Chronic Disease Registry Research Articles

Perceived facilitators and barriers to chronic disease management in primary care networks of Singapore: a qualitative study

ObjectiveThe increasing chronic disease burden has placed tremendous strain on tertiary healthcare resources in most countries, necessitating a shift in chronic disease management from tertiary to primary care providers. The...

Primary Care Networks and Starfield's 4Cs: A Case for Enhanced Chronic Disease Management.

The primary care network (PCN) was implemented as a healthcare delivery model which organises private general practitioners (GPs) into groups and furnished with a certain level of resources for chronic disease management. A secondary qualitative analysis was conducted with data from an earlier study exploring facilitators and barriers GPs enrolled in PCN’s face in chronic disease management. The objective of this study is to map features of PCN to Starfield’s “4Cs” framework. The “4Cs” of primary care—comprehensiveness, first contact access, coordination and continuity—offer high-quality design options for chronic disease management. Interview transcripts of GPs (n = 30) from the original study were purposefully selected. Provision of ancillary services, manpower, a chronic disease registry and extended operating hours of GP practices demonstrated PCN’s empowering features that fulfil the “4Cs”. On the contrary, operational challenges such as the lack of an integrated electronic medical record and disproportionate GP payment structures limit PCNs from maximising the “4Cs”. However, the enabling features mentioned above outweighs the shortfalls in all important aspects of delivering optimal chronic disease care. Therefore, even though PCN is in its early stage of development, it has shown to be well poised to steer GPs towards enhanced chronic disease management.

Advancing the Patient EXperience (APEX) in COPD Registry: Study Design and Strengths.

The Advancing the Patient Experience (APEX) in Chronic Obstructive Pulmonary Disease (COPD) registry (https://www.apexcopd.org/) is the first primary care health system-based COPD registry in the United States. While its ultimate goal is to improve the care of patients diagnosed with COPD, the registry is also designed to describe real-life experiences of people with COPD, track key outcomes longitudinally, and assess the effectiveness of interventions. It will retrospectively and prospectively collect information from 3000 patients enrolled in 5 health care organizations. Information will be obtained from electronic health records, and from extended annual and brief questionnaires completed by patients before clinic visits. Core variables to be collected into the APEX COPD registry were agreed on by Delphi consensus and fall into 3 domains: demographics, COPD monitoring, and treatment. Main strengths of the registry include: 1) its size and scope (in terms of patient numbers, geographic spread and use of multiple information sources including patient-reported information); 2) collection of variables which are clinically relevant and practical to collect within primary care; 3) use of electronic data capture systems to ensure high-quality data and minimization of data-entry requirements; 4) inclusion of clinical, database development, management and communication experts; 5) regular sharing of key findings, both at international/national congresses and in peer-reviewed publications; and 6) a robust organizational structure to ensure continuance of the registry, and that research outputs are ethical, relevant and continue to bring value to both patients and physicians.

Cardiac Morbidity in Adolescents and Young Adult Survivors of Hodgkin Lymphoma

Cardiac Morbidity in Adolescents and Young Adult Survivors of Hodgkin Lymphoma

Adults with diabetes mellitus in Newfoundland and Labrador: a population-based, cross-sectional analysis.

Although the province of Newfoundland and Labrador has the highest rates of chronic disease in Canada, the current state of many chronic diseases in the province, including diabetes mellitus, has not been well explored. We profiled the demographic characteristics associated with, and the management of, diabetes in Newfoundland and Labrador, including any rural-urban differences. We performed a population-based, cross-sectional analysis using data from the provincial Chronic Disease Registry for fiscal year 2015/16. Patients in the study sample were 20 years of age or older, with documented identifiers for age, sex and geographic location. We examined demographic characteristics, results of screening and diabetes clinical tests (glycated hemoglobin [HbA1c], low-density lipoprotein [LDL] cholesterol and urine albumin-to-creatinine ratio) and hospitalization rates. We described and compared demographic, clinical and hospitalization variables across urban and rural residents of the province. The study sample consisted of 66 325 individuals with diabetes in Newfoundland and Labrador (mean age 64.1 yr; 56.3% rural residents). Larger proportions of rural than urban residents with diabetes were aged 65 to 79 years (41.2% v. 37.5%), were female (50.2% v. 48.7%) and were identified as having the disease by laboratory tests only (19.6% v. 13.1%). Rural residents had worse clinical test outcomes than their urban counterparts, specifically with respect to HbA1c (mean and standard deviation [SD], 7.41% [SD 1.49] v. 7.26% [SD 1.50]) and LDL cholesterol (mean 2.46 [SD 0.95] v. mean 2.36 [SD 0.94] mmol/L). A total of 13.7% of individuals were admitted to hospital during the cohort year, with slightly more rural residents admitted for renal disease (standardized difference 0.021, 95% confidence interval 0.005 to 0.036). For many individuals with diabetes in Newfoundland and Labrador, recommended targets for diabetes management are not being met, and residents in rural areas have poorer clinical outcomes. To inform the development and implementation of targeted provincial strategies for chronic disease management, further research is needed to determine how outcomes relate to the availability of primary health care services.

A mid-South chronic disease registry and practice-based research network to address disparities.

To describe an innovative health information technology (HIT) model for supporting community-wide health improvement through multiprovider collaboration in a regional population health registry and practice-based research network (PBRN). Case study. We describe the HIT data structure and governance of the Diabetes Wellness and Prevention Coalition (DWPC) Registry and PBRN based in Memphis, Tennessee. The population served and their characteristics were assessed for all adult patients with at least 1 encounter in a participating health care delivery system from January 1, 2013, to March 31, 2019. Disparities in access and health care utilization were assessed by residential zip code. The DWPC Registry is a chronic disease and population health data warehouse designed to facilitate chronic disease surveillance and tracking of processes and outcomes of care in medically underserved areas of the mid-South. The Registry primarily focuses on obesity-associated chronic conditions such as diabetes, hypertension, hyperlipidemia, and chronic kidney disease. It combines patient data from 7 regional health systems, which include 6 adult hospitals and more than 50 outpatient practices, covering 462,223 adults with 2,032,425 clinic visits and 602,679 hospitalizations and/or emergency department visits from January 1, 2013, to March 31, 2019. The most prevalent chronic conditions include obesity (37.2%), hypertension (34.4%), overweight (26.4%), hyperlipidemia (18.0%), and type 2 diabetes (14.0%). The Registry provides quarterly practice improvement reports to participating clinics, facilitates surveillance of and outreach to patients with unmet health needs, and supports a pragmatic clinical trial and multiple cohort studies. Regional registries and PBRNs are powerful tools that can support real-world quality improvement and population health efforts to reduce disparities and improve equity in chronic disease care in medically underserved communities across the United States.

Prevalence and associated factors of undiagnosed atrial fibrillation among end-stage renal disease patients on maintenance haemodialysis: a cross-sectional study

BackgroundAtrial fibrillation (AF) is the most prevalent sustained arrhythmia worldwide and it aggravates cardiovascular morbidity and mortality; however, this is largely under-diagnosed. Moreover, among end-stage renal disease patients on haemodialysis, AF is substantially more common and serious. The researchers conducted this study to assess the prevalence of, and the factors correlated with AF in Jordanian haemodialysis patients.MethodsIn a cross-sectional analysis conducted from October 2018 to February 2019 in four tertiary hospitals, the researchers enrolled all consenting patients aged 18 years or older who were on haemodialysis for at least three months prior to the study. We screened for AF clinically by pulse palpation, precordial auscultation, by an automated blood pressure monitor and an electrocardiogram. The researchers reported qualitative variables as counts and frequencies, while continuous variables were summarised using the mean or median where necessary. We used multiple logistic regression with backward selection to identify independent risk factors of AF.ResultsA total of 231 patients were enrolled; mean age was 54.8 ± 15.6 years (from 20 to 86), and 44.3% of them were women. The prevalence of AF was found to be 7.8% (95% CI, 4.8–12.2), with no gender disparity. Age (adjusted odds ratio [AOR] = 1.05; 95% CI, 1.01–1.10; p = 0.031), history of ischaemic heart disease (AOR = 3.74; 95% CI, 1.09–12.34; p = 0.033), history of smoking (AOR = 0.15; 95% CI, 0.02–0.60; p = 0.019), and low interdialytic weight gain (AOR = 0.50: 95% CI, 0.25–0.91; p = 0.031) were independently correlated to AF.ConclusionsThe prevalence of AF among patients on maintenance haemodialysis is high, but largely undiagnosed. AF is generally associated with advancing age, history of ischaemic heart disease, lower interdialytic weight gain, and history of smoking. We suggest routine check-up of AF in this high-risk group of patients as anticoagulant therapy if indicated may prevent serious complications. However, there is a need for large-scale cohort studies and for the creation of regional chronic kidney disease and dialysis registries in the Middle East region.

Temporal Trends and Patient Characteristics Associated With Drug Utilisation After First-Ever Stroke: Insights From Chronic Disease Registry Data in Singapore

Data on drug utilisation among stroke patients of Asian ethnicities are lacking. The objectives of the study were to examine the temporal trends and patient characteristics associated with prescription of thrombolytic, antithrombotic and statin medications among patients with first-ever stroke. First-ever ischaemic and haemorrhagic stroke patients admitted to 2 Singapore tertiary hospitals between 2010‒2014 were included. Data were extracted from the National Healthcare Group Chronic Disease Management System. Association between drug utilisation and admission year, as well as characteristics associated with drug use, were explored using multivariable logistic regression. There was an increasing trend in the combined use of all 3 guideline medications in ischaemic stroke patients (P <0.001)-specifically thrombolytic agents (P <0.001), oral antithrombotics (P = 0.002) and statins (P = 0.003) at discharge. Among antithrombotics, the use of clopidogrel (P <0.001) and aspirin-clopidogrel (P <0.001) had increased, whereas prescription of dipyridamole (P <0.001) and aspirin-dipyridamole (P <0.001) had declined. For statins, the increase in atorvastatin prescription (P <0.001) was accompanied by decreasing use of simvastatin (P <0.001). Age, ethnicity and certain comorbidities (hyperlipidaemia, atrial fibrillation and chronic kidney disease) were associated with the combined use of all 3 guideline medications (P <0.05). In haemorrhagic stroke, prescription of statins at discharge were comparatively lower. This study reveals changes in prescription behaviour over time in a multiethnic Asian population with first-ever stroke. Patient characteristics including younger age, Malay ethnicity and certain comorbidities (i.e. hyperlipidaemia, atrial fibrillation) were associated with the combined use of all 3 guideline medications among ischaemic stroke patients.

1146. Antibiotic Use in Infants Predicts Asthma Rate in Children 1–4 years at Fine Geographic Scale

BackgroundEarly-life exposure to antibiotics is associated with childhood asthma. We previously reported that a dramatic drop in infant antibiotic use is correlated with a decline in asthma incidence in children in British Columbia (BC). This study aims to see whether antibiotic exposure predicts asthma at a fine geographic scale after adjustment for known covariates.MethodsWe used prescribing data from BC PharmaNet, a population-based database capturing all outpatient prescribing for BC population (n = 4.7 million). Prescribing rates for infants <1 year were calculated as prescriptions per 1000 population per year using age and sex-specified denominator estimates. Age-adjusted aggregate asthma incidence data for children 1–4 years were obtained from the BC Ministry of Health Chronic Disease Registry. The disease identification uses a standard case definition making using of diagnostic codes (ICD9-493 and ICD10-J45) in BC’s universal hospital and physician billing databases and relevant asthma-specific drug data from BC PharmaNet. We modeled the association between antibiotic prescribing rate and asthma incidence in 91 Local Health Areas using multivariable Poisson regression employing a generalized linear mixed-effects model adjusting for covariates.ResultsBetween 2000 and 2014, the annual asthma incidence (ages 1–4 years) fell 26% from 27.3 (95% CI: 26.5–28.0) to 20.2 (95% CI: 19.5–20.8) per 1000 population. For children aged 1–4 years in 2000, the average proportion of infants exposed to one or more courses of antibiotics fell from 66.9 to 32.1% over the same interval. Antibiotic was a significant predictor of asthma rate (IRR=1.24 per 10% absolute increase in antibiotic prescribing; 95% CI: 1.19–1.27). Other covariates that remained significant in the model included male sex (IRR=1.56; 95% CI: 1.53–1.58), and atmospheric particulate matter PM 2.5 (IRR=1.08 per interquartile increase; 95% CI: 1.06–1.10).ConclusionOur findings suggest that antibiotic exposure in the first year of life increases the risk of being diagnosed with asthma later in childhood. This is congruent with similar findings at the individual level in a prospective cohort of Canadian children that also points to a pathway through altered gut microbiota.Disclosures All authors: No reported disclosures.

The ability of primary healthcare clinics to provide quality diabetes care: An audit.

BackgroundIn South Africa, much of diabetes care takes place at primary healthcare (PHC) facilities where screening for diabetic complications is often low. Clinics require access to equipment, resources and a functional health system to do effective screening, but what is unknown is whether these components are in place.AimThe aim of this study was to assess the capacity of primary care clinics in one district to provide quality diabetes care.SettingThis study was conducted at the Tshwane district in South Africa.MethodsAn audit was done in 12 PHC clinics. A self-developed audit tool based on national and clinical guidelines was developed and completed using observation and interviewing the clinic manager and pharmacist or pharmacy assistant.ResultsScales, height rods, glucometers and blood pressure machines were available. Monofilaments were unknown and calibration of equipment was rare. The Essential Drug List was the only guideline consistently available. All sites reported consistent access to medication, glucose strips and urine dipsticks. All sites made use of the chronic disease register, and only 25% used an appointment system. No diabetes-specific structured care form was in use. All facilities had registered and enrolled nurses and access to doctors. Availability of educational material was generally poor.ConclusionThe capacity to deliver quality care is compromised by the poor availability of guidelines, educational material and the absence of monofilaments. These are modifiable risk factors that could be resolved by the clinic managers and staff development educators. However, patient records and health information systems need attention at policy level.

Prevalence of chronic liver disease among young/middle-aged adults in Northern Italy: role of hepatitis B and hepatitis C virus infection by age, sex, ethnicity

BackgroundSparse population-based data are available on the prevalence and etiology of chronic liver disease (CLD) in Italy. The study aims to assess the role of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in CLD according to age, gender and ethnicity. MethodsClinically diagnosed CLD in the general population aged 20–59 years in the Veneto Region (North-Eastern Italy) were identified through the Adjusted Clinical Groups System, by record linkage of the archive of subjects enrolled in the Regional Health System with Hospital Discharge Records, Emergency Room visits, Chronic disease registry for copayment exemptions, and the Home care database. Age-standardized prevalence rates (PR) were computed in Italians and immigrants, based on country of citizenship. ResultsOverall 22,934 subjects affected by CLD in 2016 were retrieved, 21% related to HBV and 43% to HCV infection. The prevalence of HCV-related CLD was higher in males, peaking at 50–54 years (males = 11/1000; females = 4/1000). The PR of HBV-related CLD was almost negligible in the Italian population (1/1000), and higher among immigrants, especially from East Asia (males = 17/1000; females = 11/1000) and Sub-Saharan Africa (males = 13/1000; females = 10/1000). ConclusionSpecific population sub-groups identified by age, gender, and ethnicity, were demonstrated to be at increased risk, and these trends are in line with global epidemiological patterns of viral hepatitis.

135 Clinical Implementation of a Chronic Kidney Disease (CKD) Registry with Risk Prediction

135 Clinical Implementation of a Chronic Kidney Disease (CKD) Registry with Risk Prediction

Development of an electronic health record-based chronic kidney disease registry to promote population health management

BackgroundElectronic health record (EHR) based chronic kidney disease (CKD) registries are central to population health strategies to improve CKD care. In 2015, Partners Healthcare System (PHS), encompassing multiple academic and community hospitals and outpatient care facilities in Massachusetts, developed an EHR-based CKD registry to identify opportunities for quality improvement, defined as improvement on both process measures and outcomes measures associated with clinical care.MethodsPatients are included in the registry based on the following criteria: 1) two estimated glomerular filtration rate (eGFR) results < 60 ml/min/1.73m2 separated by 90 days, including the most recent eGFR being < 60 ml/min/1.73m2; or 2) the most recent two urine protein values > 300 mg protein/g creatinine on either urine total protein/creatinine ratio or urine albumin/creatinine ratio; or 3) an EHR problem list diagnosis of end stage renal disease (ESRD). The registry categorizes patients by CKD stage and includes rates of annual testing for eGFR and proteinuria, blood pressure control, use of angiotensin converting enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs), nephrotoxic medication use, hepatitis B virus (HBV) immunization, vascular access placement, transplant status, CKD progression risk; number of outpatient nephrology visits, and hospitalizations.ResultsThe CKD registry includes 60,503 patients and has revealed several opportunities for care improvement including 1) annual proteinuria testing performed for 17% (stage 3) and 31% (stage 4) of patients; 2) ACE-I/ARB used in 41% (stage 3) and 46% (stage 4) of patients; 3) nephrotoxic medications used among 23% of stage 4 patients; and 4) 89% of stage 4 patients lack HBV immunity. For advanced CKD patients there are opportunities to improve vascular access placement, transplant referrals and outpatient nephrology contact.ConclusionsA CKD registry can identify modifiable care gaps across the spectrum of CKD care and enable population health strategy implementation. No linkage to Social Security Death Master File or US Renal Data System (USRDS) databases limits our ability to track mortality and progression to ESRD.

920. A Sharp Fall in Antibiotic Use in Infants Is Correlated With a Population-Wide Reduction in Asthma Incidence for Children Under 5

BackgroundAntibiotic use in infants <1 is associated with increased relative risk (~1.5) for childhood asthma in cohort studies. This may be mediated by removal from the infant microbiome of organisms shown to protect against asthma, a hypothesis supported by experiment. We launched this study to see whether reductions in antibiotic use at population level are associated with benefit by way of asthma reduction.MethodsWe obtained antibiotic prescribing data from BC PharmaNet, a population-based database that captures all outpatient prescribing for British Columbia, Canada (n = 4.7 million). We focused on prescriptions in children <1 and calculated prescription rate per 1,000 population per year. We obtained asthma incidence data from the BC Ministry of Health Chronic Disease Registry. Asthma case identification uses a standard case definition making use of community and hospital diagnostic codes as well as asthma drug data from BC’s universal physician billing, hospital and drug databases. We focused on age-stratified asthma incidence for children aged 1–4. The correlation between antibiotic prescription rate in children < 1 and asthma incidence in the following year was estimated using the Spearman test.ResultsAntibiotic prescribing for all age groups fell 9.5% between 1999 and 2013. The rate for infants <1 dropped 58% from 1,014 to 427 prescriptions per 1,000 population/year. Between 2000 and 2014, asthma incidence (ages 1–4) fell 26% from 27.3 (95% CI: 26.5–28.0) to 20.2 (95% CI: 19.5–20.8) per 1,000 population/year. These trends were strongly correlated: Spearman’s rho = 0.81 (P = 0.0002). The magnitude of fall in asthma incidence is slightly greater than that predicted based on calculated population attributable risk for antibiotic exposure.ConclusionThe population health benefit from antibiotic stewardship in infants may not be confined to slowing the emergence of resistance and could include a reduced risk of asthma. As this is a population-based ecological study, a reduction in other risk factors may also have contributed to the fall in asthma incidence. This promising trend should be further studied at individual level within a large cohort study. Disclosures All authors: No reported disclosures.

Effectiveness of a Best Practice Alerts at Improving Hypertension Control.

Inadequately treated hypertension (HTN) leads to considerable morbidity and mortality. Despite many treatment options, blood pressure (BP) control is suboptimal. Missed opportunities due to the growing complexity of primary care office visits contribute. Electronic health records (EHRs) offer best practice alerts (BPA) tools to support clinicians in identifying poor BP control. BPAs have demonstrated effectiveness for other health outcomes. EHR data were collected for patients ≥18 years old seen for primary care office visits prior to, during, and after the BPA active period and used to identify patients for whom the BPA fired or would have fired during control periods. Logistic regression examined the association of BPA activation with follow-up BP check within 14-90 days and with BP control at follow-up, controlling for demographics and health conditions. The BPA active period was associated with reduced patient follow-up; however, a number of covariates were predictive of increased follow-up: Black non-Hispanics, Hispanics, patients on the chronic kidney disease, HTN, or diabetes registries, as well as the morbidly obese, insurance status, and seasonal factors. For those who did follow-up, BPA activation was associated with improved BP control. BPA activation was associated with worse patient follow-up but improved BP control. Some subgroups had significantly different rates of follow-up and BP control. This study did not have an experimental design as the BPA was a quality improvement initiative. These results highlight the critical importance of planning experimentally designed organizational initiatives to fully understand their impact.

A SINGLE COMMUNITY CENTER UNBLINDED CROSS-SECTIONAL STUDY ON SPIROMETRY OR PULMONARY FUNCTION TEST UTILITY OF PATIENTS INCLUDED IN THE COPD REGISTRY AT TERTIARY CARE COMMUNITY HOSPITAL

SESSION TITLE: Obstructive Lung Diseases 1 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: Spirometry or pulmonary function testing is required for the diagnosis of chronic obstructive pulmonary disease yet this practice is often not followed. An academic satellite tertiary care community hospital analyzed the effects of provider education on utilization of spirometry and deficiencies in the COPD registry. METHODS: An un-blinded cross sectional observational study quantified the summit educational intervention on provider practice while refining the COPD registry. By using filters and billing codes to clarify missing data, the EPIC electronic medical record applied data monitoring of compliance of formal COPD diagnoses with testing. RESULTS: In July 2017, the COPD registry at our hospital had 7,264 people involved. The number of pulmonary function tests were 1,795 before August 2017. In February 2018, there are 6858 people involved in the COPD registry and 1,932 have pulmonary function testing on file. The utilization of lung function testing has improved from 24% to 38% usage since the summit educational intervention. CONCLUSIONS: In conclusion, our hypothesis described that the pulmonary testing adherence percentage would increase after the educational summit meeting on lung function testing and COPD diagnosis while concurrently purifying the COPD registry. These results are possibly reflective of a typical community hospital practice. The accuracy of registry is important to report reliable mortality and readmissions data to Centers of Medicare & Medicaid Services. CLINICAL IMPLICATIONS: Chronic Obstructive Pulmonary Disease is pervasive in southwest Michigan. “Symptomatic COPD affects more than 5 percent of the adult population, is the fourth leading cause of death, and the twelfth leading cause of morbidity in the United States.” Patients are often added to the to the Chronic Obstructive Pulmonary Disease registry without formal diagnosis. Spirometry is required to make the diagnosis of COPD. The Global Initiative of Chronic Obstructive Lung Disease states FEV1/FVC ratio is necessary to describe the disease process. The spirometry measurements are the foundation for staging the disease according to GOLD criteria. Doctor Ferguson further proved trending the patients spirometry measurements was beneficial in reducing mortality. Interventions from primary care spirometry “Reduced the relative risk of exacerbations by 20 to 25 percent and the absolute risk by 5 to 6 percent.” In our community, spirometry is underutilized. Standard practice should be 100% compliance but as Dr. Bolton showed, spirometry usage is at 85.6% for COPD diagnosis and management. An area wide Summit educational seminar was held in July to address this utilization issue. This research is aimed to quantify the change made to the COPD registry including spirometry performed, patients remaining without spirometry, incorrect diagnosis and labeling and verification of registered members. DISCLOSURES: No relevant relationships by Brittany Haines, source=Web Response No relevant relationships by Furqan Shoaib Siddiqi, source=Web Response

Diabetes management in a Primary Care Network (PCN) of private general practitioners in Singapore: An observational study.

A Primary Care Network (PCN) is a virtual network of general practitioners (GPs), sharing common resources and common clinical governance framework for effective chronic disease management. In this study, we analyzed the frequency of assessment as well as control of HbA1c, blood pressure (BP), and low-density lipoprotein (LDL) over time among adult patients with diabetes managed by a group of private GPs under PCN.Data, including clinical measurements of HbA1c, BP, and LDL from 2012 to 2015, of 943 subjects at 9 GP clinics that piloted PCN in Singapore in 2012 was obtained from the chronic disease register for this analysis.The total number of PCN patients increased from 371 in 2012 to 911 in 2015. The average HbA1c decreased from 7.5% in 2012 to 7.3% in 2015, with a significant yearly improving trend of -0.11% (P < .001). The trends in change for systolic BP and LDL were not statistically significant during the same follow-up period. Regular assessment of HbA1c decreased from 80% in 2012 to 55% in 2015. Such decreases were also found in BP and LDL assessments. We also found that receiving government subsidies under a national scheme was a major determinant for maintaining regular assessment, with patients so covered 3 to 20 times more likely to have regular assessments.The PCN model can help improve care and clinical outcomes in adult patients with diabetes in the private primary care sector. Investing greater financial and human resources to augment service capacity and expanding subsidy coverage may be important to ensure the effectiveness, scalability, and sustainability of such a model of care.

Linkage of Chronic Disease Data from Provincial Sources for Strategic Decision Support and Population Health Surveillance in British Columbia (BC)

IntroductionBC Ministry of Health (MoH)’s health administrative data holdings for a variety of general health care data are not readily linked with various data registries maintained by specialized care agencies of the Provincial Health Services Authority (PHSA). These provincial data sources have rich chronic disease information for BC residents.&#x0D; Objectives and ApproachThe objective of this project is to develop a system for cross-agency linkage of provincial level chronic disease data to improve chronic disease information that would support the BC’s health system, MoH and PHSA agencies in particular, in healthcare delivery and chronic disease prevention planning. We aim to achieve linkage of data from various provincial chronic disease data sources of the MoH and PHSA, with further potential to link with variety of other external databases such as Census data for socio-economic determinants of health. We are reporting here the outcome of the first phase of this project.&#x0D; ResultsThe outcomes from the project to date were as follows: Data linkage between the MoH’s administrative databases, Chronic Disease Registries (CDRs) in particular and Census based socio-economic status (SES) data was achieved, providing the population level evidence of health outcomes such as health inequity, comorbidities and multimorbidities (sub-project # 1). Preliminary results on data quality and health outcomes by SES will be presented. This was followed by completion of securing approval to ensure data security compliance for data linkages of CDRs with the Provincial Renal Agency’s Registry called “PROMIS” (sub-project # 2), Cardiac Services BC’s Registry called “HEARTis” ((sub-project # 3), and BC Cancer Agency’s Registry and BC Generations Project data (sub-project # 4), for implementation to answer agency specific research questions.&#x0D; Conclusion/ImplicationsThis data linkage project to consolidate information from chronic disease and socio-economic databases for providing answers to various analytic questions posed will improve decision support and enhanced population health surveillance. The lessons learned from this multi-agency collaboration and their implications for other jurisdictions will be addressed.

Age-specific association between blood pressure and vascular and non-vascular chronic diseases in 0·5 million adults in China: a prospective cohort study.

SummaryBackgroundThe age-specific association between blood pressure and vascular disease has been studied mostly in high-income countries, and before the widespread use of brain imaging for diagnosis of the main stroke types (ischaemic stroke and intracerebral haemorrhage). We aimed to investigate this relationship among adults in China.Methods512 891 adults (59% women) aged 30–79 years were recruited into a prospective study from ten areas of China between June 25, 2004, and July 15, 2008. Participants attended assessment centres where they were interviewed about demographic and lifestyle characteristics, and their blood pressure, height, and weight were measured. Incident disease was identified through linkage to local mortality records, chronic disease registries, and claims to the national health insurance system. We used Cox regression analysis to produce adjusted hazard ratios (HRs) relating systolic blood pressure to disease incidence. HRs were corrected for regression dilution to estimate associations with long-term average (usual) systolic blood pressure.FindingsDuring a median follow-up of 9 years (IQR 8–10), there were 88 105 incident vascular and non-vascular chronic disease events (about 90% of strokes events were diagnosed using brain imaging). At ages 40–79 years (mean age at event 64 years [SD 9]), usual systolic blood pressure was continuously and positively associated with incident major vascular disease throughout the range 120–180 mm Hg: each 10 mm Hg higher usual systolic blood pressure was associated with an approximately 30% higher risk of ischaemic heart disease (HR 1·31 [95% CI 1·28–1·34]) and ischaemic stroke (1·30 [1·29–1·31]), but the association with intracerebral haemorrhage was about twice as steep (1·68 [1·65–1·71]). HRs for vascular disease were twice as steep at ages 40–49 years than at ages 70–79 years. Usual systolic blood pressure was also positively associated with incident chronic kidney disease (1·40 [1·35–1·44]) and diabetes (1·14 [1·12–1·15]). About half of all vascular deaths in China were attributable to elevated blood pressure (ie, systolic blood pressure >120 mm Hg), accounting for approximately 1 million deaths (<80 years of age) annually.InterpretationAmong adults in China, systolic blood pressure was continuously related to major vascular disease with no evidence of a threshold down to 120 mm Hg. Unlike previous studies in high-income countries, blood pressure was more strongly associated with intracerebral haemorrhage than with ischaemic stroke. Even small reductions in mean blood pressure at a population level could be expected to have a major impact on vascular morbidity and mortality.FundingUK Wellcome Trust, UK Medical Research Council, British Heart Foundation, Cancer Research UK, Kadoorie Charitable Foundation, Chinese Ministry of Science and Technology, and the National Science Foundation of China.

A case-mix classification system for explaining healthcare costs using administrative data in Italy

BackgroundThe Italian National Health Service (NHS) provides universal coverage to all citizens, granting primary and hospital care with a copayment system for outpatient and drug services. Financing of Local Health Trusts (LHTs) is based on a capitation system adjusted only for age, gender and area of residence. We applied a risk-adjustment system (Johns Hopkins Adjusted Clinical Groups System, ACG® System) in order to explain health care costs using routinely collected administrative data in the Veneto Region (North-eastern Italy). MethodsAll residents in the Veneto Region were included in the study. The ACG system was applied to classify the regional population based on the following information sources for the year 2015: Hospital Discharges, Emergency Room visits, Chronic disease registry for copayment exemptions, ambulatory visits, medications, the Home care database, and drug prescriptions. Simple linear regressions were used to contrast an age-gender model to models incorporating more comprehensive risk measures aimed at predicting health care costs. ResultsA simple age-gender model explained only 8% of the variance of 2015 total costs. Adding diagnoses-related variables provided a 23% increase, while pharmacy based variables provided an additional 17% increase in explained variance. The adjusted R-squared of the comprehensive model was 6 times that of the simple age-gender model. ConclusionsACG System provides substantial improvement in predicting health care costs when compared to simple age-gender adjustments. Aging itself is not the main determinant of the increase of health care costs, which is better explained by the accumulation of chronic conditions and the resulting multimorbidity.