The association between influenza vaccination and socioeconomic status in high income countries varies by the measure used: a systematic review.

BACKGROUND: The purpose of this paper is to systematically review the literature on the relationship between socioeconomic status (SES) and influenza immunization and to examine how certain measures of SES may influence interpretations of this relationship. METHODS: We conducted a systematic review of existing peer-reviewed literature to evaluate the above relationship in the general population. Electronic databases (MEDLINE and EMBASE) were searched from January 2012 to May 2017 to identify English-language studies relevant to this review. Studies were included where influenza vaccination was explicitly reported as the dependent variable and SES as the independent variable. We limited our review to measures of SES that focus on education, income, social class, occupation, and deprivation. Studies that measured SES using other variables (e.g., race, ethnicity, geographic location, rural or urban status, or insurance status) were excluded. Studies were also excluded if they did not report on the human population or did not analyze original data. The population of interest included all age groups, levels of health status, and sociodemographic backgrounds. The review was also limited to World Bank high-income countries. Two authors independently screened full-text articles after obtaining a Kappa score of K = 0.867. The methodological quality of manuscripts was assessed using the appraisal tools developed by the Joanna Briggs Institute. Results were qualitatively reported and synthesized. RESULTS: Of the 42 articles included in this review, 52.4% (n = 22) found that higher levels of SES resulted in higher levels of influenza vaccination; 4.5% (n = 2) reported a negative association; and 14.3% (n = 6) found no association. Just over a quarter (26.2%, n = 12) of articles reported mixed results. CONCLUSIONS: There was consistently a relationship between SES and influenza immunization, which varied according to how SES was measured. It is recommended that authors be explicit in defining the SES concept they are trying to capture and that they utilize multiple measures of SES (e.g., education, income, class).

Strategies for improving physician documentation in the emergency department: a systematic review.

BACKGROUND: Physician chart documentation can facilitate patient care decisions, reduce treatment errors, and inform health system planning and resource allocation activities. Although accurate and complete patient chart data supports quality and continuity of patient care, physician documentation often varies in terms of timeliness, legibility, clarity and completeness. While many educational and other approaches have been implemented in hospital settings, the extent to which these interventions can improve the quality of documentation in emergency departments (EDs) is unknown. METHODS: We conducted a systematic review to assess the effectiveness of approaches to improve ED physician documentation. Peer reviewed electronic databases, grey literature sources, and reference lists of included studies were searched to March 2015. Studies were included if they reported on outcomes associated with interventions designed to enhance the quality of physician documentation. RESULTS: Nineteen studies were identified that report on the effectiveness of interventions to improve physician documentation in EDs. Interventions included audit/feedback, dictation, education, facilitation, reminders, templates, and multi-interventions. While ten studies found that audit/feedback, dictation, pharmacist facilitation, reminders, templates, and multi-pronged approaches did improve the quality of physician documentation across multiple outcome measures, the remaining nine studies reported mixed results. CONCLUSIONS: Promising approaches to improving physician documentation in emergency department settings include audit/feedback, reminders, templates, and multi-pronged education interventions. Future research should focus on exploring the impact of implementing these interventions in EDs with and without emergency medical record systems (EMRs), and investigating the potential of emerging technologies, including EMR-based machine-learning, to promote improvements in the quality of ED documentation.

Barriers to data quality resulting from the process of coding health information to administrative data: a qualitative study.

BACKGROUND: Administrative health data are increasingly used for research and surveillance to inform decision-making because of its large sample sizes, geographic coverage, comprehensivity, and possibility for longitudinal follow-up. Within Canadian provinces, individuals are assigned unique personal health numbers that allow for linkage of administrative health records in that jurisdiction. It is therefore necessary to ensure that these data are of high quality, and that chart information is accurately coded to meet this end. Our objective is to explore the potential barriers that exist for high quality data coding through qualitative inquiry into the roles and responsibilities of medical chart coders. METHODS: We conducted semi-structured interviews with 28 medical chart coders from Alberta, Canada. We used thematic analysis and open-coded each transcript to understand the process of administrative health data generation and identify barriers to its quality. RESULTS: The process of generating administrative health data is highly complex and involves a diverse workforce. As such, there are multiple points in this process that introduce challenges for high quality data. For coders, the main barriers to data quality occurred around chart documentation, variability in the interpretation of chart information, and high quota expectations. CONCLUSIONS: This study illustrates the complex nature of barriers to high quality coding, in the context of administrative data generation. The findings from this study may be of use to data users, researchers, and decision-makers who wish to better understand the limitations of their data or pursue interventions to improve data quality.

Methods of defining hypertension in electronic medical records: validation against national survey data.

BACKGROUND: Electronic medical records (EMR) can be a cost-effective source for hypertension surveillance. However, diagnosis of hypertension in EMR is commonly under-coded and warrants the needs to review blood pressure and antihypertensive drugs for hypertension case identification. METHODS: We included all the patients actively registered in The Health Improvement Network (THIN) database, UK, on 31 December 2011. Three case definitions using diagnosis code, antihypertensive drug prescriptions and abnormal blood pressure, respectively, were used to identify hypertension patients. We compared the prevalence and treatment rate of hypertension in THIN with results from Health Survey for England (HSE) in 2011. RESULTS: Compared with prevalence reported by HSE (29.7%), the use of diagnosis code alone (14.0%) underestimated hypertension prevalence. The use of any of the definitions (38.4%) or combination of antihypertensive drug prescriptions and abnormal blood pressure (38.4%) had higher prevalence than HSE. The use of diagnosis code or two abnormal blood pressure records with a 2-year period (31.1%) had similar prevalence and treatment rate of hypertension with HSE. CONCLUSIONS: Different definitions should be used for different study purposes. The definition of 'diagnosis code or two abnormal blood pressure records with a 2-year period' could be used for hypertension surveillance in THIN.

Systematic review of risk adjustment models of hospital length of stay (LOS).

BACKGROUND: Policy decisions in health care, such as hospital performance evaluation and performance-based budgeting, require an accurate prediction of hospital length of stay (LOS). This paper provides a systematic review of risk adjustment models for hospital LOS, and focuses primarily on studies that use administrative data. METHODS: MEDLINE, EMBASE, Cochrane, PubMed, and EconLit were searched for studies that tested the performance of risk adjustment models in predicting hospital LOS. We included studies that tested models developed for the general inpatient population, and excluded those that analyzed risk factors only correlated with LOS, impact analyses, or those that used disease-specific scales and indexes to predict LOS. RESULTS: Our search yielded 3973 abstracts, of which 37 were included. These studies used various disease groupers and severity/morbidity indexes to predict LOS. Few models were developed specifically for explaining hospital LOS; most focused primarily on explaining resource spending and the costs associated with hospital LOS, and applied these models to hospital LOS. We found a large variation in predictive power across different LOS predictive models. The best model performance for most studies fell in the range of 0.30-0.60, approximately. CONCLUSIONS: The current risk adjustment methodologies for predicting LOS are still limited in terms of models, predictors, and predictive power. One possible approach to improving the performance of LOS risk adjustment models is to include more disease-specific variables, such as disease-specific or condition-specific measures, and functional measures. For this approach, however, more comprehensive and standardized data are urgently needed. In addition, statistical methods and evaluation tools more appropriate to LOS should be tested and adopted.

Administrative health data in Canada: lessons from history.

BACKGROUND: Health decision-making requires evidence from high-quality data. As one example, the Discharge Abstract Database (DAD) compiles data from the majority of Canadian hospitals to form one of the most comprehensive and highly regarded administrative health databases available for health research, internationally. However, despite the success of this and other administrative health data resources, little is known about their history or the factors that have led to their success. The purpose of this paper is to provide an historical overview of Canadian administrative health data for health research to contribute to the institutional memory of this field. METHODS: We conducted a qualitative content analysis of approximately 20 key sources to construct an historical narrative of administrative health data in Canada. Specifically, we searched for content related to key events, individuals, challenges, and successes in this field over time. RESULTS: In Canada, administrative health data for health research has developed in tangent with provincial research centres. Interestingly, the lessons learned from this history align with the original recommendations of the 1964 Royal Commission on Health Services: (1) standardization, and (2) centralization of data resources, that is (3) facilitated through governmental financial support. CONCLUSIONS: The overview history provided here illustrates the need for longstanding partnerships between government and academia, for classification, terminology and standardization are time-consuming and ever-evolving processes. This paper will be of interest to those who work with administrative health data, and also for countries that are looking to build or improve upon their use of administrative health data for decision-making.

"It's a tradition of naming injustice": An oral history of the social determinants of health - Canadian reflections, 1960s-present.

The 'social determinants of health' (SDOH) approach in Canada is widely acknowledged as having emerged through contributions such as the 1974 Lalonde Report or 1986 Ottawa Charter. Drawing on original oral histories, I consider this history through the reflections of past and present leaders in Canadian public health. Through this rich information, I identified three phases in the recent history of the SDOH, from a social awareness (1960s-1970s, when participants underwent training and gained exposure to social and health inequities), to a loose collection of theoretical and empirical concepts (1970s-1990s, when the evidence base on health inequities and the mechanisms behind them began to solidify), to a distinct research approach (2000s-present, when high profile events led to acceptance of the SDOH approach) that encompassed the spirit of its previous iterations. This paper will be of interest to health researchers and professionals, decision-makers, and trainees as they contemplate their own role in this ongoing history.

Commentary - Is the future of "population/public health" in Canada united or divided? Reflections from within the field. / Commentaire - La « santé publique et des populations ¼ au Canada va-t-elle à l'avenir s'unir ou se diviser? Réflexions de l'intérieur.

INTRODUCTION: "Are population and public health truly a unified field, or is population health simply attaching itself to public health as a means of gaining credibility?" This commentary was prompted by the above question, which was asked during K. L.'s PhD candidacy exam. In response, K. L. cited recent developments in the field to support her conviction that population and public health (PPH) existed positively as a unified discipline. However, through conversations that ensued over the subsequent weeks and months, we concluded that this issue goes deeper than the existence of departments and organizations labelled "population and public health," and may benefit from debate and discussion, particularly for the incoming generation of PPH scholars. In this commentary, we argue that (1) the PPH label at times implies a coherence of ideas, values and priorities that may not be present; (2) it is important and timely to work towards a more unified PPH; and (3) both challenges to and opportunities for a more unified PPH exist, which we illustrate using the broad areas of research funding, the public health workforce and PPH ethics.

INTRODUCTION: « Est-ce que la santé publique et des populations constitue véritablement un domaine unifié, ou est-ce que la santé des populations s'est simplement agrégée à la santé publique pour gagner en crédibilité? ¼ Le commentaire présenté ici résulte de cette question, posée à Kelsey Lucyk (KL) dans le cadre de son examen d'admission au doctorat. En réponse, KL a cité les récents développements dans le domaine pour justifier de sa conviction que la santé publique et des populations (SPP) constitue bel et bien une discipline unifiée. Toutefois, au fil des conversations des semaines et des mois qui ont suivi, nous avons conclu que cet enjeu allait bien audelà de l'étiquetage de ministères et d'organismes de « santé publique et des populations ¼ et qu'en débattre pouvait être pertinent, particulièrement pour la prochaine génération de chercheurs en SPP. Dans ce commentaire, nous faisons la démonstration 1) que parfois l'expression SPP sous-entend une cohérence d'idées, de valeurs et de principes qui n'est pas forcément réalisée, 2) qu'il est temps et important de viser à une SPP plus unifiée et 3) que l'unification de la SPP offre à la fois des défis et des opportunités, ce que nous illustrons dans les domaines du financement de la recherche, des effectifs en santé publique et de l'éthique en SPP.

Taking stock of the social determinants of health: A scoping review.

BACKGROUND: In recent decades, the social determinants of health (SDOH) has gained increasing prominence as a foundational concept for population and public health in academic literature and policy documents, internationally. However, alongside its widespread dissemination, and in light of multiple conceptual models, lists, and frameworks, some dilution and confusion is apparent. This scoping review represents an attempt to take stock of SDOH literature in the context of contemporary population and public health. METHODS: We conducted a scoping review to synthesize and map SDOH literature, informed by the methods of Arksey and O'Malley (2005). We searched 5 academic and 3 grey literature databases for "social determinants of health" and "population health" or "public health" or "health promotion," published 2004-2014. We also conducted a search on "inequity" or "inequality" or "disparity" or "social gradient" and "Canad*" to ensure that we captured articles where this language was used to discuss the SDOH. We included articles that discussed SDOH in depth, either explicitly or in implicit but nuanced ways. We hand-searched reference lists to further identify relevant articles. FINDINGS: Our synthesis of 108 articles showed wide variation by study setting, target audience, and geographic scope, with most articles published in an academic setting, by Canadian authors, for policy-maker audiences. SDOH were communicated by authors as a list, model, or story; each with strengths and weaknesses. Thematic analysis identified one theme: health equity as an overarching and binding concept to the SDOH. Health equity was understood in different ways with implications for action on the SDOH. CONCLUSIONS: Among the vast SDOH literature, there is a need to identify and clearly articulate the essence and implications of the SDOH concept. We recommend that authors be intentional in their efforts to present and discuss SDOH to ensure that they speak to its foundational concept of health equity.

Coder perspectives on physician-related barriers to producing high-quality administrative data: a qualitative study.

BACKGROUND: Professional coding specialists ("coders") are experts at translating patient chart information into alphanumerical codes, which are then widely used in research and health policy decision-making. Coders rely solely on documentation by health care providers to complete this task. We aimed to explore physician-related barriers to coding that results in high-quality administrative data. METHODS: In a qualitative study conducted from December 2015 to March 2016, we recruited 28 coders who worked in health care facilities in Alberta using purposive and snowball sampling. Semistructured interviews were conducted, audio-recorded and transcribed. The interviews delved into coder training, work environment, documentation and coding standards. Thematic content analysis of transcripts was performed by 2 study investigators through line-by-line coding and constant comparison, after which the codes were collated into themes. RESULTS: Five themes emerged regarding physician-related barriers in coding of high-quality administrative data: 1) coders are limited in their ability to add to, modify or interpret physician documentation, which supersedes all other chart documentation, 2) physician documentation is incomplete and nonspecific, 3) chart information tends to be replete with errors and discrepancies, 4) physicians and coders use different terminology to describe clinical diagnoses and 5) there is a communication divide between coders and physicians, such that questions and issues regarding physician documentation cannot be reconciled. INTERPRETATION: Physicians play a major role in influencing the quality of administrative data. There is a need for physicians to advocate for culture change in physicians' attitudes toward coders and chart documentation, in recognition of the importance of accurate chart information.

Intersectoral action on the social determinants of health and health equity in Canada: December 2019 federal government mandate letter review. / Action intersectorielle sur les déterminants sociaux de la santé et l'équité en santé au Canada : examen des lettres de mandat du gouvernement fédéral de décembre 2019.

Mandate letters for the current federal government cabinet ministers identify opportunities for intersectoral action on social determinants of health and health equity. Key areas for intersectoral action identified in 2019 mandate letters include adopting measures of wellbeing in the federal budget, redistributive tax policies, and initiatives in employment, housing, education and other sectors. Continued monitoring and reporting on health inequalities in Canada is important in assessing progress and identifying areas where intersectoral collaboration can be strengthened.

Les lettres de mandat des ministres du gouvernement fédéral définissent les possibilités d'action intersectorielle sur les déterminants sociaux de la santé et sur l'équité en santé. Les principaux domaines d'action intersectorielle définis dans les lettres de mandat de 2019 sont l'adoption de mesures de bien­être dans le budget fédéral, de politiques fiscales de redistribution et d'initiatives dans les secteurs notamment de l'emploi, du logement et de l'éducation. Il est important d'assurer la surveillance continue des inégalités en matière de santé au Canada et d'en rendre compte afin de pouvoir évaluer les progrès et déterminer les secteurs dans lesquels la collaboration intersectorielle peut être renforcée.

Public health perspectives on postwar mental health: gender, housing and family in Kitimat, British Columbia, 1950s.

BACKGROUND: The aftermath of World War II brought rapid change to the ways in which Canadian communities were designed and how their populations experienced their lives. The purpose of this study is to explore how mental health was understood and experienced in the context of the postwar period using the well-documented construction (in 1953) of the comprehensively planned, resource-based community of Kitimat, British Columbia as a case example. METHODS: A qualitative content analysis of primary sources from Kitimat's archival collections was conducted, and eight semi-structured, in-depth interviews were held with long-term residents to enrich the historical data. Findings were then interpreted to construct a historical narrative informed by an operationalized definition of mental health. RESULTS AND DISCUSSION: Kitimat residents in the 1950s understood and experienced their lives in ways consistent with contemporary holistic conceptualizations of mental health, namely, their daily living experiences. A historic interpretation revealed that mental health was understood as something achieved and maintained through conformance with postwar ideals for gendered norms and the family unit, as well as being experienced through issues like housing and expectations of community living. CONCLUSIONS: Understanding mental health demands consideration of local circumstances of time and place. The use of historical analysis in public health provides important evidence for how mental health was understood in the past, in a place and at a time when explicit modern language was limited, and illustrates the prominent role of the social determinants of health vis-à-vis population well-being. This article may be of special interest to those working collaboratively in the fields of public health and urban planning.