Time trends in preeclampsia and gestational diabetes in Denmark and Alberta, Canada, 2005-2018-A population-based cohort study.

INTRODUCTION: Preeclampsia and gestational diabetes mellitus share risk factors such as obesity and increased maternal age, which have become more prevalent in recent decades. We examined changes in the prevalence of preeclampsia and gestational diabetes between 2005 and 2018 in Denmark and Alberta, Canada, and investigated whether the observed trends can be explained by changes in maternal age, parity, multiple pregnancy, comorbidity, and body mass index (BMI) over time. MATERIAL AND METHODS: This study was a register-based cohort study conducted using data from the Danish National Health Registers and the provincial health registers of Alberta, Canada. We included in the study cohort all pregnancies in 2005-2018 resulting in live-born infants and used binomial regression to estimate mean annual increases in the prevalence of preeclampsia and gestational diabetes in the two populations across the study period, adjusted for maternal characteristics. RESULTS: The study cohorts included 846 127 (Denmark) and 706 728 (Alberta) pregnancies. The prevalence of preeclampsia increased over the study period in Denmark (2.5% to 2.9%) and Alberta (1.7% to 2.5%), with mean annual increases of 0.03 (95% confidence interval [CI] 0.02-0.04) and 0.06 (95% CI 0.05-0.07) percentage points, respectively. The prevalence of gestational diabetes also increased in Denmark (1.9% to 4.6%) and Alberta (3.9% to 9.2%), with average annual increases of 0.20 (95% CI 0.19-0.21) and 0.44 (95% CI 0.42-0.45) percentage points. Changes in the distributions of maternal age and BMI contributed to increases in the prevalence of both conditions but could not explain them entirely. CONCLUSIONS: The prevalence of both preeclampsia and gestational diabetes increased significantly from 2005 to 2018, which portends future increases in chronic disease rates among affected women. Increasing demand for long-term follow up and care will amplify the existing pressure on healthcare systems.

Impact of a modified screening approach during the COVID-19 pandemic on the diagnosis and outcomes of gestational diabetes mellitus: A population-level analysis of 90,518 pregnant women.

AIMS: To provide real-world evidence on the uptake of and outcomes associated with the modified gestational diabetes mellitus (GDM) screening approach offered during the COVID-19 pandemic compared with the standard screening approach. METHODS: All pregnancies between 01 January 2020 and 31 December 2021, in Alberta, Canada, were included in the study. We examined GDM screening and diagnosis rates, and large-for-gestational-age (LGA) outcomes. RESULTS: Annual GDM screening rates were > 95% during the study time period. Overall, 84.7%, and 11.6% of the 92,505 pregnancies underwent standard and modified screening for GDM, respectively. The use of modified screening was the highest among deliveries in August 2020 (49.8%) which corresponded to the early first wave of the pandemic. GDM diagnosis rate was lower in the modified screening (7.4%) than in the standard screening (12.3%, p < 0.001) group. The LGA rates in the modified screening with GDM and the standard screening with GDM groups were 24.8% and 12.6%, respectively (p < 0.001). Women in the modified screening with GDM group were at a higher risk of having an LGA infant (adjusted odds ratio: 3.46; 95% confidence interval: 2.93, 4.08) compared to the standard screening with no GDM group. CONCLUSIONS: The COVID-19 epidemic had no impact on screening for GDM. Women who underwent modified screening, based on HbA1c/random plasma glucose, had lower rates of GDM cases.

Health care impact of implementing a clinical pathway for acute care of pediatric concussion: a stepped wedge, cluster randomised trial.

OBJECTIVES: To test the effects of actively implementing a clinical pathway for acute care of pediatric concussion on health care utilization and costs. METHODS: Stepped wedge, cluster randomized trial of a clinical pathway, conducted in 5 emergency departments (ED) in Alberta, Canada from February 1 to November 30, 2019. The clinical pathway emphasized standardized assessment of risk for persistent symptoms, provision of consistent information to patients and families, and referral for outpatient follow-up. De-identified administrative data measured 6 outcomes: ED return visits; outpatient follow-up visits; length of ED stay, including total time, time from triage to physician initial assessment, and time from physician initial assessment to disposition; and total physician claims in an episode of care. RESULTS: A total of 2878 unique patients (1164 female, 1713 male) aged 5-17 years (median 11.00, IQR 8, 14) met case criteria. They completed 3009 visits to the 5 sites and 781 follow-up visits to outpatient care, constituting 2910 episodes of care. Implementation did not alter the likelihood of an ED return visit (OR 0.77, 95% CI 0.39, 1.52), but increased the likelihood of outpatient follow-up visits (OR 1.84, 95% CI 1.19, 2.85). Total length of ED stay was unchanged, but time from physician initial assessment to disposition decreased significantly (mean change - 23.76 min, 95% CI - 37.99, - 9.52). Total physician claims increased significantly at only 1 of 5 sites. CONCLUSIONS: Implementation of a clinical pathway in the ED increased outpatient follow-up and reduced the time from physician initial assessment to disposition, without increasing physician costs. Implementation of a clinical pathway can align acute care of pediatric concussion more closely with existing clinical practice guidelines while making care more efficient. TRIAL REGISTRATION: ClinicalTrials.gov NCT05095012.

ABSTRAIT: OBJECTIFS: Mettre à l'essai les effets de la mise en œuvre active d'une voie clinique pour le traitement aigu des commotions cérébrales chez les enfants sur l'utilisation et les coûts des soins de santé. MéTHODES: Essai randomisé en grappes d'une voie clinique, échelonné, mené dans cinq services d'urgence en Alberta, au Canada, du 1 février au 30 novembre 2019. Le cheminement clinique mettait l'accent sur l'évaluation normalisée du risque de symptômes persistants, la fourniture de renseignements uniformes aux patients et aux familles, et l'aiguillage vers un suivi externe. Les données administratives dépersonnalisées ont permis de mesurer six résultats : visites de retour à l'urgence; visites de suivi en clinique externe; durée du séjour à l'urgence, y compris le temps total. le temps entre le triage et l'évaluation initiale du médecin, et le temps entre l'évaluation initiale du médecin et la décision; et le nombre total de demandes de remboursement du médecin dans un épisode de soins. RéSULTATS: Un total de 2878 patients uniques (1164 femmes, 1713 hommes) âgés de 5 à 17 ans (médiane 11,00, IQR 8, 14) répondaient aux critères de cas. Ils ont effectué 3009 visites aux 5 sites et 781 visites de suivi aux soins ambulatoires, ce qui représente 2910 épisodes de soins. La mise en œuvre n'a pas modifié la probabilité d'une visite de retour à l'urgence (RC 0,77, IC à 95 %, 0,39, 1,52), mais a augmenté la probabilité de visites de suivi en clinique externe (RC 1,84, IC à 95 %, 1,19, 2,85). La durée totale du séjour à l'urgence est demeurée inchangée, mais le temps écoulé entre l'évaluation initiale du médecin et la décision a diminué considérablement (changement moyen : -23,76 minutes, IC à 95 %, -37,99, -9,52). Le nombre total de demandes de règlement de médecins a augmenté de façon significative à seulement 1 site sur 5. CONCLUSIONS: La mise en œuvre d'un cheminement clinique à l'urgence a augmenté le suivi des patients externes et réduit le temps entre l'évaluation initiale du médecin et son élimination, sans augmenter les coûts des médecins. La mise en œuvre d'un cheminement clinique peut harmoniser davantage les soins de courte durée en cas de commotion cérébrale pédiatrique avec les lignes directrices de pratique clinique existantes tout en rendant les soins plus efficaces. ENREGISTREMENT D'ESSAI: ClinicalTrials.gov NCT05095012.

Longitudinal trends in incidence and health care use for pediatric concussion in Alberta, Canada.

BACKGROUND: We described longitudinal trends in the incidence of episodes of care (EOC) and follow-up care for pediatric concussion in relation to age, sex, rurality of patient residence, point of care, and area-based socioeconomic status (SES) in Alberta, Canada. METHODS: A retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients <18 years of age who received a diagnosis of concussion, other specified injuries of head, unspecified injury of head, or post-concussion syndrome between April 1, 2004 and March 31, 2018. Data were geospatially mapped. RESULTS: Concussion EOCs increased 2.2-fold over the study period, follow-up visits 5.1-fold. Care was increasingly received in physician office (PO) settings. Concussion diagnoses in rural and remote areas occurred in emergency department (ED) settings more often than in metro centres or urban areas (76%/75% vs. 52%/60%). Proportion of concussion diagnoses was positively related to SES and age. Diagnosis and point of care varied geographically. CONCLUSIONS: The shift in care to PO settings, increased incidence of all diagnoses, and the higher use of the ED by some segments of the population all have important implications for appropriate clinical management and the efficient provision of health care for pediatric concussion. IMPACT: This is the first study to use EOC to describe longitudinal trends in incidence and follow-up care for pediatric concussion in relation to age, sex, rurality, point of care, and area-based SES. We report increased incidence of concussion in both emergency and outpatient settings and the proportion of diagnoses was positively related to SES and age. Patients increasingly received care for concussion in PO over time. Geospatial mapping indicated that the incidence of concussion and unspecified injury of head varied geographically and temporally. Results have important implications for appropriate clinical management and efficient provision of health care following pediatric concussion.

Administrative Databases: Friend or Foe in Paediatric Cardiomyopathy.

Background: Cardiomyopathy (CM) is a rare childhood disease associated with morbidity and mortality. Limited data exist on paediatric CM in Canada. Given the rare nature, single-centre studies are not sufficiently powered to address important questions. Therefore, administrative health data may serve as a resource for the study of childhood CM. The goal of this study was to validate the accuracy of International Classification of Diseases (ICD)-based algorithms to identify paediatric CM in health databases using a clinical registry as the gold standard. Methods: The clinical registry was compiled from outpatient and inpatient records at the Stollery Children's Hospital (January 1, 2013, to December 31, 2021). Patients were categorized as having CM or screened without CM. Data were linked to administrative health databases using the patient's Unique Lifetime Identifier. Algorithms based on the presence of ICD, 10th Revision, codes for CM were then evaluated, and cross-tabulations against the clinical registry were generated. Accuracy, positive predictive value, negative predictive value, sensitivity, and specificity were calculated. Results: The clinical registry had 90 patients with CM and 249 screened without CM. The algorithms ruled out CM (high negative predictive value) but had variability in the ability to diagnose CM positive predictive value. The algorithm that performed the best was based on a diagnosis of CM in a hospitalization or 2 ambulatory visits. Conclusions: A combination of inpatient and outpatient databases can be used, with acceptable accuracy, to identify paediatric patients with CM. This finding allows for the use of the identified algorithm for the comprehensive study of paediatric CM in Canada.

Contexte: La cardiomyopathie (CM) est une maladie rare de l'enfance associée à des taux élevés de morbidité et de mortalité et sur laquelle les données sont limitées en contexte canadien. En raison de la rareté de cette maladie, les études monocentriques ne peuvent atteindre la puissance statistique nécessaire pour répondre à certaines questions importantes. Les données administratives sur la santé peuvent donc constituer une ressource intéressante pour examiner la CM chez les enfants. La présente étude visait à valider l'exactitude d'algorithmes fondés sur la Classification internationale des maladies (CIM) pour repérer les cas de CM pédiatrique dans des bases de données sur la santé, en utilisant un registre clinique comme référence. Méthodologie: Un registre clinique a été élaboré à partir des dossiers de clinique interne et externe du Stollery Children's Hospital (du 1er janvier 2013 au 31 décembre 2021). Les patients ont été classés en deux catégories : atteints de CM ou dépistés sans CM. Les données ont été liées aux bases de données administratives sur la santé en utilisant le numéro d'identification unique des patients (Unique Lifetime Identifier). Des algorithmes fondés sur les codes de la CIM-10 ont été évalués et des analyses croisées avec le registre clinique ont été réalisées. L'exactitude, la valeur prédictive positive (VPP), la valeur prédictive négative (VPN), la sensibilité et la spécificité des algorithmes ont été calculées. Résultats: Le registre clinique comprenait 90 patients atteints de CM et 249 patients dépistés sans CM. Les algorithmes permettaient d'exclure correctement la CM (VPN élevée), mais leur capacité à établir le diagnostic de CM variait (VPP). L'algorithme le plus performant était fondé sur l'attribution d'un code diagnostique de CM lors d'une hospitalisation ou de deux visites ambulatoires. Conclusions: La combinaison de bases de données sur les hospitalisations et sur les soins externes peut être utilisée pour identifier les enfants atteints de CM avec une exactitude acceptable. Cette observation corrobore l'utilisation de l'algorithme ciblé pour réaliser une étude exhaustive de la CM chez l'enfant au Canada.

Primary care service use during adolescence and young adulthood: Tertiary care cohort affected by chronic health conditions.

OBJECTIVE: To understand use of family physician services and emergency department visits by adolescents and young adults with chronic health conditions. DESIGN: Longitudinal retrospective observational cohort study using administrative health data. SETTING: Chronic care clinics at a tertiary care pediatric hospital in Calgary, Alta. PARTICIPANTS: In total, 1326 adolescents who were between 12 and 15 years old in 2008, who were observed until 2016, and who received medical services for chronic conditions were enrolled in the study. Eligible participants had at least 4 visits to the same chronic disease clinic in any 2-year window before age 18. MAIN OUTCOMES MEASURES: Group-based trajectory modeling was used to identify groups of adolescents with distinct patterns of health care use (for visits to emergency departments and to primary care practices), while 2 tests explored trajectory group differences (eg, sex, location of residence). RESULTS: Median age was 14 years (range 12 to 17 years) at study entry, and 22 years (range 14 to 24 years) at study exit. Half were female and most (85.4%) lived in an urban area. Median observation period was 8.7 person-years (range 1.3 to 9.1 years). Group-based trajectory modeling identified 5 distinct trajectory groups of primary care use and 4 groups of emergency services use. Groups differed by sex and location of residence in each trajectory model. CONCLUSION: Many adolescents increased their use of emergency services between the ages of 12 and 24 years, with distinct patterns of primary care use being observed. Association of additional patient- and system-level factors (eg, disease severity, distance to nearest family physician office) should be explored.

Factors associated with follow-up care after pediatric concussion: A longitudinal population-based study in Alberta, Canada.

Background: Concussion is a common injury in children and adolescents. Current best practice guidelines indicate that recovery should be supervised through recurrent follow-up visits. A more detailed understanding of the system-level and individual factors that are associated with follow-up care is a critical step towards increasing evidence-based practice. The objective of this study was to identify predisposing, enabling, and need-based factors associated with follow-up care after pediatric concussion. Materials and methods: A retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients <18 years of age with a diagnosis of concussion, other specified injuries of the head, unspecified injury of head, or post-concussion syndrome (PCS) between April 1, 2004 and March 31, 2018 in Alberta, Canada. The association between predisposing, enabling, and need-based factors and the receipt of follow-up care within a defined episode of care (EOC) was analyzed using logistic regression models for the entire cohort and for EOC that began with a concussion diagnosis. Predisposing factors included age and sex. Enabling factors included the community type of patient residence, area-based socioeconomic status (SES), and visit year. Need-based factors included where the EOC began (outpatient vs. emergency settings) and history of previous concussion-related EOC. Results: 194,081 EOCs occurred during the study period but only 13% involved follow-up care (n = 25,461). Males and adolescents were more likely to receive follow-up care. Follow-up was less likely among patients who lived in remote communities or in areas of lower SES, while EOCs beginning in 2011 or later were more likely to involve follow-up care. Patients whose EOC began in outpatient settings, had more than one EOC, or a diagnosis of concussion were more likely to receive follow-up care. Conclusion: Follow-up care for pediatric concussion has increased over time and is associated with patient age and sex, history of concussion-related EOC, where a patient lives (community type and area-based SES), and when and where the index visit occurs. A better understanding of which children are more likely to receive follow-up care, as well as how and when they do, is an important step in aligning practice with follow-up guidelines.

Identifying a retrospective cohort of adolescents with chronic health conditions from a paediatric hospital prior to transfer to adult care: the Calgary Transition Cohort.

PURPOSE: The Calgary Transition Cohort was created to examine health service utilisation by adolescents affected by chronic health conditions seen in a tertiary paediatric hospital in the province of Alberta, Canada. The cohort includes adolescents who received care before the implementation of a hospital-wide intervention to improve transitions to adult care. PARTICIPANTS: Using hospital records, a stepwise methodology involving a series of algorithms based on adolescents' visit frequency to a hospital ambulatory chronic care clinic (CCC) was used to identify the cohort. A visit frequency of ≥4 visits in any 24-month window, during the ages of 12-17 years old, was used to identify eligible adolescents, as agreed on by key stakeholders and chronic disease clinical providers, and reflects the usual practice at the hospital for routine care of children with chronic disease. FINDINGS TO DATE: Adolescents with ≥4 visits to the same CCC in any 2-year period (n=1344) with a median of 8.7 years of follow-up data collected (range 1.4-9.1). The median age at study entry was 14 years (range 12-17) and 22 years (range 14-24) at study exit. The cohort was linked (97% successful match proportion) to their population-level health records that allowed for examination of occurrence of chronic disease codes in health utilisation encounters (ie, physician claims, hospital admissions and emergency room visits). At least one encounter with a chronic disease code (International Classification of Diseases, 9th/10th Revisions) was observed during the entire study window in 87.9% of the cohort. FUTURE PLANS: The Calgary Transition Cohort will be used to address existing knowledge gaps about health service utilisation by adolescents, seen at a tertiary care hospital, affected by a broad group of chronic health conditions. These adolescents will require transition to adult-oriented care. Longitudinal analysis of health service use patterns over a 9-year window (2008-2016) will be conducted.