canada. Results A total of 26 121 cases and 2 369 020 controls from LTCHs and the community were included in this analysis. Many of the drugs and drug classes evaluated did not yield significant associations with SARS-CoV-2 detection. However, some drugs and drug classes appeared to be significantly associated with reduced SARS-CoV-2 detection, including cardioprotective drug classes such as statins (weighted odds ratio [OR], 0.91; standard P Conclusions Using this epidemiologic approach, which can be applied to current and future pandemics, we have identified a variety of target drugs and drug classes that could offer therapeutic benefit in coronavirus disease 2019 (COVID-19) and may warrant further validation. Some of these agents (eg, fluoxetine) have already been identified for their therapeutic potential.

La disponibilite croissante des donnees generees par les prestataires de soins de sante ainsi que par la surveillance de l’incidence des maladies et des indicateurs de l’evolution des maladies a transforme le caractere de la recherche en sante. Les donnees de sante collectees en

Patients want personalized information before surgery; most do not receive personalized risk estimates. Inadequate information contributes to poor experience and medicolegal complaints. We hypothesized that exposure to the Personalized Risk Evaluation and Decision Making in Preoperative Clinical Assessment (PREDICT) app, a personalized risk communication tool, would improve patient knowledge and satisfaction after anesthesiology consultations compared with standard care.We conducted a prospective clinical study (before-after design) and used patient-reported data to calculate personalized risks of morbidity, mortality, and expected length of stay using a locally calibrated National Surgical Quality Improvement Program risk calculator embedded in the PREDICT app. In the standard care (before) phase, the application's materials and output were not available to participants; in the PREDICT app (after) phase, personalized risks were communicated. Our primary outcome was knowledge score after the anesthesiology consultation. Secondary outcomes included patient satisfaction, anxiety, feasibility, and acceptability.We included 183 participants (90 before; 93 after). Compared with standard care phase, the PREDICT app phase had higher post-consultation: knowledge of risks (14.3% higher; 95% confidence interval [CI], 6.5 to 22.0; P0.001) and satisfaction (0.8 points; 95% CI, 0.1 to 1.4; P = 0.03). Anxiety was unchanged (- 1.9%; 95% CI, - 4.2 to 0.5; P = 0.13). Acceptability was high for patients and anesthesiologists.Exposure to a patient-facing, personalized risk communication app improved knowledge of personalized risk and increased satisfaction for adults before elective inpatient surgery.www.clinicaltrials.gov (NCT03422133); registered 5 February 2018.RéSUMé: OBJECTIF: Les patients veulent disposer d’informations personnalisées avant leur chirurgie, mais la plupart d’entre eux ne reçoivent pas d’estimations de leur risque personnalisées. Des informations inadéquates contribuent à une mauvaise expérience et à des plaintes médicolégales. Nous avons émis l’hypothèse qu’une exposition à l’application PREDICT (Personalized Risk Evaluation and Decision Making in Preoperative Clinical Assessment), un outil de communication du risque personnalisé, améliorerait les connaissances et la satisfaction des patients après leurs consultations en anesthésiologie comparativement à des soins standard. MéTHODE: Nous avons réalisé une étude clinique prospective (de type avant-après) et utilisé les données rapportées par les patients afin de calculer leur risque personnalisé de morbidité et de mortalité, ainsi que la durée de séjour anticipée à l’aide d’un calculateur de risque tiré du Programme national d’amélioration de la qualité chirurgicale que nous avons calibré localement et intégré à l’application PREDICT. Dans la phase de soins standard (avant), le contenu et les résultats de l’application n’étaient pas divulgués aux participants; dans la phase comportant l’application PREDICT (après), les risques personnalisés étaient communiqués. Notre critère d’évaluation principal était le score des connaissances des patients après la consultation en anesthésiologie. Les critères d’évaluation secondaires comprenaient la satisfaction des patients et leur niveau d’anxiété ainsi que la faisabilité et l’acceptabilité d’une telle approche. RéSULTATS: Nous avons inclus 183 participants (90 avant; 93 après). Comparativement à la phase de soins standard, la phase avec l’application PREDICT a démontré un niveau plus élevé de connaissances des risques post consultation (14,3 % plus élevé; intervalle de confiance [IC] 95 %, 6,5 à 22,0; P0,001) et de satisfaction (0,8 point; IC 95 %, 0,1 à 1,4; P = 0,03). L’anxiété est demeurée inchangée (− 1,9 %; IC 95 %, − 4,2 à 0,5; P = 0,13). L’acceptabilité était élevée, tant chez les patients que chez les anesthésiologistes. CONCLUSION: L’exposition des patients à une application de communication du risque personnalisé a amélioré leurs connaissances de leur risque personnalisé et augmenté la satisfaction des adultes avant une chirurgie non urgente et non ambulatoire. ENREGISTREMENT DE L’éTUDE: www.clinicaltrials.gov (NCT03422133); enregistrée le 5 février 2018.

Supplemental Digital Content is Available in the Text., Background: Aging and increasing comorbidity is changing the end-of-life experience of people living with HIV (PLHIV) in the developed world. We quantified, at a population level, the receipt of health care services and associated costs across a comprehensive set of sectors among decedents with and without HIV. Methods: We conducted a retrospective population-level observational study of all decedents in Ontario and their receipt of health care services, captured through linked health administrative databases, between April 1, 2010 and March 31, 2013. We identified PLHIV using a validated algorithm. We described the characteristics of PLHIV and their receipt of health care services and associated costs by health care sector in the last year of life. Results: We observed 264,754 eligible deaths, 570 of whom had HIV. PLHIV were significantly younger than those without HIV (mean age of death 56.1 years vs. 76.6 years, [P < 0.01]). PLHIV spent a mean of 20.0 days in an acute care hospital in the last 90 days of life compared with 12.1 days for decedents without HIV (P < 0.01); after adjustment, HIV was associated with 4.5 more acute care days (P < 0.01). Mean cost of care in the last year was significantly higher among PLHIV ($80,885.62 vs. $53,869.77), mostly attributable to acute care costs. Interpretation: PLHIV in Ontario are dying younger, spending more time and dying more often in hospital, and incur significantly increased costs before death. Greater involvement of community-based palliative care may improve the dying experience for this complex population.

Objective To determine whether implementation of universal bilirubin screening in Ontario, Canada is associated with improved rates of recommended follow-up care across socioeconomic status (SES). Methods We conducted a retrospective population-based cohort study of all babies born at ≥35 weeks' gestation and discharged to home within 72 hours from 97 hospitals between April, 2003 and February, 2011. We used linked administrative health data sets to measure recommended follow-up care (physician visit within 1 day of discharge for babies discharged ≤24 hours after birth, or physician visit within 2 days for babies discharged 24–72 hours after birth). We used maternal postal code and the Canadian Deprivation Index to determine material deprivation quintile. We modeled the relationship between universal bilirubin screening and outcomes using generalized estimating equations to account for clustering according to hospital, underlying temporal trends, and important covariates. Results Universal bilirubin screening was associated with a modest increase in recommended follow-up from 29.9% to 35.0% (n = 711,242; adjusted relative risk: 1.11; P = .047). Disparity in recommended follow-up increased after screening implementation, with 40% of the crude increase attributable to the highest SES quintile and none to the lowest SES quintile. Conclusions Universal bilirubin screening has had only a modest effect in ensuring timely follow-up for Ontario newborn babies, which represents an ongoing weakness in efforts to prevent severe hyperbilirubinemia. The observed increase in SES disparity in access to recommended follow-up suggests that universal programs that fail to address root causes of disparities might lead to overall improvements in population outcomes but increased inequity.

Background Rural residence is associated with stroke incidence and mortality, but little is known about potential rural/urban differences in ambulatory stroke care. Methods and Results We used the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) cohort, created from linked administrative databases from the province of Ontario, Canada, and divided into primary (N=6 207 032) and secondary (N=75 823) prevention cohorts based on the absence or presence of prior stroke. We defined rural communities as those with a population size of ≤10 000 and within each of the primary and secondary prevention cohorts, compared cardiovascular risk factors and care between rural and urban areas. We then calculated sex-/age-standardized rates of stroke incidence and mortality per 1000 person-years between January 1, 2008 and December 31, 2012 and used cause-specific hazard models to compare outcomes in rural versus urban areas adjusting for age, sex, income, ethnicity, smoking, physical activity and comorbid conditions, and accounting for the competing risk of death in the model for the occurrence of stroke incidence. In the primary prevention cohort, rural residents were less likely than urban ones to be screened for diabetes mellitus (70.9% versus 81.3%) and hyperlipidemia (66.2% versus 78.4%) and less likely to achieve diabetes mellitus control (hemoglobin A1c ≤7% in 51.3% versus 54.3%; P0.001 for all comparisons). In the secondary prevention cohort, the prevalence and treatment of risk factors were similar in rural and urban residents. After adjustment for sociodemographic and comorbid conditions, rural residence was associated with higher rates of stroke and all-cause mortality in both the primary prevention (adjusted hazard ratio [aHR] for stroke, 1.06; 95% CI, 1.04-1.09; aHR for mortality, 1.09; 95% CI, 1.08-1.10) and the secondary prevention cohort (aHR for stroke, 1.11; 95% CI, 1.02-1.19; aHR for mortality, 1.07; 95% CI, 1.03-1.11). Conclusions In this population-based study of over 6 million people with universal access to physician and hospital services, risk factors were more prevalent but less likely to be controlled in rural than in urban residents without prior stroke, whereas in those with prior stroke, risk factor prevalence and treatment were similar. Rural residence was associated with the rate of stroke and death even after adjustment for risk factors. Future efforts should focus not only on control of known vascular risk factors but also on addressing other determinants of health in rural communities.

Background: Rural residence is associated with stroke incidence and mortality, but little is known about potential rural/urban differences in ambulatory stroke care. Methods and Results: We used the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) cohort, created from linked administrative databases from the province of Ontario, Canada, and divided into primary (N=6 207 032) and secondary (N=75 823) prevention cohorts based on the absence or presence of prior stroke. We defined rural communities as those with a population size of ≤10 000 and within each of the primary and secondary prevention cohorts, compared cardiovascular risk factors and care between rural and urban areas. We then calculated sex-/age-standardized rates of stroke incidence and mortality per 1000 person-years between January 1, 2008 and December 31, 2012 and used cause-specific hazard models to compare outcomes in rural versus urban areas adjusting for age, sex, income, ethnicity, smoking, physical activity and comorbid conditions, and accounting for the competing risk of death in the model for the occurrence of stroke incidence. In the primary prevention cohort, rural residents were less likely than urban ones to be screened for diabetes mellitus (70.9% versus 81.3%) and hyperlipidemia (66.2% versus 78.4%) and less likely to achieve diabetes mellitus control (hemoglobin A1c ≤7% in 51.3% versus 54.3%; P Conclusions: In this population-based study of over 6 million people with universal access to physician and hospital services, risk factors were more prevalent but less likely to be controlled in rural than in urban residents without prior stroke, whereas in those with prior stroke, risk factor prevalence and treatment were similar. Rural residence was associated with the rate of stroke and death even after adjustment for risk factors. Future efforts should focus not only on control of known vascular risk factors but also on addressing other determinants of health in rural communities.

IntroductionNational health surveys, available in over 100 countries, are the most common data used for health behaviour surveillance and are increasingly being linked to individual-level health outcomes. We propose that improved health behaviour hazard estimates can be obtained from pooled international population health surveys linked to outcome data. Objectives and ApproachThe objective of this study was to compare smoking, alcohol, diet and physical activity all-cause mortality hazards in Canada and the United States using individual-level, linked population health survey data and common model specifications. The Canadian Community Health Survey (CCHS) (2003-2007) and the United States National Health Interview Survey (NHIS) (2000, 2005) linked to individual-level mortality outcomes with follow up to December 31, 2011 were used. Variable definitions consistent across the CCHS and NHIS were developed and used to estimate country-specific mortality hazards with sex-specific Cox proportional hazard models, including health behaviours, sociodemographic indicators and proximal factors including disease history. ResultsA total of 296,407 respondents and 1,813,884 million person-years of follow-up from the CCHS and 62,226 respondents and 497,909 person-years from the NHIS were included. Hazards of smoking, alcohol consumption, diet and physical activity in Canada and the United States are of similar magnitude and direction, with similar dose response relationships. The largest health behaviour mortality hazards were associated with female heavy smokers in both Canada (HR: 3.36, 95% CI: 2.86, 3.95) and the United States (Female HR: 2.63, 95% CI: 2.11, 3.27), compared to non-smokers. Conclusion/ImplicationsHealth behaviour mortality hazards are comparable in Canada and the United States, supporting the use of hazards obtained from pooled analyses for population heath. These hazards can replace those obtained from independent epidemiology studies that are often incompletely adjusted, rarely population-based and often not generalizable to the population of interest.

IntroductionInflammatory bowel disease (IBD) is a chronic immune-mediated disease of the gastrointestinal tract. Significant improvements in treatments for IBD have occurred in the past two decades. However, the benefits of new treatments on mortality is uncertain and no prior study has evaluated the life expectancy (LE) of patients with IBD. Objectives and ApproachWe determined trends in the LE and health-adjusted life expectancy (HALE) in IBD. The Ontario Crohn’s and Colitis Cohort includes all patients in Ontario with IBD, identified from health administrative data using a previously validated algorithm. Cases were matched to five controls based on age, sex, rural/urban, and mean neighbourhood income quintile. Period life tables were used to calculate LE on July 1, 1996, 2000, and 2008. The Canadian National Population Health Survey (1996/97) and Canadian Community Health Survey (Cycles 1.1 and 2009/10) were used to estimate health utility index (HUI3). HALE was estimated using HUI3-weighted disability-free years lived. ResultsLE increased from 75.5 years (y) in 1996 to 78.0y in 2008 among women with IBD (∆2.5y, 95%CI 0.8 to 4.1) and from 72.2y in 1996 to 75.1y in 2008 among men with IBD (∆2.9y, 95%CI 1.8 to 4.0). HALE decreased among men with IBD (∆3.9y, 95%CI 1.2 to 6.6; 1996: 67.0y; 2008: 63.1y) but was stable among women with IBD (∆2.0y, 95%CI -1.6 to 5.7; 1996: 62.3y; 2008: 64.3y) and female controls (∆-0.4y, 95%CI -2.3 to 1.5; 1996: 74.3y; 2008: 73.9y) and male controls (∆0.2y, 95%CI -1.7 to 2.2; 1996: 69.6y; 2008: 69.8y). LE and HALE in both men and women with IBD were significantly decreased compared to controls (LE: women ∆6-8y, men ∆5y; HALE: women ∆10-14y, men ∆3-7y). Conclusion/ImplicationsAlthough patients with IBD experienced increases in LE at a pace similar to those without IBD, the gap in LE between cases and controls remains significant. Increases in LE have not been accompanied by increases in HALE. Treatments that increase both LE and HALE in patients with IBD are needed.

Background Multiple external environmental exposures related to residential location and urban form including, air pollutants, noise, greenness, and walkability have been linked to health impacts or benefits. The Canadian Urban Environmental Health Research Consortium (CANUE) was established to facilitate the linkage of extensive geospatial exposure data to existing Canadian cohorts and administrative health data holdings. We hypothesize that this linkage will enable investigators to test a variety of their own hypotheses related to the interdependent associations of built environment features with diverse health outcomes encompassed by the cohorts and administrative data. Methods We developed a protocol for compiling measures of built environment features that quantify exposure; vary spatially on the urban and suburban scale; and can be modified through changes in policy or individual behaviour to benefit health. These measures fall into six domains: air quality, noise, greenness, weather/climate, and transportation and neighbourhood factors; and will be indexed to six-digit postal codes to facilitate merging with health databases. Initial efforts focus on existing data and include estimates of air pollutants, greenness, temperature extremes, and neighbourhood walkability and socioeconomic characteristics. Key gaps will be addressed for noise exposure, with a new national model being developed, and for transportation-related exposures, with detailed estimates of truck volumes and diesel emissions now underway in selected cities. Improvements to existing exposure estimates are planned, primarily by increasing temporal and/or spatial resolution given new satellite-based sensors and more detailed national air quality modelling. Novel metrics are also planned for walkability and food environments, green space access and function and life-long climate-related exposures based on local climate zones. Critical challenges exist, for example, the quantity and quality of input data to many of the models and metrics has changed over time, making it difficult to develop and validate historical exposures. Discussion CANUE represents a unique effort to coordinate and leverage substantial research investments and will enable a more focused effort on filling gaps in exposure information, improving the range of exposures quantified, their precision and mechanistic relevance to health. Epidemiological studies may be better able to explore the common theme of urban form and health in an integrated manner, ultimately contributing new knowledge informing policies that enhance healthy urban living.

Importance People who immigrate face unique health literacy, communication, and system navigation challenges, and they may have diverse preferences that influence end-of-life care. Objective To examine end-of-life care provided to immigrants to Canada in the last 6 months of their life. Design, Setting, and Participants This population-based cohort study (April 1, 2004, to March 31, 2015) included 967 013 decedents in Ontario, Canada, using validated linkages between health and immigration databases to identify immigrant (since 1985) and long-standing resident cohorts. Exposures All decedents who immigrated to Canada between 1985 and 2015 were classified as recent immigrants, with subgroup analyses assessing the association of time since immigration, and region of birth, with end-of-life care. Main Outcomes and Measures Location of death and intensity of care received in the last 6 months of life. Analysis included modified Poisson regression with generalized estimating equations, adjusting for age, sex, socioeconomic position, causes of death, urban and rural residence, and preexisting comorbidities. Results Among 967 013 decedents of whom 47 514 (5%) immigrated since 1985, sex, socioeconomic status, urban (vs rural) residence, and causes of death were similar, while long-standing residents were older than immigrant decedents (median [interquartile range] age, 75 [58-84] vs 80 [68-87] years). Recent immigrant decedents were overall more likely to die in intensive care (15.6% vs 10.0%; difference, 5.6%; 95% CI, 5.2%-5.9%) after adjusting for differences in age, sex, income, geography, and cause of death (relative risk, 1.30; 95% CI, 1.27-1.32). In their last 6 months of life, recent immigrant decedents experienced more intensive care admissions (24.9% vs 19.2%; difference, 5.7%; 95% CI, 5.3%-6.1%), hospital admissions (72.1% vs 68.2%; difference, 3.9%; 95% CI, 3.5%-4.3%), mechanical ventilation (21.5% vs 13.6%; difference, 7.9%; 95% CI, 7.5%-8.3%), dialysis (5.5% vs 3.4%; difference, 2.1%; 95% CI, 1.9%-2.3%), percutaneous feeding tube placement (5.5% vs 3.0%; difference, 2.5%; 95% CI, 2.3%-2.8%), and tracheostomy (2.3% vs 1.1%; difference, 1.2%; 95% CI, 1.1%-1.4%). Relative risk of dying in intensive care for recent immigrants compared with long-standing residents varied according to recent immigrant region of birth from 0.84 (95% CI, 0.74-0.95) among those born in Northern and Western Europe to 1.96 (95% CI, 1.89-2.05) among those born in South Asia. Conclusions and Relevance Among decedents in Ontario, Canada, recent immigrants were significantly more likely to receive aggressive care and to die in an intensive care unit compared with other residents. Further research is needed to understand the mechanisms behind this association.

ObjectivesIncreasingly, national health surveys are being linked to vital statistics and health care information, providing a new and unique source of individual population health data. Given that nationally-representative health surveys are performed in over a hundred countries, these linkages create comprehensive data sets that are potentially larger than most existing cohort studies. To date, this resource has not been utilized. ApproachThe purpose, study base, content and methods of the Canadian Community Health Survey (CCHS) cycles 2.1 (2003-04) and 3.1 (2005-06) and the United States 2000 and 2005 National Health Interview Survey (NHIS) were examined for comparability and consistency. Smoking, alcohol, physical activity and diet questions were identified, question construct and response categorization were compared, and variable constructions possible for both national health surveys were created. All respondents 20+ years of age were identified and stratified by country and sex. Cox proportional hazard models were used to estimate 5-year hazards of mortality associated with the common smoking, alcohol, physical activity and diet variables. ResultsThe CCHS and NHIS are highly consistent and comparable. Health behaviour questions are similar and permit the creation of smoking, alcohol, physical activity and diet variables that are comparable across surveys. A total of 284 475 survey respondents from Canada and the United States (CCHS, N= 226 731; NHIS, N= 57 744) were included. The largest mortality hazards were associated with female heavy smokers in both Canada (HR: 2.91; 95% CI: 2.52, 3.37) and the United States (Female HR: 2.96; 95% CI: 2.59, 3.38), compared to non-smokers. Moderate variation in the age adjusted all-cause mortality hazard ratios was observed; both smoking and physical activity hazard ratios were consistently higher in the United States than in Canada. ConclusionThis study provides initial support for the methodological feasibility of pooling linked population health surveys however, challenges introduced by dissimilarities will require the use of innovative methodologies, and discussions regarding how to manage jurisdictional data restrictions and privacy issues are needed. Pooled population health data has the potential to improve national and international health surveillance and public health.

Objectives Ontario, the most populous province in Canada, has a universal healthcare system that routinely collects health administrative data on its 13 million legal residents that is used for health research. Record linkage has become a vital tool for this research by enriching this data with the Immigration, Refugees and Citizenship Canada (IRCC) Permanent Resident database and the Office of the Registrar General’s Vital Statistics-Death (VSD) registry. Our objectives were to estimate linkage rates and compare characteristics of individuals in the linked versus unlinked files. Approach We used both deterministic and probabilistic linkage methods to link the IRCC database (1985-2012) and VSD registry (1990-2012) to the Ontario’s Registered Persons Database. Linkage rates were estimated and standardized differences were used to assess differences in socio-demographic and other characteristics between the linked and unlinked records. Results The overall linkage rates for the IRCC database and VSD registry were 86.4% and 96.2%, respectively. The majority (68.2%) of the record linkages in IRCC were achieved after the three deterministic passes with the remaining 18.2% being linked probabilistically. Similarly the majority (79.8%) of the record linkages in the ORGD were linked using deterministic record linkage and the remaining 16.3% were linked after probabilistic and manual review. Unlinked and linked files were similar for most characteristics, such as age and marital status for IRCC and sex and most causes of death for VSD. However, lower linkage rates were observed among people born in East Asia (78%) in the IRCC database and certain causes of death in the VSD registry, namely perinatal conditions (61.3%) and congenital anomalies (81.3%). Conclusion The linkages of immigration and vital statistics data to existing population-based healthcare data in Ontario, Canada will enable many novel cross-sectional and longitudinal studies to be conducted. Analytic techniques to account for sub-optimal linkage rates may be required in studies of certain ethnic groups or certain causes of death among children and infants.

Introduction: Little is known about stroke incidence, mortality and risk factor prevalence in rural versus urban regions. We used linked population-based administrative databases to compare cardiovascular risk factors, stroke incidence and stroke-related death in residents of rural and urban Ontario, Canada. Methods: We used a sub-population of the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) cohort, consisting of individuals aged 40 to 105 in Ontario with no known hospitalization for stroke in the 20 years prior to January 1, 2008. We defined rural regions as those with a population size ≤ 30, 000. We compared the age- and sex- standardized prevalence of risk factors, as well as 5-year stroke incidence and stroke-related mortality rates, in people residing in rural versus urban areas. Results: The study sample consisted of 6,207,032 individuals. Compared to residents of urban regions, rural residents were more likely to smoke (25.3% versus 19.3%), be obese (25.1% versus 19.3%) and live in a low-income area (43.5% versus 38.3%) (P Conclusions: Certain cardiovascular risk factors have increased prevalence in rural areas compared to urban areas. Furthermore, stroke incidence and mortality rates were greater in rural areas in Ontario. Future efforts should focus on reducing regional discrepancies in social determinants of health and addressing risk factor prevalence, particularly smoking and obesity, in rural regions.

Background: The recent increase in the incidence of primary liver cancer in Canada has been attributed to a higher proportion of immigrants from countries endemic for hepatitis B virus (HBV) and hepatitis C virus (HCV). We examined hospital discharges for liver disease in Canada, focusing on those for all liver-related diseases, HBV infection, HCV infection and primary liver cancer, by 3 immigration-related variables: immigration status, duration of residence in Canada and risk level of the source country. Methods: We calculated annualized crude and age-standardized rates of a hospital stay in Canada for HBV infection, HCV infection, primary liver cancer and all liver-related diseases using data from the 2006 Canadian census (long form) linked to the Canadian Institute for Health Information Discharge Abstract Database for fiscal years 2006/07 to 2008/09. We estimated the odds of a hospital stay using logistic regression for the 3 immigration-related variables, adjusting for sociodemographic indicators. Results: Immigrants were less likely than Canadian-born residents to be discharged with a diagnosis of any liver-related condition (odds ratio [OR] 0.83, 95% confidence interval [CI] 0.78–0.89); however, they were more likely to be discharged with a diagnosis of HBV infection (OR 2.02, 95% CI 1.57–2.60) and primary liver cancer (OR 1.43, 95% CI 1.22–1.68). There was a clear association between a hospital stay for HBV infection and immigration from HBV-endemic countries (OR 5.15, 95% CI 3.87–6.84) and between a stay for HCV infection and immigration from HCV-endemic countries (OR 2.98, 95% CI 1.74–5.11). Adjustment for low income status and urban residence did not change the results. Interpretation: Although the odds of a liver-related hospital stay were lower among immigrants than among those born in Canada, immigrants from countries at high risk for HBV infection, HCV infection and primary liver cancer were more likely than Canadian-born residents to have a corresponding liver-related hospital stay. These findings emphasize the importance of identifying immigrants with hepatitis and engaging them in care to prevent complications.

Rates of obesity and diabetes have increased substantially in recent decades; however, the potential role of the built environment in mitigating these trends is unclear.To examine whether walkable urban neighborhoods are associated with a slower increase in overweight, obesity, and diabetes than less walkable ones.Time-series analysis (2001-2012) using annual provincial health care (N ≈ 3 million per year) and biennial Canadian Community Health Survey (N ≈ 5500 per cycle) data for adults (30-64 years) living in Southern Ontario cities.Neighborhood walkability derived from a validated index, with standardized scores ranging from 0 to 100, with higher scores indicating more walkability. Neighborhoods were ranked and classified into quintiles from lowest (quintile 1) to highest (quintile 5) walkability.Annual prevalence of overweight, obesity, and diabetes incidence, adjusted for age, sex, area income, and ethnicity.Among the 8777 neighborhoods included in this study, the median walkability index was 16.8, ranging from 10.1 in quintile 1 to 35.2 in quintile 5. Resident characteristics were generally similar across neighborhoods; however, poverty rates were higher in high- vs low-walkability areas. In 2001, the adjusted prevalence of overweight and obesity was lower in quintile 5 vs quintile 1 (43.3% vs 53.5%; P .001). Between 2001 and 2012, the prevalence increased in less walkable neighborhoods (absolute change, 5.4% [95% CI, 2.1%-8.8%] in quintile 1, 6.7% [95% CI, 2.3%-11.1%] in quintile 2, and 9.2% [95% CI, 6.2%-12.1%] in quintile 3). The prevalence of overweight and obesity did not significantly change in areas of higher walkability (2.8% [95% CI, -1.4% to 7.0%] in quintile 4 and 2.1% [95% CI, -1.4% to 5.5%] in quintile 5). In 2001, the adjusted diabetes incidence was lower in quintile 5 than other quintiles and declined by 2012 from 7.7 to 6.2 per 1000 persons in quintile 5 (absolute change, -1.5 [95% CI, -2.6 to -0.4]) and 8.7 to 7.6 in quintile 4 (absolute change, -1.1 [95% CI, -2.2 to -0.05]). In contrast, diabetes incidence did not change significantly in less walkable areas (change, -0.65 in quintile 1 [95% CI, -1.65 to 0.39], -0.5 in quintile 2 [95% CI, -1.5 to 0.5], and -0.9 in quintile 3 [95% CI, -1.9 to 0.02]). Rates of walking or cycling and public transit use were significantly higher and that of car use lower in quintile 5 vs quintile 1 at each time point, although daily walking and cycling frequencies increased only modestly from 2001 to 2011 in highly walkable areas. Leisure-time physical activity, diet, and smoking patterns did not vary by walkability (P .05 for quintile 1 vs quintile 5 for each outcome) and were relatively stable over time.In Ontario, Canada, higher neighborhood walkability was associated with decreased prevalence of overweight and obesity and decreased incidence of diabetes between 2001 and 2012. However, the ecologic nature of these findings and the lack of evidence that more walkable urban neighborhood design was associated with increased physical activity suggest that further research is necessary to assess whether the observed associations are causal.

Birth weight of children born at term may theoretically be associated with risk of adverse events from immunization.We analyzed data on children born between April 1st 2002 and March 31st 2009 in the province of Ontario. Using the self-controlled case series design, we examined the risk of the combined endpoint of emergency room visit and hospital admission in the immediate three days post vaccination at 2 months of age compared to a control period 9-18 days after vaccination. In term children, we conducted 4 comparisons of relative incidence (RI) of events: (1) 4 lower birth weight quintiles compared to the largest quintile (2) SGA10 infants compared to non SGA10 infants, (3) low birth weight infants (2500g) compared to non low birth weight infants and (4) SGA10 infants vaccinated before 60 days compared to those vaccinated after 60 days.There was a significant trend towards increasing relative incidence of the combined endpoint with decreasing birth weight quintile (p=0.016). There was an increased relative incidence of events in SGA10 versus non SGA10 infants (RI 1.25 (95% CI 1.09-1.44)) and in SGA10 children vaccinated before 60 days of age compared to after 60 days of age (RI 1.57 (95% CI 1.14-2.18)). No significant effect was observed in low birth weight children. The impact of birth weight was primarily mediated through an increase in ER visits in the 24h following vaccination.Lower birth weight appears to be correlated with an increased risk of emergency room visits within 24h of vaccination. The absolute risk is small and there was no impact on admissions or death.

Rationale, aims and objectives Diabetes mellitus is a growing health and economic burden. Identification of patients with unrecognized diabetes, or those at high risk for diabetes, provides an opportunity for timely intervention. This study assessed the accuracy of using electronic health care data to identify patients with undiagnosed diabetes. Methods The study was conducted at a tertiary-care teaching facility in Ottawa, Canada. The study cohort was a stratified random sample of hospitalizations between 1 January 2003 and 31 December 2008. We used diagnostic codes, pharmacy orders and serum glucose tests to classify patients into six groups: ‘recognized diabetes’ (a diabetes diagnostic code or any diabetes medication), ‘probable diabetes’ (maximum glucose ≥ 11.1 mmol L−1), ‘possible diabetes’ (maximum glucose between 7.8 and 11.1 mmol L−1), ‘unlikely diabetes’ (maximum glucose between 6.0 and 7.8 mmol L−1), ‘no diabetes’ (maximum glucose 7.8 mmol L−1), the corresponding values were 0.921, 0.971 and 0.872. Conclusions Patients with diagnosed and undiagnosed diabetes can be accurately identified using electronic health care data.

Objective Women referred to an obstetrician-gynaecologist because of abnormal uterine bleeding (AUB) should be seen within 12weeks, according to the benchmarks recommended for medically acceptable wait times established by the Society of Obstetricians and Gynaecologists of Canada. Our study aimed to determine the proportion of patients having wait times that meet this recommendation, and to understand patient-level sources of variation in these waits. Methods We performed a secondary analysis of data from the Delivering Primary Healthcare Information (DELPHI) project database. Electronic medical record data from 10 family practices across south-western Ontario were used to study AUB wait times. Results Over a 30-month period, 223 referrals were made to obstetrician-gynaecologists because of AUB. The mean wait time for initial assessment was 70.4days (median=51days); the range among referring practices varied from 36 to 111days. Seventy-one percent of women were seen by the obstetrician-gynaecologist within the recommended time of 12weeks or less. Multi-level regression analysis indicated that older patients were more likely to have shorter waits. The intraclass correlation was 0.256, indicating that nearly a quarter of the variation in wait time was explained at the practice level. Conclusion Nearly 30% of women referred to specialists because of AUB wait longer than the period of time recommended by the SOGC, with younger women more likely to wait longer. This difference may be due to the perception of an increased risk of malignancy in older women. Future research on correlates of AUB wait times should take factors such as severity and prior family physician work up into account.

Objective To investigate access to effective primary health care services in children of new immigrants to Canada by assessing immunization coverage at age 2. Methods We used multiple linked administrative data sets to analyze primary health service use and immunizations of children born between July 1, 1997, and June 30, 1998, in Ontario, Canada. These children were linked via their mothers' records to a federal Landed Immigrant Database. We used logistic regression to assess the effect on up-to-date (UTD) status at age 2 of having an immigrant mother, controlling for patient and physician characteristics. We examined the relationship of region of origin, period of immigration, and refugee status on coverage. Results The study population comprised 98 123 children, of whom 66.5% had complete immunization coverage. Children of immigrant mothers were more likely to be UTD (adjusted odds ratio, 1.15; 95% confidence interval, 1.10, 1.19) than children born to nonimmigrant mothers. Within the group of children of immigrant mothers, those whose mothers were refugees had the lowest rates of coverage (66.6%), but when adjusting for maternal age, sex, neighborhood income quintile, and health services characteristics, region of origin was the most important predictor of coverage. Those from the region of Southeast and Northeast Asia were most likely to be UTD (odds ratio, 1.63; 95% confidence interval, 1.46, 1.81). Period of immigration was not associated with coverage. Conclusions Contrary to expectations, immigrant mothers are accessing immunizations at least as well as nonimmigrants for their young children in Ontario. There is variation by region of origin and socioeconomic status. Universal access to care reduces disparities in immunization coverage, but overall rates are too low.

▪ Abstract This article reviews the historical development of population health indicators. We have long known that environmental, socioeconomic, early life conditions, individual actions, and medical care all interact to affect health. Present quantitative reporting on the impact of these factors on population health grew out of Bills of Mortality published in the 1500s. Since then, regular censuses, civil registration of vital statistics, and international classification systems have improved data quality and comparability. Regular national health interview surveys and application of administrative data contributed information on morbidity, health services use, and some social determinants of health. More recently, traditional health databases and datasets on “nonhealth” sector determinants have been linked. Statistical methods for map-making, risk adjustment, multilevel analysis, calculating population-attributable risks, and summary measures of population health have further helped to integrate information. Reports on the health of populations remain largely confined to focused areas. This paper suggests a conceptual framework for using indicators to report on all the domains of population health. Future ethical development of indicators will incorporate principles of justice, transparency, and effectiveness.

OBJECTIVES. We studied the association between immunization coverage for a cohort of 2-year-old children covered by a universal health insurance plan and pediatric provider and other health services characteristics.METHODS. We assembled a cohort of 101570 infants born in urban areas in Ontario, Canada, between July 1, 1997, and June 31, 1998. Children were considered to have up-to-date (UTD) immunization coverage if they had ≥5 immunizations by 2 years of age, ie, the recommended 3 doses and 1 booster of diphtheria-polio-tetanus-pertussis/Haemophilus influenzae type b vaccine and 1 dose of measles-mumps-rubella vaccine. Provider practice characteristics were derived from outpatient billing records, and 1996 census data were used to derive neighborhood income quintiles. The association between UTD immunization status and provider characteristics was assessed with multilevel regression models, controlling for patient characteristics.RESULTS. Overall, the rate of complete UTD immunization coverage was low (66.3%) despite a large number of primary care visits (median: 19 visits). Children whose usual provider had a low volume of pediatric primary care were less than one half as likely to be UTD. Other factors associated with not being UTD included very low continuity of care, low continuity of care, and usual provider in practice for CONCLUSIONS. Despite universal access to primary care services, rates of complete immunization coverage among 2-year-old children in Ontario are low. Because visit rates are high, primary care reform should include interventions directed at provider immunization practices to reduce missed opportunities.

Routine childhood immunizations remain one of the most cost-effective preventive health interventions. As such, immunization coverage is a well-established performance measure of the primary care (1) and public health (2) systems. We have called for reporting on the performance of the Canadian public health system, including childhood immunization coverage (3), but this has not yet become universally routine or public. Canada ranks last among reporting Organisation for Economic Co-operation and Development countries for up-to-date pertussis coverage at two years of age (4), and we continue to have outbreaks of vaccine-preventable diseases. The most recent publicly available results are from the 2004 National Immunization Coverage Survey, a telephone household survey conducted by the Public Health Agency of Canada (5). Complete up-to-date coverage is very low: 61% among two-year-old children and 41% among seven-year-old children. Assigning accountability for this poor health system performance and improving coverage is complex. Provision of childhood immunizations across Canada varies both across and within provinces and territories. For example, for routine childhood immunizations, over 90% are given by physicians in Ontario, whereas close to 100% are administered by public health nurses in Alberta, Nunavut, Prince Edward Island and the Northwest Territories. However, even within one jurisdiction, a child might receive immunizations from multiple providers across a number of settings (primary series from a primary care physician, hepatitis B from a public health nurse in school or influenza from a nurse in a public health clinic). The national data, although helpful in drawing a broad picture of overall coverage, cannot be reported at the level responsible for providing immunizations (ie, public health unit or primary care practice) or identify communities of underimmunized populations. Province/territory (P/T) immunization registries, on the other hand, have the potential to serve a number of important functions, including timely reporting of coverage, identifying populations with low coverage, monitoring programs designed to achieve target rates, and generating reminders and recalls, which is shown to be one of the most effective strategies for improving coverage irrespective of the provider (6). A number of countries have achieved population-based immunization registries. The Australian Childhood Immunisation Register (7), operational since 1996, was the first complete national immunization registry. More recently, Great Britain, New Zealand and Denmark have developed registries and have achieved high rates of immunization coverage (8). In the United States, even with its challenges surrounding universal health coverage, 56% of children younger than six years of age are enrolled in a city or state registry (9).

Seniors constitute the largest group of hospital users. The increasing share of immigrants in Canada's senior population can affect the demand for hospital care.This study used the linked 2006 Census-Hospital Discharge Abstract Database to examine hospitalization during the 2004-to-2006 period, by immigrant status, of Ontario seniors living in the community. Hospitalization was assessed with logistic regressions; cumulative length of stay, with zero-truncated negative binomial regressions. All-cause hospitalization and hospitalizations specific to circulatory and digestive diseases were examined.Immigrant seniors had significantly low age-/sex-adjusted odds of hospitalization, compared with Canadian-born seniors (OR = 0.81). The odds varied from 0.4 among East Asians to 0.89 among Europeans, and rose with length of time since arrival from 0.54 for recent (1994 to 2003) to 0.86 for long-term (before 1984) immigrants. Adjustment for demographic and socio-economic characteristics did not change the overall patterns. Immigrants' cumulated length of hospital stay tended to be shorter than or similar to that of Canadian-born seniors.Immigrant seniors, especially recent arrivals, had lower odds of hospitalization and similar time in hospital, compared with Canadian-born seniors. These patterns likely reflect differences in health status. Variations by world region and disease reflect the diverse health care needs of immigrant seniors.

s S267 always/always buying lunch at school had 1.84 (1.77-1.92, p 3 times per week compared with children who reported sometimes or never buying lunch at school. CONCLUSION: Eating dinner as a family more frequently was associated with decreased cardiometabolic risk factors. There were no clinically significant associations between buying lunch at school or eating at restaurants and cardiometabolic risk. There were significant associations between infrequently eating together as a family and buying lunch at school and buying lunch at school and more frequently eating at restaurants. These associations may help identify potentially modifiable risk factors regarding adolescent eating behaviours and cardiometabolic risk. Canadian Cardiovascular Society (CCS) Plenary

Computer simulation modeling makes it possible to project physical activity levels and the prevalence of related health outcomes. Such projections can help to inform programs that aim to increase physical activity levels and improve population health.The Population Health Model (POHEM) platform was used to develop a dynamic microsimulation model of physical activity among Canadian adults. Key parameters were derived from the National Population Health Survey (1994/1995 to 2006/2007) and the 2000/2001 Canadian Community Health Survey. To assess the validity of the physical activity module (POHEM-PA), estimates from the simulation projections were compared with results from nationally representative surveys.Trends over time in physical activity levels, chronic disease prevalence, and Health Utilities Index based on POHEM-PA projections were similar to those based on data from subsequent cycles of the Canadian Community Health Survey.The addition of a physical activity module to POHEM provides a tool that can improve understanding of the complex dynamics underlying the relationship between physical activity and health outcomes as a population ages.

Published data on quality of care indicators from various countries indicate the challenges of providing high-quality diabetes care. The objective of this study was to evaluate the quality of care provided to members of the Canadian Forces (CF) who have diabetes, by determining the extent to which healthcare providers adhere to recommendations outlined in the 2008 Canadian Diabetes Association (CDA) clinical practice guidelines.All 14 CF bases meeting eligibility criteria were included in the evaluation. Cases of diabetes were ascertained based on laboratory criteria. Adherence to 21 CDA guideline recommendations was evaluated following a review of patient medical records.The CF demonstrated high adherence (75%) with 9 recommendations, moderate adherence (50% to 75%) with 7 recommendations and low adherence (50%) with 5 recommendations. Most notably, there were 4 recommendations for which adherence was greater than 90%. The mean rate of adherence with all applicable recommendations per patient was 60.3% (95% Confidence Interval [CI], 59.0% to 61.6%). CF adherence rates were generally similar to or better than comparable rates in the civilian population within Canada and other industrialized countries.It is unclear what accounts for the favourable quality of diabetes care in the CF Health Services, but this highly structured practice setting has a number of features that distinguish it from provincial healthcare systems. Several strategies can be considered to improve diabetes care even further, including providing feedback to physicians about their performance, promoting the use of diabetes care flow sheets and creating a diabetes registry.

Background Self-reported height and weight are commonly collected at the population level; however, they can be subject to measurement error. The impact of this error on predicted risk, discrimination, and calibration of a model that uses body mass index (BMI) to predict risk of diabetes incidence is not known. The objective of this study is to use simulation to quantify and describe the effect of random and systematic error in self-reported height and weight on the performance of a model for predicting diabetes. Methods Two general categories of error were examined: random (nondirectional) error and systematic (directional) error on an algorithm relating BMI in kg/m2 to probability of developing diabetes. The cohort used to develop the risk algorithm was derived from 23,403 Ontario residents that responded to the 1996/1997 National Population Health Survey linked to a population-based diabetes registry. The data and algorithm were then simulated to allow for estimation of the impact of these errors on predicted risk using the Hosmer-Lemeshow goodness-of-fit χ2 and C-statistic. Simulations were done 500 times with sample sizes of 9,177 for males and 10,618 for females. Results Simulation data successfully reproduced discrimination and calibration generated from population data. Increasing levels of random error in height and weight reduced the calibration and discrimination of the model. Random error biased the predicted risk upwards whereas systematic error biased predicted risk in the direction of the bias and reduced calibration; however, it did not affect discrimination. Conclusion This study demonstrates that random and systematic errors in self-reported health data have the potential to influence the performance of risk algorithms. Further research that quantifies the amount and direction of error can improve model performance by allowing for adjustments in exposure measurements.