Denis Hamel

Evaluation of Care and Surveillance of Cardiovascular Disease: Can We Trust Medico-administrative Hospital Data?

BACKGROUNDnThe evaluation of care and the surveillance of disease are important in respect to cardiovascular disease because it is prevalent and costly. In Canada, medico-administrative hospital data are readily available, continuously updated, and offer comprehensive coverage of the patient population. However, there is concern about the quality of the information.nnnMETHODSnThe reliability and predictive capability of comorbidity data contained within Québecs hospital discharge database were assessed in comparison with data collected by clinical medical record reabstraction in a sample of 1989 patients hospitalized from 2002 to 2006 in a mix of 13 hospitals. Patients either had a principal diagnosis of myocardial infarction or underwent angioplasty or bypass surgery. Twenty-one comorbidities included in the Charlson comorbidity index or known to be associated with mortality were validated via medical record reabstraction.nnnRESULTSnOf 14 comorbidities with > 2% prevalence, 8 had excellent agreement with medical record review (κ > 0.8) while 6 had substantial agreement (κ > 0.6). In general, positive predictive values were high, while measures of sensitivity were more variable. Univariate associations between comorbidities and 30-day and 1-year mortality were generally similar in the 2 data sources. Comorbidities retained in the final multivariate stepwise regression models from each data source were almost identical, as were the 2 models abilities to predict mortality.nnnCONCLUSIONSnHospital discharge data in Québec are, in general, reliably coded and compare favourably with clinical medical record review in their ability to predict mortality. It appears sufficiently reliable to provide useful information about clinical outcomes of cardiac care and to identify problems that warrant investigation.

Impact of Socioeconomic Deprivation and Area of Residence on Access to Coronary Revascularization and Mortality After a First Acute Myocardial Infarction in Québec

BACKGROUNDnSocioeconomic status (SES) and area of residence are known to impact access to invasive cardiac procedures. Low SES adversely affects long-term mortality after acute myocardial infarction (AMI). Most of the data were derived from private healthcare systems. Our objectives were to evaluate the effects of SES and area of residence on access to coronary angiography, revascularization and mortality after a first AMI in a publicly-funded healthcare system with a high supply of catheterization facilities.nnnMETHODSnQuébec administrative databases were used to identify all patients with a first AMI between 1997 and 2001. The SES was determined with the population deprivation index, which has 2 dimensions: material and social. Six-month access to angiography, revascularization and 1-year mortality were considered in proportional hazards survival regression analyses measuring the effect of deprivation and the geographical area of residence, accounting for several other covariates.nnnRESULTSnThe study cohort consisted of 50,242 patients. The most materially and socially deprived patients had a 16% (95% confidence interval [CI], 1.08-1.25) and 13% (95% CI, 1.05-1.21) relative increased hazard of dying within 1 year respectively compared with the most privileged subjects. This mortality gradient could not be explained by meaningful differences in access to angiography or revascularization. Geography did not influence access to revascularization procedures.nnnCONCLUSIONSnDespite universal healthcare system, SES measured with a material and social deprivation index, had significant adverse effect on 1-year mortality after a first AMI. Such findings were not explained by lower access to coronary angiography or revascularization.

Prevalence, incidence, awareness and control of hypertension in the province of Quebec: Perspective from administrative and survey data

OBJECTIVES: Hypertension is a major risk factor for cardiovascular diseases. Nearly one adult in four was diagnosed with hypertension in 2007–2008 in Canada. One of the objectives of this study was to determine whether the prevalence of hypertension in Quebec as assessed using administrative data is comparable to that specifically measured, especially for the elderly population.METHODS: Trends in prevalence, incidence and mortality were examined using the Quebec Integrated Chronic Disease Surveillance System built from grouping numerous administrative databases from 1996–1997 to 2009–2010. Blood pressure measurements, hypertension prevalence, awareness and control were obtained in 1,706 Quebecers in the combined cycles of the Canadian Health Measures Survey.RESULTS: Using administrative databases, 23.6% [95% confidence interval, 23.5–23.6] of the Quebec population (n=1,433,400) aged >20 years was diagnosed with hypertension in 2009–2010, an increase of 32.1 % compared to 2000–2001. The incidence decreased by 27.3%. Among people aged >65 years, the prevalence rose to 69.0% [95% CI: 68.8–69.2] in women and 61.7% [95% CI: 61.5–61.9] in men. For people aged 20–79 years, the prevalence of hypertension was lower with the administrative data compared to the survey (20.2% and 23.1 %, respectively). The level of awareness, treatment and control were 84.3%, 83.1% and 67.9%, respectively.CONCLUSION: The prevalence of hypertension derived from administrative data is comparable to that obtained with a health measured survey. Elderly women (>65 years) are a very high-risk subgroup. The levels of awareness, treatment and control of hypertension in Quebec are very high.RésuméOBJECTIFS: L’hypertension artérielle est un facteur de risque majeur des maladies cardiovasculaires. Près d’un adulte sur quatre a été diagnostiqué hypertendu en 2007–2008, au Canada. Un des objectifs de cette étude était de déterminer si la prévalence de l’hypertension au Québec obtenue à partir de données médico-administratives est comparable à celle mesurée, en particulier chez les personnes âgées.METHODES: Les tendances de la prévalence, de l’incidence et de la mortalité ont été examinées avec le Système Intégré de Surveillance des Maladies Chroniques du Québec regroupant de nombreuses bases de données médico-administratives de 1996–1997 à 2009–2010. Des mesures de pression artérielle, de prévalence d’hypertension, de conscience et de contrôle ont été obtenus chez 1 706 Québécois dans les cycles combinés de l’Enquête canadienne sur les mesures de la santé.RÉSULTATS: En utilisant les données médico-administratives, 23,6 % [Intervalle de confiance à 95%, 23,5–23,6] de la population du Québec (n=1 433 400) âgés de ≥20 ans a été diagnostiqué hypertendue en 2009–2010, ce qui représente une augmentation de 32,1 % comparativement à 2000–2001. L’incidence a diminué de 27,3 %. Parmi les personnes âgées de ≥65 ans, cette prévalence est passée à 69,0 % [IC à 95%, 68,8–69,2] chez les femmes et à 61,7 % [IC à 95%, 61,5–61,9] chez les hommes. Pour les personnes âgées de 20–79 ans, la prévalence de l’hypertension était inférieure avec les données médico-administratives comparativement à celles avec l’enquête (20,2 % et 23,1 %, respectivement). Les niveaux de conscience, traitement et de contrôle étaient de 84,3 %, 83,1 % et 67,9 %, respectivement.CONCLUSION: La prévalence de l’hypertension provenant des données médico-administratives est comparable à celle obtenue avec une enquête des mesures de la santé. Les femmes âgées (≥65 ans) sont un sous-groupe à risque très élevé. Les niveaux de conscience, de traitement et de contrôle de l’hypertension au Québec sont très élevés.

A new metric for centralization of ruptured abdominal aortic aneurysm repair in large territories.

OBJECTIVEnThis study proposes the DEDE (Door-from-Emergency to Door-to-EVAR [endovascular aneurysm repair]) time as a new metric for ruptured abdominal aortic aneurysm (RAAA) delay time to surgery, permitting coherent centralization in large territories. It demonstrates how the DEDE time can be applied, using data from the province of Quebec, and looks at its potential effect on 30-day mortality.nnnMETHODSnWe used the Quebec Integrated Chronic Disease Surveillance System (QICDSS), the linkage of five health administrative databases, to build a retrospective cohort of RAAA patients repaired operatively between April 1, 2006, and March 31, 2013. A validated algorithm was used to identify open surgical repair (OSR) and EVAR patients. Hospitals performing these operations were further characterized according to their location, volume of RAAA, types of surgeries (OSR vs EVAR), and surgeons volume. Logistic and log-binomial regression analyses identified the risk of 30-day mortality with age, sex, hospital volume, and surgical groups as variables. Using the DEDE 90 metric and the attributable fraction, we projected how centralization and increasing the number of EVAR would affect the 30-day mortality.nnnRESULTSnAmong patients aged ≥65 years, 895 RAAAs were identified. OSR was performed in 839 patients (93.7%) and EVAR in 56 (6.3%). The overall 30-day mortality was 34.4%, and more specifically, was 35.5% for OSR compared with 17.9% for EVAR (P = .0046). RAAAs were treated in 39 hospitals, including 16 centers averaging less than one RAAA repair per year. Low-volume (39.4%) vs high-volume centers (32.5%) had similar 30-day mortality (P = .2198). In the multivariate analysis, the relative risk for OSR was 1.95 (P = .0211) and was not significant for hospital volume. Applying the DEDE 90 metric and increasing access to EVAR to 50% of patients, the overall 30-day mortality would be 26.8%.nnnCONCLUSIONSnDEDE 90 is a new metric for a coherent centralization model, particularly in large territories, where transport time is crucial. Increasing access to EVAR performed in high-volume centers, with consideration to transport time, could improve the 30-day mortality after a RAAA repair.

Incidence, Prevalence, and Mortality Trends in Chronic Obstructive Pulmonary Disease over 2001 to 2011: A Public Health Point of View of the Burden

Background. An increase of chronic obstructive pulmonary disease (COPD) prevalence was reported in Canada despite the decline of the main risk factor. Objectives. To estimate incidence, prevalence, and mortality of COPD from 2001 to 2011 and establish the COPD burden by the evaluation of the age-period-cohort effects on incidence trends and the comorbidities prevalence estimations. Methods. A retrospective population-based cohort was built using Quebec health administrative data. Change in trends was measured by relative percentage of changes and by joinpoint regression. After a descriptive analysis of the trends, an age-period-cohort analysis was performed on incidence rates. Results. Overall increase in prevalence along with a decrease of incidence and all-cause mortality was observed. Over time, all age-standardized trends were higher in men than women. Despite higher rates, the number of incident and prevalent cases in women exceeds men since 2004. The curve analysis by age groups showed over time a downshift for both sexes in incidence and all-cause mortality. Further analysis showed the presence of a cohort effect in women. Conclusion. The burden of COPD has risen over time. Women younger than 65 years old have been identified as at-risk group for healthcare planning.

Population-level trends in the distribution of body mass index in Canada, 2000–2014

ObjectiveResearch studying population-level body mass index (BMI) trends document increases in mean or prevalence of overweight/obese but less consideration has been given to describing the changing distribution of BMI. The objective of this research was to perform a detailed analysis of changes in the BMI distribution in Canada.MethodsUsing data from the CCHS (2000–2014), we analyzed distributional parameters of BMI for 492,886 adults aged 25–64xa0years. We further stratified these analyses for women and men, education level, and region of residence.ResultsMean BMI has increased for most subgroups of the Canadian population. Mean BMI values were higher for men, while standard deviation (SD) of the BMI distribution was systematically higher in women. Increases in mean BMI were accompanied with increases in SD of BMI across cycles. Across survey cycles, the 95th percentile increased more than 10 times more rapidly compared to the 5th percentile, showing a very unequal change between extreme values in the BMI distribution over time. There was a relationship between SD with BMI, but these relations were generally not different between educational categories and regions. This suggests that the growing inter-individual inequalities (i.e., dispersion) in BMI were not solely attributable to socioeconomic and demographic factors.ConclusionsThis study supports the hypothesis that the simultaneous increases in mean BMI and SD of the BMI distribution are occurring, and suggests the need to move beyond the mean-centric paradigm when studying a complex public health phenomenon such as population change in BMI.RésuméObjectifLes recherches populationnelles portant sur l’évolution de l’indice de masse corporelle (IMC) rapportent une augmentation de la moyenne et de la prévalence de l’embonpoint/obésité, mais accordent moins d’intérêt aux changements distributionnels. L’objectif de cette recherche était de réaliser une analyse détaillée des changements distributionnels de l’IMC au Canada.MéthodologieÀ partir des données de l’ESCC (2000–2014), nous avons analysé les paramètres distributionnels de l’IMC de 492,886 adultes âgés de 25 à 64 ans. Les analyses ont été stratifiées entre les femmes et les hommes, le niveau d’instruction et la région de résidence.RésultatsL’IMC moyen a augmenté pour la majorité des sous-groupes de la population canadienne. Les valeurs de l’IMC moyen étaient plus élevées pour les hommes, alors que celles de l’écart-type (É-T) de la distribution de l’IMC étaient systématiquement plus élevées chez les femmes. L’augmentation de l’IMC moyen était accompagnée d’une augmentation de l’É-T de l’IMC à travers les cycles. À travers les cycles de l’enquête, le 95ème percentile augmentait plus de dix fois plus rapidement que le 5ème percentile, révélant un changement très inégal entre les valeurs extrêmes de la distribution de l’IMC dans le temps. Il y avait une relation entre l’É-T et l’IMC, mais de façon générale, ces relations n’étaient pas différentes entre les catégories du niveau d’instruction et de la région de résidence. Ceci suggère que la croissance des inégalités interindividuelles de l’IMC n’est pas uniquement attribuable à des facteurs socioéconomiques et démographiques.ConclusionsCette étude supporte l’hypothèse que la croissance de l’IMC moyen et de l’É-T de la distribution de l’IMC se produisent de façon simultanée et suggère le besoin d’aller au-delà du paradigme de recherche centré sur la moyenne pour l’étude de phénomènes de santé publique complexes comme celui de l’évolution de l’IMC à l’échelle des populations.

THE IMPACT OF PHARMACOTHERAPY ON LONG-TERM SURVIVAL AND STROKE AFTER HOSPITALIZATION FOR ATRIAL FIBRILLATION

We aim to evaluate the impact of several drugs on long-term all-cause mortality and risk of stroke or transient ischemic attack (TIA), in patients hospitalized for atrial fibrillation (AF).nnUsing Quebec provincial health administrative databases, we conducted a retrospective cohort study of all