Carolyn De Coster

Variation in health services utilization among ethnic populations

Background: Although racial and ethnic disparities in health services utilization and outcomes have been extensively studied in several countries, this issue has received little attention in Canada. We therefore analyzed data from the 2001 Canadian Community Health Survey to compare the use of health services by members of visible minority groups and nonmembers (white people) in Canada. Methods: Logistic regression was used to compare physician contacts and hospital admissions during the 12 months before the survey and recent cancer screening tests. Explanatory variables recorded from the survey included visible minority status, sociodemographic factors and health measures. Results: Respondents included 7057 members of visible minorities and 114 255 white people for analysis. After adjustments for sociodemographic and health characteristics, we found that minority members were more likely than white people to have had contact with a general practitioner (adjusted odds ratio [OR] 1.28, 95% confidence interval [CI] 1.14–1.42), but not specialist physicians (OR 1.01, 95% CI 0.93–1.10). Members of visible minorities were less likely to have been admitted to hospital (OR 0.83, 95% CI 0.70– 0.98), tested for prostate-specific antigen (OR 0.64, 95% CI 0.52–0.79), administered a mammogram (OR 0.68, 95% CI 0.59–0.80) or given a Pap test (OR 0.47, 95% CI 0.39–0.56). Interpretation: Use of health services in Canada varies considerably by ethnicity according to type of service. Although there is no evidence that members of visible minorities use general physician and specialist services less often than white people, their utilization of hospital and cancer screening services is significantly less.

Identifying priorities in methodological research using ICD-9-CM and ICD-10 administrative data: report from an international consortium

BackgroundHealth administrative data are frequently used for health services and population health research. Comparative research using these data has been facilitated by the use of a standard system for coding diagnoses, the International Classification of Diseases (ICD). Research using the data must deal with data quality and validity limitations which arise because the data are not created for research purposes. This paper presents a list of high-priority methodological areas for researchers using health administrative data.MethodsA group of researchers and users of health administrative data from Canada, the United States, Switzerland, Australia, China and the United Kingdom came together in June 2005 in Banff, Canada to discuss and identify high-priority methodological research areas. The generation of ideas for research focussed not only on matters relating to the use of administrative data in health services and population health research, but also on the challenges created in transitioning from ICD-9 to ICD-10. After the brain-storming session, voting took place to rank-order the suggested projects. Participants were asked to rate the importance of each project from 1 (low priority) to 10 (high priority). Average ranks were computed to prioritise the projects.ResultsThirteen potential areas of research were identified, some of which represented preparatory work rather than research per se. The three most highly ranked priorities were the documentation of data fields in each countrys hospital administrative data (average score 8.4), the translation of patient safety indicators from ICD-9 to ICD-10 (average score 8.0), and the development and validation of algorithms to verify the logic and internal consistency of coding in hospital abstract data (average score 7.0).ConclusionThe group discussions resulted in a list of expert views on critical international priorities for future methodological research relating to health administrative data. The consortiums members welcome contacts from investigators involved in research using health administrative data, especially in cross-jurisdictional collaborative studies or in studies that illustrate the application of ICD-10.

Appropriateness of healthcare interventions: Concepts and scoping of the published literature

OBJECTIVES This report is a scoping review of the literature with the objective of identifying definitions, conceptual models and frameworks, as well as the methods and range of perspectives, for determining appropriateness in the context of healthcare delivery. METHODS To lay groundwork for future, intervention-specific research on appropriateness, this work was carried out as a scoping review of published literature since 1966. Two reviewers, with two screens using inclusion/exclusion criteria based on the objective, focused the research and articles chosen for review. RESULTS The first screen examined 2,829 abstracts/titles, with the second screen examining 124 full articles, leaving 37 articles deemed highly relevant for data extraction and interpretation. Appropriateness is defined largely in terms of net clinical benefit to the average patient and varies by service and setting. The most widely used method to assess appropriateness of healthcare services is the RAND/UCLA Model. There are many related concepts such as medical necessity and small-areas variation. CONCLUSIONS A broader approach to determining appropriateness for healthcare interventions is possible and would involve clinical, patient and societal perspectives.

Comparison and validity of procedures coded With ICD-9-CM and ICD-10-CA/CCI.

Background: The use of health administrative data in health services research is facilitated by standardized classification systems, such as the International Classification of Diseases (ICD). Canada, among other countries, recently introduced the tenth version of ICD and its accompanying Canadian Classification of Interventions (CCI). It is imperative to assess errors that could occur in administrative data due to the introduction of the new coding system. Objective: To evaluate the validity of procedure coding in hospital discharge data, comparing CCI with ICD-9-CM. Research Design: Trained reviewers examined 4008 randomly selected charts from 4 teaching hospitals in Alberta, Canada, for the presence of 30 procedures. The charts, already coded using CCI, were recoded using ICD-9-CM. Comprehensive lists of procedure codes in both systems were identified using literature, health records technicians, surgeons and online resources. Measures: Three databases were created for the same hospital discharge record, including CCI, ICD-9-CM, and chart review data. Sensitivity, specificity, positive predictive value, negative predictive value and kappa scores were calculated. Results: Compared with the chart review data, ICD-9-CM data under-reported 17 procedures, over-reported 12, and equivalently reported 1. CCI data under-reported 19 procedures, over-reported 9, and equivalently reported 2. Kappa value was within 0.1 difference between ICD-9-CM and CCI for 14 procedures. Conclusions: Both ICD-9-CM and CCI coded the more major or invasive procedures reasonably well, but were not valid for less invasive or minor procedures. CCI can be used by health services and population health researchers with as much confidence as ICD-9-CM.

Relative urgency for referral from primary care to rheumatologists: The Priority Referral Score

Timely access to rheumatology consultation is fundamental to appropriate and effective management of patients with musculoskeletal and autoimmune diseases. Yet, for a variety of reasons, limited and delayed access is commonplace. Moreover, information exchange for referral is often inadequate or poorly communicated. The objective of this work was to improve referral from primary care to rheumatology by formulating and testing a clinically coherent, reliable, and non–diagnosis‐dependent Priority Referral Score (PRS).

Validity of AHRQ patient safety indicators derived from ICD-10 hospital discharge abstract data (chart review study)

Objective To assess if the Agency for Healthcare Research and Quality patient safety indictors (PSIs) could be used for case findings in the International Classification of Disease 10th revision (ICD-10) hospital discharge abstract data. Design We identified and randomly selected 490 patients with a foreign body left during a procedure (PSI 5—foreign body), selected infections (IV site) due to medical care (PSI 7—infection), postoperative pulmonary embolism (PE) or deep vein thrombosis (DVT; PSI 12—PE/DVT), postoperative sepsis (PSI 13—sepsis)and accidental puncture or laceration (PSI 15—laceration) among patients discharged from three adult acute care hospitals in Calgary, Canada in 2007 and 2008. Their charts were reviewed for determining the presence of PSIs and used as the reference standard, positive predictive value (PPV) statistics were calculated to determine the proportion of positives in the administrative data representing ‘true positives’. Results The PPV for PSI 5—foreign body was 62.5% (95% CI 35.4% to 84.8%), PSI 7—infection was 79.1% (67.4% to 88.1%), PSI 12—PE/DVT was 89.5% (66.9% to 98.7%), PSI 13—sepsis was 12.5% (1.6% to 38.4%) and PSI 15—laceration was 86.4% (75.0% to 94.0%) after excluding those who presented to the hospital with the condition. Conclusions Several PSIs had high PPV in the ICD administrative data and are thus powerful tools for true positive case finding. The tools could be used to identify potential cases from the large volume of admissions for verification through chart reviews. In contrast, their sensitivity has not been well characterised and users of PSIs should be cautious if using them for ‘quality of care reporting’ presenting the rate of PSIs because under-coded data would generate falsely low PSI rates.

Perspectives of Canadian Stakeholders on Criteria for Appropriateness for Total Joint Arthroplasty in Patients With Hip and Knee Osteoarthritis.

As rates of total joint arthroplasty (TJA) for osteoarthritis (OA) rise, there is a need to ensure appropriate use. We undertook this study to develop criteria for appropriate use of TJA.

Follow-through after calling a nurse telephone advice line: a population-based study

BACKGROUND Nurse telephone advice (NTA) lines, a major initiative in primary health care reform, provide symptom triage and health information. Compliance studies utilizing database analysis are frequently limited to a defined population, such as children or Emergency Department (ED) users. OBJECTIVES To explore caller characteristics associated with following NTA advice to go to the ED, see a health care professional or self-care for Calgary, Canada (population 1 million). METHODS NTA data were linked with utilization data to assess ED and physician visits following a call. Four nurse advice categories were defined: go to ED, health care provider in 24 hours, health care provider in 72 hours if symptoms persist and self-care. Follow-through was defined based on health care utilization within specified time periods following the call. Logistic regression identified characteristics associated with follow-through of NTA nurse advice; characteristics included age, sex, neighbourhood income, health status, time of call and type of care protocol. RESULTS Follow-through was highest for self-care advice (83.7%), followed by ED advice (52.3%) and then 24-hour advice (43.2%). Lower follow-through on ED or 24-hour advice was associated with age <4 years, and having lower income, and the opposite was true for self-care advice. Patients with a cardiac complaint had the highest odds of following ED advice. Patients with a gastrointestinal or obstetrics/gynaecology/genitourinary complaint were less likely to follow 24-hour advice. Patients with fever were less likely to follow self-care advice. CONCLUSIONS Understanding characteristics associated with lower follow-through may help the NTA service to refine its approaches to clients.

Priority-setting tools for rheumatology disease referrals: a review of the literature

As part of a larger body of work to develop a rheumatology priority referral score, a literature review was conducted. The objective of the literature review was to identify preexisting priority-setting, triage, and referral tools/scales developed to guide referrals from primary care to specialist care/consultation usually provided by a rheumatologist. Using a combination of database, citation, Internet, and hand-searching, 20 papers were identified that related to referral prioritization in three areas: rheumatoid arthritis (RA; 5), musculoskeletal (MSK) diseases other than RA (3), and MSK diseases in general (12). No single set of priority-setting criteria was identified for rheumatologic disorders across the spectrum of patients who may be referred from primary care providers (PCPs) to rheumatologists. There appears to be more congruence on conditions at either end of the urgency spectrum with conditions such as suspected cranial arteritis or systemic vasculitis deemed to be emergency referrals and fibromyalgia and other soft-tissue syndromes deemed to be more routine referrals. Between these two extremes, there is a divergence of opinion about urgency and few papers on the issue. The exception to this is referral for early RA for which several criteria have been established. Despite the inherent complexities in developing a tool to prioritize patients referred by PCPs to rheumatologists, there are compelling reasons to proceed. With the aging of the population, the number of patients being referred to rheumatologists is expected to increase. With pharmaceutical advances, there are demonstrable benefits in early referral for some conditions. These trends have led to increased pressure on scarce rheumatological human resources. A tool to prioritize referrals is a critical component of improving access and the referral process.

Estimating Nursing Home Bed Demand: 20-Year Projection From Administrative Data and Stakeholder Input

We describe methods to project the requirement for nursing home beds in Manitoba until 2020. Three methods were developed: Trend, Recent Use, and Combined. The first two methods yielded widely divergent projections, differing by 3,400 beds. Stakeholder feedback and theoretical analysis suggested the third (Combined) method, the arithmetic mean of the first two. Model testing found the Combined method to be the most accurate. The projections have been used by RHAs for their planning activities.