Astrid Guttmann

The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) Statement

Routinely collected health data, obtained for administrative and clinical purposes without specific a priori research goals, are increasingly used for research. The rapid evolution and availability of these data have revealed issues not addressed by existing reporting guidelines, such as Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). The REporting of studies Conducted using Observational Routinely collected health Data (RECORD) statement was created to fill these gaps. RECORD was created as an extension to the STROBE statement to address reporting items specific to observational studies using routinely collected health data. RECORD consists of a checklist of 13 items related to the title, abstract, introduction, methods, results, and discussion section of articles, and other information required for inclusion in such research reports. This document contains the checklist and explanatory and elaboration information to enhance the use of the checklist. Examples of good reporting for each RECORD checklist item are also included herein. This document, as well as the accompanying website and message board (http://www.record-statement.org), will enhance the implementation and understanding of RECORD. Through implementation of RECORD, authors, journals editors, and peer reviewers can encourage transparency of research reporting.

Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada

Objective To determine whether patients who are not admitted to hospital after attending an emergency department during shifts with long waiting times are at risk for adverse events. Design Population based retrospective cohort study using health administrative databases. Setting High volume emergency departments in Ontario, Canada, fiscal years 2003-7. Participants All emergency department patients who were not admitted (seen and discharged; left without being seen). Outcome measures Risk of adverse events (admission to hospital or death within seven days) adjusted for important characteristics of patients, shift, and hospital. Results 13 934 542 patients were seen and discharged and 617 011 left without being seen. The risk of adverse events increased with the mean length of stay of similar patients in the same shift in the emergency department. For mean length of stay ≥6 v <1 hour the adjusted odds ratio (95% confidence interval) was 1.79 (1.24 to 2.59) for death and 1.95 (1.79 to 2.13) for admission in high acuity patients and 1.71 (1.25 to 2.35) for death and 1.66 (1.56 to 1.76) for admission in low acuity patients). Leaving without being seen was not associated with an increase in adverse events at the level of the patient or by annual rates of the hospital. Conclusions Presenting to an emergency department during shifts with longer waiting times, reflected in longer mean length of stay, is associated with a greater risk in the short term of death and admission to hospital in patients who are well enough to leave the department. Patients who leave without being seen are not at higher risk of short term adverse events.

Increasing incidence of paediatric inflammatory bowel disease in Ontario, Canada: evidence from health administrative data

Objective: Health administrative databases can be used to track chronic diseases. The aim of this study was to validate a case ascertainment definition of paediatric-onset inflammatory bowel disease (IBD) using administrative data and describe its epidemiology in Ontario, Canada. Methods: A population-based clinical database of patients with IBD aged <15 years was used to define cases, and patient information was linked to health administrative data to compare the accuracy of various patterns of healthcare use. The most accurate algorithm was validated with chart data of children aged <18 years from 12 medical practices. Administrative data from the period 1991–2008 were used to describe the incidence and prevalence of IBD in Ontario children. Changes in incidence were tested using Poisson regression. Results: Accurate identification of children with IBD required four physician contacts or two hospitalisations (with International Classification of Disease (ICD) codes for IBD) within 3 years if they underwent colonoscopy and seven contacts or three hospitalisations within 3 years in those without colonoscopy (children <12 years old, sensitivity 90.5%, specificity >99.9%; children <15 years old, sensitivity 89.6%, specificity >99.9%; children <18 years old, sensitivity 91.1%, specificity 99.5%). Age- and sex-standardised prevalence per 100 000 population of paediatric IBD has increased from 42.1 (in 1994) to 56.3 (in 2005). Incidence per 100 000 has increased from 9.5 (in 1994) to 11.4 (in 2005). Statistically significant increases in incidence were noted in 0–4 year olds (5.0%/year, p = 0.03) and 5–9 year olds (7.6%/year, p<0.0001), but not in 10–14 or 15–17 year olds. Conclusion: Ontario has one of the highest rates of childhood-onset IBD in the world, and there is an accelerated increase in incidence in younger children.

Patterns and Costs of Health Care Use of Children With Medical Complexity

BACKGROUND AND OBJECTIVE: Health care use of children with medical complexity (CMC), such as those with neurologic impairment or other complex chronic conditions (CCCs) and those with technology assistance (TA), is not well understood. The objective of the study was to evaluate health care utilization and costs in a population-based sample of CMC in Ontario, Canada. METHODS: Hospital discharge data from 2005 through 2007 identified CMC. Complete health system use and costs were analyzed over the subsequent 2-year period. RESULTS: The study identified 15 771 hospitalized CMC (0.67% of children in Ontario); 10 340 (65.6%) had single-organ CCC, 1063 (6.7%) multiorgan CCC, 4368 (27.6%) neurologic impairment, and 1863 (11.8%) had TA. CMC saw a median of 13 outpatient physicians and 6 distinct subspecialists. Thirty-six percent received home care services. Thirty-day readmission varied from 12.6% (single CCC without TA) to 23.7% (multiple CCC with TA). CMC accounted for almost one-third of child health spending. Rehospitalization accounted for the largest proportion of subsequent costs (27.2%), followed by home care (11.3%) and physician services (6.0%). Home care costs were a much larger proportion of costs in children with TA. Children with multiple CCC with TA had costs 3.5 times higher than children with a single CCC without TA. CONCLUSIONS: Although a small proportion of the population, CMC account for a substantial proportion of health care costs. CMC make multiple transitions across providers and care settings and CMC with TA have higher costs and home care use. Initiatives to improve their health outcomes and decrease costs need to focus on the entire continuum of care.

Transition to adult care for youths with diabetes mellitus: findings from a Universal Health Care System.

OBJECTIVES: The goals were (1) to describe rates of diabetes mellitus (DM)-related hospitalizations and retinopathy screening before and after transition to adult care and (2) to test whether different methods of transfer of care were associated with improved outcomes. METHODS: In a retrospective cohort study, we included 1507 young adults with DM of ≥5-year duration and tracked these patients until 20 years of age. RESULTS: DM-related hospitalization rates increased from 7.6 to 9.5 cases per 100 patient-years in the 2 years after transition to adult care (P = .03). Previous DM-related hospitalizations, lower income, female gender, and living in areas with low physician supply were associated with higher admission rates. With controlling for all other factors, individuals who were transferred to a new allied health care team with no change in physician were 77% less likely (relative risk: 0.23 [95% confidence interval: 0.05–0.79]) to be hospitalized after the transition than were those transferred to a new physician with either a new or no allied health care team. The rates of eye examinations were stable across the transition to adult care (72% vs 70%; P = .06). Female patients, patients with higher income, and patients with previous eye care were more likely to have an eye care visit after transfer. CONCLUSIONS: During the transition to adult health care, there is increased risk of DM-related hospitalizations, although this may be attenuated in youths for whom there is physician continuity. Eye care visits were not related to transition; however, rates were below evidence-based guideline recommendations.

Development and use of reporting guidelines for assessing the quality of validation studies of health administrative data

BACKGROUND AND OBJECTIVES Validation of health administrative data for identifying patients with different health states (diseases and conditions) is a research priority, but no guidelines exist for ensuring quality. We created reporting guidelines for studies validating administrative data identification algorithms and used them to assess the quality of reporting of validation studies in the literature. METHODS Using Standards for Reporting of Diagnostic accuracy (STARD) criteria as a guide, we created a 40-item checklist of items with which identification accuracy studies should be reported. A systematic review identified studies that validated identification algorithms using administrative data. We used the checklist to assess the quality of reporting. RESULTS In 271 included articles, goals and data sources were well reported but few reported four or more statistical estimates of accuracy (36.9%). In 65.9% of studies reporting positive predictive value (PPV)/negative predictive value (NPV), the prevalence of disease in the validation cohort was higher than in the administrative data, potentially falsely elevating predictive values. Subgroup accuracy (53.1%) and 95% confidence intervals for accuracy measures (35.8%) were also underreported. CONCLUSIONS The quality of studies validating health states in the administrative data varies, with significant deficits in reporting of markers of diagnostic accuracy, including the appropriate estimation of PPV and NPV. These omissions could lead to misclassification bias and incorrect estimation of incidence and health services utilization rates. Use of a reporting checklist, such as the one created for this study by modifying the STARD criteria, could improve the quality of reporting of validation studies, allowing for accurate application of algorithms, and interpretation of research using health administrative data.

Development of measures of the quality of emergency department care for children using a structured panel process

BACKGROUND. Performance measures are essential components of public reporting and quality improvement. To date, few such measures exist to provide a comprehensive assessment of the quality of emergency department services for children. OBJECTIVES. Our goal was to use a systematic process to develop measures of emergency department care for children (0–19 years) that are (1) based on research evidence and expert opinion, (2) representative of a range of conditions treated in most emergency departments, (3) related to links between processes and outcomes, and (4) feasible to measure. METHODS. We presented a panel of providers and managers data from emergency department use to identify common conditions across levels of patient acuity, which could be targets for quality improvement. We used a structured panel process informed by a literature review to (1) identify condition-specific links between processes of care and defined outcomes and (2) select indicators to assess these process-outcome links. We determined the feasibility of calculating these indicators using an administrative data set of emergency department visits for Ontario, Canada. RESULTS. The panel identified 18 clinical conditions for indicator development and 61 condition-specific links between processes of care and outcomes. After 2 rounds of ratings, the panel defined 68 specific clinical indicators for the following conditions: adolescent mental health problems, ankle injury, asthma, bronchiolitis, croup, diabetes, fever, gastroenteritis, minor head injury, neonatal jaundice, seizures, and urinary tract infections. Visits for these conditions account for 23% of all pediatric emergency department use. Using an administrative data set, we were able to calculate 19 indicators, covering 9 conditions, representing 20% of all emergency department visits by children. CONCLUSIONS. Using a structured panel process, data on emergency department use, and literature review, it was possible to define indicators of emergency department care for children. The feasibility of these indicators will depend on the availability of high-quality data.

Inflammatory Bowel Disease in Immigrants to Canada And Their Children: A Population-Based Cohort Study

OBJECTIVES:The risk of inflammatory bowel disease (IBD) contributed by the environment can be elucidated by assessing the risk in migrants from low prevalence to Western countries. The incidence of IBD in immigrants to Canada and their Canadian-born children was compared with nonimmigrants.METHODS:A population-based cohort of IBD patients derived from health administrative data was linked to immigration data to determine the standardized incidence of IBD in immigrants to Ontario, Canada, by region of birth between 1994 and 2010. The hazard contributed by younger age at immigration was determined. Incidence for Ontario-born children of immigrant mothers was compared with the children of nonimmigrants.RESULTS:In 2,144,660 immigrants, incidence of IBD was 7.3/100,000 person-years compared with 23.9/100,000 in 12,036,921 nonimmigrants (incidence rate ratio (IRR) 0.34, 95% CI 0.26–0.44). Incidence was lowest risk in East Asians (IRR 0.14, 95% CI 0.11–0.18) and highest in Western Europeans/North Americans (IRR 0.59, 95% CI 0.46–0.75). Increased age at immigration was associated with decreased risk of IBD (HR 0.986, 95% CI 0.982–0.990), a 14% increased risk per younger decade of life at immigration. Children of immigrants from the Middle East/North Africa, South Asia, Sub-Saharan Africa, and North America/Western Europe had similar risk of IBD as children of nonimmigrants; however, the incidence remained lower among children of immigrants from other regions.CONCLUSIONS:Younger age at arrival to Canada increased the risk of IBD in immigrants. Canadian-born children of immigrants from some regions assumed the high Canadian incidence of IBD, indicating that the underlying risk is activated with earlier life exposure to the Canadian environment in certain groups.

Validation of a health administrative data algorithm for assessing the epidemiology of diabetes in Canadian children

Guttmann A, Nakhla M, Henderson M, To T, Daneman D, Cauch‐Dudek K, Wang X, Lam K, Hux J. Validation of a health administrative data algorithm for assessing the epidemiology of diabetes in Canadian children.

Changing age demographics of inflammatory bowel disease in Ontario, Canada: a population-based cohort study of epidemiology trends.

Background:International cohort studies have reported increased incidence of inflammatory bowel disease (IBD) in recent years, and Canada has among the highest rates of IBD in the world. This study assessed incidence and prevalence of IBD in Ontario, the most populous province of Canada, to determine changing trends in age of onset. Methods:We used a population-based cohort derived from validated health administrative data consisting of all Ontario residents living with IBD from 1999 to 2008. We determined trends over time using Poisson regression analysis, assessing rates in 10-year age groups, children, adults, and the elderly. Results:In 2008, 68,071 people were living with IBD among 12,738,350 people (standardized prevalence 534.3 per 100,000 people). Between 1999 and 2008, standardized IBD incidence increased from 21.3 to 26.2 per 100,000 (2.3% per yr, P < 0.0001). Incidence of Crohns increased from 9.6 to 12.1 per 100,000 (1.9% per yr, P < 0.0001). Ulcerative colitis incidence increased from 10.7 to 12.1 per 100,000 (2.0% per yr, P < 0.0001). For IBD, incidence increased significantly in people younger than 10 years of age (9.7% per yr, P < 0.0001), 10 to 19 years of age (3.8% per yr, P < 0.0001), 30 to 39 years of age (1.8% per yr, P = 0.0006), 40 to 49 years of age (2.8% per yr, P = 0.0001), and 50 to 59 years of age (2.8% per yr, P < 0.0001). Incidence was stable in patients older than 65 years of age at diagnosis (−0.1% per yr, P = 0.73). Although incidence did not change significantly over time in adults 20 to 29 years, IBD incidence peaked in this age group. Conclusions:Ontario has among the highest prevalence of IBD in the world. Incidence of IBD increased between 1999 and 2008, owing to increased incidence in children and adults, with stable rates in elderly people. These findings demonstrate the changing age demographics and growing burden of IBD in Ontario, Canada.