Jun Guan

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 100u2009000 population of paediatric IBD has increased from 42.1 (in 1994) to 56.3 (in 2005). Incidence per 100u2009000 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, pu200a=u200a0.03) 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.

School-based influenza vaccine delivery, vaccination rates, and healthcare use in the context of a universal influenza immunization program: an ecological study.

Influenza vaccines are universally funded in Ontario, Canada. Some public health units (PHUs) vaccinate children in schools. We examined the impact of school-based delivery on vaccination rates and healthcare use of the entire population over seven influenza seasons (2000-2007) using population-based survey and health administrative data. School-based vaccination was associated with higher vaccination rates in school-age children only. Doctors office visits were lower for PHUs with school-based vaccination for children aged 12-19 but not for other age groups. Emergency department use and hospitalizations were similar between the two groups. In the context of universal influenza vaccination, school-based delivery is associated with higher vaccination rates and modest reductions in healthcare use in school-age children.

Residential movement patterns of families of young children with chronic conditions in Ontario, Canada: a population-based cohort study

IntroductionCare giving for children with chronic diseases can lead to financial strain and compromised family well being. Little is known about whether these stresses lead to changes in residential movement patterns as they relate to income adequacy and proximity to care.MethodsWe compared the residential movement patterns and associated changes in neighbourhood income of children with mild to severe chronic diseases compared with those that are healthy. A cohort of infants born from 2002–2007 in Ontario, Canada was followed for 5xa0years and divided into those with single- or multiple- body system complex chronic conditions (CCCs); low birth weight (LBW); asthma/recurrent wheeze (A/RW) and the control group of otherwise healthy children.ResultsOf 598,716 children studied, 15,207 had a single CCC, 3,600 multiple CCCs, 33,206 LBW, 57,137 A/RW and 489,566 were healthy. Lowest income quintile children were most likely to move residence. Compared with healthy controls, chronic disease cohorts, apart from those with asthma, were more likely to be born in the lowest income quintile neighbourhood and to move. Among children who moved, all chronic disease cohorts were significantly more likely to move to a low income quintile neighborhood (adjusted odds ratios for all chronic disease cohorts of 1.1-1.2). There were no differences across cohorts in residential movement close to a children’s hospital.ConclusionsYoung children with chronic conditions, particularly those born in low income neighbourhoods, are more likely to move residence than other healthy young children. However, it does not seem that proximity to specialized care is driving this movement. Further research is required to determine if these movement patterns impact the ability of children with chronic conditions to secure health services.

The association of asthma education centre characteristics on hospitalizations and emergency department visits in Ontario: a population-based study

BackgroundInternational guidelines recommend patient education as an essential component of optimal asthma management. Since 1990 hospital-based asthma education centres (AECs) have been established in Ontario, Canada. It is unknown whether patient outcomes are related to the level of services provided.MethodsUsing linked, population-based health administrative and hospital survey data we analyzed a population of patients aged 2 to 55 years with a hospitalization for asthma (Nu2009=u200912 029) or a high acuity asthma emergency department (ED) visit (Nu2009=u200963 025) between April 2004 and March 2007 and followed for three years. Administrative data documenting individuals’ attendance at AECs were not available. Poisson models were used to test the association of potential access to various AEC service models (outpatient service availability and in-hospital services) with asthma readmissions, ED visits or death within 6 to 36 months following the index admission or ED visit.ResultsFifty three of 163 acute care hospitals had an AEC (Nu2009=u200936) or had access by referral (Nu2009=u200917). All AECs documented use with guideline-based recommendations for AE programs. ED patients having access to an AEC that offered full-time, extended hours had reduced rates of adverse outcomes (adjusted relative rate [aRR] 0.78, 95% confidence interval [CI] 0.69, 0.90) compared to those with no AEC access. Hospitalized patients with access to asthma education during hospitalization had reduced rates of adverse events (aRR 0.87, 95% CI 0.75, 1.00) compared to those with no inhospital AEC access.ConclusionAlthough compliant with asthma guideline-based program elements, on a population basis access to asthma education centres is associated only with a modest benefit for some admitted and ED patients and depends on the level of access to services provided. Review of both services provided and strategies to address potential barriers to care are necessary.

Risk of firearm injuries among children and youth of immigrant families

BACKGROUND: Firearm injuries contribute to substantial morbidity and mortality. The immigrant paradox suggests that, despite being more socially disadvantaged, immigrants are less likely than nonimmigrants to have poor outcomes. We tested the association of immigrant characteristics with firearm injuries among children and youth. METHODS: We conducted a population-based cohort study involving residents of Ontario aged 24 years and younger from 2008–2012 using health and administrative databases. We estimated rate ratios of unintentional and assault-related firearm injuries by immigrant status using Poisson regression models with Generalized Estimating Equations. RESULTS: We included 15 866 954 nonimmigrant and 4 551 291 immigrant person-years in our analysis. Nonimmigrant males had 1032 unintentional (12.4 per 100 000, 95% confidence interval [CI] 11.7–13.2) and 304 assault-related (3.6 per 100 000, 95% CI 3.2–4.0) firearm injuries. Immigrant males had 148 unintentional (7.2 per 100 000, 95% CI 6.1–8.5) and 113 assault-related (5.5 per 100 000, 95% CI 4.5–6.6) firearm injuries. Compared with nonimmigrants, immigrants had a lower rate of unintentional firearm injury (adjusted rate ratio 0.5, 95% CI 0.4–0.6) but a similar rate of assault-related firearm injury. Among immigrants, refugees had a 43% higher risk of assault-related firearm injury compared with nonrefugees (adjusted rate ratio 1.4, 95% CI 1.0–2.0). Immigrants from Central America and Africa accounted for 68% of immigrants with assault-related firearm injuries. INTERPRETATION: Compared with nonimmigrants, immigrant children and youth had a lower risk of unintentional firearm injury, although the risk of assault-related firearm injury was higher among refugees and immigrants from Central America and Africa. The results suggest that prevention strategies for firearm safety should target nonimmigrant youth as well as these newly identified high-risk immigrant populations.

Evaluating the Impact of Clinical Decision Tools in Pediatric Acute Gastroenteritis: A Population-based Cohort Study

OBJECTIVEnAcute gastroenteritis (AGE) is a leading cause of pediatric emergency department (ED) visits. Despite evidence-based guidelines, variation in adherence exists. Clinical decision tools can enhance evidence-based care, but little is known about their use and effectiveness in pediatric AGE. This study sought to determine if the following tools-1) pathways/order sets, 2) medical directives for oral rehydration therapy (ORT) or ondansetron, and 3) printed discharge instructions-are associated with AGE admission and ED revisits.nnnMETHODSnThis was a retrospective population-based cohort study of all children 3 months-18 years with an AGE ED visit in Ontario, Canada, from 2008 to 2010, using linked survey and health administrative databases. Logistic regression models associating clinical decision tools (CDTs) with hospitalizations and revisits controlling for hospital and patient characteristics were employed.nnnRESULTSnOf the 57,921 patient visits during the study period, there were 2,401 hospitalizations (4.2%). A total of 55,520 patients were discharged from the ED, with 2,378 (4.3%) experiencing a 72-hour return visit. In adjusted models, none of the tools were significantly associated with admission. Medical directive for ORT was associated with lower return visit rates (adjusted odds ratio [aOR] = 0.86, 95% confidence interval [CI] = 0.79-0.94] and printed discharge instructions with higher return visits (aOR = 1.33, 95% CI = 1.08-1.65); pathways/order sets and medical directives for ondansetron had no association.nnnCONCLUSIONSnAdmissions in children with AGE are not associated with the presence of CDTs. While ORT medical directives are associated with lower ED revisits, printed discharge instructions have the opposite effect. The simple presence/absence of decision support tools does not guarantee improved clinical outcomes.

Unintentional injuries among refugee and immigrant children and youth in Ontario, Canada: a population-based cross-sectional study

Background Unintentional injuries are a leading reason for seeking emergency care. Refugees face vulnerabilities that may contribute to injury risk. We aimed to compare the rates of unintentional injuries in immigrant children and youth by visa class and region of origin. Methods Population-based, cross-sectional study of children and youth (0–24u2009years) from immigrant families residing in Ontario, Canada, from 2011 to 2012. Multiple linked health and administrative databases were used to describe unintentional injuries by immigration visa class and region of origin. Poisson regression models estimated rate ratios for injuries. Results There were 6596.0 and 8122.3 emergency department visits per 100u2009000 non-refugee and refugee immigrants, respectively. Hospitalisation rates were 144.9 and 185.2 per 100u2009000 in each of these groups. The unintentional injury rate among refugees was 20% higher than among non-refugees (adjusted rate ratio (ARR) 1.20, 95% CI 1.16, 1.24). In both groups, rates were lowest among East and South Asians. Young age, male sex, and high income were associated with injury risk. Compared with non-refugees, refugees had higher rates of injury across most causes, including for motor vehicle injuries (ARR 1.51, 95%u2009CI 1.40, 1.62), poisoning (ARR 1.40, 95%u2009CI 1.26, 1.56) and suffocation (ARR 1.39, 95%u2009CI 1.04, 1.84). Interpretation The observed 20% higher rate of unintentional injuries among refugees compared with non-refugees highlights an important opportunity for targeting population-based public health and safety interventions. Engaging refugee families shortly after arrival in active efforts for injury prevention may reduce social vulnerabilities and cultural risk factors for injury in this population.

Unintentional injuries in children and youth from immigrant families in Ontario, Canada: a population-based cross-sectional study

BACKGROUNDnUnintentional injury is the leading cause of childhood death. Injury is associated with a number of sociodemographic characteristics, but little is known about risk in immigrants. Our objective was to examine the association between family immigrant status and unintentional injury in children and youth.nnnMETHODSnWe performed a population-based, cross-sectional study involving children and youth (age 0-24 yr) residing in Ontario from 2008 to 2012. Multiple linked health and administrative databases were used to describe unintentional injuries by family immigrant status. Unintentional injury events (e.g., emergency department visits, admissions to hospital, deaths) were analyzed using Poisson regression models to estimate rate ratios (RRs) for injury by immigrant status.nnnRESULTSnAnnualized injury rates were 11 749 emergency department visits per 100u202f000 population, 267 hospital admissions per 100u202f000 population and 12 deaths per 100u202f000 population. Injury rates were lower among immigrants across all causes of unintentional injury (adjusted RR 0.56, 95% confidence interval [CI] 0.54-0.59). Among nonimmigrants, lowest neighbourhood income quintile was associated with the highest rates (RR 1.13, 95% CI 1.08-1.18, quintile 5 v. 1); among immigrants, lowest income quintile was associated with the lowest rates of injury (RR 0.88, 95% CI 0.82-0.94, quintile 5 v. 1). Highest rates of injury for nonimmigrants were among adolescents (age 10-14 yr, RR 1.23, 95% CI 1.18-1.28; v. 20-24 yr), but for immigrants, was highest among young children (0-4 yr RR 1.23, 95% CI 1.16-1.31; v. 20-24 yr).nnnINTERPRETATIONnRates of unintentional injury are lower among immigrant than among Canadian-born children, supporting a healthy immigrant effect. Socioeconomic status and age have different associations with injury risk, suggesting alternative causal pathways for injuries in immigrant children and youth.

The shrinking health advantage: unintentional injuries among children and youth from immigrant families

BackgroundImmigrants typically arrive in good health. This health benefit can decline as immigrants adopt behaviours similar to native-born populations. Risk of injury is low in immigrants but it is not known whether this changes with increasing time since migration. We sought to examine the association between duration of residence in Canada and risk of unintentional injury.MethodsPopulation-based cross-sectional study of children and youth 0 to 24 years in Ontario, Canada (2011-2012), using linked health and administrative databases. The main exposure was duration of Canadian residence (recent: 0–5 years, intermediate: 6–10 years, long-term: >10 years). The main outcome measure was unintentional injuries. Cause-specific injury risk by duration of residence was also evaluated. Poisson regression models estimated rate ratios (RR) for injuries.Results999951 immigrants were included with 24.2% recent and 26.4% intermediate immigrants. The annual crude injury rates per 100000 immigrants were 6831 emergency department visits, 151 hospitalizations, and 4 deaths. In adjusted models, recent immigrants had the lowest risk of injury and risk increased over time (RR 0.79; 95% CI 0.77, 0.81 recent immigrants, RR 0.90; 95% CI 0.88, 0.92 intermediate immigrants, versus long-term immigrants). Factors associated with injury included young age (0-4 years, RR 1.30; 95% CI 1.26, 1.34), male sex (RR 1.52; 95% CI 1.49, 1.55), and high income (RR 0.93; 95% CI 0.89, 0.96 quintile 1 versus 5). Longer duration of residence was associated with a higher risk of unintentional injuries for most causes except hot object/scald burns, machinery-related injuries, non-motor vehicle bicycle and pedestrian injuries. The risk of these latter injuries did not change significantly with increasing duration of residence in Canada. Risk of drowning was highest in recent immigrants.ConclusionsRisk of all-cause and most cause-specific unintentional injuries in immigrants rises with increasing time since migration. This indicates the need to develop strategies for maintaining the immigrant health advantage over time while balancing the desire to support integration, active living, and healthy child development.

Health care for children with diabetes mellitus from low-income families in Ontario and California: a population-based cohort study

BACKGROUNDnChildren with diabetes mellitus in low-income families have poor outcomes, but little is known as to how this relates to healthcare system structure. Our objective was to gain insight into how best to structure health systems to serve these children by describing their health care use in 2 health system models: a Canadian model, with an organized diabetes care network that includes generalists, and an American model, with targeted support services for children from low-income families.nnnMETHODSnWe performed a population-based retrospective cohort study involving children aged 1-17 years with type 1 diabetes mellitus. We used administrative data from between 2009 and 2012 from the California Childrens Services program and Ontario. We used Ontario Drug Benefit Program enrolment to identify children from low-income families. Proportions of children receiving 2 or more routine diabetes visits per year were compared using χ2 tests, and diabetes-complication hospital admission rates were compared using direct standardization.nnnRESULTSnMore California children from low-income families (n = 4922) received routine care for diabetes from pediatric endocrinologists (63.9% v. 26.9%, p < 0.001) and used insulin pumps (22.8% v. 16.4%, p < 0.001) than Ontario children (n = 2050).California children from low-income families were less likely than Ontario children to receive 2 visits for routine diabetes care per year (64.7% v. 75.7%, p < 0.001), and had slightly higher per-patient year hospital admission rates for diabetes complications (absolute differences 0.02, 95% confidence interval [CI] 0.02-0.02, for boys; 0.03, 95% CI 0.03-0.03, for girls).nnnINTERPRETATIONnOntario children from low-income families received more routine diabetes care than did California children from low-income families. Both groups of children had clinically comparable rates of hospital admission for diabetes complications. Diabetes care networks that integrate generalists may play a role in improving access and outcomes for the growing population of children with diabetes.