HealthyPlan.City: A Web Tool to Support Urban Environmental Equity and Public Health in Canadian Communities.

Urban environmental factors such as air quality, heat islands, and access to greenspaces and community amenities impact public health. Some vulnerable populations such as low-income groups, children, older adults, new immigrants, and visible minorities live in areas with fewer beneficial conditions, and therefore, face greater health risks. Planning and advocating for equitable healthy urban environments requires systematic analysis of reliable spatial data to identify where vulnerable populations intersect with positive or negative urban/environmental characteristics. To facilitate this effort in Canada, we developed HealthyPlan.City ( https://healthyplan.city/ ), a freely available web mapping platform for users to visualize the spatial patterns of built environment indicators, vulnerable populations, and environmental inequity within over 125 Canadian cities. This tool helps users identify areas within Canadian cities where relatively higher proportions of vulnerable populations experience lower than average levels of beneficial environmental conditions, which we refer to as Equity priority areas. Using nationally standardized environmental data from satellite imagery and other large geospatial databases and demographic data from the Canadian Census, HealthyPlan.City provides a block-by-block snapshot of environmental inequities in Canadian cities. The tool aims to support urban planners, public health professionals, policy makers, and community organizers to identify neighborhoods where targeted investments and improvements to the local environment would simultaneously help communities address environmental inequities, promote public health, and adapt to climate change. In this paper, we report on the key considerations that informed our approach to developing this tool and describe the current web-based application.

The equitable impact of sugary drink taxation structures on sugary drink consumption among Canadians: a modelling study using the 2015 Canadian Community Health Survey-Nutrition.

OBJECTIVE: Estimate the impact of 20 % flat-rate and tiered sugary drink tax structures on the consumption of sugary drinks, sugar-sweetened beverages and 100 % juice by age, sex and socio-economic position. DESIGN: We modelled the impact of price changes - for each tax structure - on the demand for sugary drinks by applying own- and cross-price elasticities to self-report sugary drink consumption measured using single-day 24-h dietary recalls from the cross-sectional, nationally representative 2015 Canadian Community Health Survey-Nutrition. For both 20 % flat-rate and tiered sugary drink tax scenarios, we used linear regression to estimate differences in mean energy intake and proportion of energy intake from sugary drinks by age, sex, education, food security and income. SETTING: Canada. PARTICIPANTS: 19 742 respondents aged 2 and over. RESULTS: In the 20 % flat-rate scenario, we estimated mean energy intake and proportion of daily energy intake from sugary drinks on a given day would be reduced by 29 kcal/d (95 % UI: 18, 41) and 1·3 % (95 % UI: 0·8, 1·8), respectively. Similarly, in the tiered tax scenario, additional small, but meaningful reductions were estimated in mean energy intake (40 kcal/d, 95 % UI: 24, 55) and proportion of daily energy intake (1·8 %, 95 % UI: 1·1, 2·5). Both tax structures reduced, but did not eliminate, inequities in mean energy intake from sugary drinks despite larger consumption reductions in children/adolescents, males and individuals with lower education, food security and income. CONCLUSIONS: Sugary drink taxation, including the additional benefit of taxing 100 % juice, could reduce overall and inequities in mean energy intake from sugary drinks in Canada.

Characterizing high-cost healthcare users among adults with back pain in Ontario, Canada: a population-based cohort study.

ABSTRACT: Some patients with back pain contribute disproportionately to high healthcare costs; however, characteristics of high-cost users with back pain are not well defined. We described high-cost healthcare users based on total costs among a population-based cohort of adults with back pain within the Ontario government's single-payer health system across sociodemographic, health, and behavioural characteristics. We conducted a population-based cohort study of Ontario adult (aged 18 years or older) respondents of the Canadian Community Health Survey (CCHS) with back pain (2003-2012), linked to administrative data (n = 36,605; weighted n = 2,076,937, representative of Ontario). Respondents were ranked based on gradients of total healthcare costs (top 1%, top 2%-5%, top 6%-50%, and bottom 50%) for 1 year following the CCHS survey, with high-cost users as top 5%. We used multinomial logistic regression to investigate characteristics associated with the 4 cost groups. Top 5% of cost users accounted for 49% ($4 billion CAD) of total healthcare spending, with inpatient hospital care as the largest contributing service type (approximately 40% of costs). Top 5% high-cost users were more likely aged 65 years or older (ORtop1% = 16.6; ORtop2-5% = 44.2), with lower income (ORtop1% = 3.6; ORtop 2-5% = 1.8), chronic disease(s) (ORtop1% = 3.8; ORtop2-5% = 1.6), Aggregated Diagnosis Groups measuring comorbidities (ORtop1% = 25.4; ORtop2-5% = 13.9), and fair/poor self-rated general health (ORtop1% = 6.7; ORtop2-5% = 4.6) compared with bottom 50% users. High-cost users tended to be current/former smokers, obese, and report fair/poor mental health. High-cost users (based on total costs) among adults with back pain account for nearly half of all healthcare spending over a 1-year period and are associated with older age, lower income, comorbidities, and fair/poor general health. Findings identify characteristics associated with a high-risk group for back pain to inform healthcare and public health strategies that target upstream determinants.

Modeling chronic disease risk across equity factors using a population-based prediction model: the Chronic Disease Population Risk Tool (CDPoRT).

BACKGROUND: Predicting chronic disease incidence at a population level can help inform overall future chronic disease burden and opportunities for prevention. This study aimed to estimate the future burden of chronic disease in Ontario, Canada, using a population-level risk prediction algorithm and model interventions for equity-deserving groups who experience barriers to services and resources due to disadvantages and discrimination. METHODS: The validated Chronic Disease Population Risk Tool (CDPoRT) estimates the 10-year risk and incidence of major chronic diseases. CDPoRT was applied to data from the 2017/2018 Canadian Community Health Survey to predict baseline 10-year chronic disease estimates to 2027/2028 in the adult population of Ontario, Canada, and among equity-deserving groups. CDPoRT was used to model prevention scenarios of 2% and 5% risk reductions over 10 years targeting high-risk equity-deserving groups. RESULTS: Baseline chronic disease risk was highest among those with less than secondary school education (37.5%), severe food insecurity (19.5%), low income (21.2%) and extreme workplace stress (15.0%). CDPoRT predicted 1.42 million new chronic disease cases in Ontario from 2017/2018 to 2027/2028. Reducing chronic disease risk by 5% prevented 1500 cases among those with less than secondary school education, prevented 14 900 cases among those with low household income and prevented 2800 cases among food-insecure populations. Large reductions of 57 100 cases were found by applying a 5% risk reduction in individuals with quite a bit workplace stress. CONCLUSION: Considerable reduction in chronic disease cases was predicted across equity-defined scenarios, suggesting the need for prevention strategies that consider upstream determinants affecting chronic disease risk.

Bridging ethics and epidemiology: Modelling ethical standards of health equity.

Health inequities are differences in health that are 'unjust'. Yet, despite competing ethical views about what counts as an 'unjust difference in health', theoretical insights from ethics have not been systematically integrated into epidemiological research. Using diabetes as an example, we explore the impact of adopting different ethical standards of health equity on population health outcomes. Specifically, we explore how the implementation of population-level weight-loss interventions using different ethical standards of equity impacts the intervention's implementation and resultant population health outcomes. We conducted a risk prediction modelling study using the nationally representative 2015-16 Canadian Community Health Survey (n = 75,044, 54% women). We used the Diabetes Population Risk Tool (DPoRT) to calculate individual-level 10-year diabetes risk. Hypothetical weight-loss interventions were modelled in individuals with overweight or obesity based on each ethical standard: 1) health sufficiency (reduce DPoRT risk below a high-risk threshold (16.5%); 2) health equality (equalize DPoRT risk to the low risk group (5%)); 3) social-health sufficiency (reduce DPoRT risk <16.5 in individuals with lower education); 4) social-health equality (equalize DPoRT risk to the level of individuals with high education). For each scenario, we calculated intervention impacts, diabetes cases prevented or delayed, and relative and absolute educational inequities in diabetes. Overall, we estimated that achieving health sufficiency (i.e., all individuals below the diabetes risk threshold) was more feasible than achieving health equality (i.e., diabetes risk equalized for all individuals), requiring smaller initial investments and fewer interventions; however, fewer diabetes cases were prevented or delayed. Further, targeting only diabetes inequalities related to education reduced the target population size and number of interventions required, but consequently resulted in even fewer diabetes cases prevented or delayed. Using diabetes as an example, we found that an explicit, ethically-informed definition of health equity is essential to guide population-level interventions that aim to reduce health inequities.

Predictive risk modelling of high resource users under different prescription drug coverage policies in Ontario and Manitoba, Canada.

INTRODUCTION: Studying high resource users (HRUs) across jurisdictions is a challenge due to variation in data availability and health services coverage. In Canada, coverage for pharmaceuticals varies across provinces under a mix of public and private plans, which has implications for ascertaining HRUs. We examined sociodemographic and behavioural predictors of HRUs in the presence of different prescription drug coverages in the provinces of Manitoba and Ontario. METHODS: Linked Canadian Community Health Surveys were used to create two cohorts of respondents from Ontario (n = 58,617, cycles 2005-2008) and Manitoba (n = 10,504, cycles 2007-2010). HRUs (top 5%) were identified by calculating health care utilization 5 years following interview date and computing all costs in the linked administrative databases, with three approaches used to include drug costs: (1) costs paid for by the provincial payer under age-based coverage; (2) costs paid for by the provincial payer under income-based coverage; (3) total costs regardless of the payer (publicly insured, privately insured, and out-of-pocket). Logistic regression estimated the association between sociodemographic, health, and behavioral predictors on HRU risk. RESULTS: The strength of the association between age (≥ 80 vs. <30) and becoming an HRU were attenuated with the inclusion of broader drug data (age based: OR 37.29, CI: 30.08-46.24; income based: OR 27.34, CI: 18.53-40.33; all drug payees: OR 29.08, CI: 19.64-43.08). With broader drug coverage, the association between heavy smokers vs. non-smokers on odds of becoming an HRU strengthened (age based: OR 1.58, CI: 1.32-1.90; income based: OR 2.97, CI: 2.18-4.05; all drug payees: OR 3.12, CI: 2.29-4.25). Across the different drug coverage policies, there was persistence in higher odds of becoming an HRU in low income households vs. high income households and in those with a reported chronic condition vs. no chronic conditions. CONCLUSIONS: The study illustrates that jurisdictional differences in how HRUs are ascertained based on drug coverage policies can influence the relative importance of some behavioural risk factors on HRU status, but most observed associations with health and sociodemographic risk factors were persistent, demonstrating that predictive risk modelling of HRUs can occur effectively across jurisdictions, even with some differences in public drug coverage policies.

Effects of chiropractic use on medical healthcare utilization and costs in adults with back pain in Ontario, Canada from 2003 to 2018: a population-based cohort study.

BACKGROUND: Adults with back pain commonly consult chiropractors, but the impact of chiropractic use on medical utilization and costs within the Canadian health system is unclear. We assessed the association between chiropractic utilization and subsequent medical healthcare utilization and costs in a population-based cohort of Ontario adults with back pain. METHODS: We conducted a population-based cohort study that included Ontario adult respondents of the Canadian Community Health Survey (CCHS) with back pain from 2003 to 2010 (n = 29,475), followed up to 2018. The CCHS data were individually-linked to individual-level health administrative data up to 2018. Chiropractic utilization was self-reported consultation with a chiropractor in the past 12 months. We propensity score-matched adults with and without chiropractic utilization, accounting for confounders. We evaluated back pain-specific and all-cause medical utilization and costs at 1- and 5-year follow-up using negative binomial and linear (log-transformed) regression, respectively. We assessed whether sex and prior specialist consultation in the past 12 months were effect modifiers of the association. RESULTS: There were 6972 matched pairs of CCHS respondents with and without chiropractic utilization. Women with chiropractic utilization had 0.8 times lower rate of cause-specific medical visits at follow-up than those without chiropractic utilization (RR5years = 0.82, 95% CI 0.68-1.00); this association was not found in men (RR5years = 0.96, 95% CI 0.73-1.24). There were no associations between chiropractic utilization and all-cause physician visits, all-cause emergency department visits, all-cause hospitalizations, or costs. Effect modification of the association between chiropractic utilization and cause-specific utilization by prior specialist consultation was found at 1-year but not 5-year follow-up; cause-specific utilization at 1 year was lower in adults without prior specialist consultation only (RR1year = 0.74, 95% CI 0.57-0.97). CONCLUSIONS: Among adults with back pain, chiropractic use is associated with lower rates of back pain-specific utilization in women but not men over a 5-year follow-up period. Findings have implications for guiding allied healthcare delivery in the Ontario health system.

Overcrowded housing during adolescence and future risk of premature mortality: a 28-year follow-up of 556,191 adolescents from Switzerland.

Background: Few large-scale studies have examined the health impacts of overcrowded housing in European countries. The aim of this study was to assess whether household crowding during adolescence increases the risk of all-cause and cause-specific mortality in Switzerland. Methods: Study participants were 556,191 adolescents aged 10-19 years at the 1990 census from the Swiss National Cohort. Household crowding at baseline was measured as the ratio between the number of persons living in the household and the number of available rooms, categorized as none (ratio ≤ 1), moderate (1 < ratio ≤ 1.5), and severe (ratio > 1.5). Participants were linked to administrative mortality records through 2018 and followed for premature mortality from all causes, cardiometabolic disease and self-harm or substance use. Cumulative risk differences between ages 10 and 45 were standardized by parental occupation, residential area, permit status and household type. Findings: Of the sample, 19% lived in moderately and 5% lived in severely crowded households. During an average follow-up of 23 years, 9766 participants died. Cumulative risk of death from all causes was 2359 (95% compatibility intervals: 2296-2415) per 100,000 persons when living in non-crowded households. Living in moderately crowded households led to 99 additional deaths (-63 to 256) per 100,000 persons and living in severely crowded households 258 additional deaths (-37 to 607) per 100,000 persons. The effect of crowding on mortality from cardiometabolic diseases, self-harm or substance use was negligible. Interpretation: Excess risk of premature mortality in adolescents living in overcrowded households appears to be small or negligible in Switzerland. Funding: University of Fribourg Scholarship Programme for foreign post-doctoral researchers.

Association between physiotherapy utilization and medical healthcare utilization and costs in adults with back pain from Ontario, Canada: a population-based cohort study.

ABSTRACT: This study examined the association between physiotherapy utilization and subsequent medical healthcare utilization and costs in a population-based sample of adults with back pain in Ontario. We conducted a population-based cohort study of Ontario respondents with back pain (≥18 years) of the Canadian Community Health Survey 2003 to 2010 cycles, linked to health administrative data up to 2018. Physiotherapy utilization was defined as self-reported consultation with a physiotherapist in the past 12 months. A propensity score-matched cohort was conducted to match adults with and without physiotherapy utilization, accounting for potential confounders. We assessed associations using negative-binomial and linear (log-transformed) regression to evaluate outcomes of healthcare utilization (back pain-specific and all-cause) and costs, respectively, at 1- and 5-year follow-up. There were 4343 pairs of matched respondents. Compared with those who did not receive physiotherapy, adults who received physiotherapy were more likely to have back pain-specific physician visits (RR women (5years) = 1.48, 95% CI 1.24-1.75; RR men (5years) = 1.42, 95% CI 1.10-1.84). Women who received physiotherapy had 1.11 times the rate of all-cause physician visits (RR 1year = 1.11, 95% CI 1.02-1.20), and men who received physiotherapy had 0.84 times the rate of all-cause hospitalizations (RR 5years = 0.84, 95% CI 0.71-0.99) than those who did not. There was no association between physiotherapy utilization and healthcare costs. Adults with back pain who received physiotherapy are more likely to have back pain-specific physician visits up to 5-year follow-up than those who did not. Physiotherapy utilization is linked to some sex-based differences in all-cause healthcare utilization but not differences in costs. Findings inform interprofessional collaboration and allied healthcare delivery for back pain in Ontario.

Association Between Smoking Cessation Treatment and Healthcare Costs in a Single-Payer Public Healthcare System.

INTRODUCTION: There has been little investigation of whether the clinical effectiveness of smoking cessation treatments translates into differences in healthcare costs, using real-world cost data, to determine whether anticipated benefits of smoking cessation treatment are being realized. AIMS AND METHODS: We sought to determine the association between smoking cessation treatment and healthcare costs using linked administrative healthcare data. In total, 4752 patients who accessed a smoking cessation program in Ontario, Canada between July 2011 and December 2012 (treatment cohort) were each matched to a smoker who did not access these services (control cohort). The primary outcome was total healthcare costs in Canadian dollars, and secondary outcomes were sector-specific costs, from one year prior to the index date until December 31, 2017, or death. Costs were partitioned into four phases: pretreatment, treatment, posttreatment, and end-of-life for those who died. RESULTS: Among females, total healthcare costs were similar between cohorts in pretreatment and posttreatment phases, but higher for the treatment cohort during the treatment phase ($4,554 vs. $3,237, p < .001). Among males, total healthcare costs were higher in the treatment cohort during pretreatment ($3,911 vs. $2,784, p < .001), treatment ($4,533 vs. $3,105, p < .001) and posttreatment ($5,065 vs. $3,922, p = .001) phases. End-of-life costs did not differ. Healthcare sector-specific costs followed a similar pattern. CONCLUSIONS: Five-year healthcare costs were similar between females who participated in a treatment program versus those that did not, with a transient increase during the treatment phase only. Among males, treatment was associated with persistently higher healthcare costs. Further study is needed to address the implications with respect to long-term costs. IMPLICATIONS: The clinical effectiveness of pharmacological and behavioral smoking cessation treatments is well established, but whether such treatments are associated with healthcare costs, using real-world data, has received limited attention. Our findings suggest that the use of a smoking cessation treatment offered by their health system is associated with persistent higher healthcare costs among males but a transient increase among females. Given increasing access to evidence-based smoking cessation treatments is an important component in national tobacco control strategies, these data highlight the need for further exploration of the relations between smoking cessation treatment engagement and healthcare costs.

Neighbourhood socioeconomic improvement, residential mobility and premature death: a population-based cohort study and inverse probability of treatment weighting analysis.

BACKGROUND: Causal inference using area-level socioeconomic measures is challenging due to risks of residual confounding and imprecise specification of the neighbourhood-level social exposure. By using multi-linked longitudinal data to address these common limitations, our study aimed to identify protective effects of neighbourhood socioeconomic improvement on premature mortality risk. METHODS: We used data from the Canadian Community Health Survey, linked to health administrative data, including longitudinal residential history. Individuals aged 25-69, living in low-socioeconomic status (SES) areas at survey date (n = 8335), were followed up for neighbourhood socioeconomic improvement within 5 years. We captured premature mortality (death before age 75) until 2016. We estimated protective effects of neighbourhood socioeconomic improvement exposures using Cox proportional hazards models. Stabilized inverse probability of treatment weights (IPTW) were used to account for confounding by baseline health, social and behavioural characteristics. Separate analyses were carried out for three exposure specifications: any improvement, improvement by residential mobility (i.e. movers) or improvement in place (non-movers). RESULTS: Overall, 36.9% of the study cohort experienced neighbourhood socioeconomic improvement either by residential mobility or improvement in place. There were noted differences in baseline health status, demographics and individual SES between exposure groups. IPTW survival models showed a modest protective effect on premature mortality risk of socioeconomic improvement overall (HR = 0.86; 95% CI 0.63, 1.18). Effects were stronger for improvement in place (HR = 0.67; 95% CI 0.48, 0.93) than for improvement by residential mobility (HR = 1.07, 95% 0.67, 1.51). CONCLUSIONS: Our study provides robust evidence that specific neighbourhood socioeconomic improvement exposures are important for determining mortality risks.

Clarifying rural-urban disparities in alcohol-related emergency department visits and hospitalizations in Ontario, Canada: A spatial analysis.

PURPOSE: Rates of alcohol-related harm are higher in rural versus urban Canada. This study characterized the spatial distribution and regional determinants of alcohol-related emergency department (ED) visits and hospitalizations in Ontario to better understand this rural-urban disparity. METHODS: This was a cross-sectional spatial analysis of rates of alcohol-related ED visits and hospitalizations by Ministry of Health subregion (n = 76) in Ontario, Canada between 2016 and 2019. Regional hot- and cold-spots of alcohol-related harm were identified using spatial autocorrelation methods. Rurality was measured as the population weighted geographic remoteness of a subregion. The associations between rurality and rates of alcohol-related ED visits and hospitalizations were evaluated using hierarchical Bayesian spatial regression models. FINDINGS: Rates of alcohol-related ED visits and hospitalizations varied substantially between subregions, with high rates clustering in Northern Ontario. Overall, increasing rurality was associated with higher subregion-level rates of alcohol-related ED visits (males adjusted relative rate [aRR]: 1.67, 95% credible interval [CI]: 1.49-1.87; females aRR: 1.78, 95% CI: 1.60-1.98) and hospitalizations (males aRR: 1.34, 95% CI: 1.24-1.45; females aRR: 1.59, 95% CI: 1.45-1.74). However, after the province was separated into Northern and Southern strata, this association only held in Northern subregions. In contrast, increasing rurality was associated with lower rates of alcohol-related ED visits in Southern subregions (males aRR: 0.87, 95% CI: 0.79-0.96; females aRR: 0.88, 95% CI: 0.81-0.97). CONCLUSIONS: There are regional differences in the association between rurality and alcohol-related health service use. This regional variation should be considered when developing health policies to minimize geographic disparities in alcohol-related harm.

Priorities for successful use of artificial intelligence by public health organizations: a literature review.

Artificial intelligence (AI) has the potential to improve public health's ability to promote the health of all people in all communities. To successfully realize this potential and use AI for public health functions it is important for public health organizations to thoughtfully develop strategies for AI implementation. Six key priorities for successful use of AI technologies by public health organizations are discussed: 1) Contemporary data governance; 2) Investment in modernized data and analytic infrastructure and procedures; 3) Addressing the skills gap in the workforce; 4) Development of strategic collaborative partnerships; 5) Use of good AI practices for transparency and reproducibility, and; 6) Explicit consideration of equity and bias.

Rural-urban disparities in post-discharge outcomes following alcohol-related hospitalizations in Ontario, Canada: A retrospective cohort study.

BACKGROUND: Limited access to mental health and addiction (MHA) services in rural areas may increase the risk of recurrent alcohol-related harm among rural, relative to urban, residents. This study evaluated (1) rural-urban differences in clinical trajectories following alcohol-related hospitalizations and (2) whether limited access to MHA services mediates an increased risk of adverse post-discharge outcomes in rural areas. METHODS: This was a population-based retrospective cohort study of individuals in Ontario, Canada, who experienced an alcohol-related hospitalization between 2016 and 2018. The primary exposure was rurality. The outcomes of interest were outpatient MHA care, alcohol-related emergency department visits, alcohol-related hospitalizations, and all-cause mortality within one-year of discharge from the index alcohol-related hospitalization. Data were collected using provincial health administrative databases. The associations between rurality and the time to each outcome were assessed using multivariable time-to-event regression. Mediation analyses were conducted using a counterfactual approach. RESULTS: 46,657 individuals were included. 11.5% of the cohort died within one year of discharge from the index alcohol-related hospitalization. Relative to urban residents, rural residents were less likely to receive MHA outpatient care (adjusted hazard ratio (aHR): 0.80, 95% confidence interval (CI): 0.75-0.86) and more likely to die (aHR: 1.19, 95% CI: 1.06-1.34) in the year following discharge. The lower likelihood of post-discharge MHA-related care among rural residents mediated 31% (95% CI: 13-46%) of the increased risk of mortality. CONCLUSIONS: A lack of follow-up MHA care mediates an increased risk of short-term mortality following alcohol-related hospitalizations in rural, relative to urban, communities.

Prevalence and health care costs of mitochondrial disease in Ontario, Canada: A population-based cohort study.

BACKGROUND: Mitochondrial disease prevalence has been estimated at 1 in 4000 in the United States, and 1 in 5000 worldwide. Prevalence in Canada has not been established, though multi-linked health administrative data resources present a unique opportunity to establish robust population-based estimates in a single-payer health system. This study used administrative data for the Ontario, Canada population between April 1988 and March 2019 to measure mitochondrial disease prevalence and describe patient characteristics and health care costs. RESULTS: 3069 unique individuals were hospitalized with mitochondrial disease in Ontario and eligible for the study cohort, representing a period prevalence of 2.51 per 10,000 or 1 in 3989. First hospitalization was most common between ages 0-9 or 50-69. The mitochondrial disease population experiences a high need for health care and incurred high costs (mean = CAD$24,023 in 12 months before first hospitalization) within the single-payer Ontario health care system. CONCLUSIONS: This study provides needed insight into mitochondrial disease in Canada, and demonstrates the high health burden on patients. The methodology used can be adapted across jurisdictions with similar routine collection of health data, such as in other Canadian provinces. Future work should seek to validate this approach via record linkage of existing disease cohorts in Ontario, and identify specific comorbidities with mitochondrial disease that may contribute to high health resource utilization.

Describing the linkage between administrative social assistance and health care databases in Ontario, Canada.

Background: The linkage of records across administrative databases has become a powerful tool to increase information available to undertake research and analytics in a privacy protective manner. Objective: The objective of this paper was to describe the data integration strategy used to link the Ontario Ministry of Children, Community and Social Services (MCCSS)-Social Assistance (SA) database with administrative health care data. Methods: Deterministic and probabilistic linkage methods were used to link the MCCSS-SA database (2003-2016) to the Registered Persons Database, a population registry containing data on all individuals issued a health card number in Ontario, Canada. Linkage rates were estimated, and the degree of record linkage and representativeness of the dataset were evaluated by comparing socio-demographic characteristics of linked and unlinked records. Results: There were a total of 2,736,353 unique member IDs in the MCCSS-SA database from the 1st January 2003 to 31st December 2016; 331,238 (12.1%) were unlinked (linkage rate = 87.9%). Despite 16 passes, most record linkages were obtained after 2 deterministic (76.2%) and 14 probabilistic passes (11.7%). Linked and unlinked samples were similar for most socio-demographic characteristics (i.e., sex, age, rural dwelling), except migrant status (non-migrant versus migrant) (standardized difference of 0.52). Linked and unlinked records were also different for SA program-specific characteristics, such as social assistance program, Ontario Works and Ontario Disability Support Program (standardized difference of 0.20 for each), data entry system, Service Delivery Model Technology only and both Service Delivery Model Technology and Social Assistance Management System (standardized difference of 0.53 and 0.52, respectively), and months on social assistance (standardized difference of 0.43). Conclusions: Additional techniques to account for sub-optimal linkage rates may be required to address potential biases resulting from this data linkage. Nonetheless, the linkage between administrative social assistance and health care data will provide important findings on the social determinants of health.

Socioeconomic position and consumption of sugary drinks, sugar-sweetened beverages and 100% juice among Canadians: a cross-sectional analysis of the 2015 Canadian Community Health Survey-Nutrition.

OBJECTIVE: The aim of this study was to describe sugary drink (beverages with free sugars), sugar-sweetened beverage (beverages with added sugars, SSB) and 100% juice (beverages with natural sugars) consumption across socioeconomic position (SEP) among Canadians. METHODS: We conducted a cross-sectional analysis of 19,742 respondents of single-day 24-h dietary recalls in the nationally representative 2015 Canadian Community Health Survey-Nutrition. Poisson regressions were used to estimate the prevalence of consuming each beverage type on a given day. Among consumers on a given day, linear regressions were used to estimate mean energy intake. Models included household education, food security and income quintiles as separate unadjusted exposures. Sex-specific models were estimated separately for children/adolescents (2-18 years) and adults (19 +). RESULTS: Among female children/adolescents, the prevalence of consuming sugary drinks and, separately, SSB ranged from 11 to 21 and 8 to 27 percentage-points higher among lower education compared to 'Bachelor degree or above' households. In female adults, the prevalence of consuming sugary drinks and, separately, SSB was 10 (95% CI: 1, 19) and 14 (95% CI: 2, 27) percentage-points higher in food insecure compared to secure households. In males, the prevalence of consuming 100% juice was 9 (95% CI: - 18, 0) percentage-points lower among food insecure compared to secure households. Social inequities in energy intake were observed in female adult consumers, among whom mean energy from sugary drinks was 27 kcal (95% CI: 3, 51) higher among food insecure compared to secure and 35 kcal (95% CI: 2, 67) higher from 100% juice among 'less than high school' education compared to 'Bachelor degree or above' households. CONCLUSION: Social inequities in sugary drink consumption exist in Canada. The associations differed by SEP indicator. Equitable interventions to reduce consumption are warranted.

RéSUMé: OBJECTIF: Dresser le portrait de la consommation de boissons sucrées (boissons contenant des sucres libres), de boissons contenant du sucre ajouté et de jus purs à 100 % (boissons contenant des sucres naturels) chez la population canadienne en fonction du statut socioéconomique. MéTHODE: Nous avons effectué une analyse transversale des rappels alimentaires de 24 heures réalisés par 19 742 personnes dans le cadre de l'Enquête sur la santé dans les collectivités canadiennes ­ Nutrition 2015, laquelle est représentative de la population nationale. Nous avons utilisé la régression de Poisson pour estimer la prévalence de la consommation de chaque type de boisson durant un jour donné. Pour calculer l'apport énergétique quotidien moyen, nous avons utilisé des régressions linéaires. Les modèles d'analyse traitent la scolarité, la sécurité alimentaire et les quintiles de revenu des ménages comme des expositions non ajustées distinctes. L'analyse en fonction du sexe est divisée en deux groupes, soit les enfants et adolescents (2 à 18 ans) et les adultes (19 ans et plus). RéSULTATS: Chez les filles et les adolescentes, la prévalence de la consommation de boissons sucrées et de boissons contenant du sucre ajouté est plus élevée (de 11 à 21 points de pourcentage et de 8 à 27 points de pourcentage, respectivement) dans les ménages moins scolarisés que dans les ménages plus scolarisés (baccalauréat et études supérieures). Chez les femmes vivant de l'insécurité alimentaire, la prévalence de la consommation de boissons sucrées et de boissons contenant du sucre ajouté est plus élevée de 10 points de pourcentage (IC de 95 % : 1, 19) et de 14 points de pourcentage (IC de 95 % : 2, 27), respectivement, que chez celles qui n'en vivent pas. Chez les sujets masculins, la prévalence de consommation des jus purs à 100 % est moins élevée de 9 points de pourcentage (IC de 95 % : -18, 0) dans les ménages vivant de l'insécurité alimentaire. Nous avons remarqué des disparités sur le plan social dans l'apport énergétique chez les femmes; l'apport moyen provenant de boissons sucrées est plus élevé de 27 kcal (IC de 95% : 3, 51) dans les ménages vivant de l'insécurité alimentaire, et l'apport moyen provenant de jus pur à 100 % est plus élevé de 35 kcal (IC de 95 % : 2, 67) dans les ménages moins scolarisés (pas de diplôme d'études secondaires) que chez les ménages plus scolarisés (baccalauréat et études supérieures). CONCLUSION: Il existe des disparités sur le plan social dans la consommation de boissons sucrées au Canada. Les résultats variaient en fonction de l'indicateur de statut économique. Nous recommandons des interventions équitables pour réduire la consommation de ces boissons.

Joint effects of back pain and mental health conditions on healthcare utilization and costs in Ontario, Canada: a population-based cohort study.

ABSTRACT: We assessed the joint effects of back pain and mental health conditions on healthcare utilization and costs in a population-based sample of adults in Ontario. We included Ontario adult respondents of the Canadian Community Health Survey between 2003 and 2012, followed up to 2018 by linking survey data to administrative databases. Joint exposures were self-reported back pain and mental health conditions (fair/poor mental health, mood, and anxiety disorder). We built negative binomial, modified Poisson and linear (log-transformed) models to assess joint effects (effects of 2 exposures in combination) of comorbid back pain and mental health condition on healthcare utilization, opioid prescription, and costs. The models were adjusted for sociodemographic, health-related, and behavioural factors. We evaluated positive additive and multiplicative interaction (synergism) between back pain and mental health conditions with relative excess risk due to interaction (RERI) and ratio of rate ratios (RRs). The cohort (n = 147,486) had a mean age of 46 years (SD = 17), and 51% were female. We found positive additive and multiplicative interaction between back pain and fair/poor mental health (RERI = 0.40; ratio of RR = 1.12) and mood disorder (RERI = 0.41; ratio of RR = 1.04) but not anxiety for back pain-specific utilization. For opioid prescription, we found positive additive and multiplicative interaction between back pain and fair/poor mental health (RERI = 2.71; ratio of risk ratio = 3.20) and anxiety (RERI = 1.60; ratio of risk ratio = 1.80) and positive additive interaction with mood disorder (RERI = 0.74). There was no evidence of synergism for all-cause utilization or costs. Combined effects of back pain and mental health conditions on back pain-specific utilization or opioid prescription were greater than expected, with evidence of synergism. Health services targeting back pain and mental health conditions together may provide greater improvements in outcomes.

Looking beyond Administrative Health Care Data: The Role of Socioeconomic Status in Predicting Future High-cost Patients with Mental Health and Addiction.

INTRODUCTION: Previous research has shown that the socioeconomic status (SES)-health gradient also extends to high-cost patients; however, little work has examined high-cost patients with mental illness and/or addiction. The objective of this study was to examine associations between individual-, household- and area-level SES factors and future high-cost use among these patients. METHODS: We linked survey data from adult participants (ages 18 and older) of 3 cycles of the Canadian Community Health Survey to administrative health care data from Ontario, Canada. Respondents with mental illness and/or addiction were identified based on prior mental health and addiction health care use and followed for 5 years for which we ascertained health care costs covered under the public health care system. We quantified associations between SES factors and becoming a high-cost patient (i.e., transitioning into the top 5%) using logistic regression models. For ordinal SES factors, such as income, education and marginalization variables, we measured absolute and relative inequalities using the slope and relative index of inequality. RESULTS: Among our sample, lower personal income (odds ratio [OR] = 2.11, 95% confidence interval [CI], 1.54 to 2.88, for CAD$0 to CAD$14,999), lower household income (OR = 2.11, 95% CI, 1.49 to 2.99, for lowest income quintile), food insecurity (OR = 1.87, 95% CI, 1.38 to 2.55) and non-homeownership (OR = 1.34, 95% CI, 1.08 to 1.66), at the individual and household levels, respectively, and higher residential instability (OR = 1.72, 95% CI, 1.23 to 2.42, for most marginalized), at the area level, were associated with higher odds of becoming a high-cost patient within a 5-year period. Moreover, the inequality analysis suggested pro-high-SES gradients in high-cost transitions. CONCLUSIONS: Policies aimed at high-cost patients with mental illness and/or addiction, or those concerned with preventing individuals with these conditions from becoming high-cost patients in the health care system, should also consider non-clinical factors such as income as well as related dimensions including food security and homeownership.

Exploring the dynamic transitions of polysubstance use patterns among Canadian youth using Latent Markov Models on COMPASS data.

Background: Understanding what factors lead to youth polysubstance use (PSU) patterns and how the transitions between use patterns can inform the design and implementation of PSU prevention programs. We explore the dynamics of PSU patterns from a large cohort of Canadian secondary school students using machine learning techniques. Methods: We employed a multivariate latent Markov model (LMM) on COMPASS data, with a linked sample (N = 8824) of three-annual waves, Wave I (WI, 2016-17, as baseline), Wave II (WII, 2017-18), and Wave III (WIII, 2018-19). Substance use indicators, i.e., cigarette, e-cigarette, alcohol and marijuana, were self-reported and were categorized into never/occasional/current use. Outcomes: Four distinct use patterns were identified: no-use (S1), single-use of alcohol (S2), dual-use of e-cigarettes and alcohol (S3), and multi-use (S4). S1 had the highest prevalence (60.5%) at WI, however, S3 became the prominent use pattern (32.5%) by WIII. Most students remained in the same subgroup over time, particularly S4 had the highest transition probability (0.87) across the three-wave. With time, those who transitioned typically moved towards a higher use pattern, with the most and least likely transition occurring S2→S3 (0.45) and S3→S2 (<0.01), respectively. Among all covariates being examined, truancy, being measured by the # of classes skipped, significantly affected transition probabilities from any low→high (e.g., ORS2→S4 = 2.41, 95% CI [2.11, 2.72], p < 0.00001) and high→low (e.g., ORS3→S1 = 0.38, 95% CI [0.33, 0.44], p < 0.00001) use directions over time. Older students, blacks (vs. whites), and breakfast eaters were less likely to transition from low→high use direction. Students with more weekly allowance, with more friends that smoked, longer sedentary time, and attended attended school unsupportive to resist or quit drug/alcohol were more likely to transition from low→high use direction. Except for truancy, all other covariates had inconsistent effects on the transition probabilities from the high→low use direction. Interpretation: This is the first study to ascertain the dynamics of use patterns and factors in youth PSU utilizing LMM with population-based longitudinal health surveys, providing evidence in developing programs to prevent youth PSU. Funding: The Applied Health Sciences scholarship; the Microsoft AI for Good grant; the Canadian Institutes of Health Research, Health Canada, the Canadian Centre on Substance Abuse, the SickKids Foundation, the Ministère de la Santé et des Services sociaux of the province of Québec.