How well does the minimum data set measure healthcare use? a validation study.

BACKGROUND: To improve care, planners require accurate information about nursing home (NH) residents and their healthcare use. We evaluated how accurately measures of resident user status and healthcare use were captured in the Minimum Data Set (MDS) versus administrative data. METHODS: This retrospective observational cohort study was conducted on all NH residents (N = 8832) from Winnipeg, Manitoba, Canada, between April 1, 2011 and March 31, 2013. Six study measures exist. NH user status (newly admitted NH residents, those who transferred from one NH to another, and those who died) was measured using both MDS and administrative data. Rates of in-patient hospitalizations, emergency department (ED) visits without subsequent hospitalization, and physician examinations were also measured in each data source. We calculated the sensitivity, specificity, positive and negative predictive values (PPV, NPV), and overall agreement (kappa, κ) of each measure as captured by MDS using administrative data as the reference source. Also for each measure, logistic regression tested if the level of disagreement between data systems was associated with resident age and sex plus NH owner-operator status. RESULTS: MDS accurately identified newly admitted residents (κ = 0.97), those who transferred between NHs (κ = 0.90), and those who died (κ = 0.95). Measures of healthcare use were captured less accurately by MDS, with high levels of both under-reporting and false positives (e.g., for in-patient hospitalizations sensitivity = 0.58, PPV = 0.45), and moderate overall agreement levels (e.g., κ = 0.39 for ED visits). Disagreement was sometimes greater for younger males, and for residents living in for-profit NHs. CONCLUSIONS: MDS can be used as a stand-alone tool to accurately capture basic measures of NH use (admission, transfer, and death), and by proxy NH length of stay. As compared to administrative data, MDS does not accurately capture NH resident healthcare use. Research investigating these and other healthcare transitions by NH residents requires a combination of the MDS and administrative data systems.

Comparing Health Status, Health Trajectories and Use of Health and Social Services between Children with and without Developmental Disabilities: A Population-based Longitudinal Study in Manitoba.

BACKGROUND: Little information exists on health of children with developmental disabilities (DDs) in the Canadian province of Manitoba. METHOD: The present authors linked 12 years of administrative data and compared health status, changes in health and access to health and social services between children with (n = 1877) and without (n = 5661) DDs living in the province, matched by age, sex and region of residence. RESULTS: Children with DDs were significantly more likely than children in the matched comparison group to die before the age of 17 and have a history of respiratory illness, diabetes and injury-related hospitalizations. Children with DD also had significantly higher average number of ambulatory physician visits and higher rate of continuity of care. CONCLUSIONS: Children with DDs had poorer health status than the matched comparison group. The health disparities experienced by children with DDs persisted over time. Further population-based longitudinal research is needed in this area.

Pressure Ulcers Among Newly Admitted Nursing Home Residents: Measuring the Impact of Transferring From Hospital.

OBJECTIVES: Pressure ulcers (PUs) are reported more often among newly admitted nursing home (NH) residents who transfer from hospital versus community. We examine for whom this increased risk is greatest, further defining hospitalized patients most in need of better PU preventive care. RESEARCH DESIGN: Retrospective observational cohort study. SUBJECTS: All NH residents (N=5617) newly admitted between April 1, 2008 and March 31, 2012 in Winnipeg, MB, Canada. MEASURES: RAI-MDS 2.0 data were linked to administrative health care use files capturing each person's NH admission date, their presence of a PU at this time, whether they transferred into NH from hospital or community, and their PU susceptibility (eg, amount of help needed to maneuver in bed or to transfer from one surface to another, frequency of incontinence, presence of diabetes, amount of food consistently left uneaten). Log-binomial regression with interaction terms was used to analyze data. RESULTS: 67.6% of our cohort transferred into a NH directly from hospital; 9.2% of these residents were reported to have a stage 1+ PU on NH admission versus 2.6% of those who transferred from community. From regression models, transferring from hospital versus community was associated with increased PU risk equally across various subgroups of less and more susceptible residents. CONCLUSIONS: Transferring from hospital versus community places both more and less susceptible newly admitted NH residents at increased PU risk. Using evidence-based preventive care practices is thus needed for all subgroups of hospital patients before NH use, to help reduce PU risk.

Inequities in ambulatory care and the relationship between socioeconomic status and respiratory hospitalizations: a population-based study of a canadian city.

PURPOSE: Individuals of lower socioeconomic status have higher rates of hospitalization due to ambulatory care-sensitive conditions, particularly chronic obstructive pulmonary disease and asthma. We examined whether differences in patient demographics, ambulatory care use, or physician characteristics could explain this disparity in avoidable hospitalizations. METHODS: Using administrative data from the city of Winnipeg, Manitoba, Canada, we identified all adults aged 18 to 70 years with chronic obstructive pulmonary disease or asthma, grouped together as obstructive airway disease. We divided patients into census-derived income quintiles using average household income. We performed a series of multivariate logistic regression analyses to determine how the association of socioeconomic status with the risk of obstructive airway disease-related hospitalizations changed after controlling for blocks of covariates related to patient demographics (socioeconomic status, age, sex, and comorbidity), ambulatory care use (continuity influenza vaccination and specialist referral), and characteristics of the patient's usual physician (eg, payment mechanism, sex, years in practice). RESULTS: We included 34,741 patients with obstructive airway disease, 729 (2.1%) of whom were hospitalized with a related diagnosis during a 2-year period. Patients having a lower income were more likely to be hospitalized than peers having the highest income, and this effect of socioeconomic status remained virtually unchanged after controlling for every other variable studied. In a fully adjusted model, patients in the lowest income quintile had approximately 3 times the odds of hospitalization relative to counterparts in the highest income quintile (odds ratio = 2.93; 95% confidence limits: 2.19, 3.93). CONCLUSIONS: In the setting of universal health care, the income-based disparity in hospitalizations for respiratory ambulatory care-sensitive conditions cannot be explained by factors directly related to the use of ambulatory services that can be measured using administrative data. Our findings suggest that we look beyond the health care system at the broader social determinants of health to reduce the number of avoidable hospitalizations among the poor.

Health care utilization for injury in cataract surgery patients.

BACKGROUND: Although visual impairment has been associated with falls, fractures, and other injuries, the relation between cataract surgery and injuries is unclear. This study assesses whether persons waiting for cataract surgery are at increased risk of requiring health care services for an injury compared with a control group, and, if so, whether the risk changes after cataract surgery. METHODS: This is a retrospective case-control study of first-eye cataract surgery recipients in Manitoba in fiscal 1999-2000. Health care administrative data and cataract waiting list registry data were the data sources. Cataract surgery recipients were matched 3:1 with controls on age, sex, and region. The outcome measure was a diagnosis of injury identified using International Classification of Diseases 9 (Clinical Modification) codes in the physician or hospital claims. Data were analyzed for 2 years before and after cataract surgery. A multivariate logistic regression adjusted for potential confounders, such as burden of illness, presence of diabetes, stroke or dementia, number of different medications, and use of psychoactive mediations. RESULTS: There were 3811 cases and 11,359 controls. Cases were found to be much more likely to have a history of stroke, diabetes, or dementia, and were more likely to have been prescribed multiple medications or a psychoactive drug. After adjustment for comorbidities and pharmaceutical use, cases had a significantly higher probability of an injury before surgery (0.2784 vs. 0.2538; chi2 = 5.01, p = 0.03). This decreased significantly after surgery to 0.2333 (chi2 = 18.05, p < 0.0001). After surgery, the adjusted probability of injury was lower among cases (0.2333) than controls (0.2385), though this was not significant. The adjusted odds ratio for having an injury was 1.032 (95% confidence interval 1.026, 1.039) per week of waiting. INTERPRETATION: Cataract patients have a significantly increased risk of injury compared with controls before surgery, but their risk decreases to that of controls following surgery. Given that cataract patients also bear a much heavier burden of illness, including conditions that are associated with a higher risk of falls and injuries, the imperative of performing cataract surgery without delay becomes even more pressing.

An evaluation of early medication use for COPD: a population-based cohort study.

PURPOSE: The aim of this study was to evaluate the first initiation, sequence of addition, and appropriate prescribing of COPD medications in Manitoba, Canada. PATIENTS AND METHODS: A population-based cohort study of COPD medication use was conducted using administrative health care data (1997-2012). Those aged ≥35 years with COPD based on three or more COPD-related outpatient visits over a rolling 24-month window or at least one COPD-related hospitalization were included. The first medication(s) dispensed on or after the date of COPD diagnosis were determined based on pharmacy claims. The next medication(s) in sequence were determined to be additions or switches to the previous regimen. Evaluation of guideline-based appropriateness to receive inhaled corticosteroids (ICS) was based on exacerbation history and past medication use. RESULTS: Of 13,369 patients dispensed COPD medications after diagnosis, 66.0% were dispensed short-acting bronchodilators as first medications. Although long-acting bronchodilators alone were uncommonly used as first or subsequent medications, ICS were dispensed as first medications in 28.2% of patients. Over the study period, use of short-acting bronchodilators as first medications declined from 70.6% to 59.4% (P<0.0001), whereas the use of ICS as a first medication increased from 23.5% to 34.4% (P<0.0001). Dispensation of an ICS plus a long-acting ß-agonist increased dramatically from 1.2% to 27.3% (P<0.0001). By the end of the study period, the majority of patients (53.3%) were being initiated on two or more medications. Of 5,823 patients dispensed an ICS, 52.4% met Canadian guideline criteria for initiating an ICS, whereas 0.3% met Global Initiative for Chronic Obstructive Lung Disease guideline criteria. CONCLUSION: The use of first-line medications has declined over time, replaced primarily by combination inhalers prescribed early without prior trials of appropriate next step medications. This, along with an increasingly predominant use of multiple first medications, indicates a significant degree of medication burden in this already complex patient population.

Estimating nursing home bed demand: 20-year projection from administrative data and stakeholder input.

We describe methods to project the requirement for nursing home beds in Manitoba until 2020. Three methods were developed: Trend, Recent Use, and Combined. The first two methods yielded widely divergent projections, differing by 3,400 beds. Stakeholder feedback and theoretical analysis suggested the third (Combined) method, the arithmetic mean of the first two. Model testing found the Combined method to be the most accurate. The projections have been used by RHAs for their planning activities.

Risk of physician-diagnosed asthma in the first 6 years of life.

OBJECTIVE: The objective of this cohort study was to determine if complications of pregnancy and labor, characteristics at birth, and exposure to infections influence the incidence of asthma in the first 6 years of life. DESIGN: We identified all children born between 1980 and 1990 in the Province of Manitoba, Canada. We used records of physician contacts (inpatient and outpatient) and services of the universal provincial health insurance plan to follow up 170,960 children from birth to the age of 6 years to identify the first diagnosis of asthma. Information on mothers and siblings was also obtained to determine family history of disease and exposure to infections. RESULTS: During the study period, a diagnosis of asthma was made in 14.1% of children by the age of 6 years. The incidence was higher in boys than in girls, in those with family history of allergic diseases. It was higher in urban than in rural areas, and lowest in those born in winter. Asthma was more likely in those with low birth weight and premature birth. Certain congenital abnormalities and complications of pregnancy and labor also increased the risk of asthma. The risk of asthma increased with maternal age. Both upper and lower respiratory infections increased the risk of subsequent asthma, and this effect was more important than exposure to familial respiratory infections, which also tended to increase asthma risk. The risk of asthma decreased with the number of siblings when siblings had a history of allergic disorders. CONCLUSIONS: In addition to genetic influences, intrauterine and labor conditions are determinants of asthma. Exposure to both upper and lower respiratory tract infections increases the risk; these infections do not explain the protective effect associated with the increasing number of siblings.

Profiling the multidimensional needs of new nursing home residents: evidence to support planning.

INTRODUCTION: Nursing home (NH) residents have various needs that affect the care they require. This article describes the diverse needs that new NH residents have, emphasizing the proportion of people with milder needs in multiple areas. METHODS: Research was conducted on all older adults newly admitted to not-for-profit NHs in the Winnipeg Health Region, between April 1, 2005, and March 31, 2007, provided that they were assessed using the Resident Assessment Instrument Minimum Data Set (RAI/MDS 2.0) within 30 days of admission (n = 1061). Using the Activities of Daily Living (ADL) Hierarchy scale, residents were first defined as low, intermediate, or high ADL dependent. Residents' needs were also defined using the RAI/MDS 2.0 cognitive performance (CPS) and pain scales, by their degree of behavioral problems and visual challenges, and by their frequency of bladder and bowel incontinence. Cluster analysis was used to create subgroups of residents by their severity of clinical challenges. RESULTS: Of our cohort, 26.8% were low ADL dependent. Although some of these residents had moderate to severe needs in another area, many (46.8% of low ADL-dependent residents; 12.5% of our entire cohort) had milder needs across all clinical domains. Conversely, about one-third of our cohort was high ADL dependent; 31.7% of these residents had moderate to severe challenges in one clinical domain, and 35.5% had moderate to severe comorbid challenges. CONCLUSIONS: Overall, 12.5% of our cohort had lower needs, demonstrating the capacity for community-based programs to offset NH demands. Also, the diversity of residents' needs highlights the importance of having both the appropriate resources and strategies available to provide quality NH care. Future research is discussed for both low- and higher-need NH residents.

Prevalence of Depression and Dementia among Adults with Developmental Disabilities in Manitoba, Canada.

Study Objective. To estimate and compare the prevalence of dementia and depression among adults with and without developmental disabilities (DDs). Methods. We linked data from several provincial administrative databases to identify persons with DDs. We matched cases with DD with persons without DD as to sex, age, and place of residence. We estimated the prevalence of dementia and depression and compared the two groups using the Generalized Estimating Equations (GEEs) technique. Results. The estimated prevalence of depression and dementia among younger adults (20-54) and older adults (50+) with DD was significantly higher than the estimated rates for the matched non-DD group (Depression: younger adults: RR = 2.96 (95% CI 2.59-3.39); older adults: RR = 2.65 (95% CI 1.84-3.81)), (Dementia: younger adults: RR = 4.01 (95% CI 2.72-5.92); older adults: RR = 4.80 (95% CI 2.48-9.31)). Conclusion. Significant disparities exist in mental health between persons with and without DDs.

Nursing home adverse events: further insight into highest risk periods.

INTRODUCTION: Adverse events (AEs) occur frequently in nursing homes (NHs). Although the literature identifies several AE risk factors, the effect of resident transition on AE risk is less well defined. This article is the first to describe how AE risk varies across several NH transition periods and to define the most vulnerable junctures of an NH stay. METHODS: This research was conducted on the population of NH residents in Manitoba, Canada, from April 1, 1999, to March 31, 2004. AEs were captured using physician-based diagnostic claims for hip fractures, other fractures, hospitalized falls, skin ulcers, and respiratory infections. AE rates were compared across several transition periods (eg, following first NH admission from hospital versus elsewhere, after NH transfer, and preceding resident death), before and after adjustment for several resident demographic, clinical, and facility-level factors. RESULTS: Although residents (n = 22,846) spent only 6.6% of all NH days in transition, between 15.3% (skin ulcers) and 27.8% (respiratory infections) of AEs occurred during these times. Except following NH transfers, adjusted AE rates were consistently higher during all transition versus nontransition periods. Among transition periods, adjusted hip fractures, hospitalized falls, and respiratory infections were most strongly associated with resident death. Adjusted skin ulcer and non-hip fracture rates were equally highest during "pre-death" and for new residents admitted from hospital. CONCLUSIONS: This article is the first to identify the most vulnerable times of a NH stay. For newly admitted residents, our results also show that previous exposure to a hospital environment, and not simply resident illness, at least partially contributes to increased AE risk. This and additional evidence can help clinicians and administrators to better identify periods of high risk for NH residents, and also to develop more targeted care improvement strategies. More robust and frequently obtained measures of resident illness are required to further examine these issues in more detail.

Pediatric appendicitis rupture rate: disparities despite universal health care.

BACKGROUND/PURPOSE: Significant socioeconomic disparities have been observed in the rates of perforated appendicitis among children in private health care. We seek to explore if, in the Canadian system of public, universal health care access, pediatric appendicitis rupture rates are an indicator of health disparities. METHODS: Using the Population Health Research Data Repository housed at Manitoba Centre for Health Policy, a retrospective analysis over a 20-year period (1983-2003) examined all patients aged less than 18 years with International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes for appendicitis (N = 7475). Multivariate logistic regression analysis was used to calculate odds ratios in the association between appendiceal rupture rates and the patient's socioeconomic status (SES) based upon average household income of the census area adjusted for age, sex, area of residence, and treating hospital. RESULTS: The overall appendiceal rupture rate was 28.8%. Significant positive predictors of appendiceal rupture were lower rural SES, lower urban SES, younger age, northern area of residence, and receiving treatment at the province's only pediatric tertiary care hospital. CONCLUSION: Despite free, universal access health care, children from lower SES areas have increased appendiceal rupture rates. Seeking and accessing medical attention can be complicated by social, behavioral, and geographical problems.

Physician-diagnosed asthma and allergic rhinitis in Manitoba: 1985-1998.

BACKGROUND: A worldwide increase has been noted in the prevalence of asthma, but the data for other allergic disorders are less consistent. OBJECTIVE: To study 14-year trends in utilization of physician resources for asthma and compare them to trends for allergic rhinitis. METHODS: We studied visits to physicians by Manitoba residents for asthma (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 493) and allergic rhinitis (ICD-9 code 477) between 1985 and 1998. Prevalence and incidence of physician resources utilization were calculated annually for the total population and by age groups. Aggregate statistics and frequency of physician resources utilization were also analyzed. RESULTS: The prevalence and incidence of physician resources utilization for asthma increased more than for allergic rhinitis; differences were most striking in the youngest age groups. In adults, the differences were smaller and changed little with time. Most of the increase in asthma care occurred in children and in people without allergic rhinitis. Overall, 17% of Manitobans were diagnosed as having asthma, and the average asthmatic patient made 6 visits. Approximately 14% had an allergic rhinitis diagnosis, each person being seen twice on average. Coexistence of asthma and allergic rhinitis led to increased physician resources utilization for each of the conditions. CONCLUSIONS: Trends in utilization of physician resources for allergic rhinitis differed strikingly from trends for asthma, particularly in the youngest age group. Asthma and allergic rhinitis affected comparable proportions of the population, but a diagnosis of asthma resulted in much higher utilization of physician resources. The relationship of physician-diagnosed asthma and atopy, as indicated by the diagnosis of allergic rhinitis, appears to have weakened with time in children but not in adults.