Exploring the use of experimental small area estimates to examine the relationship between individual-level and area-level community belonging and self-rated health.

Background: Small area estimation refers to statistical modelling procedures that leverage information or "borrow strength" from other sources or variables. This is done to enhance the reliability of estimates of characteristics or outcomes for areas that do not contain sufficient sample sizes to provide disaggregated estimates of adequate precision and reliability. There is growing interest in secondary research applications for small area estimates (SAEs). However, it is crucial to assess the analytic value of these estimates when used as proxies for individual-level characteristics or as distinct measures that offer insights at the area level. This study assessed novel area-level community belonging measures derived using small area estimation and examined associations with individual-level measures of community belonging and self-rated health. Data and methods: SAEs of community belonging within census tracts produced from the 2016-2019 cycles of the Canadian Community Health Survey (CCHS) were merged with respondent data from the 2020 CCHS. Multinomial logistic regression models were run between area-level SAEs, individual-level sense of community belonging, and self-rated health on the study sample of people aged 18 years and older. Results: Area-level community belonging was associated with individual-level community belonging, even after adjusting for individual-level sociodemographic characteristics, despite limited agreement between individual- and area-level measures. Living in a neighbourhood with low community belonging was associated with higher odds of reporting being in fair or poor health, versus being in very good or excellent health (odds ratio: 1.53; 95% confidence interval: 1.22, 1.91), even after adjusting for other factors such as individual-level sense of community belonging, which was also associated with self-rated health. Interpretation: Area-level and individual-level sense of community belonging were independently associated with self-rated health. The novel SAEs of community belonging can be used as distinct measures of neighbourhood-level community belonging and should be understood as complementary to, rather than proxies for, individual-level measures of community belonging.

Mortality and Life Expectancy Lost in Canada Attributable to Dietary Patterns: Evidence From Canadian National Nutrition Survey Linked to Routinely Collected Health Administrative Databases.

Using 5 diet quality indexes, we estimated the mortality and life expectancy lost, at the national level, attributable to poor dietary patterns, which had previously been largely unknown. We used the Canadian Community Health Survey 2004, linked to vital statistics (n = 16,212 adults; representing n = 22,898,880). After a median follow-up of 7.5 years, 1,722 deaths were recorded. Population attributable fractions were calculated to estimate the mortality burden of poor dietary patterns (Dietary Guidelines for Americans Adherence Index 2015, Dietary Approaches to Stop Hypertension, Healthy Eating Index, Alternative Healthy Eating Index, and Mediterranean Style Dietary Pattern Score). Better diet quality was associated with a 32%-51% and 21%-43% reduction in all-cause mortality among adults aged 45-80 years and ≥20 years, respectively. Projected life expectancy at 45 years was longer for Canadians adhering to a healthy dietary pattern (average of 5.2-8.0 years (men) and 1.6-4.1 (women)). At the population level, 26.5%-38.9% (men) and 8.9%-22.9% (women) of deaths were attributable to poor dietary patterns. Survival benefit was greater for individuals with higher scores on all diet indexes, even with relatively small intake differences. The large attributable burden was likely from assessing overall dietary patterns instead of a limited range of foods and nutrients.

Sodium, added sugar and saturated fat intake in relation to mortality and CVD events in adults: Canadian National Nutrition Survey linked with vital statistics and health administrative databases.

This study aimed to determine whether higher intakes of Na, added sugars and saturated fat are prospectively associated with all-cause mortality and CVD incidence and mortality in a diverse population. The nationally representative Canadian Community Health Survey-Nutrition 2004 was linked with the Canadian Vital Statistics - Death Database and the Discharge Abstract Database (2004-2011). Outcomes were all-cause mortality and CVD incidence and mortality. There were 1722 mortality cases within 115 566 person-years of follow-up (median (interquartile range) of 7·48 (7·22-7·70) years). There was no statistically significant association between Na density or energy from saturated fat and all-cause mortality or CVD events for all models investigated. The association of usual percentage of energy from added sugars and all-cause mortality was significant in the base model with participants consuming 11·47 % of energy from added sugars having 1·34 (95 % CI 1·01, 1·77) times higher risk of all-cause mortality compared with those consuming 4·17 % of energy from added sugars. Overall, our results did not find statistically significant associations between the three nutrients and risk of all-cause mortality or CVD events at the population level in Canada. Large-scale linked national nutrition datasets may not have the discrimination to identify prospective impacts of nutrients on health measures.

Associations of free sugars from solid and liquid sources with cardiovascular disease: a retrospective cohort analysis.

BACKGROUND: The World Health Organization recommends a 10% total energy (TE%) limit for free sugars (i.e., added sugars and naturally occurring sugars in fruit juice, honey, and syrups) based on evidence linking higher intakes with overweight and dental caries. Evidence for cardiovascular disease (CVD) is limited. Impacts may differ by sex, age group, and solid vs. liquid sources; liquids may stimulate more adverse CVD profiles (due to their rapid absorption in the body along along with triggering less satiety). We examined associations of consuming total free sugars ≥ 10 TE% with CVD within four sex and age-defined groups. Given roughly equal free sugar intakes from solid and liquid sources, we also evaluated source-specific associations of free sugars ≥ 5 TE% thresholds. METHODS: In this retrospective cohort study, we estimated free sugars from 24-h dietary recall (Canadian Community Health Survey, 2004-2005) in relationship to nonfatal and fatal CVD (Discharge Abstract and Canadian Mortality Databases, 2004-2017; International Disease Classification-10 codes for ischemic heart disease and stroke) through multivariable Cox proportional hazards models adjusted for overweight/obesity, health behaviours, dietary factors, and food insecurity. We conducted analyses in separate models for men 55 to 75 years, women 55 to 75 years, men 35 to 55 years, and women 35 to 55 years. We dichotomized total free sugars at 10 TE% and source-specific free sugars at 5 TE%. RESULTS: Men 55 to 75 years of age had 34% higher CVD hazards with intakes of free sugars from solid sources ≥ 5 TE% vs. below (adjusted HR 1.34, 95% CI 1.05- 1.70). The other three age and sex-specific groups did not demonstrate conclusive associations with CVD. CONCLUSIONS: Our findings suggest that from a CVD prevention standpoint in men 55 to 75 years of age, there may be benefits from consuming less than 5 TE% as free sugars from solid sources.

Exploring the intersectionality of characteristics among those who experienced opioid overdoses: A cluster analysis.

Background: As Canada continues to experience an opioid crisis, it is important to understand the intersection between the demographic, socioeconomic and service use characteristics of those experiencing opioid overdoses to better inform prevention and treatment programs. Data and methods: The Statistics Canada British Columbia Opioid Overdose Analytical File (BCOOAF) represents people's opioid overdoses between January 2014 and December 2016 (n = 13,318). The BCOOAF contains administrative health data from British Columbia linked to Statistics Canada data, including on health, employment, social assistance and police contacts. Cluster analysis was conducted using the k-prototypes algorithm. Results: The results revealed a six-cluster solution, composed of three groups (A, B and C), each with two distinct clusters (1 and 2). Individuals in Group A were predominantly male, used non-opioid prescription medications and had varying levels of employment. Individuals in Cluster A1 were employed, worked mostly in construction, had high incomes and had a high rate of fatal overdoses, while individuals in Cluster A2 were precariously employed and had varying levels of income. Individuals in Group B were predominantly female; were mostly taking prescription opioids, with about one quarter or less receiving opioid agonist treatment (OAT); mostly had precarious to no employment; and had low to no income. People in Cluster B1 were primarily middle-aged (45 to 65 years) and on social assistance, while people in Cluster B2 were older, more frequently used health services and had no social assistance income. Individuals in Group C were primarily younger males aged 24 to 44 years, with higher prevalence of having experienced multiple overdoses, were medium to high users of health care services, were mostly unemployed and were recipients of social assistance. Most had multiple contacts with police. Those in Cluster C1 predominantly had no documented use of prescription opioid medications, and all had no documented OAT, while all individuals in Cluster C2 were on OAT. Interpretation: The application of machine learning techniques to a multidimensional database enables an intersectional approach to study those experiencing opioid overdoses. The results revealed distinct patient profiles that can be used to better target interventions and treatment.

Comparison of mortality hazard ratios associated with health behaviours in Canada and the United States: a population-based linked health survey study.

BACKGROUND: Modern health surveillance and planning requires an understanding of how preventable risk factors impact population health, and how these effects vary between populations. In this study, we compare how smoking, alcohol consumption, diet and physical activity are associated with all-cause mortality in Canada and the United States using comparable individual-level, linked population health survey data and identical model specifications. METHODS: The Canadian Community Health Survey (CCHS) (2003-2007) and the United States National Health Interview Survey (NHIS) (2000, 2005) linked to individual-level mortality outcomes with follow up to December 31, 2011 were used. Consistent variable definitions were used to estimate country-specific mortality hazard ratios with sex-specific Cox proportional hazard models, including smoking, alcohol, diet and physical activity, sociodemographic indicators and proximal factors including disease history. RESULTS: A total of 296,407 respondents and 1,813,884 million person-years of follow-up from the CCHS and 58,232 respondents and 497,909 person-years from the NHIS were included. Absolute mortality risk among those with a 'healthy profile' was higher in the United States compared to Canada, especially among women. Adjusted mortality hazard ratios associated with health behaviours were generally of similar magnitude and direction but often stronger in Canada. CONCLUSION: Even when methodological and population differences are minimal, the association of health behaviours and mortality can vary across populations. It is therefore important to be cautious of between-study variation when aggregating relative effect estimates from differing populations, and when using external effect estimates for population health research and policy development.

Hospitalization related to chronic hepatitis B and C in recent immigrants in Canada: An immigration administrative data-linked, population-based cohort study.

Background: Canadian immigrants from countries where the hepatitis B virus (HBV) and hepatitis C virus (HCV) are endemic may be at higher risk of liver-related disease than Canadian-born residents. This study compared HBV- and HCV-related hospitalizations in Canadian immigrants (arriving from 1980 to 2013) and long-term residents (Canadian-born population and pre-1980 immigrants) and aimed to describe the burden of disease in both groups. Methods: Based on the 2004/2005-to-2013/2014 hospital Discharge Abstract Database linked to the 1980-to-2013 Longitudinal Immigration Database, this descriptive cross-sectional study examined the distribution of HBV- and HCV-related hospitalizations, lengths of stay, comorbidities, and sequelae incurred by immigrants and long-term residents in Canada. With a linkage rate of 85%, 5,854,949 immigrants were included in the study. Proportions of HBV- and HCV-related hospitalizations attributable to immigrants were calculated. Results: By birth country risk level, 22% of HBV-related hospital events among recent immigrants, and 20% of those related to HCV, were among people from high-risk countries. Proportionally, fewer immigrants had comorbidities than long-term residents. The top two hospital-related sequelae in both groups were cirrhosis and ascites, and liver cancer. While immigrants made up 16% of the Canadian population, they incurred 37% of HBV-related hospitalizations and 9% of HCV-related hospitalizations, giving ratios of hepatitis-related hospitalizations relative to the population share of 2.3 (95% confidence interval [CI]: 2.2 to 2.5) and 0.5 (95% CI: 0.5 to 0.6) respectively. These ratios were higher among seniors, at 4.4 (95% CI: 3.9 to 4.9) and 2.3 (95% CI: 1.9 to 2.6), respectively. Interpretation: Immigrants can require hospitalization for hepatitis in Canada, especially for HBV. These results may inform health screening for HBV or HCV in the Canadian immigration context.

Linkage of the nationally representative Canadian Community Health Survey - Nutrition 2004 to routinely collected mortality records.

Introduction: The Canadian Community Health Survey (CCHS) - Nutrition 2004 (n=35,107; interview dates from January 2004 to January 2005) linked to the Canadian Vital Statistics - Death Database (CVSD) (2011) represents a novel linkage of a population-based, nationally representative nutrition survey with routinely collected mortality records (including date and cause of death). The linkage was done through individual tax data in Canada, and contains longitudinal records for 29,897 Canadians aged 0 years and older-1,753 of whom died-in the 10 provinces of Canada. The median follow-up time was 7.49 years, with 102,953 person-years among males and 114,876 person-years among females (unweighted), and included a special sampling survey weight (for linked data) to account for those who did not agree to share and link their information. The CCHS - Nutrition 2004 linked to CVSD has been used to evaluate associations between lifestyle and sociodemographic characteristics and mortality. Using these data, statistical methods have been developed and tested to control random and systematic measurement errors when evaluating the relationship between different dietary exposures (evaluated using repeated 24-hour dietary recalls) and health outcomes. The linked data are available through Statistics Canada's Research Data Centres.

A pan-Canadian dataset of neighbourhood retail food environment measures using Statistics Canada's Business Register.

BACKGROUND: The objective of this study was to create the Canadian Food Environment Dataset (Can-FED) and to demonstrate its validity. DATA AND METHODS: Food outlet data were extracted from Statistics Canada's Business Register (BR) in 2018. Retail food environment access measures (both absolute and relative measures) were calculated using network buffers around the centroid of 56,589 dissemination areas in Canada. A k-medians clustering approach was used to create categorical food environment variables that were easy to use and amenable to dissemination. Validity of the measures was assessed by comparing the food environment measures from Can-FED with measures created using Enhanced Points of Interest data by DMTI Spatial Inc. and data from a municipal health inspection list. Validity was also assessed by calculating the geographic variability in food environments across census metropolitan areas (CMAs) and assessing associations between CMA-level food environments and CMA-level health indicators. RESULTS: Two versions of Can-FED were created: a researcher file that must be accessed within a secure Statistics Canada environment and a general-use file available online. Agreement between Can-FED food environment measures and those derived from a proprietary dataset and a municipal health inspection list ranged from rs=0.28 for convenience store density and rs=0.53 for restaurant density. At the CMA level, there is wide geographic variation in the food environment with evidence of patterning by health indicators. INTERPRETATION: Can-FED is a valid and accessible dataset of pan-Canadian food environment measures that was created from the BR, a data source that has not been explored fully for health research.

Associations of overweight and gestational diabetes mellitus with free sugars from solid and liquid sources: cross-sectional and nested case-control analyses.

BACKGROUND: Sugar-sweetened beverages have obesogenic and diabetogenic effects ascribed to free sugars. These include added sugars and naturally occurring sugars in juices. A meta-analysis indicates that some foods with added sugars are associated with lower type 2 diabetes rates. To expand the evidence relevant to free sugars from solid sources, we examined a young to middle-aged population with respect to overweight and gestational diabetes (GDM) outcomes. METHODS: We studied female participants (12-50 years old) from the 2004-2005 Canadian Community Health Survey 2.2 (CCHS) with data linked to the hospital Discharge Abstract Database (DAD) until 2017, providing 13 years of follow-up. We estimated free sugars by solid and liquid sources from 24-h dietary recalls as percent total energy intake (TE%), and computed body mass index (BMI). We applied ICD-10 diagnostic codes for deliveries and GDM to DAD. We conducted multivariable logistic regression analyses to evaluate associations between free sugars with overweight at baseline (cross-sectional component) and, in those who delivered, with GDM during follow-up (nested case control component). We compared those with consumption above versus below various thresholds of intake for free sugars, considering solid and liquid sources separately (2.TE%, 5TE%, 10TE% and 15TE% thresholds). RESULTS: Among 6305 participants, 2505 (40%) were overweight, defined as BMI ≥ 85th percentile below 18 years and BMI ≥ 25 kg/m2 for adults. Free sugars from solid sources were associated with lower odds of overweight above versus below the 2.5TE% (adjusted odds ratio [adjOR] 0.80, 95%CI 0.70-0.92), 5TE% (adjOR 0.89, 95%CI 0.79-0.99), and 10TE% (adjOR 0.86, 95%CI 0.75-0.97) thresholds. Free sugars from liquid sources were associated with greater odds of overweight across the 2.5TE% (adjOR 1.20, 95%CI 1.07-1.36), 10TE% (adjOR 1.17, 95%CI 1.02-1.34), and 15TE% (adjOR 1.43, 95%CI 1.23-1.67) thresholds. There were 113 cases of GDM among the 1842 women who delivered (6.1%). Free sugars from solid sources were associated with lower odds of GDM above versus below the 5TE% threshold (adjOR 0.56, 95%CI 0.36-0.85). CONCLUSIONS: Our findings support limiting free sugars from liquid sources, given associations with overweight. We did not identify adverse associations of free sugars from solid sources across any of the thresholds examined.

Significant factors associated with problematic use of opioid pain relief medications among the household population, Canada, 2018.

BACKGROUND: Reliance on the use of opioids to manage pain has increased over time, as have opioid-related morbidity and deaths. In 2018, 12.7% of Canadians reported having used opioid pain relief medications (OPRMs) in the previous year. Among these people, 9.6% had engaged in problematic use that could cause harm to their health. Though socioeconomic characteristics associated with opioid-related harms have previously been reported, population-level evidence based on administrative health data lacks important behavioural and psychosocial information. This analysis extends previous research by using modelling to report factors related to the problematic use of OPRMs for the household population aged 15 and older in Canada. DATA AND METHODS: This analysis uses responses to the 2018 Canadian Community Health Survey to identify factors that are significantly associated, after adjustment using multivariate logistic regression models, with elevated odds of problematic use of OPRMs. RESULTS: The fully adjusted model confirmed that being male, being younger (ages 20 to 24), having fair or poor mental health, having unmet needs for help with mental or emotional health or substance problems, being a smoker, or being unattached and living with others were significantly related to problematic OPRM use. INTERPRETATION: Subjective perceptions significantly related to problematic OPRM use, independent of socioeconomic circumstances, were examined in this study. While previous research based on administrative health data has contributed much to knowledge about factors associated with opioid harms, modelled results revealed that self-reported experiential factors also warrant consideration as they are significantly associated with problematic use. Having fair or poor mental health, having unmet perceived needs for help, and being unattached in terms of household arrangement relationship were related to problematic use of OPRMs, even after adjustment for socioeconomic and other health covariates. This study suggests risk profiles that could be used to inform health care providers, and strategies to support safe pain management.

Understanding the socioeconomic profile of people who experienced opioid overdoses in British Columbia, 2014 to 2016.

BACKGROUND: Following the 2016 opioid overdose emergency declaration in British Columbia (B.C.), provincial stakeholders collaborated to link data that resulted in the B.C. Provincial Overdose Cohort. This database provides information about people who have experienced opioid overdoses to inform policy and intervention developments. Subsequently, Statistics Canada likewise constructed a cohort and integrated federal data to broaden the scope of the B.C. initiative. This provided federally sourced information about people's circumstances that was not otherwise available. DATA AND METHODS: The Statistics Canada British Columbia Opioid Overdose Analytical File further characterizes the socioeconomic circumstances of 13,318 people who experienced illicit drug toxicity deaths and non-fatal opioid overdoses in B.C. between January 1, 2014, and December 31, 2016. Statistics Canada linked federal data on immigration, employment, the justice system and social assistance receipt in the year of, and prior to, people's first overdose. RESULTS: During the observation period, most people (78%) had one overdose episode, rather than several. Seven percent were immigrants or temporary residents, 41% of whom arrived in Canada more than 20 years before their index overdose. Half (49.6%) had not received social assistance, and one-third (33.8%) were employed-primarily within construction (21% of those employed)-in the year prior to their index overdose. Most employed people (65.5%) experienced periods of unemployment within five years prior to their index overdose. Employment was more prevalent among people who experienced illicit-drug toxicity death (36.1%). About 60% of people had not had any formal police contact within the two years prior to the index overdose. DISCUSSION: This project demonstrated further added value to existing data by using this linkage approach and aligned with strategies underway by BC public health partners to provide cross-sectoral evidence to inform efforts to prevent and manage opioid overdoses.

Effects of Cardiovascular Health Shocks on Spouses' Work and Earnings: A National Study.

BACKGROUND: Acute health shocks can reduce the ability to work and earn among working-age survivors. The full economic impact includes labor market effects on spouses/partners, but there is a knowledge gap in this area. OBJECTIVES: The objective of this study was to assess how 3 common health shocks, acute myocardial infarction, stroke, and cardiac arrest, influence work and earnings of spouses aged 35-61 years. RESEARCH DESIGN: This retrospective cohort study of case and control couples used population-based, linked Canadian income tax and hospitalization data from 2005 to 2013. SUBJECTS: Case couples comprised 1 partner aged 41-61 years who experienced a health shock in the index year and survived 3 years hence, and a working-age partner. Control couples were matched up to 5:1 on 12 characteristics, with neither experiencing the health shock of interest in the index year. MEASURES: Primary outcome was the change in spousal annual earnings between the year prior and 3 years after the event. Pre-to-post spousal income changes were categorized into 9 levels and compared between case spouses and control spouses by the Pearson χ test. RESULTS: There were 11,208 matched case couples for acute myocardial infarction, 622 for cardiac arrest, and 2288 for stroke. Overall, case and control spouses experienced similar distributional changes in preevent to postevent earning (all P≥0.27). Heterogeneity analysis indicated that spouses of more severe stroke sufferers ceased working at a higher rate than for control spouses. CONCLUSION: Beyond assessing average values, detailed analysis of changes in spousal earnings after common cardiovascular health shocks did not demonstrate effects attributable to those health shocks.

International population-based health surveys linked to outcome data: A new resource for public health and epidemiology.

BACKGROUND: National health surveys linked to vital statistics and health care information provide a growing source of individual-level population health data. Pooling linked surveys across jurisdictions would create comprehensive datasets that are larger than most existing cohort studies, and that have a unique international and population perspective. This paper's objectives are to examine the feasibility of pooling linked population health surveys from three countries, facilitate the examination of health behaviours, and present useful information to assist in the planning of international population health surveillance and research studies. DATA AND METHODS: The design, methodologies and content of the Canadian Community Health Survey (2003 to 2008), the United States National Health Interview Survey (2000, 2005) and the Scottish Health Survey (SHeS) (2003, 2008 to 2010) were examined for comparability and consistency. The feasibility of creating common variables for measuring smoking, alcohol consumption, physical activity and diet was assessed. Sample size and estimated mortality events were collected. RESULTS: The surveys have comparable purposes, designs, sampling and administration methodologies, target populations, exclusions, and content. Similar health behaviour questions allow for comparable variables to be created across the surveys. However, the SHeS uses a more detailed risk factor evaluation for alcohol consumption and diet data. Therefore, comparisons of alcohol consumption and diet data between the SHeS and the other two surveys should be performed with caution. Pooling these linked surveys would create a dataset with over 350,000 participants, 28,424 deaths and over 2.4 million person-years of follow-up. DISCUSSION: Pooling linked national population health surveys could improve population health research and surveillance. Innovative methodologies must be used to account for survey dissimilarities, and further discussion is needed on how to best access and analyze data across jurisdictions.

Effects of cardiovascular and cerebrovascular health events on work and earnings: a population-based retrospective cohort study.

BACKGROUND: Survivors of acute health events can experience lasting reductions in functional status and quality of life, as well as reduced ability to work and earn income. We aimed to assess the effect of acute myocardial infarction (MI), cardiac arrest and stroke on work and earning among working-age people. METHODS: For this retrospective cohort study, we used the Canadian Hospitalization and Taxation Database, which contains linked hospital and income tax data, from 2005 to 2013 to perform difference-in-difference analyses. We matched patients admitted to hospital for acute MI, cardiac arrest or stroke with controls who were not admitted to hospital for these indications. Participants were aged 40-61 years, worked in the 2 years before the event and were alive 3 years after the event. Patients were matched to controls for 11 variables. The primary outcome was working status 3 years postevent. We also assessed earnings change attributable to the event. We matched 19 129 particpants who were admitted to hospital with acute MI, 1043 with cardiac arrest and 4395 with stroke to 1 820 644, 307 375 and 888 481 controls, respectively. RESULTS: Fewer of the patients who were admitted to hospital were working 3 years postevent than controls for acute MI (by 5.0 percentage points [pp], 95% confidence interval [CI] 4.5-5.5), cardiac arrest (by 12.9 pp, 95% CI 10.4-15.3) and stroke (by 19.8 pp, 95% CI 18.5-23.5). Mean (95% CI) earnings declines attributable to the events were $3834 (95% CI 3346-4323) for acute MI, $11 143 (95% CI 8962-13 324) for cardiac arrest, and $13 278 (95% CI 12 301-14 255) for stroke. The effects on income were greater for patients who had lower baseline earnings, comorbid disease, longer hospital length of stay or needed mechanical ventilation. Sex, marital status or self-employment status did not affect income declines. INTERPRETATION: Acute MI, cardiac arrest and stroke all resulted in substantial loss in employment and earnings that persisted for at least 3 years after the events. These outcomes have consequences for patients, families, employers and governments. Identification of subgroups at high risk for these losses may assist in targeting interventions, policies and legislation to promote return to work.

Development and validation of a cardiovascular disease risk-prediction model using population health surveys: the Cardiovascular Disease Population Risk Tool (CVDPoRT).

BACKGROUND: Routinely collected data from large population health surveys linked to chronic disease outcomes create an opportunity to develop more complex risk-prediction algorithms. We developed a predictive algorithm to estimate 5-year risk of incident cardiovascular disease in the community setting. METHODS: We derived the Cardiovascular Disease Population Risk Tool (CVDPoRT) using prospectively collected data from Ontario respondents of the Canadian Community Health Surveys, representing 98% of the Ontario population (survey years 2001 to 2007; follow-up from 2001 to 2012) linked to hospital admission and vital statistics databases. Predictors included body mass index, hypertension, diabetes, and multiple behavioural, demographic and general health risk factors. The primary outcome was the first major cardiovascular event resulting in hospital admission or death. Death from a noncardiovascular cause was considered a competing risk. RESULTS: We included 104 219 respondents aged 20 to 105 years. There were 3709 cardiovascular events and 818 478 person-years follow-up in the combined derivation and validation cohorts (5-year cumulative incidence function, men: 0.026, 95% confidence interval [CI] 0.025-0.028; women: 0.018, 95% 0.017-0.019). The final CVDPoRT algorithm contained 12 variables, was discriminating (men: C statistic 0.82, 95% CI 0.81-0.83; women: 0.86, 95% CI 0.85-0.87) and was well-calibrated in the overall population (5-year observed cumulative incidence function v. predicted risk, men: 0.28%; women: 0.38%) and in nearly all predefined policy-relevant subgroups (206 of 208 groups). INTERPRETATION: The CVDPoRT algorithm can accurately discriminate cardiovascular disease risk for a wide range of health profiles without the aid of clinical measures. Such algorithms hold potential to support precision medicine for individual or population uses. Study registration: ClinicalTrials.gov, no. NCT02267447.

Using data linkage to report surgical treatment of breast cancer in Canada.

BACKGROUND: National population information about the surgical treatment rate for primary cancers, including breast cancer, has remained a significant data gap in Canada. This gap has implications for cancer care planning and evaluating health system performance. New linkages between the Canadian Cancer Registry and hospital discharge records were conducted by Statistics Canada in 2016. Using already existing, routinely collected health administrative data, these linkages allow viable reporting of surgical cancer treatment for the first time for all provinces and territories (except Quebec). DATA AND METHODS: Hospital record information about type and date of surgical treatment of tumours was provided by information from linked data. These linked data reported 50,740 incident primary malignant breast tumours diagnosed between January 1, 2010, and December 31, 2012, among females aged 19 years or older. The unadjusted treatment rate for primary surgical intervention within one year was calculated as the proportion of total tumours that were linkable to hospital records. RESULTS: For three combined years (2010, 2011 and 2012), 88.3% (N=44,780) of patients overall received at least one surgical treatment. Variations to the surgical rate occurred across jurisdictions, with the highest rate at 91-92% for Prince Edward Island, Newfoundland and Labrador, British Columbia and New Brunswick. Generally, there was an inverse gradient between surgical treatment rate and tumour stage. DISCUSSION: The surgical treatment rate of new primary breast cancers varied across provinces and territories from 2010 to 2012. New linked data could be used to further identify geographic and demographic inequities in terms of receiving surgical cancer treatment and contribute to the evaluation of cancer system performance and outcomes.

Social and economic characteristics of those experiencing hospitalizations due to opioid poisonings.

Hospitalizations due to opioid poisonings are increasing. While considerable information is available on the demographic and geographic distribution of opioid-related events, national data on the social and economic circumstances of those experiencing these events are limited. This study uses data from the National Household Survey (2011) linked to the Discharge Abstract Database (2011 to 2016) to provide the first national-level estimates of the socio-economic characteristics of individuals experiencing opioid-related hospitalizations. Results reveal elevated hospitalization rates among people who have lower levels of income and education, are unemployed or out of the labour force, identify as Indigenous, live in lone-parent households, and spend more than 50% of their household income on housing. Understanding the circumstances of individuals who experienced adverse opioid events will help inform policies addressing potential determinants.

Tuberculosis-related hospital use among recent immigrants to Canada.

BACKGROUND: While the incidence of active tuberculosis (TB) in Canada is among the lowest in the world, the rates of TB among immigrants and Indigenous people remain high. In fact, the majority of new active TB cases are disproportionately found among immigrants. This study profiles TB-related acute care hospitalizations among new immigrants to Canada by selected characteristics. DATA AND METHODS: This study is based on the 2000-to-2013 Longitudinal Immigration Database (IMDB) linked to the Canadian Institute for Health Information's Discharge Abstract Database (DAD) from 2001/2002 to 2013/2014. It examines the timing of first TB-related acute care hospitalization occurring from the fiscal year 2001/2002 to the fiscal year 2013/2014 among immigrants who landed in Canada from 2000 to 2013 outside of Quebec and the territories. Mean and median hospital days and the percentage of total TB hospitalizations incurred by these new immigrants are calculated to measure the burden of hospital care among recent immigrants. RESULTS: From 2001/2002 to 2013/2014, 1,120 out of 2.7 million immigrants arriving between 2000 and 2013 were found to have, in total, 1,340 TB-related hospital discharges. The majority of cases (97%) were among immigrants from the Immigration, Refugees and Citizenship Canada (IRCC) designated country list for TB, in which abour three quarters of the cases were from the World Health Organization (WHO) list of high TB-burden countries. Approximately half (45%) of immigrants hospitalized for TB were aged 18 to 34 at the time of hospitalization. Around 10% of all TB patients had been hospitalized before formally landing as immigrants. Mean and median length of hospital stay were 17 days and 11 days, respectively (22 days and 14 days, respectively, for the overall population in Canada). While new immigrants who landed between 2000 and 2013 represent 7% of the overall population of Canada, they incurred 17% of all TB-related hospital discharges occurring during this period. DISCUSSION: This paper demonstrates the value of linked administrative data to understanding immigrant health and is important for future work in this area. Current immigration protocols surrounding TB involve screening for active pulmonary TB and identifying some migrants with latent TB. Results of this study, linking TB-related hospitalizations to immigrant landing files, provide unique information that can inform public health action, as well as migration policy and program development to contribute to the efforts to eliminate TB.

Transitions to long-term and residential care among older Canadians.

BACKGROUND: The aging of the Canadian population has increased attention on the future need for nursing home beds. Although current projections rely primarily on age and sex, other factors also contribute to the need for long-term care. This study seeks to identify additional factors to age and sex that contribute to Canadians transitioning from living at home to living in a seniors' residence or nursing home. DATA AND METHODS: As part of a larger record linkage project, three cycles of the Canadian Community Health Survey (CCHS) were linked to the 2011 Census of Population: Cycle 3.1 (2005/2006), Cycle 4.1 (2007/2008), and CCHS-Healthy Aging (2008/2009). The sample was limited to successfully linked CCHS respondents who were aged 60 years or older as of Census Day 2011 (May 10, 2011; n=81,411). Sex-specific generalized multinomial logistic regression models were conducted to examine the association between each respondent's characteristics and dwelling location (private dwelling, private dwelling with additional family, nursing home, or seniors' residence) on Census Day. RESULTS: On Census Day, 1.4% of the study sample were living in a nursing home, 1.2% in a seniors' residence, 7.1% in a private dwelling with additional family, and 90.3% in a private dwelling. Women were more likely than men to be living in a nursing home (1.8% of women vs. 0.9% of men) or seniors' residence (1.7% of women vs. 0.7% of men). Regression models showed that, aside from age, there were increased odds of living in a nursing home or seniors' residence among individuals who lost their spouse or who were not married, who did not own their dwelling, who had poor self-rated health, or who had been diagnosed with dementia. The association of other factors with dwelling place differed according to sex and type of dwelling. DISCUSSION: Although age is strongly associated with living in a nursing home or seniors' residence, other demographic and health factors affect the likelihood of an individual transitioning to an institutional dwelling. Such factors could be considered when planning for the future housing and care needs of the Canadian population.