Charles Burchill

Frequent Users of Emergency Departments: Developing Standard Definitions and Defining Prominent Risk Factors

STUDY OBJECTIVE We identify factors that define frequent and highly frequent emergency department (ED) users. METHODS Administrative health care records were used to define less frequent (1 to 6 visits), frequent (7 to 17 visits), and highly frequent (≥18 visits) ED users. Analyses were conducted to determine the most unique demographic, disease, and health care use features of these groups. RESULTS Frequent users composed 9.9% of all ED visits, whereas highly frequent users composed 3.6% of visits. Compared with less frequent users, frequent users were defined most strongly by their substance abuse challenges and by their many visits to primary care and specialist physicians. Substance abuse also distinguished highly frequent from frequent ED users strongly; 67.3% versus 35.9% of these patient groups were substance abusers, respectively. Also, 70% of highly frequent versus only 17.8% of frequent users had a long history of frequent ED use. Last, highly frequent users did not use other health care services proportionally more than their frequent user counterparts, suggesting that these former patients use EDs as a main source of care. CONCLUSION This research develops objective thresholds of frequent and highly frequent ED use. Although substance abuse is prominent in both groups, only highly frequent users seem to visit EDs in place of other health care services. Future analyses can investigate these patterns of health care use more closely, including how timely access to primary care affects ED use. Cluster analysis also has value for defining frequent user subgroups who may benefit from different yet equally effective treatment options.

Neurodevelopmental Assessment in Kindergarten in Children Exposed to General Anesthesia before the Age of 4 Years: A Retrospective Matched Cohort Study.

Background:Animal studies demonstrate general anesthetic (GA) toxicity in the developing brain. Clinical reports raise concern, but the risk of GA exposure to neurodevelopment in children remains uncertain. Methods:The authors undertook a retrospective matched cohort study comparing children less than 4 yr of age exposed to GA to those with no GA exposure. The authors used the Early Development Instrument (EDI), a 104-component questionnaire, encompassing five developmental domains, completed in kindergarten as the outcome measure. Mixed-effect logistic regression models generated EDI estimates for single versus multiple GA exposure and compared both single and multiple exposures by the age of 0 to 2 or 2 to 4 yr. Known sociodemographic and physical confounders were incorporated as covariates in the models. Results:A total of 18,056 children were studied: 3,850 exposed to a single GA and 620 exposed to two or more GA, who were matched to 13,586 nonexposed children. In children less than 2 yr of age, there was no independent association between single or multiple GA exposure and EDI results. Paradoxically, single exposure between 2 and 4 yr of age was associated with deficits, most significant for communication/general knowledge (estimate, −0.7; 95% CI, −0.93 to −0.47; P < 0.0001) and language/cognition (estimate, −0.34; 95% CI, −0.52 to −0.16; P < 0.0001) domains. Multiple GA exposure at the age of 2 to 4 yr did not confer greater risk than single GA exposure. Conclusions:These findings refute the assumption that the earlier the GA exposure in children, the greater the likelihood of long-term neurocognitive risk. The authors cannot confirm an association between multiple GA exposure and increased risk of neurocognitive impairment, increasing the probability of confounding to explain the results.

A population-based risk algorithm for the development of diabetes: development and validation of the Diabetes Population Risk Tool (DPoRT)

Background National estimates of the upcoming diabetes epidemic are needed to understand the distribution of diabetes risk in the population and to inform health policy. Objective To create and validate a population-based risk prediction tool for incident diabetes using commonly collected national survey data. Methods With the use of a cohort design that links baseline risk factors to a validated population-based diabetes registry, a model (Diabetes Population Risk Tool (DPoRT)) was developed to predict 9-year risk for diabetes. The probability of developing diabetes was modelled using sex-specific Weibull survival functions for people >20 years of age without diabetes (N=19 861). The model was validated in two external cohorts in Ontario (N=26 465) and Manitoba (N=9899). Predictive accuracy and model performance were assessed by comparing observed diabetes rates with predicted estimates. Discrimination and calibration were measured using a C statistic and Hosmer–Lemeshow χ2 statistic (χ2H–L). Results Predictive factors included were body mass index, age, ethnicity, hypertension, immigrant status, smoking, education status and heart disease. DPoRT showed good discrimination (C=0.77–0.80) and calibration (χ2H–L <20) in both external validation cohorts. Conclusions This algorithm can be used to estimate diabetes incidence and quantify the effect of interventions using routinely collected survey data.

Monitoring the impact of hospital downsizing on access to care and quality of care.

The most recent data used for monitoring the potential effects of bed closures in Winnipeg hospitals since 1992/93 found that despite downsizing, access to care was by no means compromised. Just as many patients were cared for in 1995/96 as in 1991/92. Changes in patterns of care included more outpatient and fewer inpatient surgeries, and a decrease in the number of hospital days. The number of high-profile surgical procedures, such as angioplasty, bypass, and cataract surgery, performed increased dramatically during downsizing. Quality of care delivered to patients, measured by mortality and readmission rates, was unaffected by bed closures. Of particular concern was the impact of downsizing on the two most vulnerable health groups--the elderly and Manitobans in the lowest income group. Access and quality of care for these groups also remained unchanged. However, those in the lowest income group spent almost 43% more days in hospital than those in the middle income group, and research demonstrates that these variations in hospital use across socioeconomic groups reflect real and important health differences and are not driven by social reasons for admissions. Finally, a large decrease in waiting time for nursing home placement underlines the relationship between downsizing and availability of alternatives to hospitalization.

A Population-Based Health Information System

The authors introduce the Population Health Information System, its conceptual framework, and the data elements required to implement such a system in other jurisdictions. Among other innovations, the Population Health Information System distinguishes between indicators of health status (outcomes measures) and indicators of need for health care (socioeconomic measures of risk for poor health). The system also can be used to perform needs-based planning and challenge delivery patterns.

Who are the high hospital users? A Canadian case study.

OBJECTIVES Researchers have taken two different approaches to understanding high use of hospital services, one focusing on the large proportion of services used by a small minority and a second focusing on the poor health status and high hospital use of the poor. This work attempts to bridge these two widely researched approaches to understanding health care use. METHODS Administrative data from Winnipeg, Manitoba covering all hospitalizations in 1995 were combined with public use Census measures of socio-economic status (neighbourhood household income). High users were defined as the 1% of the population who spent the most days in hospital in 1995 (n = 6487 hospital users out of population of 648715 including non-users). RESULTS One per cent of the Winnipeg population consumed 69% of the hospital days in 1995. Thirty-one per cent of the highest users were among the 20% of residents of neighbourhoods with the lowest household incomes, and 10% of the highest users were among the 20% from neighbourhoods with the highest household incomes. However, on most other dimensions, including gender, age, average days in hospital, average admissions, percentage who died in hospital and diagnostic reasons for being hospitalized, the similarities between high users, regardless of their socio-economic group, were striking. CONCLUSIONS The lower the socio-economic status, the more likely an individual is to make high demands on hospitals. However, patterns of use as well as the diseases and accidents that produce high use among residents of low income neighbourhoods are not much different from those that produce high use among residents of high income neighbourhoods.

Socioeconomic Variations in the Prevalence and Incidence of Parkinson’s Disease: A Population-Based Analysis

Background For many chronic conditions, lower socioeconomic status is associated with higher rates of disease. Previous research has not investigated whether this inverse relationship exists for Parkinsons disease (PD). The purpose was to investigate the association between socioeconomic status and prevalence and incidence of PD. Methods The study was conducted using population-based administrative data from Manitoba, Canada. PD cases were identified from diagnoses in hospital and physician records. Area-level census data on average household income and residential postal codes in health insurance registration files were used to assign PD cases to urban and rural income quintiles. Annual adjusted prevalence and incidence estimates were calculated for fiscal years 1987/88–2006/07. Hypotheses about differences between quintiles in average estimates and average rates of change were tested using generalised linear models with generalised estimating equations. Results The estimated prevalence of PD increased over the 20-year-period but incidence remained unchanged. In urban regions, average prevalence and incidence estimates were significantly higher for the lowest income quintile than the highest quintile. In rural regions, average prevalence estimates were significantly higher for the lowest quintile than for the highest quintile but incidence estimates were not significantly different. The annual rate of increase in the PD prevalence was significantly different for the lowest urban and rural income quintiles. Conclusions There is a greater burden of PD in low-income areas. An understanding of socioeconomic inequalities is useful when formulating hypotheses about factors associated with disease onset and developing equity-oriented policies about access to healthcare resources.

Utilization of hospital resources.

A population-based approach was used to analyze the utilization patterns of hospital care by Manitoba residents during the fiscal year 1991/1992. Patterns were analyzed for eight administrative regions, with use assigned to the patients region of residence, regardless of the location of the hospitalization. Regional boundaries consistent with those used for presentation of data on health status and socioeconomic risk permitted integration of findings across the Population Health Information System. Marked differences in acute hospital use were found. Residents of the urban Winnipeg (“good health”) region had the lowest rates of use of acute care overall, and northern rural (“poor health”) regions had significantly higher rates of use. However, almost one-half of hospital days by Winnipeg residents were used in long-stay care (60+ days), while rural residents were more likely to use short-stay hospital care. Despite a concentration of surgical specialists in Winnipeg, there were only small regional differences in overall rates of surgery.

Prevalence of Depression and Dementia among Adults with Developmental Disabilities in Manitoba, Canada

Study Objective. To estimate and compare the prevalence of dementia and depression among adults with and without developmental disabilities (DDs). Methods. We linked data from several provincial administrative databases to identify persons with DDs. We matched cases with DD with persons without DD as to sex, age, and place of residence. We estimated the prevalence of dementia and depression and compared the two groups using the Generalized Estimating Equations (GEEs) technique. Results. The estimated prevalence of depression and dementia among younger adults (20–54) and older adults (50+) with DD was significantly higher than the estimated rates for the matched non-DD group (Depression: younger adults: RR = 2.96 (95% CI 2.59–3.39); older adults: RR = 2.65 (95% CI 1.84–3.81)), (Dementia: younger adults: RR = 4.01 (95% CI 2.72–5.92); older adults: RR = 4.80 (95% CI 2.48–9.31)). Conclusion. Significant disparities exist in mental health between persons with and without DDs.

Adding Up Provincial Expenditures on Health Care for Manitobans: A POPULIS Project

OBJECTIVES Using the POPULIS framework, this project estimated health care expenditures across the entire population of Manitoba for inpatient and outpatient hospital utilization, physician visits, mental health inpatient, and nursing home utilization. RESEARCH DESIGN This estimated expenditure information was then used to compare per capita expenditures relative to premature mortality rates across the various areas of Manitoba. RESULTS Considerable variation in health care expenditures was found, with those areas having high premature mortality rates also having higher health care expenditures.