Physician Billing Research Articles

P2.15-31 The Evolution of Costs in the Treatment of Advanced Non-Small Cell Lung Cancer (NSCLC) in Ontario, Canada Between 1999 to 2014

Treatment options for patients with advanced non-small cell lung cancer (NSCLC) have evolved substantially since the 1990s. Newer agents are more expensive to acquire and administer and the perception is the cost of lung cancer care has increased considerably in the last two decades. We conducted a cost analysis study to evaluate changes in the total cost of NSCLC care over time. We conducted a retrospective cohort study of all NSCLC patients diagnosed in Ontario from Apr 1, 1999 to Mar 30, 2014, who received palliative chemotherapy for advanced disease. Variables of interest were extracted from provincial registry data electronically linked by the Institute for Clinical Evaluative Sciences (ICES). The use of oral systemic therapy is not universally captured in these databases. The mean total cost of care including, systemic therapy, and supportive care (hospitalizations, physician billings, lab tests, out-patient visits, emergency visits, home care, and most prescription medications), was calculated in 2015 CAD dollars by fiscal year of diagnosis. Regression analysis was used to project costs in years with missing supportive care costs. Of all NSCLC cases diagnosed in Ontario (n=89,936), 21.6% (n=19,447) received any chemotherapy for advanced disease. In this population, median age ranged from 65 to 69 years, 54.9% were male, 15.4% resided rurally, 45.0% were adenocarcinoma, 58.6% with de novo stage IV disease, and 25.8% received second line chemotherapy. At the time of the data analysis, 6.8% of patients are presumed to be alive. The average cost of care per patient treated rose from $85,339 to $102,026. The cost of systemic therapy rose from $3,856 to $12,554. During the same time period, average supportive care costs changed from $84,732 to $93,495. The proportion of total costs of systemic therapy changed from 4.5% to 12.3%. Utilization of palliative chemotherapy in only those with de novo stage IV disease remained stable over time (29.8%). Patients who received second line chemotherapy cost 5.9 times that of patients who did not ($11,342 and $1,924 respectively). Costs in the final year of life increased from 61.9% to 68.0% of total lifetime costs from 2003 to 2014. The cost of systemic therapy for lung cancer patients is rising disproportionately to that of supportive care. Ongoing analyses are assessing the main drivers of cost of care and model the impact of oral targeted therapies and immunotherapies on the cost of lung cancer care.

Changes in preoperative endoscopic and percutaneous bile drainage in patients with periampullary cancer undergoing pancreaticoduodenectomy in Ontario: effect on clinical practice of a randomized trial.

In 2010, a multicentre randomized controlled trial reported increased postoperative complications in pancreaticoduodenectomy (pde) patients undergoing preoperative biliary decompression (pbd). We evaluated the effect of that publication on rates of pbd at the population level. This retrospective observational cohort study identified patients undergoing pde for malignancy, 2005-2013, linking them with administrative health care databases covering medical services for a population of 13.5 million. Patients undergoing pbd within 6 weeks before their surgery were identified using physician billing codes and were divided into those undergoing pde before and after article publication, with a 6-month washout period. Chi-square tests were used to compare rates of pbd. Of 1997 pde patients identified, 963 underwent surgery before article publication, and 911, after (123 during the washout period). The rate of pbd was 47.5% before publication, and 41.6% after (p = 0.01). The lowest pbd rates occurred immediately after publication, in 2010 and 2011. Similar results were observed when the cohort was restricted to patients seen preoperatively by a gastroenterologist (n = 1412). Rates of pbd have declined a small, but significant, amount after randomized trial publication. Persistence of pbd might relate to suboptimal knowledge translation, the role of pbd in diagnosis of periampullary malignancy, and treatment of complications (cholangitis, severe hyperbilirubinemia) or anticipation of delay from diagnosis to surgery. The nadir in pbd rates after article publication and the subsequent rise suggest an element of transience in the effect of article publication on clinical practice. Further investigation into the reasons for persistent pbd is needed.

Use of radiotherapy for bladder cancer: A population-based study of evolving referral and practice patterns.

Definitive treatment for muscle-invasive bladder cancer includes either cystectomy or radiotherapy (RT). We describe use of RT and radiation oncology (RO) referral patterns in the contemporary era. The Ontario Cancer Registry and linked records of treatment were used to identify all patients who received cystectomy or RT for bladder cancer from 1994-2013. Physician billing records were linked to identify RO consultation before radical treatment. Multilevel logistic regression models were used to examine patient factors and physician-level variation in referral to RO and use of RT. A total of 7461 patients underwent cystectomy or RT for bladder cancer from 1994-2013; 5574 (75%) had cystectomy and 1887 (25%) had RT. Use of RT decreased from 43% (126/289) in 1994 to 23% (112/478) in 2008 and remained stable from 2009-2013 (23%, 507/2202). RO referral rate among all cases decreased from 46% (134/289) in 1994 to 30% (143/478) in 2008; however, the rates began to rise in the contemporary era from 31% (137/442) in 2009 to 37% (165/448) in 2013 (p=0.03). Patient factors associated with use of RT include older age, greater comorbidity, and geographic location. Surgeon-level factors associated with greater preoperative referral to RO include higher surgeon case volume and practicing in a teaching hospital. One-quarter of patients treated with curative intent therapy for bladder cancer receive RT. While referral rates to RO are increasing, future data will identify the extent to which this has altered practice. Collaborative efforts promoting multidisciplinary care and RO consultation before radical treatment are warranted.

Identifying Knowledge Gaps with Administrative Health Data: A Cohort Study of Traumatic and Non-Traumatic Spinal Cord Injury in Alberta

IntroductionThe Spinal Cord Injury (SCI) population consists of two main sub-groups: traumatic (TSCI) and non-traumatic (NTSCI). TSCI has been studied; however less attention has been given to NTSCI. It is important to understand both SCI sub-groups for identification of knowledge gaps and subsequent health service planning.
 Objectives and ApproachThe goal is to study the SCI population (both TSCI and NTSCI) in Alberta, Canada, leveraging recent administrative health data. It is difficult to identify NTSCI patients for their heterogeneous conditions, and relatively low prevalence. Consequently, we followed a validated algorithm using particular ICD-10-CA codes, to identify (and index) adult SCI patients from Ambulatory and Inpatient records between April 1, 2006 and March 31, 2016.
 Indexed patients were linked to various databases (inpatient, ambulatory, physician claims, provincial insurance registry), and analyzed in multiple perspectives such as demographics patterns, deaths, resource and cost utilization, geographic distribution, and care equity between groups.
 ResultsThrough 10 years of data we have identified 5217 SCI patients (3309 TSCI; 1908 NTSCI). 68.7% TSCI and 58.6% NTSCI are male. NTSCI patients are approximately 10 years older (46.3 TSCI; 54.5 NTSCI), and have a 3-point higher Charlson score. 1-year mortality in NTSCI is approximately 2.4 times the TSCI group.
 Hospitalizations, ER visits, critical care time have also been examined. Patients with NTSCI had a higher median index LOS (14 days IQR (4-51)) compared to the traumatic group who had much higher variability (11 days IQR (11-65.5)). Noted 13.7% NTSCI patients and 19.5% TSCI do not have hospitalizations after index (a diverse characteristic of SCI). Resource Intensity Weights, physician billing, rural-urban area utilization have also been compared between the sub-groups.
 Conclusion/ImplicationsWith the use of administrative databases and a validated algorithm, we described a diverse patient cohort with two main sub-groups (TSCI/NTSCI). Both groups were analyzed upon multiple topics and showed variations. Our results have provided updated knowledge of a comprehensive SCI population in Alberta, Canada, and may lead to improvements on care-giving model.

Linking big data for cardiovascular health surveillance – opportunities and challenges using the CANHEART cohort

IntroductionOur increasing ability to link large population-based health administrative datasets to create ‘big data’ cohorts offers unique opportunities to conduct health and health services surveillance at lower costs than traditional methods using surveys or primary data collection. However, comparability of findings from big data with traditional methods is unknown.
 Objectives and ApproachIn the CArdiovascular HEalth in Ambulatory Care Research Team (CANHEART) ‘big data’ initiative, we linked 19 population-based health databases to obtain baseline and 5-year follow-up health information on a cohort of 9.8 million adult residents of Ontario, Canada as of January 2008. We compared cardiovascular risk factor prevalence with results from 3500 participants in the 2007-09 Canadian Health Measures Survey (CHMS), a traditional population health surveillance survey. Additionally, we determined cardiovascular preventative care use and clinical event rates by sex and age. Planned linkages to new data sources will enable continued cohort surveillance of population health-related and care indicators.
 ResultsCholesterol and glucose levels determined from the CANHEART cohort were comparable to the CHMS, whereas blood pressure values and obesity rates were substantially higher. Overall, receipt of cardiovascular preventive care in the CANHEART cohort was high, with 85.7% of males and 91.8% of females having blood pressure assessments, and 67.8% of males and 79.4% of females having weight assessments. Cholesterol and diabetes screening rates among those recommended for screening were over 75%. Incidence of myocardial infarction, stroke or cardiovascular death was 51% higher among males than females (3.8 and 2.5 events per 1000 person-years, respectively). Challenges encountered in analyzing data included treatment of repeated and time-varying measures, selection of valid diagnostic and physician billing codes, changing coding practices and handling of missing and outlying data.
 Conclusion/ImplicationsComparability of cardiovascular risk factor prevalence using linked administrative data with survey methods varies by indicator. Selection biases amongst survey participants and different measurement methods could explain discrepancies. The added ability to examine health care indicators longitudinally and by subgroup supports use of linked population-based data to enhance health surveillance.

Access to palliative care in Canada

IntroductionMany Canadians prefer to remain in the community at end-of-life, and to die at home. To do so, early and integrated palliative care (PC) is needed to provide individuals with care and support services across care settings. Measuring access to PC can help to evaluate progress over time.
 Objectives and ApproachThis presentation will show findings from our study on whether Canadian decedents had access to PC in the last year of life. Data from physician billings, drug claims, home care, long-term care and acute care were linked to identify decedents and PC service use. These data were also used to examine how PC may affect, or be affected by other interactions with the health system, including inpatient alternate level care days, admissions from long-term care, emergency department visits and stays in intensive care units. Gaps in data availability and quality will also be highlighted.
 ResultsAbout 70% of decedents were identified using administrative health data, although there were variations across jurisdictions due to differences in data availability and quality (9%-81%). For decedents identified across care settings, few received PC in the community in their last year of life, ranging from 4% in long-term care to 12% in home care. More decedents were identified as palliative in acute care (44%) but only one-third received PC in another setting despite multiple interactions with the health system in the last year of life. Those who had integrated, community-based PC were less likely to have a stay in an intensive care unit, and more likely to die in the community. However, few Canadian decedents had access to this type of care.
 Conclusion/ImplicationsData linkage identified opportunities for earlier integration of PC and improved care transitions. However, lack of common definitions of PC across sectors and jurisdictions, limitations in data availability and issues in PC coding were identified. Improvements in PC data are required to evaluate progress for the future.

Utilization of Radiotherapy for Bladder Cancer: Evolving referral and practice patterns in the general population

IntroductionDefinitive treatment for muscle invasive bladder cancer (MIBC) includes either cystectomy or radical radiotherapy (RT). Despite the growing evidence suggesting that cystectomy and RT may offer comparable survival benefit, utilization of RT and referral rate to radiation oncology (RO) have historically been low in routine practice.
 Objectives and ApproachThe aims were to describe the use of RT and RO referral patterns in the contemporary era. A retrospective cohort study was conducted by linking administrative treatment records with the Ontario Cancer Registry to identify all patients who received treatment with curative intent for bladder cancer in Ontario from 1994-2013. Physician billing records were linked to identify RO consultation before radical treatment. Practice patterns in the contemporary era (2009-2013) were compared with data from 1994 to 2008. Multilevel (patient-, surgeon- and hospital-level) logistic regression models were used to examine sociodemographic and organizational variation in referral to RO.
 ResultsIn total, 7461 patients underwent cystectomy or RT for bladder cancer in Ontario from 1994-2013; 5574 (75%) had primary cystectomy and 1887 (25%) primary had RT. Use of RT decreased from 43% in 1994 to 23% in 2008 and remained stable during 2009-2013 (23%). RO referral rate among all cases decreased from 46% in 1994 to 30% in 2008; however, the rates began to rise in the contemporary era from 31% in 2009 to 37% in 2013. A similar trend was seen in preoperative referral rate among patients treated with cystectomy (11% in 1994-1998, 9% in 1999-2008, and 14% in 2009-2013). Patient, surgeon, and hospital-level factors associated with preoperative referral to RO include older age, year of cystectomy, higher surgeon case volume, and teaching hospital.
 Conclusion/ImplicationsA minority of patients underwent curative intent therapy for bladder cancer received RT. Recent data suggest that referral rates to RO are increasing; future data will identify the extent to which this has altered practice. Collaborative efforts promoting multidisciplinary care and RO consultation at the urologist and hospital-level are warranted.

Methods for identifying health state transitions from administrative data: the case of metastasis in prostate cancer

IntroductionHealth administrative data are a rich source of population-based information, useful for building state transition models for medical decision making. These models require identification of health state transitions and associated times. Indirect methods are needed to predict this information, as it is rarely available in administrative data.
 Objectives and ApproachWe considered a set of criteria to identify transitions to metastasis for prostate cancer patients in administrative data, utilizing dates of diagnostic and medical billing codes for secondary malignancy, palliative radiation therapy, chemotherapy and bone disorders or procedures. We evaluated the criteria using the true date of metastasis from medical charts of 195 patients linked to health care administrative data in Ontario, Canada. We also built a recursive partitioning tree to optimally combine these criteria and construct rules for identifying metastatic patients. For the evaluation, both misclassification and discrepancy between true and predicted dates for the true positives were considered.
 ResultsCriteria involving chemotherapy drugs or hospital visits with secondary malignancy ICD10 diagnosis gave the best results, with high sensitivity and specificity. Criteria involving bone related problems, radiation therapy or diagnosis of metastatic cancer in physician billing data were very specific but not sensitive. The criterion involving prescriptions for narcotics was sensitive but not specific. The fitted tree was parsimonious involving only two of the criteria, while improving the accuracy over individual criteria. Most criteria gave a “delayed” prediction, with criterion based on chemotherapy giving on average the smallest delay, as well as exhibiting the least variability. Criteria involving narcotics and bone related problems predicted metastasis date very prematurely, probably triggered by conditions other than prostate cancer.
 Conclusion/ImplicationsSeveral criteria from administrative databases satisfactorily classified prostate cancer patients with metastasis. A classification tree was built and improved the results over single criteria, demonstrating the added benefits in using advanced statistical learning methods for this task. However, “transition to metastasis” dates were predicted inaccurately, often with significant delay.

Linking air pollution and administrative health databases to examine health effects of wildfire smoke exposure in Calgary, Canada in 2015

IntroductionWildfires are increasing in frequency and severity due to climate change. Fine particulate matter (PM2.5) in wildfire smoke is an important indicator of health effects of most combustion sources. The evidence based on adverse health impacts of PM2.5 from wildfire smoke are increasingly being studied but some gaps still remain.
 Objectives and ApproachWe examined the association of PM2.5 from Pacific Northwest wildfires with multiple respiratory and cardiovascular morbidity events related physician and emergency department visits, hospital admissions, health-link calls and medications dispensed among Calgary city population from August 1 – September 30, 2015. Physician billing claims, discharge abstract, Pharmaceutical Information Network, Health-link calls databases were linked with the air quality monitoring information database. Quasi-Poisson regression model for time lags of zero to five days and a three-day moving average, and conditional logistic regression model was used with adjustment for air pollutants and meteorological variables. Age and disease-specific stratified analyses were performed.
 ResultsCompared to the pre-wildfire period (Aug 1 – Aug 23), a 10 µg/m3 increase in PM2.5 increased the risk for respiratory physician visits by 54.8% (95% CI: 41.6% - 69.3%) and 32.6% (95% CI: 10.4% - 58.9%) in the respective post (Sep 1- Sep 30) and during (Aug 24 – Aug 31) wildfire periods. The strongest association of PM2.5 with respiratory physician visits was observed for children aged 0-9 years in the post-wildfire period (Relative Risk [RR] = 2.11, 95% CI: 1.86 - 2.39) compared to during wildfire period (RR = 1.56, 95% CI: 1.21 - 2.02) and was consistent for asthma, acute bronchitis and acute respiratory infection. Statistically significant effects of PM2.5 on cardiovascular hospitalizations, ED and physician visits were not observed during the wildfire period.
 Conclusion/ImplicationsWildfire-related PM2.5 led to increased physician visits due to respiratory morbidity during and after the wildfires, particularly for asthma, acute bronchitis and acute respiratory infections in children. The absence of cardiovascular health impact in general population during wildfires provides useful information for targeted public health messaging during adverse air quality events.

Respiratory health service utilization of children with neuromuscular disease.

To quantify health service utilization including assessment, monitoring, and treatment of respiratory complications of children with neuromuscular disease (NMD), identifying practice variation and adherence to guideline recommendations at a population level. North American population-based cohort study (2003-2015) of children with NMD using hospital diagnostic and physician billing codes within health administrative databases. We identified 18 163 children with NMD. Mean (SD) age was 7.8 (5.6) years with 40% ≤5; 45% were female. Most common diagnoses were cerebral palsy (50%) and spina bifida (16%); 8% had muscular dystrophy. From fiscal years 2003-2014, 15 600 (86%) children went to an emergency department on average 3.5 times every 3 years; 6575 (36%) for respiratory reasons. 8788 (48%) were admitted to hospital with 2190 (12%) for respiratory reasons and 2451 (13%) required intensive care. Respiratory specialist outpatient visits occurred for 2226 (12%) children on average 6.5 visits every 3 years; 723 (4%) had in-hospital respiratory specialist consultation. Pulmonary function testing was conducted in 3194 (18%) children on average 2.4 times every 3 years; sleep studies in 1389 (8%). In this population-based study of children with NMD, healthcare utilization for respiratory complications was considerable. Frequency of respiratory specialist consultation, monitoring of respiratory function and sleep disordered breathing was variable but on average reflected professional society recommendations. Children with NMD are frequent ED users suggesting a need to improve community and social supports. We did not detect reduced access to respiratory monitoring or specialist consultation in adolescents transitioning to adult services.

Development and validation of case-finding algorithms for recurrence of breast cancer using routinely collected administrative data

IntroductionRecurrence free survival is frequently investigated in cancer outcome studies, however is not explicitly documented in cancer registry data that is widely used for research. Patterns of events after initial treatment such as oncology visits, re-operation, chemotherapy or radiation may herald recurrence.
 Objectives and ApproachThis study aimed to develop and validate algorithms for identifying breast cancer recurrence using large administrative data.Two cohorts with high recurrence rates were used: 1) all young (≤ 40 years) breast cancer patients (2007-2010), and 2) all neoadjuvant chemotherapy patients (2012-2014) in Alberta, Canada. Health events after primary treatment were obtained from the Alberta cancer registry, physician billing claims, and vital statistics databases. Positive recurrence status (defined as either locoregional, distant or both) was ascertained by primary chart review. The cohort was divided into a developing (60%) and validating (40%) set. Development of algorithms geared towards high sensitivity, PPV and accuracy respectively were performed using classification and regression tree (CART) models. Key variables in the models included: a new round of chemotherapy, a second mastectomy, and a new cluster of radiologist, oncologist or general surgeon visits occurring after the primary treatment. Compared with chart review data, the sensitivity, specificity, PPV, NPV and accuracy of the algorithms were calculated.
 ResultsOf 606 patients, 121 (20%) had recurrence after a median follow-up 4 years. The high sensitivity algorithm had 94.2% (95% CI: 90.1-98.4%) sensitivity, 92.8% (90.5-95.1%) specificity, 76.5% (70.0-88.3%) PPV, 98.5% (97.3-99.6%) NPV and 93.1% (91.0-95.1%) accuracy. The high PPV algorithm had 74.4% (66.6-82.2%) sensitivity, 97.8% (96.5-99.2%) specificity, 90.0% (84.1-95.9%) PPV, 93.6% (91.4-95.7%) NPV and 92.9% (90.9-95.0%) accuracy. The high accuracy algorithm had 88.4% (82.7-94.1%) sensitivity, 97.1% (95.6-98.6%) specificity, 88.4% (82.7-94.1%) PPV, 97.1% (95.6-98.6%) NPV and 95.4% (93.7-97.1%) accuracy.
 Conclusion/ImplicationsThe proposed algorithms achieved favourably high validity for identifying recurrence using widely available administrative data. Further study may be needed for improving sensitivity and PPV, and validating the algorithms in larger data for widespread use.

Sex differences in outcomes of heart failure in an ambulatory, population-based cohort from 2009 to 2013.

Heart failure remains a substantial cause of morbidity and mortality in women. We examined the sex differences in heart failure incidence, mortality and hospital admission in a population-based cohort. All Ontario residents who were diagnosed with heart failure in an ambulatory setting between Apr. 1, 2009, and Mar. 31, 2014, were included in this study. Incident cases of heart failure were captured through physician billing using a validated algorithm. Outcomes were mortality and hospital admission for heart failure within 1 year of the diagnosis. Probability of death and hospital admission were calculated using the Kaplan-Meier method. The hazard of death was assessed using a multivariable Cox proportional hazard model. A total of 90 707 diagnoses of heart failure were made in an ambulatory setting during the study period (47% women). Women were more likely to be older and more frail, and had different comorbidities than men. The incidence of heart failure decreased during the study period in both sexes. The mortality rate decreased in both sexes, but remained higher in women than men. The female age-standardized mortality rate was 89 (95% confidence interval [CI] 80-100) per 1000 in 2009 and 85 (95% CI 75-95) in 2013, versus male age-standardized mortality rates of 88 (95% CI 80-97) in 2009 and 83 (95% CI 75-91) in 2013. Conversely, the rates of incident heart failure hospital admissions after heart failure diagnosis decreased in men and increased in women. Despite decreases in overall heart failure incidence and mortality in ambulatory patients, mortality rates remain higher in women than in men, and rates of hospital admission for heart failure increased in women and declined in men. Further studies should focus on sex differences in health-seeking behaviour, medical therapy and response to therapy to provide guidance for personalized care.

Professional fee payments by specialty for inpatient open ventral hernia repair: who gets paid for treating comorbidities and complications?

The purpose of this study was to determine perioperative professional fee payments to providers from different specialties for the care of patients undergoing inpatient open ventral hernia repair (VHR). Perioperative data of patients undergoing VHR at a single center over 3 years were selected from our NSQIP database. 180-day follow-up data were obtained via retrospective review of records and phone calls to patients. Professional fee payments (PFPs) to all providers were obtained from our physician billing system for the VHR hospitalization, the 180days prior to operation (180Prior) and the 180days post-discharge (180Post). PFPs for 283 cases were analyzed. Average total 360-day PFPs per patient were $3409 ± SD 3294, with 14.5% ($493 ± 1546) for services in the 180Preop period, 72.5% ($2473 ± 1881) for the VHR hospitalization, and 13.0% ($443 ± 1097) in the 180Postop period. The surgical service received 62% of PFPs followed by anesthesia (18%), medical specialties (9%), radiology (6%), and all other provider services (5%). Medical specialties received increased PFPs for care of patients with COPD and HCT < 38% ($90 and $521, respectively) and for the pulmonary complications ($2471) and sepsis ($2714) that correlated with those patient comorbidities; surgeons did not. Operative duration, mesh size, and separation of components were associated with increased surgeon PFPs (p < .05). At 6 months, wound complications were associated with increased surgeon and radiology payments (p < .01). Management of acute comorbid conditions and the associated higher postoperative morbidity is not reimbursed to the surgeon under the 90-day global fee. These represent opportunity costs of care that pressure busy surgeons to select against these patients or to delegate more management to their medical specialty colleagues, thereby increasing total system costs. A comorbid risk adjustment of procedural reimbursement is warranted. In negotiating bundled payments, surgeon groups should keep in mind that surgeon reimbursement, unlike medical specialty and hospital reimbursement, have been bundled since the 1990s.

High-volume general practitioners in Alberta: a descriptive analysis.

Alberta is considering capping daily fee-for-service physician billings, but little is known about high-volume practice in the province and its impact on patient health outcomes. In this initial study, we conducted a descriptive analysis of general practitioners' patient volumes and billing practices in relation to associated practitioner demographic characteristics. We conducted a retrospective descriptive analysis of the associations of practitioner characteristics, including full-time versus non-full-time practice, provider sex, years in practice, geographic location and international medical graduate status, with high-volume (> 50 visits/d) practice using general practice billing data from 2011 to 2016. Use of general practitioner service codes was described and compared by general practitioner volume status, with adjustment for physician demographic characteristics and geographic parameters. We included 3465 general practitioners practising fee-for-service in Alberta between 2011 and 2016, of whom 233 (6.7%) were identified as high-volume providers. Physicians who had been in practice longer (odds ratio [OR] 1.04 per year, 95% confidence interval [CI] 1.02-1.05) and international medical graduates (OR 1.89, 95% CI 1.40-2.54) were more likely to exceed 50 patient visits/day. Female physicians were less likely to exceed 50 patient visits/day (OR 0.14, 95% CI 0.07-0.28). Rural practice location was negatively associated with high-volume practice (OR 0.87, 95% CI 0.79-0.95) when we controlled for zone within the province. Zone 5 (North) was associated with high-volume practice (OR 1.95, 95% CI 1.06-3.58). Less than full-time practice was prevalent (1836 providers [53.0%]). High-volume general practitioners billed fewer service codes requiring longer visits, except for the most highly remunerated code (patients with complex health issues). These results can inform policy-makers when considering payment system changes. Our next step is to examine the association of high-volume practice with outcomes important to patients, such as evidence of treatment failure (emergency department visits and hospital admissions) for conditions sensitive to primary care management.

Implementation of electronic charting is not associated with significant change in physician productivity in an academic emergency department.

ObjectivesTo compare physician productivity and billing before and after implementation of electronic charting in an academic emergency department (ED).Materials and methodsThis retrospective, blinded, observational study compared the 6 months pre-implementation (January to June 2012) with the 6 months post-implementation 1 year later (January to June 2013). Thirty-one ED physicians were recruited, with each physician acting as his/her own control in a before-after design. Productivity was measured via total number of encounters and “productivity index” defined as worked relative value units divided by the clinical full-time equivalent. Values for charges, encounters, and productivity index were determined during each study period and separately for procedures, observational stays, and critical care.ResultsNo differences were found for total productivity index per month (758 [623-876] pre-group vs. 756 [673-886] post-group; P = 0.30). There was, however, a 9% decrease in total encounters per month (138 [101-163] pre-group vs. 125 [99-159] post-group; P = 0.01). Significant decreases were seen across all observation stay categories. Conversely, significant increases were seen across all critical care categories. There was no difference in total charges per month.DiscussionThis is one of few studies to demonstrate minimal disruption in physician productivity after transitioning to electronic documentation. The reasons for these findings are likely multi-factorial.ConclusionIn this study, implementation of electronic charting was not associated with decreases in productivity or billing for total ED care, but may be associated with increases for critical care and decreases for observational stays.

A Comparison of Mental Health Performance Indicators in Canada

BackgroundThere is growing recognition of the need for consistent and reliable reporting on mental health and addiction (MHA) services in Canada. While there have been improvements in the area of reporting within provinces, comparable measures across provinces are often confined to hospitalization data. The aim of this project was to test the feasibility of creating MHA performance indicators that could be compared across Canadian provinces.&#x0D; MethodsA team of scientists from five provinces collaboratively developed the following six MHA performance indicators for ages 10 and up, using hospital, emergency, physician billing and mortality data (pop. 33.2 million):&#x0D; &#x0D; Access to the same family physician for people with MHA problems&#x0D; First contact for MHA problems was in an emergency department&#x0D; Physician follow-up after hospitalization for MHA problems&#x0D; Rate of suicide attempts among people diagnosed with MHA problems&#x0D; Suicide rates among people diagnosed with MHA problems&#x0D; Mortality of people diagnosed with MHA problems&#x0D; &#x0D; To facilitate meaningful inter-provincial comparisons, consensus definitions and standardized analytic processes were developed. Within age groups, 95% CI’s were calculated to determine if there were significant differences across years within age bands. Results are presented in a comparative format.&#x0D; FindingsWe found similar patterns across provinces but significant variation in the absolute rates, with no province consistently best across all indicators. In general, outcomes were poor among adolescents and young adults compared to older groups.&#x0D; ConclusionsThe results of this pilot indicate the process is feasible and meaningful. Future work could include generating comparisons on a regular basis to track system improvement; development of other measures of importance to stakeholders; and the expansion of the process to other provinces and territories. To our knowledge, this is the first report of provincial teams working collaboratively to generate comparable data on the performance of mental health services in Canada.

Using the CollaboraKTion framework to report on primary care practice recruitment and data collection: costs and successes in a cross-sectional practice-based survey in British Columbia, Ontario, and Nova Scotia, Canada

BackgroundAcross Canada and internationally we have poor infrastructure to regularly collect survey data from primary care practices to supplement data from chart audits and physician billings. The purpose of this work is to: 1) examine the variable costs for carrying out primary care practice-based surveys and 2) share lessons learned about the level of engagement required for recruitment of practices in primary care.MethodsThis work was part of a larger study, TRANSFORMATION that collected data from three provincial study sites in Canada. We report here on practice-based engagement. Surveys were administered to providers, organizational practice leads, and up to 20 patients from each participating provider. We used the CollaboraKTion framework to report on our recruitment and engagement strategies for the survey work. Data were derived from qualitative sources, including study team meeting minutes, memos/notes from survey administrators regarding their interactions with practice staff, and patients and stakeholder meeting minutes. Quantitative data were derived from spreadsheets tracking numbers for participant eligibility, responses, and completions and from time and cost tracking for patient survey administration.ResultsA total of 87 practices participated in the study (n = 22 in BC; n = 26 in ON; n = 39 in NS). The first three of five CollaboraKTion activities, Contacting and Connecting, Deepening Understandings, and Adapting and Applying the Knowledge Base, and their associated processes were most pertinent to our recruitment and data collection. Practice participation rates were low but similar, averaging 36% across study sites, and completion rates were high (99%). Patient completion rates were similarly high (99%), though participation rates in BC were substantially lower than the other sites. Recruitment and data collection costs varied with the cost per practice ranging from $1503 to $1792.ConclusionsA comprehensive data collection system in primary care is possible to achieve with partnerships that balance researcher, clinical, and policy maker contexts. Engaging practices as valued community members and independent business owners requires significant time, and financial and human resources. An integrated knowledge translation and exchange approach provides a foundation for continued dialogue, exchange of ideas, use of the information produced, and recognises recruitment as part of an ongoing cycle.

32 A population-based study of melanoma brain metastasis treatment: Has new progress in systemic therapy and new technology in radiotherapy improved patient outcomes?

Background: Outcomes for patients with melanoma brain metastases (MBM) have been poor. New radiotherapy technologies and systemic agents have improved outcomes. Outcomes have rarely been studied at the population-level. We undertook a population-based study investigating changes in management and outcome for patients with MBM in Ontario from 2007-2016. Methods: This was a retrospective population-based cohort study of patients treated for MBM in Ontario from 2007-2016. Melanoma was identified through the Ontario Cancer Registry. Treatments and outcome were described by era (2007-2009, 2010-2012, 2013-2016). Treatment with cranial radiotherapy and drugs were defined using Cancer Care Ontario data and supplemented by physician billing and drug reimbursement data. Neurosurgery was identified using CIHI hospital records. Time to event was investigated using Kaplan-Meier curves. Results: From January 2007-June 2016, 1096 patients with MBM were treated. Whole brain radiation therapy was the first brain-directed treatment in 75.5% of patients in 2007-2009, dropping to 52.0% for 2013-2016. Patients receiving stereotactic radiation or other conformal techniques as the first brain treatment increased from 3.4% in 2007-2009 to 21.3% 2013-2016. Use of BRAF/MEK inhibitors and immunotherapy increased: &lt;2.0% in 2007-2009 to 40.9% 2013-2016. One-year and two-year overall survival (OS) following first brain-directed treatment was greater in 2013-2016: 21.8% at one year and 13.8% after two years (Wilcoxon p=0.001). This compared to 12.3% and 6.4% 2007-2009, and 10.7% and 5.5% 2010-2012. Conclusion: The advent of new radiation technologies and systemic treatments for MBM was associated with increased survival and greater avoidance of whole brain radiotherapy.

Risk factors for infection, revision, death, blood transfusion and longer hospital stay 3months and 1year after primary total hip or knee arthroplasty.

Total joint replacement (TJR) is increasingly performed in older patients with more comorbidities, who are considered at higher risk for postoperative complications. We aimed to identify and calculate the odds ratio of the risk factors for infection, revision and death 3 months and 1 year after TJR as well as for postoperative blood transfusion and longer hospital stay. We analyzed all primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) cases in Nova Scotia between Apr. 1, 2000, and Mar. 31, 2014, as identified from the Discharge Abstract Database. We used the Charlson Comorbidity Index as a surrogate measure of comorbidities. We used hospital and physician billings data and Nova Scotia Vital Statistics data to identify the postoperative events in this cohort. A total of 10 123 primary THA and 17 243 primary TKA procedures were performed during the study period. The mean patient age was 66.1 (standard deviation 11.7) years and 67.1 (standard deviation 9.3) years, respectively. With THA, the risk of infection was higher in patients with heart failure and those with diabetes. For TKA, liver disease and blood transfusion were associated with a higher risk of infection. Revision rates were higher among patients with hypertension and those with paraparesis/hemiparesis for THA, and among patients with metastatic disease for TKA. Significant risk factors for death included metastatic disease, older age, heart failure, myocardial infarction, dementia, rheumatologic disease, renal disease, blood transfusion and cancer. Multiple medical comorbidities and older age were associated with higher rates of blood transfusion and longer hospital stay. We have identified the risk factors associated with higher rates of postoperative complications and longer hospital stay after TJR. The results enable individualized risk stratification during the preoperative consultation.

Carotid body size measured by computed tomographic angiography in individuals born prematurely

PurposeWe tested the hypothesis that the carotid bodies would be smaller in individuals born prematurely or exposed to perinatal oxygen therapy when compared individuals born full term that did not receive oxygen therapy. MethodsA retrospective chart review was conducted on patients who underwent head/neck computed tomography angiography (CTA) at the Mayo Clinic between 10 and 40 years of age (n = 2503). Patients were identified as premature ( < 38 weeks) or receiving perinatal oxygen therapy by physician completion or billing codes (n = 16 premature and n = 7 receiving oxygen). Widest axial measurements of the carotid body images captured during the CTA were performed. ResultsCarotid body visualization was possible in 43% of patients and 52% of age, sex, and body mass index (BMI)-matched controls but only 17% of juvenile preterm subjects (p = .07). Of the carotid bodies that could be visualized, widest axial measurements of the carotid bodies in individuals born prematurely (n = 7, 34 ± 4 weeks gestation, birth weight: 2460 ± 454 g; average size: 2.5 ± 0.2 cm) or individuals exposed to perinatal oxygen therapy (n = 3, 38 ± 2 weeks gestation, Average size: 2.2 ± 0.1 cm) were not different when compared to controls (2.3 ± 0.2 cm and 2.3 ± 0.2 cm, respectively, p > 0.05). ConclusionsCarotid body size, as measured using CTA, is not smaller in adults born prematurely or exposed to perinatal oxygen therapy when compared to sex, age, and BMI-matched controls. However, carotid body visualization was lower in juvenile premature patients. The decreased ability to visualize the carotid bodies in these individuals may be a result of their prematurity.