Canadian Health Region Research Articles

An evaluation of autoimmune antibody testing patterns in a Canadian health region and an evaluation of a laboratory algorithm aimed at reducing unnecessary testing

Autoantibody tests are often ordered inappropriately. We aimed to evaluate the ordering patterns of these tests in our local health region and to develop a laboratory algorithm aimed at reducing unnecessary tests. Laboratory data including the number and sequence of tests, ordering physician specialties and results for antinuclear (ANA), extractable nuclear antigen (ENA) and anti-double stranded DNA (anti-dsDNA) antibody tests from 2007 to 2009 were evaluated. Based on this information and a clinical consensus meeting, an algorithm was developed and applied retrospectively to 1 year of inpatient laboratory data to simulate potential cost savings. We identified a large volume of these autoantibody tests performed, equating to testing costs of $862,706.72, where less than 17 % of each were positive. Repeated ANA tests were mostly ordered after a previously negative result, and 1 % of patients with negative results changed to ≥1:160 on repeat testing. Close to half of all ENA and anti-dsDNA tests that were ordered were done so simultaneously with ANA, suggesting their use as screening tests. This was done more frequently in the inpatient setting. An algorithm was developed where ENA and anti-dsDNA tests would be cancelled if ANA was negative in the same sample. ANA repeated within 1 year would be cancelled and the prior result provided. Application of the algorithm retrospectively simulated a 30 % cost savings. Repeat testing and simultaneous ordering of multiple tests contributed to the excessive ordering of autoantibody tests in our health region. Our proposed algorithm would reduce testing costs and should be accompanied by appropriate educational information for physicians.

Patient Satisfaction with the Endoscopy Experience and Willingness to Return in a Central Canadian Health Region

Patient experiences with endoscopy visits within a large central Canadian health region were evaluated to determine the relationship between the visit experience and the patients' willingness to return for future endoscopy, and to identify the factors associated with patients' willingness to return. A self-report survey was distributed to 1200 consecutive individuals undergoing an upper and⁄or lower gastrointestinal endoscopy at any one of the six hospital-based endoscopy facilities in the region. The Spearman correlation coefficient was used to assess the association between the patients' overall rating of the visits and willingness to return for repeat procedures under similar medical circumstances. Logistic regression analyses were performed to identify the factors associated with willingness to return for repeat endoscopy and overall satisfaction (rating) of the visit. A total of 529 (44%) individuals returned the questionnaire, with 45% rating the visit as excellent and 56% indicating they were extremely likely to return for repeat endoscopy. There was a low moderate correlation between overall rating of the visit and patients' willingness to return for repeat endoscopy (r=0.30). The factors independently associated with patient willingness to return for repeat endoscopy included perceived technical skills of the endoscopists (OR 2.7 [95% CI 1.3 to 5.5]), absence of pain during the procedure (OR 2.2 [95% CI 1.3 to 3.6]) and history of previous endoscopy (OR 2.4 [95% CI 1.4 to 4.1]). In contrast, the independent factors associated with the overall rating of the visit included information provided pre- and postprocedure, wait time before and on the day of the visit, and the physical environment. To facilitate patient return for needed endoscopy, it is important to assess patients' willingness to return because positive behavioural intent is not simply a function of satisfaction with the visit.

Use of Fecal Occult Blood Test in Hospitalized Patients: Survey of Physicians Practicing in a Large Central Canadian Health Region and Canadian Gastroenterologists

Although the fecal occult blood test (FOBT) was developed for colorectal cancer screening in the outpatient setting, it continues to be used among hospitalized patients. No previous study has evaluated the knowledge, beliefs and attitudes of practicing physicians on the use of FOBT among hospitalized patients and compared practices among physicians with different medical specialty training. To survey physicians in the Winnipeg Regional Health Authority (WRHA) and Canadian gastroenterologists (GIs) on the use of FOBT in hospitals. A survey was distributed by e-mail to internists (n=198), emergency medicine (EM) physicians (n=118), general surgeons (n=47) and family medicine (FM) physicians with admitting privileges (n=29) in the WRHA. Canadian GIs were surveyed through the membership database of the Canadian Association of Gastroenterology (CAG) (n=449). The survey included items regarding demographics of the respondents and their current use of FOBT in hospitals. Response rates ranged from 18% among CAG members to 69% among FM physicians in the WRHA. General internal medicine, general surgeon and GI respondents were less likely to order a FOBT and less likely to believe that an FOBT was useful in assessing emergency room or hospitalized patients when compared with FM and EM respondents (P<0.001). The most common indications for ordering a FOBT were black stools and anemia with and without iron deficiency. Two-thirds of EM physicians preferred point-of-care testing rather than laboratory reporting of FOBT. The present survey suggests that FOBTs are commonly used in hospitals by EM and FM physicians for indications such as anemia and black stools.

A Regional Survey to Determine Factors Influencing Patient Choices in Selecting a Particular Emergency Department for Care

Increases in regional emergency department (ED) efficiencies might be obtained by shifting patients to less crowded EDs. The authors sought to determine factors associated with a patient's decision to choose a specific regional ED. Based on prior focus group discussions with volunteers, the hypothesis was that distance to a specific ED and perceived ED wait times would be important. A cross-sectional survey was developed using qualitative focus group methodology. The resulting survey was composed of 17 questions relating to patient decisions in choosing a specific ED and was administered in each of six EDs in a single urban Canadian health region at all hours of the day. Ambulatory patients with a Canadian Triage and Acuity Scale (CTAS) level 3 to 5 and aged ≥19 years were surveyed. The primary outcome was the proportion of patients whose main motivation for attending a specific ED was either distance traveled to reach the ED or perceived ED waiting time. Multivariable logistic regression was performed to assess factors influencing both of these reasons. A total of 757 patients were approached and 634 surveys (83.8%) were completed. Distance from the ED (named by 44.0% of respondents as their primary reason) and perceived ED wait times (9.3%) were the main motivations for patients to attend a specific ED. Multivariable analysis of factors associated with choosing distance revealed that ED distance < 10 km (adjusted odds ratio [OR] = 2.20, 95% confidence interval [CI] = 1.45 to 3.33; p = 0.001) and age ≥ 60 years (adjusted OR = 1.58, 95% CI = 1.12 to 2.26; p = 0.04) were significant in choosing a particular ED. Multivariable analysis of factors influencing wait times demonstrated that having a painful complaint (adjusted OR = 1.42, 95% CI = 1.05 to 1.98; p = 0.047) and age < 60 years (OR = 1.47, 95% CI = 1.02 to 2.14; p = 0.049) were significant in choosing a particular ED. In a multicenter survey of patients from an urban health region, distance to a specific ED and perceived ED wait times were the most important reasons for choosing that ED. Younger patients and those with painful conditions appear to place greater priority on wait times.

Erratum

Addington D, Berzins S, Yeo M. Psychosis literacy in a Canadian health region: results from a general population sample. Can J Psychiatry. 2012;57(6):381–388. It has come to our attention that the article by Dr Addington et al included an incorrect age range for the youth at risk of psychosis in the Abstract Method section on page 381. The text should have read: “A cross-sectional telephone survey using a random phone number selection procedure was conducted to identify a sample of 1685 participants comprised of youth at risk (aged 15 to 39 years) and parents of youth at risk of psychosis (aged 35 to 59 years).” The Canadian Journal of Psychiatry regrets the error and any inconvenience it might have caused.

Development and validation of a case definition for epilepsy for use with administrative health data

The objective of this study was to develop and validate coding algorithms for epilepsy using ICD-coded inpatient claims, physician claims, and emergency room (ER) visits. 720/2049 charts from 2003 and 1533/3252 charts from 2006 were randomly selected for review from 13 neurologists' practices as the "gold standard" for diagnosis. Epilepsy status in each chart was determined by 2 trained physicians. The optimal algorithm to identify epilepsy cases was developed by linking the reviewed charts with three administrative databases (ICD 9 and 10 data from 2000 to 2008) including hospital discharges, ER visits and physician claims in a Canadian health region. Accepting chart review data as the gold standard, we calculated sensitivity, specificity, positive, and negative predictive value for each ICD-9 and ICD-10 administrative data algorithm (case definitions). Of 18 algorithms assessed, the most accurate algorithm to identify epilepsy cases was "2 physician claims or 1 hospitalization in 2 years coded" (ICD-9 345 or G40/G41) and the most sensitive algorithm was "1 physician clam or 1 hospitalization or 1 ER visit in 2 years." Accurate and sensitive case definitions are available for research requiring the identification of epilepsy cases in administrative health data.

Acute care inpatients with long-term delayed-discharge: evidence from a Canadian health region

BackgroundAcute hospital discharge delays are a pressing concern for many health care administrators. In Canada, a delayed discharge is defined by the alternate level of care (ALC) construct and has been the target of many provincial health care strategies. Little is known on the patient characteristics that influence acute ALC length of stay. This study examines which characteristics drive acute ALC length of stay for those awaiting nursing home admission.MethodsPopulation-level administrative and assessment data were used to examine 17,111 acute hospital admissions designated as alternate level of care (ALC) from a large Canadian health region. Case level hospital records were linked to home care administrative and assessment records to identify and characterize those ALC patients that account for the greatest proportion of acute hospital ALC days.ResultsALC patients waiting for nursing home admission accounted for 41.5% of acute hospital ALC bed days while only accounting for 8.8% of acute hospital ALC patients. Characteristics that were significantly associated with greater ALC lengths of stay were morbid obesity (27 day mean deviation, 99% CI = ±14.6), psychiatric diagnosis (13 day mean deviation, 99% CI = ±6.2), abusive behaviours (12 day mean deviation, 99% CI = ±10.7), and stroke (7 day mean deviation, 99% CI = ±5.0). Overall, persons with morbid obesity, a psychiatric diagnosis, abusive behaviours, or stroke accounted for 4.3% of all ALC patients and 23% of all acute hospital ALC days between April 1st 2009 and April 1st, 2011. ALC patients with the identified characteristics had unique clinical profiles.ConclusionsA small number of patients with non-medical days waiting for nursing home admission contribute to a substantial proportion of total non-medical days in acute hospitals. Increases in nursing home capacity or changes to existing funding arrangements should target the sub-populations identified in this investigation to maximize effectiveness. Specifically, incentives should be introduced to encourage nursing homes to accept acute patients with the least prospect for community-based living, while acute patients with the greatest prospect for community-based living are discharged to transitional care or directly to community-based care.

Psychosis Literacy in a Canadian Health Region: Results from a General Population Sample

To assess the public's level of mental health literacy for psychosis. A cross-sectional telephone survey using a random phone number selection procedure was conducted to identify a sample of 1685 participants comprised of youth at risk (aged 15 to 39 [corrected] years) and parents of youth at risk of psychosis (aged 35 to 59 years). The Canadian Journal of Psychiatry regrets the error and any inconvenience it might have caused. [corrected]. Participants were asked about their awareness of symptoms and causes of schizophrenia and psychosis, treatment options, and preferred channels for obtaining information about health and mental health. The response rate was 73%. There was a high reported knowledge of the term schizophrenia (76%), but a low reported knowledge of the term psychosis (23%). Ninety-one per cent of participants agreed that medications can control symptoms of schizophrenia. Significant barriers to getting help included not knowing the early signs of psychosis, concerns about being labelled mentally ill or psychotic, and not knowing where to go for help. Preferred communication elements to reach at-risk youth and their families were pamphlets at family physicians' and school counsellors' offices, posters on buses, television and radio advertisements, and information on websites. Whereas there is good knowledge about recognition and treatment of schizophrenia, there is less awareness of the broader concept of psychosis. Barriers to accessing care included recognition of early signs of psychosis and stigma. Public education programs aimed at promoting earlier intervention would need to address information about both psychosis and stigma.

A population-based study of sport and recreation-related head injuries treated in a Canadian health region

ObjectivesTo report the rates of SR-related HIs presenting to EDs in a Canadian population-based sample. DesignDescriptive epidemiology study. MethodsUsing administrative data, sport and recreation-related emergency department presentations for persons 0–35 years of age, from April 1997 through March 2008, were obtained from the Edmonton Zone (formerly the Capital Health Region), Alberta Health Services through the Ambulatory Care Classification System. ResultsOf the 3,230,890 visits to the emergency departments of the five hospitals in Edmonton, 63,219 sport and recreation-related injury records and 4935 sport and recreation-head injury records were identified. Head injuries were most frequently treated for the activities of hockey (20.7%), cycling (12.0%), and skiing/snowboarding/sledding. Males accounted for 71.9% (n=3546) and patients less than 18 years of age sustained 3446 (69.8%) sport and recreation-head injuries. ConclusionsSport and recreation-related head injuries most frequently treated in emergency departments involve common activities such as hockey, cycling, skiing/snowboarding/sledding, and soccer. Males and those less than 18 years of age sustain the majority of sport and recreation-related head injuries treated in emergency departments. These findings underscore the importance of sport-specific policies and safety promotion for the prevention of head injuries, in sports and recreational activities.

Development and Validation of an Administrative Case Definition for Inflammatory Bowel Diseases

A population-based database of inflammatory bowel disease (IBD) patients is invaluable to explore and monitor the epidemiology and outcome of the disease. In this context, an accurate and validated population-based case definition for IBD becomes critical for researchers and health care providers. IBD and non-IBD individuals were identified through an endoscopy database in a western Canadian health region (Calgary Health Region, Calgary, Alberta). Subsequently, using a novel algorithm, a series of case definitions were developed to capture IBD cases in the administrative databases. In the second stage of the study, the criteria were validated in the Capital Health Region (Edmonton, Alberta). A total of 150 IBD case definitions were developed using 1399 IBD patients and 15,439 controls in the development phase. In the validation phase, 318,382 endoscopic procedures were searched and 5201 IBD patients were identified. After consideration of sensitivity, specificity and temporal stability of each validated case definition, a diagnosis of IBD was assigned to individuals who experienced at least two hospitalizations or had four physician claims, or two medical contacts in the Ambulatory Care Classification System database with an IBD diagnostic code within a two-year period (specificity 99.8%; sensitivity 83.4%; positive predictive value 97.4%; negative predictive value 98.5%). An alternative case definition was developed for regions without access to the Ambulatory Care Classification System database. A novel scoring system was developed that detected Crohn disease and ulcerative colitis patients with a specificity of >99% and a sensitivity of 99.1% and 86.3%, respectively. Through a robust methodology, a reproducible set of criteria to capture IBD patients through administrative databases was developed. The methodology may be used to develop similar administrative definitions for chronic diseases.

Neurologists’ and neurology residents’ knowledge of issues related to pregnancy for women with epilepsy

We aimed to assess physician knowledge for 2009 guidelines established by the American Academy of Neurology and American Epilepsy Society regarding issues related to pregnancy for women with epilepsy. A questionnaire was developed and distributed to all neurologists and neurology residents practicing in a large Canadian health region serving a population of 1.4 million. Descriptive statistics were obtained and percentage of correct responses was calculated. Forty-five physicians completed the survey (response rate = 83.3%), with a median correct score of 50%. Residents were more likely (93.3%) to state that this information was important to their practice than staff physicians (40.0%). Overall knowledge of outcomes associated with specific AEDs was poor; less than half of the physicians correctly indicated which AEDs were associated with adverse outcomes for the majority of drug-related questions. We recommend multifaceted, interactive implementation strategies for increasing knowledge of guideline contents.

Risk factors for recurrence and death after bacteraemia: a population-based study

Although most bacteraemic outcome studies have focused on mortality, a repeated episode(s) is another important outcome of bacteraemia. We sought to characterize patient factors and microbial species associated with recurrence and death from bacteraemia. Population-based surveillance for bacteraemia was conducted in a Canadian health region during 2000–2008. Episodes of bacteraemia were extracted and characterized. Transition intensities of both recurrence and death were estimated by separate multivariate Cox proportional hazards models. We identified 9713 patients with incident episodes of bacteraemia. Within 1 year: 892 (9.2%) had recurrent bacteraemia, 2401 (24.7%) had died without a recurrent episode and 330 (3.4%) had died after a recurrent episode. Independent risk factors for recurrence within 1 year (hazard ratio; 95% confidence interval) were: increasing Charlson comorbidity scores (score 1–2: 2.2; 1.8–2.7 and score 3+: 3.4; 2.8–4.2), origin of infection (nosocomial: 2.1; 1.8–2.6 and healthcare-associated: 2.4; 2.0–2.8), microorganism (polymicrobial: 1.5; 1.2–2.0 and fungal: 2.8; 1.9–4.2) and focus of infection (verified urogenital: 0.4; 0.3–0.6). Independent risk factors for death within 1 year included: a recurrent bacteraemic episode 3.6 (3.1–4.0), increasing age and different foci of infection. This study identifies patient groups at risk of having a recurrent episode and dying from these infections. It adds recurrent bacteraemia as an independent risk factor of death within 1 year and may help to target patients for prevention or changes in management.

Preventing repeat abortion in Canada: is the immediate insertion of intrauterine devices postabortion a cost-effective option associated with fewer repeat abortions?

Background In 2005, 97,254 abortions were performed in Canada, of which 38% were repeat abortions. The objective of this research was to determine if provision of free intrauterine devices (IUDs) postabortion is associated with a reduction in health-care costs and repeat abortions in a Canadian population compared with provision of oral contraceptives (OCPs) or depo-medroxyprogesterone acetate (DMPA). Study Design A retrospective cohort study was conducted by intention-to-treat chart review in a facility providing the majority of abortions in a Canadian health region. All ( n=1782) residents of this region who underwent abortion in 2003, 2004 and 2008 were included. One- and 5-year rates of repeat abortion were calculated, and a cost-effectiveness analysis was conducted to compare health-care system costs of providing patients with IUDs, OCPs or DMPA and subsequent repeat abortions. Results In 2003 and 2004, 1101 index abortions occurred. The main contraceptive cohorts were immediate IUD insertion ( n=117, 10.6%), immediate OCP ( n=413, 37.5%) and immediate DMPA administration ( n=357, 32.4%). After 5 years repeat abortion rates in the respective cohorts were: IUD, 9.4%, OCP, 17.4%, DMPA, 16.2% (p=.05). One-year rates of repeat abortion were not significantly different. Costs of providing contraception and subsequent abortions over 5 years were $142.63 (IUD), $385.61 (OCP) and $384.81 (DMPA) per user. Conclusion The immediate insertion of IUDs postabortion is associated with a lower 5-year rate of repeat abortion than provision of OCPs or DMPA. A cost reduction to the health-care system occurs when providing IUDs postabortion vs. alternate contraception of equivalent duration.

Motor vehicle accidents, suicides, and assaults in epilepsy

The goal of our study was to compare the incidence of motor vehicle accidents (MVA), attempted or completed suicides, and injuries inflicted by others between individuals with and without epilepsy. Individuals with and without epilepsy were identified using linked administrative databases between 1996 and 2003 in a Canadian health region with a 1.4 million population. We used a validated epilepsy case definition: anyone who had 2 physician claims, one hospitalization, or one emergency room visit coded with an International Classification of Diseases (ICD)-9-CM or ICD-10 epilepsy code any time during a 2-year period. Four subjects without epilepsy were matched to one patient with epilepsy by age (within 1 year) and sex. The incidence of MVAs, attempted or completed suicides, and inflicted injuries was assessed in 2003-2004. Outcomes were adjusted using the Elixhauser comorbidity index. A total of 10,240 individuals with epilepsy and 40,960 individuals without epilepsy were identified. Mean age was 39.0 ± 21.3 years (range 0.12-99.4) and 48.5% were female. One-year odds ratios before and after adjustment for comorbidity were 1.83 (95% confidence interval [CI] 1.33-2.54) and 1.38 (95% CI 0.97-1.96) for MVAs, 4.32 (95% CI 2.79-6.69) and 1.32 (95% CI 0.81-2.15) for attempted or completed suicides, and 3.54 (95% CI 2.66-4.72) and 1.46 (95% CI 1.04-2.03) for injuries inflicted by others. In this cohort-controlled population-based study, once important medical and psychiatric comorbidities were adjusted for, people with epilepsy were not more likely to attempt suicide or experience MVAs, but were still more likely to be assaulted compared to those without epilepsy.

The incidence of injuries in persons with and without epilepsy—A population‐based study

To compare the 1-year population-based incidence and types of injuries in persons with and without epilepsy. Three administrative databases (inpatient visits, physician claims, and emergency room visits) were linked from fiscal years 1996-2003 using a provincial insurance plan registry, which captures 99% of a population of 1.4 million in a large Canadian health region. Epilepsy cases (all age groups) from fiscal year 1996-2002 were identified. Three people without epilepsy were matched to one person with epilepsy for age (±1 year) and sex. Injuries were defined as any of 16 types of injuries for which medical attention was sought that occurred within fiscal year 2003. Eight thousand eight hundred ninety subjects with epilepsy were identified and matched to 26,670 controls for age and sex. The mean age was 37.4 years (range 0.01-96.4 years), and 51.3% of subjects were male. The 1-year incidence of one or more injuries was 20.6% among persons with epilepsy and 16.1% among those without epilepsy (p < 0.001). Of the 16 types of injuries studied, 11 were higher in persons with epilepsy compared to those without epilepsy, and included fractures, crushing injuries, intracranial injuries, other types of head injuries, and multiple injuries. The difference was still significant after adjusting for age, gender, and comorbidities. The 1-year incidence of injuries in this study was greater in persons with epilepsy compared to those without epilepsy, for nearly all injury types. Injury prevention should be discussed during routine visits in persons with epilepsy.

End of life care policies: Do they make a difference in practice?

Although institutional policies related to care at the end of life (EOL) are a common feature of hospitals, there has been little examination of the ways in which these policies shape the focus and provision of care. The question asked in this study was "What effect do institutional policies relating to care at the EOL have on practice?" Data were drawn from health record reviews of 310 adults who had died in 3 acute care facilities in a major urban centre of a Western Canadian health region. Medical orders relating to care at the end of life were written for the majority of decedents, highlighting the value providers placed on care planning during this time. Relatively few providers, however, followed policy directives regarding use of care plans, terminology or documentation of discussions with patients and families about treatment plans. The findings of this study demonstrate a significant gap between institutional EOL care policies and practice in this health region, challenging institutional decision makers and front-line providers to collaborate more effectively to devise clinically relevant policies that enhance patient care at a particularly vulnerable time of life.

Population-Based Study of the Epidemiology and the Risk Factors for Pseudomonas aeruginosa Bloodstream Infection

Detailed population-based data on the epidemiology of Pseudomonas aeruginosa bloodstream infections are sparse. We sought to describe the incidence rate, risk factors, and outcomes associated with P. aeruginosa bacteremia in a large Canadian health region. A retrospective population-based surveillance for P. aeruginosa bacteremia was conducted in the Calgary Health Region (CHR, population:approx. 1.2 million) during the period from 2000 to 2006. A total of 284 incident cases of P. aeruginosa bacteremia were identified in CHR residents, corresponding to an annual incidence rate of 3.6/100,000.Nosocomial acquisition accounted for 45% of cases,healthcare-associated community onset for 34% of cases,and community-acquired (CA) cases for 21%. Relative to the general population, risk factors for blood stream infection included male sex, increasing age, hemodialysis,solid organ transplant, diagnosis of cancer, heart disease, HIV infection, diabetes mellitus, and/or chronic obstructive airway disease (COPD). Overall mortality was 29%. Factors associated with mortality in univariate analysis included pulmonary focus of infection and co-morbidities, including chronic liver disease, substance abuse, heart disease, COPD, and cancer, and increased with the burden of co-morbidities. Despite those patients with CA disease having fewer co-morbidities,they had a significantly higher mortality rate than either healthcare-associated cases or nosocomial cases(RR 1.88, p = 0.05). This study documents that P. aeruginosa bacteremic disease is responsible for a significant burden of illness in general populations and identifies those groups at increased risk of infection and subsequent mortality. This information can be used to identify those individuals likely to benefit from empiric anti-pseudomonal therapies.

Epidemiology and natural history of primary biliary cirrhosis in a Canadian health region

The recent epidemiology and outcomes of primary biliary cirrhosis (PBC) in North America are incompletely described, partly due to difficulties in case ascertainment. In light of their availability, broad coverage, and limited expense, administrative databases may facilitate such investigations. We used population-based administrative data (inpatient, ambulatory care, and physician billing databases) and a validated International Classification of Diseases coding algorithm to describe the epidemiology and natural history of PBC in the Calgary Health Region (population approximately 1.1 million). Between 1996 and 2002, the overall age/sex-adjusted annual incidence of PBC was 30.3 cases per million (48.4 per million in women, 10.4 per million in men). Although the incidence remained stable, the prevalence increased from 100 per million in 1996 to 227 per million in 2002 (P < 0.0005). Among 137 incident cases with a total follow-up of 801 person-years from diagnosis (median 5.8 years), 27 patients (20%) died and six (4.4%) underwent liver transplantation. The estimated 10-year probabilities of survival, liver transplantation, and transplant-free survival were 73% (95% confidence interval [CI] 60%-83%), 6% (95% CI 2.5%-12.6%), and 68% (95% CI 55%-78%), respectively. Survival in PBC patients was significantly lower than that of the age/sex-matched Canadian population (standardized mortality ratio 2.87; 95% CI 1.89-4.17); male sex (hazard ratio [HR] 3.80; 95% CI 1.85-7.82) and an older age at diagnosis (HR per additional year, 1.06; 95% CI 1.03-1.10) were independent predictors of mortality. This population-based study demonstrates that the burden of PBC in Canada is high and growing. Survival of PBC patients is significantly lower than that of the general population, emphasizing the importance of developing new therapies for this condition.

Health systems integration: state of the evidence.

Integrated health systems are considered a solution to the challenge of maintaining the accessibility and integrity of healthcare in numerous jurisdictions worldwide. However, decision makers in a Canadian health region indicated they were challenged to find evidence-based information to assist with the planning and implementation of integrated healthcare systems. A systematic literature review of peer-reviewed literature from health sciences and business databases, and targeted grey literature sources. Despite the large number of articles discussing integration, significant gaps in the research literature exist. There was a lack of high quality, empirical studies providing evidence on how health systems can improve service delivery and population health. No universal definition or concept of integration was found and multiple integration models from both the healthcare and business literature were proposed in the literature. The review also revealed a lack of standardized, validated tools that have been systematically used to evaluate integration outcomes. This makes measuring and comparing the impact of integration on system, provider and patient level challenging. Healthcare is likely too complex for a one-size-fits-all integration solution. It is important for decision makers and planners to choose a set of complementary models, structures and processes to create an integrated health system that fits the needs of the population across the continuum of care. However, in order to have evidence available, decision makers and planners should include evaluation for accountability purposes and to ensure a better understanding of the effectiveness and impact of health systems integration.

CKD and Risk of Hospitalization and Death With Pneumonia

The effects of kidney disease on the risk of hospitalization or death from specific noncardiovascular causes, including pneumonia, are unclear. The objective of this study is to determine the associations between estimated glomerular filtration rate (eGFR) and hospitalization or death with pneumonia. Retrospective cohort study. Community-based study from a Canadian health region of 252,516 participants with 1 or more outpatient serum creatinine measurements from July 1, 2003, to June 30, 2004, who were not receiving dialysis or kidney transplantation. eGFR calculated by using the 4-variable Modification of Diet in Renal Disease Study equation. Hospitalization with pneumonia or death within 30 days after pneumonia hospitalization. Cox proportional hazards models adjusted for age, sex, socioeconomic status, and comorbidities with censoring at death, initiation of renal replacement therapy, or emigration. Lower eGFR was associated with increased risk of hospitalization with pneumonia, although the magnitude of effect varied with age. The risk associated with decreased eGFR was greatest in participants 18 to 54 years old; compared with participants with an eGFR of 60 to 104 mL/min/1.73 m(2), adjusted hazard ratios for hospitalization with pneumonia were 3.23 (95% confidence interval, 2.40 to 4.36) in those with eGFR of 45 to 59 mL/min/1.73 m(2), 9.67 (95% confidence interval, 6.36 to 14.69) for eGFR of 30 to 44 mL/min/1.73 m(2), and 15.04 (95% confidence interval, 9.64 to 23.47) for eGFR less than 30 mL/min/1.73 m(2). Associations became weaker with increasing age, although the graded inverse association between lower eGFR and risk remained for older participants. An age-dependent inverse relationship also was observed between eGFR and risk of death within 30 days of hospitalization with pneumonia. Residual confounding caused by severity of illness or unmeasured comorbidities may be present. The risk of hospitalization and death with pneumonia is greater at lower eGFRs, especially in younger adults. This association may contribute to excess mortality in people with chronic kidney disease.