Physician Claims Research Articles

Hydralazine–Isosorbide Dinitrate Use in Patients With End-Stage Kidney Disease on Dialysis

IntroductionThe combination of hydralazine–isosorbide dinitrate (H-ISDN) has potential as a heart failure (HF) therapy in the setting of maintenance dialysis.MethodsIn this retrospective study, we analyzed the efficacy of H-ISDN using United States Renal Data System (USRDS) data. We identified all adult patients with a history of HF on maintenance dialysis between January 1, 2011, and December 31, 2016, with at least 1 prescription for H-ISDN. Baseline characteristics, prescriptions, and outcomes were retrieved from institutional and physician claims. The primary outcome was death from any cause. Additional outcomes included cardiovascular death, sudden cardiac death, hospitalization for HF, an inpatient diagnosis of myocardial infarction (MI), or new-onset atrial fibrillation. Stabilized inverse probability weights were estimated using relevant baseline characteristics and were used in Cox proportional hazards regression.ResultsWe identified 6306 patients who were treated with H-ISDN and 75,509 patients who did not receive H-ISDN. The crude all-cause mortality rate was lower in patients treated with H-ISDN (16.0 events/100 patient years [PYs]) than in nonusers (27.9/100-PY). H-ISDN use was independently associated with lower mortality: hazard ratio (HR) 0.48 (95% CI 0.43–0.54). Cardiovascular death and sudden cardiac death were less common among H-ISDN users than nonusers, Weighted HR was 0.62 (95% CI 0.53–0.71) and 0.62 (95% CI 0.52–0.73), respectively. In contrast, HF admission and MI were more frequent in patients treated with H-ISDN (195.5 and 18.0 events/100-PY) compared with nonusers (73.4 and 10.2 events/100-PY).ConclusionH-ISDN therapy may improve cardiovascular outcomes in maintenance dialysis patients with HF.

Accurate classification of carotid endarterectomy indication using physician claims and hospital discharge data

Background and purposeStudies of carotid endarterectomy (CEA) require stratification by symptomatic vs asymptomatic status because of marked differences in benefits and harms. In administrative datasets, this classification has been done using hospital discharge diagnosis codes of uncertain accuracy. This study aims to develop and evaluate algorithms for classifying symptomatic status using hospital discharge and physician claims data.MethodsA single center’s administrative database was used to assemble a retrospective cohort of participants with CEA. Symptomatic status was ascertained by chart review prior to linkage with physician claims and hospital discharge data. Accuracy of rule-based classification by discharge diagnosis codes was measured by sensitivity and specificity. Elastic net logistic regression and random forest models combining physician claims and discharge data were generated from the training set and assessed in a test set of final year participants. Models were compared to rule-based classification using sensitivity at fixed specificity.ResultsWe identified 971 participants undergoing CEA at the Vancouver General Hospital (Vancouver, Canada) between January 1, 2008 and December 31, 2016. Of these, 729 met inclusion/exclusion criteria (n = 615 training, n = 114 test). Classification of symptomatic status using hospital discharge diagnosis codes was 32.8% (95% CI 29–37%) sensitive and 98.6% specific (96–100%). At matched 98.6% specificity, models that incorporated physician claims data were significantly more sensitive: elastic net 69.4% (59–82%) and random forest 78.8% (69–88%).ConclusionDischarge diagnoses were specific but insensitive for the classification of CEA symptomatic status. Elastic net and random forest machine learning algorithms that included physician claims data were sensitive and specific, and are likely an improvement over current state of classification by discharge diagnosis alone.

Bacillus Calmette-Guerin vaccination and multiple sclerosis: A population-based birth cohort study in Quebec, Canada.

The bacillus Calmette-Guerin (BCG) vaccine could reduce the incidence of multiple sclerosis (MS) through immunomodulation. Previous studies, presenting some limitations, reported no association. We re-examined this association in a large cohort focusing on relapsing-remitting MS (RRMS). The cohort included 400,563 individuals, and was linked with the Quebec provincial BCG vaccination registry and administrative health data. Individuals were followed up from 1983 to 2014 and then within Period 1 (1983-1996) and Period 2 (1997-2014), for the occurrence of MS. Incident MS cases were defined as those with ≥3hospital or physician claims for MS. Subjects with ≥1 drug reimbursement for MS disease-modifying therapies were classified as RRMS. Cox proportional hazards regression was used to estimate hazard ratios (HRs) over the follow-ups, adjusting for potential confounders. Possible effect modification due to sex was assessed. A total of 178,335 (46%) individuals were BCG vaccinated. There were 274 (0.06%) incident MS cases identified in 1983-1996, and 1433 (0.4%) in 1997-2014. No association was found with RRMS, either in Period 1 (adjusted HR [HRadj ]=0.96, 95% confidence interval [CI] = 0.63-1.45; 96 cases) or in Period 2 (HRadj =1.02, 95% CI = 0.85-1.23; 480 cases). The remaining MS cases, for whom the phenotype was unknown, were positively associated with BCG over the entire follow-up (HRadj =1.25, 95% CI = 1.10-1.41; 1131 cases) and in Period 2 (HRadj =1.33, 95% CI = 1.17-1.52; 953 cases). No interaction with sex was found. Findings suggest that BCG vaccination does not decrease the risk of RRMS, and that future studies should consider phenotypes of MS.

Early life Bacillus Calmette-Guerin vaccination and incidence of type 1, type 2, and latent autoimmune diabetes in adulthood

AimsBacillus Calmette-Guerin (BCG) vaccination limits blood sugar elevations and autoimmunity. Previous studies focused on type 1 diabetes among children, despite possible effects on other phenotypes later in life. We studied associations between BCG vaccination and type 1, type 2 and latent autoimmune diabetes (LADA) in adulthood. MethodsA 1970–1974 birth cohort was linked with the BCG vaccination registry and administrative health data of Quebec. 396,118 people aged 22–44 years were followed-up for diabetes mellitus (DM) onset. Incident DM cases were subjects with ≥1 hospitalization or ≥2 physician claims related to DM over a 2-year period. Type 1 diabetes, type 2 diabetes, and LADA cases were individuals with ≥1 reimbursement of insulin, oral antidiabetic agent, or both. Cox proportional regressions were used to estimate hazard ratios (HR), adjusting for potential confounders. ResultsForty-four percent of subjects were BCG vaccinated, 88% of these before age 1. For type 1 diabetes, no association was found before 30 years old, but vaccinated subjects had a lower risk of this phenotype after age 30 (HRadj= 0.65, 95% CI: 0.44–0.95). BCG vaccination was associated with a lower risk of type 2 diabetes (HRadj=0.85, 95% CI: 0.79–0.92), whereas no association was observed for LADA (HRadj=1.30, 95% CI: 0.71–2.38). Results did not differ by sex. ConclusionsEarly life BCG vaccination was associated with lower risks of both type 1 and type 2 diabetes from early to middle adulthood, but not of LADA. Future studies should explore these long-term associations, while distinguishing diabetes phenotypes.

Enhancing Diabetes Surveillance Across Alberta by Adding Laboratory and Pharmacy Data to the National Diabetes Surveillance System Methods

ObjectivesThe National Diabetes Surveillance System (NDSS) case definition, which identifies a case of diabetes using administrative health records as “two physician claims or one hospital discharge abstract record, within a 2-year period for a diagnosis bearing International Classification of Disease codes for diabetes,” was compared with expanded case definitions, including pharmacy (PHARM) and laboratory (LAB) data. The PHARM definition included any therapeutic antihyperglycemic agents, and the LAB definition included thresholds of ≥1 glycated hemoglobin measurement of ≥6.5%, or 2 instances of random glucose ≥11.1 mmol/L or fasting glucose ≥7.0 mmol/L. MethodsIn this retrospective study we used administrative data from the Diabetes Infrastructure for Surveillance, Evaluation, and Research project. Descriptive statistics were used to characterize participants by several subgroups. ResultsThe NDSS identified 291,242 diabetes cases, indicating a provincial prevalence of 6.83%. Using LAB plus PHARM identified 52,040 additional cases, so the combination of NDSS or LAB or PHARM identified the largest number of cases (n=343,282), increasing the diabetes prevalence estimate to 8.06%. These 3 sources resulted in 7 unique subsets: NDSS only (n=42,606), PHARM only (n=16,310), LAB only (n=32,202), NDSS+LAB (n=32,582), NDSS+PHARM (n=22,503), LAB+PHARM (n=3,528) and NDSS+LAB+PHARM (n=193,551). Refinement using demographic and clinical characteristics allowed presumptive cases of polycystic ovarian syndrome to be excluded. ConclusionsThe widely used NDSS case definition can be enhanced by the addition of LAB and PHARM data. Including PHARM and LAB data identified subsets of the diabetes population, which can maximize the yield for detection of diabetes cases in Alberta and provide a richer understanding of this population to target interventions to improve health outcomes.

Technology adoption by primary care physicians.

We study primary care physicians' prevention and monitoring technology adoption. Physicians' adoption decisions are based on benefits and costs, which depend on payment incentives, educational assistance, and market characteristics. The empirical study uses national Norwegian register and physician claims data between 2009 and 2014. In 2006, a new annual comprehensive checkup for Type 2 diabetic patients was introduced. A physician collects a fee for each checkup. In 2013, an education assistance program was introduced in two Norwegian counties. We estimate adoption decisions by fixed-effect regressions, and two-part and hazard models. We use a difference-in-difference model to estimate the education program impact. Fixed-effect estimations and separate analyses of physicians who have moved between municipalities support a peer effect. The education program has a strongly positive effect, which is positively associated with a physician's number of diabetic patients, and the fraction of physician-adopters in the same market.

Association between Bacillus Calmette-Guerin vaccination and type 1 diabetes in adolescence: A population-based birth cohort study in Quebec, Canada

The Bacillus Calmette-Guerin (BCG) vaccine could reduce the incidence of type 1 diabetes through non-specific immunomodulation. Previous epidemiological studies, presenting some limitations, report no association. We examined this association of early life BCG vaccination and age at vaccination with type 1 diabetes incidence in adolescence in a large representative cohort in Quebec.The cohort included 387,704 individuals born in Quebec between 1970 and 1974 whose BCG vaccination status was determined from a provincial registry. Individuals were followed up from 1985 to their 19th birthday (maximum to 1993) for their use of physician services. Individuals were defined as type 1 diabetes cases if they had ≥4 related physician claims over a 2-year period, with at least 30 days between two claims. Cox proportional hazards regression was used to estimate the association of BCG vaccination and age at vaccination with type 1 diabetes. Covariates were selected based on a directed acyclic graph. Interaction according to sex was evaluated.A total of 178,133 (45.9%) individuals were vaccinated and 442 (0.11%) incident cases of type 1 diabetes were identified. The risk of type 1 diabetes was similar in vaccinated compared with unvaccinated individuals (adjusted hazard ratio = 1.06 [95% CI: 0.88–1.29]). There was no association with age at vaccination, and results did not differ by sex (Interaction, p = 0.60).Our results suggest that BCG vaccination does not prevent type 1 diabetes in adolescence.

P.035 Health System Utilization and Medication Use among Adults with Migraine in Alberta: An observational cohort study using Alberta administrative health data

Background: Migraine is costly to governments. Despite significant burden, Canada lacks population data regarding migraine prevalence, resource and medication utilization. We sought to characterize the demographics, health resource utilization, and medication use in an adult migraine cohort in Alberta. Methods: Migraine cohort: previously validated case definition of migraine (ICD 10 + dispensation of abortive and/or preventative migraine drug (04/2010-03/2016). Patients over 18 years, followed three years from index date [first dispensation of migraine medication]. Health resource utilization (HRU) assessed by emergency department (ED) visits, hospital admission and physician claims. Medication assessed province-wide dispensation database linkage. Patient demographics and Charlson Comorbidity Index (CCI) included. Results: Over 5 years: 53,333 migraine cases identified (mean age 40.5 years, 79% female). Common comorbidities: hypertension, COPD, diabetes mellitus, cancer, cerebrovascular disease. Mean CCI 0.55 (SD 1.06). Metropolitan patients: 48%, urban 34.6%, rural 17.4%. Initial migraine diagnosis: 46% by GP, 31% in ED. Rural patients present more to ED/hospital for care in 3-year follow-up (IRR 2.95 [2.83, 3.08]). Conclusions: Our migraine case definition is more specific than sensitive and underestimates Alberta’s migraine prevalence. Higher female prevalence as expected. Rurally, migraine care largely occurs in ED/hospital. Study of prevalence, HRU and medications may help inform health policy in Alberta and Canada.

Gender-based differences in physician payments within the fee-for-service system in Ontario: a retrospective, cross-sectional study.

Background:Differences in physician income by gender have been described in numerous jurisdictions, but few studies have looked at a Canadian cohort with adjustment for confounders. In this study, we aimed to understand differences in fee-for-service payments to men and women physicians in Ontario.Methods:We conducted a cross-sectional analysis of all Ontario physicians who submitted claims to the Ontario Health Insurance Plan (OHIP) in 2017. For each physician, we gathered demographic information from the College of Physicians and Surgeons of Ontario registry. We compared differences in physician claims between men and women in the entire cohort and within each specialty using multivariable linear regressions, controlling for length of practice, specialty and practice location.Results:We identified a cohort of 30 167 physicians who submitted claims to OHIP in 2017, including 17 992 men and 12 175 women. When controlling for confounding variables in a linear mixed-effects regression model, annual physician claims were $93 930 (95% confidence interval $88 434 to $99 431) higher for men than for women. Women claimed 74% as much as men when adjusting for covariates. This discrepancy was present in nearly all specialty categories. Men claimed more than women throughout their careers, with the greatest gap 10–15 years into practice.Interpretation:We found a gender gap in fee-for-service claims in Ontario, with women claiming less than men overall and in nearly every specialty. Further work is required to understand the root causes of the gender pay gap.

IBD Disability Index Is Associated With Both Direct and Indirect Costs of Inflammatory Bowel Disease.

We aimed to determine both direct (medical) and indirect (lost wages) costs of IBD and the association between the degree of IBD-related disability and extent of IBD-related costs. Persons age 18-65 from the population-based University of Manitoba IBD Research Registry completed a survey including the IBD Disability Index (IBDDI) and questions related to employment, missed work (absenteeism), and reduced productivity at work (presenteeism). Administrative health data including surgeries, hospitalizations, physician claims, and prescriptions were linked to the survey and assessed. To calculate annual wage loss, number of days of missed work was multiplied by the average wage in Manitoba for the given occupation per Statistics Canada. Costs were adjusted to 2016-17 Canadian dollars. Using descriptive and regression analysis, we explored the association between IBDDI and annual direct and indirect costs associated with IBD. Average annual medical costs rose from $1918 among those with IBDDI 0-4 to $9,993 among those with IBDDI 80-86. Average annual cost of lost work rose from $0 among those with IBDDI 0-4 to $30,101 among those with IBDDI 80-86. Using linear regression, each additional unit of IBDDI was associated with an increase of $77 in annual medical cost (95% CI, $52-102; P < .001) and an increase of $341 in annual cost of lost wages (95% CI, $288-395; P < .001). Costs related to IBD are significantly associated with the degree of IBD-related disability. Among the approximate 30% of the IBD population with IBDDI scores ≥40, the indirect costs of absenteeism and presenteeism accounts for ~75% of the total IBD-related costs.

Prediction of imminent fracture risk in Canadian women and men aged 45years or older: external validation of the Fracture Risk Evaluation Model (FREM).

The FREM is a tool developed from Danish public health registers (hospital diagnoses) to identify individuals over age 45years at high imminent risk of major osteoporotic fractures (MOF) and hip fracture (HF). In this study, our aim was to examine the ability of FREM to identify individuals at high imminent fracture risk in women and men from Manitoba, Canada. We used the population-based Manitoba Bone Mineral Density (BMD) Program registry, and identified women and men aged 45years or older undergoing baseline BMD assessment with 2years of follow-up data. From linked population-based data sources, we constructed FREM scores using up to 10years of prior healthcare information. The study population comprised 74,828 subjects, and during the 2years of observation, 1612 incident MOF and 299 incident HF occurred. We found significant fracture risk stratification for all FREM scores, with AUC estimates of 0.63-0.66 for MOF for both sexes and 0.84 for women and 0.65-0.67 for men for HF. FREM performed better than age alone but not as well as FRAX® with BMD. The inclusion of physician claims data gave slightly better performance than hospitalization data alone. Overall calibration for 1-year MOF prediction was reasonable, but HF prediction was overestimated. In conclusion, the FREM algorithm shows significant fracture risk stratification when applied to an independent clinical population from Manitoba, Canada. Overall calibration for MOF prediction was good, but hip fracture risk was systematically overestimated indicating the need for recalibration.

Measuring Substance-Related Disorders Using Canadian Administrative Health Databanks: Interprovincial Comparisons of Recorded Diagnostic Rates, Incidence Proportions and Mortality Rate Ratios.

Assessing temporal changes in the recorded diagnostic rates, incidence proportions, and health outcomes of substance-related disorders (SRD) can inform public health policymakers in reducing harms associated with alcohol and other drugs. To report the annual and cumulative recorded diagnostic rates and incidence proportions of SRD, as well as mortality rate ratios (MRRs) by cause of death among this group in Canada, according to their province of residence. Analyses were performed on linked administrative health databases (AHD; physician claims, hospitalizations, and vital statistics) in five Canadian provinces (Alberta, Manitoba, Ontario, Québec, and Nova Scotia). Canadians 12 years and older and registered for their provincial healthcare coverage were included. The International Classification of Diseases (ICD-9 or ICD-10 codes) was used for case identification of SRD from April 2001 to March 2018. During the study period, the annual recorded SRD diagnostic rates increased in Alberta (2001-2002: 8.0‰; 2017-2018: 12.8‰), Ontario (2001-2002: 11.5‰; 2017-2018: 14.4‰), and Nova Scotia (2001-2002: 6.4‰; 2017-2018: 12.7‰), but remained stable in Manitoba (2001-2002: 5.5‰; 2017-2018: 5.4‰) and Québec (2001-2002 and 2017-2018: 7.5‰). Cumulative recorded SRD diagnostic rates increased steadily for all provinces. Recorded incidence proportions increased significantly in Alberta (2001-2002: 4.5‰; 2017-2018: 5.0‰) and Nova Scotia (2001-2002: 3.3‰; 2017-2018: 3.8‰), but significantly decreased in Ontario (2001-2002: 6.2‰; 2017-2018: 4.7‰), Québec (2001-2002: 4.1‰; 2017-2018: 3.2‰) and Manitoba (2001-2002: 2.7‰; 2017-2018: 2.0‰). For almost all causes of death, a higher MRR was found among individuals with recorded SRD than in the general population. The causes of death in 2015-2016 with the highest MRR for SRD individuals were SRD, suicide, and non-suicide trauma in Alberta, Ontario, Manitoba, and Québec. Linked AHD covering almost the entire population can be useful to monitor the medical service trends of SRD and, therefore, guide health services planning in Canadian provinces.

Association of Surgical Experience With Risk of Complication in Total Hip Arthroplasty Among Patients With Severe Obesity

Severe obesity is a risk factor for major early complications after total hip arthroplasty (THA). To determine the association between surgeon experience with THA in patients with severe obesity and risk of complications. This retrospective population-based cohort study was performed in Ontario, Canada, from April 1, 2007, to March 31, 2017, with data analysis performed from March 2020 to January 2021. A cohort of patients who received a primary THA for osteoarthritis and who also had severe obesity (body mass index [calculated as weight in kilograms divided by height in meters squared] ≥40) at the time of surgery was defined. These patients were identified using the Canadian Institute for Health Information Discharge Abstract Database and physician claims from the Ontario Health Insurance Plan. Generalized estimating equations were used to determine the association between overall THA and severe obesity-specific THA surgeon volume and the occurrence of complications after controlling for potential confounders. The study hypothesized that surgeon experience specific to patients with severe obesity could further reduce the risk of complications. Primary THA. Complications were considered as a composite outcome (revision, infection requiring surgery, or dislocation requiring reduction), within 1 year of surgery. This was defined before the study, as was the study hypothesis. A total of 4781 eligible patients was identified. The median age was 63 (interquartile range [IQR], 56-69) years, and 3050 patients (63.8%) were women. Overall, 186 patients (3.9%) experienced a surgical complication within 1 year of surgery. The median overall THA surgeon volume was 70 (IQR, 46-106) cases/y, whereas the median obesity-specific surgeon volume was 5 (IQR, 2-9) cases/y. After controlling for patient and hospital factors, greater obesity-specific THA surgeon volume (adjusted odds ratio per additional 10 cases, 0.65 [95% CI, 0.47-0.89]; P = .007), but not greater overall THA surgeon volume (adjusted odds ratio per 10 additional cases, 0.97 [95% CI, 0.93-1.02]; P = .24), was associated with a reduced risk of complication. Increased surgeon experience performing THA in patients with severe obesity was associated with fewer major surgical complications. These findings suggest that surgeon experience is required to mitigate the unique anatomical challenges posed by surgery in patients with severe obesity. Referral pathways for patients with severe obesity to surgeons with high obesity-specific THA volume should be considered.

Exposure to ultrafine particles and the incidence of asthma in children: A population-based open cohort study in Montreal, Canada

BACKGROUND AND AIM: Asthma is the most prevalent chronic respiratory disease in children and represents an important burden on health care systems. The association between air pollution and asthma is well established, however the role of ultrafine particles (UFPs) remains unclear. We evaluated the association between long-term exposure to UFPs and childhood-onset asthma in a population-based birth cohort in Montreal, Canada. METHODS: The cohort was constructed from the Quebec Integrated Chronic Disease Surveillance System and included all children born in Quebec between 2000 and 2015 who were resident of Montreal. Case definitions consisted of at least two physician claims with a diagnosis of asthma within a two-year period or one hospital discharge with a primary or secondary diagnosis of asthma. Annual concentrations of UFPs and of nitrogen dioxide (NO2) were estimated from land use regression models developed for Montreal and assigned at participants’ residence over the follow-up using their residential postal codes. The association between UFPs and childhood asthma onset was estimated with a Cox proportional hazards model stratified for sex and adjusted for age, neighbourhood material and social deprivation, calendar year and co-exposure to NO2. RESULTS:The cohort included 352,966 children, with 30,825 incident asthma cases. The annual average concentrations were 24,427 particles/cm3 for UFPs and 18.55 ppb for NO2. In the single pollutant model, the adjusted hazard ratio (HR) per interquartile range (IQR) increase in UFPs was 0.990 (95% CI: 0.983, 0.997). The two-pollutant model showed no association for UFPs (HR per IQR = 0.986; 95% CI: 0.979, 0.997) but a positive association for NO2 (HR per IQR = 1.038; 95% CI: 1.013, 1.051). CONCLUSIONS:In this population-based birth cohort, childhood asthma onset was not associated with UFPs but positively associated with NO2 estimated at participants’ residential location. KEYWORDS: Air pollution, Particulate matter, Asthma, Respiratory outcomes, Children's environmental health

Effect of comorbid mood and anxiety disorders on breast and cervical cancer screening in immune-mediated inflammatory disease.

We aimed to examine rates of breast and cervical cancer screening in women with immune-mediated inflammatory diseases (IMID), including inflammatory bowel disease (IBD), multiple sclerosis (MS) and rheumatoid arthritis (RA) versus a matched cohort with IMID; and examine the association of psychiatric comorbidity with screening in these populations. We conducted a retrospective cohort study in Manitoba, Canada using administrative data. We identified women with IBD, MS and RA, and controls without these IMID matched on age and region. Annually, we identified individuals with any active mood/anxiety disorder. Using physician claims, we determined the proportion of each cohort who had cervical cancer screening within three-year intervals, and mammography screening within two-year intervals. We modeled the difference in the proportion of the IMID and matched cohorts who underwent mammography; and pap tests using log-binomial regression with generalized estimating equations, adjusting for sociodemographics, comorbidity and immune therapy use. We tested for additive interactions between cohort and mood/anxiety disorder status. During 2006–2016, we identified 17,230 women with IMID (4,623 with IBD, 3,399 with MS, and 9,458 with RA) and 85,349 matched controls. Having an IMID was associated with lower (-1%) use of mammography; however, this reflected a mixture of more mammography in the IBD cohort (+2.9%) and less mammography in the MS (-4.8 to -5.2%) and RA (-1.5%) cohorts. Within the IBD, MS and RA cohorts, having an active mood/anxiety disorder was associated with more mammography use than having an inactive mood/anxiety disorder. The MS and RA cohorts were less likely to undergo Pap testing than their matched cohorts. In the absence of an active mood/anxiety disorder, the IBD cohort was more likely to undergo Pap testing than its matched cohort; the opposite was true when an active mood/anxiety disorder was present. Among women with an IMID, mood/anxiety disorder influence participation in cancer screening.

Comorbidity before and after a diagnosis of inflammatory bowel disease.

Comorbidity is an important predictor of how disease course in inflammatory bowel (IBD) evolves. To determine pre-diagnosis relative rates (RR) and post-diagnosis hazard ratios (HR) of component diseases of the Charlson Comorbidity Index (CCI) in a cohort study of persons with IBD. The University of Manitoba IBD Epidemiology Database includes all Manitobans with IBD from 1 April 1984 through 31 March 2018 and matched controls. All outpatient physician claims and hospital discharge abstracts were searched for diagnostic codes for CCI component diseases. Some diseases were collapsed into one group such that we assessed 12 conditions. We report the RR of these conditions prior to IBD and the incidence of these diagnoses after IBD. Using Cox proportional hazards regression we report post-diagnosis HR. Confidence intervals were adjusted for Bonferroni correction. The RR of cardiovascular diseases, peripheral vascular diseases, chronic pulmonary diseases, connective tissue disease/rheumatic diseases, renal disease, liver diseases, peptic ulcer disease, and cancer were all increased prior to diagnoses of IBD compared to controls. All comorbidities were increased post IBD diagnosis. The increased HR for dementia in persons with Crohn's disease was a concerning novel finding. The increased association with paraplegia/hemiplegia was unexpected. For all comorbidities, except diabetes, the age at diagnosis was younger in IBD than controls. Persons with IBD have a higher comorbidity burden than persons without IBD. Optimal care plans for persons with IBD should include an assessment for other comorbidities that include just about every other organ system.

Validation of Diagnosis and Procedure Codes for Revascularization for Peripheral Artery Disease in Ontario Administrative Databases.

To estimate the positive predictive value of diagnosis and procedure codes for open and endovascular revascularization for peripheral artery disease (PAD) in Ontario administrative databases. We conducted a retrospective validation study using population-based Ontario administrative databases (2005-2019) to identify a random sample of 600 patients who underwent revascularization for PAD at two academic centres, based on ICD-10 diagnosis codes and Canada Classification of Health Intervention procedure codes. Administrative data coding was compared to the gold standard diagnosis (PAD vs. non-PAD) and revascularization approach (open vs. endovascular) extracted through blinded hospital chart re-abstraction. Positive predictive values and 95% confidence intervals were calculated. Combinations of procedure codes with or without supplemental physician claims codes were evaluated to optimize the positive predictive value. The overall positive predictive value of PAD diagnosis codes was 87.5% (84.6%-90.0%). The overall positive predictive value of revascularization procedure codes was 94.3% (92.2%-96.0%), which improved through supplementation with physician fee claim codes to 98.1% (96.6%-99.0%). Algorithms to identify individuals revascularized for PAD had combined positive predictive values ranging from 82.8% (79.6%-85.8%) to 95.7% (93.5%-97.3%). Diagnosis and procedure codes with or without physician claims codes allow for accurate identifi-cation of individuals revascularized for PAD in Ontario administrative databases.

Association of chronic pain with comorbidities and health care utilization: a retrospective cohort study using health administrative data.

Health administrative data provide a potentially robust information source regarding the substantial burden chronic pain exerts on individuals and the health care system. This study aimed to use health administrative data to estimate comorbidity prevalence and annual health care utilization associated with chronic pain in Newfoundland and Labrador, Canada. Applying the validated Chronic Pain Algorithm to provincial Fee-for-Service Physician Claims File data (1999-2009) established the Chronic Pain (n = 184,580) and No Chronic Pain (n = 320,113) comparator groups. Applying the Canadian Chronic Disease Surveillance System coding algorithms to Claims File and Provincial Discharge Abstract Data (1999-2009) determined the prevalence of 16 comorbidities. The 2009/2010 risk and person-year rate of physician and diagnostic imaging visits and hospital admissions were calculated and adjusted using the robust Poisson model with log link function (risks) and negative binomial model (rates). Results indicated a significantly higher prevalence of all comorbidities and up to 4 times the odds of multimorbidity in the Chronic Pain Group (P-value < 0.001). Chronic Pain Group members accounted for 58.8% of all physician visits, 57.6% of all diagnostic imaging visits, and 54.2% of all hospital admissions in 2009/2010, but only 12% to 16% of these were for pain-related conditions as per recorded diagnostic codes. The Chronic Pain Group had significantly higher rates of physician visits and high-cost hospital admission/diagnostic imaging visits (P-value < 0.001) when adjusted for demographics and comorbidities. Observations made using this methodology supported that people identified as having chronic pain have higher prevalence of comorbidities and use significantly more publicly funded health services.

Provision of Dermatologic Care in a Universal Health Care System: A 17-Year Review

BackgroundLimited data is available on the burden of dermatologic disease including disease distribution and providers of care. Research is needed to facilitate health care planning and improve patient care.ObjectivesTo investigate the demographics and economics of the provision of dermatologic care in a universal health care system from fiscal year 2000 to 2016.MethodsA retrospective population-based analysis was performed on physician billing claims for dermatologic conditions from April 1, 2000 to March 31, 2017. Data came from the province of Ontario’s universal health care plan claims records accessed through IntelliHealth.ResultsDermatologic claims made up 3.6% of all physician claims, with a 20% increase seen over time. The cost of dermatologic claims increased by 70% between fiscal 2000 and 2016, with the average cost per claim increasing by 41%. However, the cost of dermatologic claims as a percentage of all health care claims experienced a decline from 3.5% in fiscal 2000 to 2.8% in fiscal 2016. Over the study period, family physicians submitted 56% to 62% of dermatologic claims, dermatologists 24% to 29%, pediatricians 3% to 4%, and internists 1%. Overall, internists billed the highest average cost per dermatologic claim ranging from $39 in 2000 to $60 in 2016, followed by pediatricians at $33 to $58, dermatologists at $28 to $39, and family physicians at $23 to $30.ConclusionsThe demographic and economic burden of dermatologic disease is changing over time, with implications for health care planning, advancing medical education, and patient care.

Delivery of Palliative Care in Acute Care Hospitals: A Population-Based Retrospective Cohort Study Describing the Level of Involvement and Timing of Inpatient Palliative Care in the Last Year of Life.

Background: Much end-of-life care is provided in hospital, yet little is known about the delivery of palliative care during end-of-life hospitalizations. Objectives: To characterize the level of palliative care involvement across hospitalizations in the last year of life. Methods: A population-based retrospective cohort study of adults in Ontario, Canada, who died between April 1, 2012, and March 31, 2017, and had at least one acute care hospitalization in their last year of life. Using linked administrative health data, we developed a hierarchy of inpatient palliative care involvement reflecting the degree to which care was delivered with palliative intent. This hierarchy was based on palliative care diagnosis and service provider codes on hospitalization records and physician claims. We examined variations in the level of palliative care involvement across key patient characteristics. Results: In the last year of life, 65.1% of hospitalizations had no indication of palliative care involvement, 16.7% had a low level of involvement, 13.5% had a medium level of involvement, and 4.7% had a high level of involvement. Most hospitalizations with palliative care involvement (85.6%) occurred in the two months before death. Compared to patients who received no inpatient palliative care, patients who received a high level of palliative care involvement tended to be younger, died of cancer, resided in urban or lower income neighborhoods, and had fewer chronic conditions. Discussion: While many hospitalizations occurred in the last year of life, the majority did not involve palliative care, and very few had a high level of palliative care involvement.