Canadian Health Research Articles

Breaking the 80:20 rule in health research using large administrative data sets.

Objective: To explore the application of online analytic processing (OLAP) to improve the efficiency of analytics using large administrative health data sets. Methods: 18 years of administrative health data (1994/95 to 2012/13) were obtained from the Alberta Ministry of Health in Canada. The data sets included hospitalization, ambulatory care and practitioner claims data. Reference files were obtained that provided information including patient demographics, resident postal code, facility, and provider details. Population counts and projections for each year, sex, age were included for rate calculations. These sources were used to develop a data cube using OLAP tools. Results: Time required for analyses was reduced to 5% of that required when comparing run-time for simple queries that did not require linkage of data sets. The data cube negated the need for many intermediary steps for data extraction and analyses for research activities. Conventional methods required over 250GB of server space for multiple analytic subsets, compared to only 10.3GB for the data cube. Conclusions: Cross-training in information technology and health analytics is recommended to provide capacity to better leverage OLAP tools which are available with many common applications.

A35 FORECASTING THE INCIDENCE AND PREVALENCE OF INFLAMMATORY BOWEL DISEASE: A CANADIAN NATION-WIDE ANALYSIS

A35 FORECASTING THE INCIDENCE AND PREVALENCE OF INFLAMMATORY BOWEL DISEASE: A CANADIAN NATION-WIDE ANALYSIS

A169 THE DIRECT COSTS OF INFLAMMATORY BOWEL DISEASE IN CANADA: A POPULATION-BASED ANALYSIS OF HISTORICAL AND CURRENT COSTS

A169 THE DIRECT COSTS OF INFLAMMATORY BOWEL DISEASE IN CANADA: A POPULATION-BASED ANALYSIS OF HISTORICAL AND CURRENT COSTS

A189 EMERGENCY DEPARTMENT UTILIZATION AND RISK OF INTESTINAL RESECTION IS LOWER AMONG CHILDREN DIAGNOSED WITH INFLAMMATORY BOWEL DISEASE BEFORE 10 YEARS OF AGE: A MULTIPROVINCE POPULATION-BASED COHORT STUDY

Abstract Background In Canada, the incidence of inflammatory bowel disease (IBD) is increasing faster among those <10 years (y) of age than in any other age group. Understanding the health services burden of IBD in this population is important for health system planning. Purpose To compare healthcare utilization and risk of surgery among children diagnosed with IBD across age groups defined by the Paris Classification (A1a: <10y; A1b: 10 to <16y) across 5 Canadian provinces. Method Children diagnosed with IBD <16 years of age were identified from health administrative data using validated algorithms in Alberta, Manitoba, Nova Scotia, Ontario, and Québec. Negative binomial regression models were used to compare (1) the pre-diagnosis frequency of health services utilization (outpatient, emergency department (ED), and hospitalization) using diagnostic codes suggestive of future IBD and (2) the annual post-diagnosis frequency of IBD-specific and IBD-related (signs, symptoms, and extra-intestinal manifestations of IBD) visits among children diagnosed <10y (A1a) and 10 to <16y (A1b). Cox proportional hazard models compared the risk of surgery (identified with validated procedure codes) across age groups. All regression models were adjusted for sex, rural/urban residence, and mean neighbourhood income quintile. Province-specific event counts (all ages combined) and models (comparing age groups; reference: A1b [10 to <16y]) were pooled using random-effects meta-analysis. Result(s) Among 5124 children with IBD (1165 [23%] were <10y at diagnosis), the mean number of pre-diagnosis healthcare encounters was 1.0 (95% CI 0.38 to 1.68, I2=99.6%). The mean annual post-diagnosis number of IBD-specific outpatient visits was 3.2 (95% CI 1.9-4.4, I2=99.6%); hospitalizations, 0.19 (95% CI 0.17-0.21, I2=74%); ED visits, 0.17 (95% CI 0.19-0.39, I2=99%). The mean annual post-diagnosis number of IBD-related outpatient visits was 3.9 (95% CI 2.3-5.5, I2=99.7%); hospitalizations, 0.21 (95% CI 0.19-0.23, I2=79%); ED visits, 0.29 (95% CI 0.19-0.39, I2=97%). Intestinal resection or colectomy within 5y of diagnosis occurred in 13% (95%CI 8-22, I2=93%) with Crohn’s disease (CD) and 16% (95% CI 14-18, I2=40%) with ulcerative colitis. IBD-specific ED visits (RR 0.70, 95% CI 0.50-0.97, I2=80) and the risk of intestinal resection in CD (HR 0.49, 95% CI 0.26-0.92, I2=40%) were significantly lower among children diagnosed <10y. There were no age-related differences in pre-diagnosis health services utilization or other post-diagnosis outcomes, including frequency of outpatient visits to a gastroenterologist. Conclusion(s) Health services utilization was generally similar for children diagnosed with IBD at <10y and between 10 and <16y, except for lower rates of IBD-specific ED visits and intestinal resection in children with CD. Further exploration of between-province differences, represented by the high statistical heterogeneity (I2) in the meta-analyses, is needed to understand sources of variation in care. Please acknowledge all funding agencies by checking the applicable boxes below CCC Disclosure of Interest E. Kuenzig: None Declared, H. Singh Consultant of: Amgen Canada, Bristol-Myers Squibb Canada, Sandoz Canada, Roche Canada, Takeda Canada and Guardant Health, A. Bitton: None Declared, G. Kaplan Grant / Research support from: Ferring, Consultant of: AbbVie, Janssen, Pfizer, Amgen, Sandoz, Pendophram, and Takeda, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, Sandoz, Pendophram, and Takeda, M. Carroll: None Declared, A. Otley Grant / Research support from: Research support: AbbVie Global. Research site: AbbVie, Pfizer, Eli-Lily, Janssen, Consultant of: AbbVie Canada, T. Stukel: None Declared, S. Spruin: None Declared, A. Griffiths Grant / Research support from: Abbvie, Consultant of: Abbvie, Amgen, BristolMyersSquibb, Janssen, Lilly, Takeda, Speakers bureau of: Abbvie, Janssen, Takeda, D. Mack: None Declared, K. Jacobson Grant / Research support from: Abbvie Canada and Janssen Canada, Consultant of: Abbvie Canada, Janssen Canada, Merck Canada and Mylan Pharmaceuticals, Speakers bureau of: Abbvie Canada and Janssen Canada, G. Nguyen: None Declared, L. Targownik Grant / Research support from: Janssen Canada, Consultant of: AbbVie Canada, Sandoz Canada, Takeda Canada, Merck Canada, Pfizer Canada, Janssen Canada, and Roche Canada, W. El-Matary Consultant of: Abbvie and MERCK, Speakers bureau of: Abbvie and MERCK, E. Benchimol Consultant of: McKesson Canada, Dairy Farmers of Ontario (unrelated to medications used to treat inflammatory bowel disease)

A210 THE BURDEN OF IBD HOSPITALIZATION IN CANADA: AN ASSESSMENT OF THE CURRENT AND FUTURE BURDEN IN A NATION-WIDE ANALYSIS

A210 THE BURDEN OF IBD HOSPITALIZATION IN CANADA: AN ASSESSMENT OF THE CURRENT AND FUTURE BURDEN IN A NATION-WIDE ANALYSIS

Provinces accept federal health funding deal.

Canada’s premiers have accepted a federal health funding deal that will see $46.2 billion in new money injected into health systems over the next 10 years. The agreement includes an immediate $2-billion top-up to the Canada Health Transfer, annual increases of at least 5% over the next five years

Making the case for citizenship-oriented mental healthcare for youth in Canada

PurposeVarying stakeholders have highlighted how recovery-oriented mental health services such as youth mental health services have traditionally focused on supporting individual resources to promote recovery (e.g., agency) to the exclusion of addressing structural issues that influence recovery (e.g. poverty). One response to this criticism has been work helping people with mental health problems recover a sense of citizenship and sense of belonging in their communities. Work on citizenship has yet to influence youth mental healthcare in Canada’s provinces and territories. This paper aims to highlight ways that youth mental healthcare can better help youth recover a sense of citizenship.Design/methodology/approachThe arguments described in this paper were established through discussion and consensus among authors based on clinical experience in youth mental health and an understanding of Canada’s healthcare policy landscape, including current best practices as well as guidelines for recovery-oriented care by the Mental Health Commission of Canada.FindingsHere, this study proposes several recommendations that can help young with mental health problems recover their sense of citizenship at the social, systems and service levels. These include addressing the social determinants of health; developing a citizenship-based system of care; addressing identity-related disparities; employing youth community health workers within services; adapting and delivering citizenship-based interventions; and connecting youth in care to civic-oriented organizations.Originality/valueThis paper provides the first discussion of how the concept of citizenship can be applied to youth mental health in Canada in multiple ways. The authors hope that this work provides momentum for adopting policies and practices that can help youth in Canada recover a sense of citizenship following a mental health crisis.

Reforming Canada's federal health‐care funding arrangements

AbstractFederal health‐care funding has long been a source of policy debate in this country, a situation exacerbated recently by the COVID‐19 pandemic and the premiers' calls for a large expansion of the Canada Health Transfer. In this article, we explore four potential pathways policy‐makers might consider in order to improve federal health‐care funding. These potential pathways should allow policy‐makers to consider how to adapt to changing circumstances while addressing citizens' concerns and the demands of provincial/territorial governments. We do not support one or another of these policy pathways. Instead, we explain what they are and what impact they could have.

Comparison of the drinking water standard for pesticides of the Brazil with other countries

The objective was to compare the types and concentrations of pesticides allowed in the water potability standard for human supply in Brazil with other countries considered to be the largest consumers of pesticides in dollars invested in purchase/trade. This is a descriptive and documentary study, with data collection in regulations available in official government websites in Brazil, USA, China, Japan, France, Germany, Canada, Argentina, India, Italy, and World Health Organization (WHO). Since Germany, France and Italy are part of the European Union (EU), the legislative resolution of the European Parliament was adopted. Pesticides number and maximum permitted values (MPV) differ between the countries and WHO. In the Brazilian ordinance there are forty pesticides, a number like the USA, Canada, China, and WHO, but that represents only 8% of the total pesticides registered for agricultural use in Brazil. When comparing the ordinance of Brazil with EU the values are only the same for Aldrin + Dieldrin. For other, amounts between 2 and 5000 times more are allowed in Brazil. Brazilian regulations do not establish a total value for the mixture of pesticides in water, only individual limits, which together can reach 1677.13 μg/L, while in EU standards it is only 0.5 μg/L. The study showed discrepancies of the pesticides allowed in water potability standard of the Brazil with other countries, but features 12 pesticides with the same concentrations as WHO guidelines, thus, a worldwide standardization in water potability regulations is necessary to promote health and reducing risk of exposure.

Energy poverty: an overlooked determinant of health and climate resilience in Canada

ObjectiveDespite Canada being an important energy producer, not all Canadians can access or afford adequate levels of energy services at home to meet their needs, maintain healthy indoor temperatures, and live a decent life—a situation known as energy poverty. Depending on the measure, 6–19% of Canadian households face energy poverty. Health risks associated with energy poverty are documented in countries with milder climates. This study explores, for the first time in the Canadian context, the association between energy poverty and health.MethodsCross-sectional data are from the 2018 Canadian Housing Survey. Analyses are conducted on a sample weighted to represent 14 million Canadian households. The associations between expenditure-based and self-reported measures of energy poverty and self-rated general and mental health were assessed using logistic regression models, adjusted for potential confounding variables.ResultsThe odds of rating one’s general (OR: 1.48; 95%CI: 1.29, 1.70) and mental (OR: 1.21; 1.04, 1.41) health as poor are significantly higher for Canadian adults in households with a high share of energy expenditure to income. The likelihood of poor general and mental health was significantly higher for those dissatisfied with the energy efficiency of their dwelling, and with their ability to maintain a comfortable temperature both in the winter and in the summer.ConclusionExposure to energy poverty is associated with significantly increased likelihood of poor general and mental health. Given the high proportion of Canadian households facing energy poverty, with demonstrated implications for population health, tackling energy poverty is essential for an equitable energy transition and for climate resilience.

The Impact of Language on the Mental Health of Black Quebecers.

Quebec's English-speaking Black community finds itself at the intersection of racial and linguistic discrimination, which presents challenges to mental wellness. The present study aims to add necessary detail to the conversations surrounding racism and mental health in Canada while including language as a determinant of health and intersecting element affecting the wellbeing of English-speaking Black Quebecers. We recruited 531 Black adults who are currently living in Quebec to complete a survey on various community-relevant items, including their mental and physical health, their experiences of discrimination, and barriers to accessing mental healthcare. Our analyses revealed that English-speaking participants experience more discrimination across all types and report more barriers to mental healthcare and lower mental health than their French-speaking counterparts. Furthermore, we found that language also had a mediated effect on mental health through discrimination and barriers to mental healthcare. Our study adds to the sparse race-based and intersectional literature about Black people in Canada and substantiates a mechanism by which language affects mental health by exposing Black Quebecers to more discrimination and thus higher barriers to care.

Intergenerational residential school attendance and increased substance use among First Nation adults living off-reserve: An analysis of the aboriginal peoples survey 2017.

The Truth and Reconciliation Commission of Canada (TRCC) published 94 Calls to Action in 2015 to address long-term, intergenerational effects of the residential school system, highlighting the pervasive impact of colonialism on the wellbeing of Indigenous peoples in Canada. Indeed, research with Indigenous populations in Canada has captured that prior experiences of residential schools contributes to the intergenerational transmission of mental and physical health disparities. Despite these studies, further research is needed that contextualizes the influence of residential schools within broader frameworks that consider Indigenous social determinants of health in Canada. As such, the purpose of the present study was to examine patterns of substance use and mental and physical health among individuals with a history of residential school attendance (RSA) and individuals reporting parent or two-generation (parent and grandparent) RSA. Data from the Aboriginal Peoples Survey (2017), involving 10,030 First Nations individuals living off reserve, were analyzed. Self-reported mental and physical health scores were significantly lower among those had attended residential schools, whose parents attended residential schools, and whose grandparents attended residential schools, when compared to those who did not. Further, family RSA was associated with increased substance use among participants, though the findings were variable based on sex and specific substance analyzed. Meanwhile, individual and family RSA was not associated with increased likelihood of a mental health diagnosis. These findings provide additional support for how both parental and two-generation family histories of RSA are associated with individual physical and mental health outcomes. Further, these findings articulate the need for the TRCC's Calls to Action to be actually implemented, including community-based approaches that harness the strength of Indigenous people and communities who aim to close the gap in these health disparities for their children and families.

Priority actions for elevating liver health in Canada: A call to action.

Chronic liver disease (CLD) has become a silent epidemic in our country and has resulted in significant physical, psychosocial, and financial burden. Although other international liver associations have published frameworks for the principal actions required to improve liver health across health systems, Canada does not have a strategy to address the growing concerns of CLD. Thus, a multidisciplinary group of care providers involved in CLD management in Canada gathered to review the current burden of disease, gaps in management, and key opportunities for improving the identification and management of people at risk of developing progressive CLD.

Needing indigenous biometrics for health in Canada

This article presents a critical analysis of the use of biometrics in clinical practice and their inadequacies for Indigenous populations in Canada and globally. Misclassifications of health status based on biometrics have health implications across the lifespan, from gestation to older adulthood, which are also examined. The social determinants of health and of Indigenous health compound the impact of inaccurate biometrics on First Nations, Inuit and Métis populations. Moving forward, biometric use should be done in partnership with Indigenous peoples and with consideration of the surrounding context. Future research should consider bridging existing gaps in knowledge on this topic in culturally safe ways, to improve the quality and depth of information available and inform more equitable health care for Indigenous populations.

Mobilization of science advice by the Canadian federal government to support the COVID-19 pandemic response

The procurement and provision of expert-driven, evidence-informed, and independent science advice is integral to timely decision-making during public health emergencies. The 2019 coronavirus disease (COVID-19) pandemic has underscored the need for sound evidence in public health policy and exposed the challenges facing government science advisory mechanisms. This paper is a jurisdictional case study describing (i) the federal science advice bodies and mechanisms for public health in Canada (i.e., the federal science advice “ecosystem”); and (ii) how these bodies and mechanisms have mobilized and evolved to procure expertise and evidence to inform decisions during the first two years of the COVID-19 pandemic. We reviewed publicly accessible Government of Canada documents, technical reports, and peer-reviewed articles available up to December 2021. Canada’s federal landscape of science advisory bodies for public health within the Health Portfolio was largely shaped by Canada’s experiences with the 2003 severe acute respiratory syndrome and 2009 H1N1 outbreaks. In parallel, Canada has a designated science advisory apparatus that has seen frequent reforms since the early 2000s, with the current Office of the Chief Science Advisor created within the Science Portfolio in 2018. The COVID-19 pandemic has further complicated Canada’s science advice ecosystem, with involvement from departments, expert advisory groups, and partnerships within both the federal Health and Science Portfolios. Although the engagement of federal departments outside the health sector is promising, the COVID-19 experience in Canada supports the need to institutionalize science advisory bodies for public health to improve pandemic preparedness and ensure rapid mobilization of well-coordinated and independent advice in future emergencies. This review also identified pressing areas for further inquiry to strengthen science advice for public health in Canada, including to assess the independence of science advisory actors and the interaction between federal and subnational authorities.

Ten years after the 2015 Canada Health Transfer reform: A persistent equity concern of insufficient risk-equalization

Two guiding principles related to equity in healthcare, both in Canada and internationally, are that healthcare should be financed according to the ability-to-pay and utilized based on need. The Canada Health Act (CHA, 1984) aims to remove financial barriers and provide equitable access to healthcare in Canada. Contingent on meeting the conditions set out in the CHA, each province receives federal funding through the Canada Health Transfer (CHT). In 2014–2015, the CHT underwent a major change in that all provinces are now receiving funds on a per capita basis. We highlight equity concerns regarding the CHT allocations by reviewing the three main provincial level healthcare need indicators of its population: aging populations, the prevalence of chronic conditions, and population density. Results show that there are significant variations in all the three indicators among Canadian provinces. Specifically, Atlantic provinces have high values for all indicators, thus making per capita healthcare costs larger in these provinces. In contrast, larger provinces, particularly Alberta, are low in all indicators compared to the rest of Canada. Having a per capita CHT allocation means that provinces with a high range of healthcare need indicator values are in a more difficult situation to deliver sufficient healthcare to its population. A need-based allocation system can better meet the important policy objective of equity in healthcare for Canada.

Development of eConsult reflective learning tools for healthcare providers: a pragmatic mixed methods approach

BackgroundElectronic consultation (eConsult) programs are crucial components of modern healthcare that facilitate communication between primary care providers (PCPs) and specialists. eConsults between PCPs and specialists. They also provide a unique opportunity to use real-world patient scenarios for reflective learning as part of professional development. However, tools that guide and document learning from eConsults are limited. The purpose of this study was to develop and pilot two eConsult reflective learning tools (RLTs), one for PCPs and one for specialists, for those participating in eConsults.MethodsWe performed a four-phase pragmatic mixed methods study recruiting PCPs and specialists from two public health systems located in two countries: eConsult BASE in Canada and San Francisco Health Network eConsult in the United States. In phase 1, subject matter experts developed preliminary RLTs for PCPs and specialists. During phase 2, a Delphi survey among 20 PCPs and 16 specialists led to consensus on items for each RLT. In phase 3, we conducted cognitive interviews with three PCPs and five specialists as they applied the RLTs on previously completed consults. In phase 4, we piloted the RLTs with eConsult users.ResultsThe RLTs were perceived to elicit critical reflection among participants regarding their knowledge and practice habits and could be used for quality improvement and continuing professional development.ConclusionPCPs and specialists alike perceived that eConsult systems provided opportunities for self-directed learning wherein they were motivated to investigate topics further through the course of eConsult exchanges. We recommend the RLTs be subject to further evaluation through implementation studies at other sites.

Profiles of quality of outpatient care use, associated sociodemographic and clinical characteristics, and adverse outcomes among patients with substance-related disorders

BackgroundThis study identified patient profiles in terms of their quality of outpatient care use, associated sociodemographic and clinical characteristics, and adverse outcomes based on frequent emergency department (ED) use, hospitalization, and death from medical causes.MethodsA cohort of 18,215 patients with substance-related disorders (SRD) recruited in addiction treatment centers was investigated using Quebec (Canada) health administrative databases. A latent class analysis was produced, identifying three profiles of quality of outpatient care use, while multinomial and logistic regressions tested associations with patient characteristics and adverse outcomes, respectively.ResultsProfile 1 patients (47% of the sample), labeled “Low outpatient service users”, received low quality of care. They were mainly younger, materially and socially deprived men, some with a criminal history. They had more recent SRD, mainly polysubstance, and less mental disorders (MD) and chronic physical illnesses than other Profiles. Profile 2 patients (36%), labeled “Moderate outpatient service users”, received high continuity and intensity of care by general practitioners (GP), while the diversity and regularity in their overall quality of outpatient service was moderate. Compared with Profile 1, they were older, less likely to be unemployed or to live in semi-urban areas, and most had common MD and chronic physical illnesses. Profile 3 patients (17%), labeled “High outpatient service users”, received more intensive psychiatric care and higher quality of outpatient care than other Profiles. Most Profile 3 patients lived alone or were single parents, and fewer lived in rural areas or had a history of homelessness, versus Profile 1 patients. They were strongly affected by MD, mostly serious MD and personality disorders. Compared with Profile 1, Profile 3 had more frequent ED use and hospitalizations, followed by Profile 2. No differences in death rates emerged among the profiles.ConclusionsFrequent ED use and hospitalization were strongly related to patient clinical and sociodemographic profiles, and the quality of outpatient services received to the severity of their conditions. Outreach strategies more responsive to patient needs may include motivational interventions and prevention of risky behaviors for Profile 1 patients, collaborative GP-psychiatrist care for Profile 2 patients, and GP care and intensive specialized treatment for Profile 3 patients.

Martha Paynter, Illustrated by Julia Hutt, Abortion to Abolition: Reproductive Health and Justice in Canada

Martha Paynter, Illustrated by Julia Hutt, Abortion to Abolition: Reproductive Health and Justice in Canada

The Challenge of Exposing and Ending Health Inequalities through Social and Policy Change: Canadian Experiences

The Canadian health system is often perceived as excellent. However, a closer examination of the political economy of health in Canada shows a radically different picture. It is a picture of persistent inequality and a history of the inability to address such inequality. Despite numerous public policy interventions to address preventable health inequalities—that is, health inequities—this societal problem persists. This research addresses how and why health inequities, especially class, race/ethnicity, and gender health inequities, persist in Canada and how to reduce such differences through public policy action. To address these questions, I performed a critical realist review, focusing on the political economy of health and policy change. Then I conducted a thematic analysis of the interview data gathered from 23 semi-structured interviews with leading Canadian policy academics, activists, and advocates. The results demonstrate that the capitalist economic system; the co-constitutives of capitalism, namely colonialism, racism, and sexism; and maldistributive public policies primarily cause health inequities in Canada. Canada's health inequities reduction requires pushing for redistributive public policies; uniting and strengthening labor unions, civil society groups, and social movements; and engaging in electoral politics. Reducing health inequities may involve struggling within and against capitalism and struggling for socialism.