Describing primary care patterns before and during the COVID-19 pandemic across Canada: a quasi-experimental pre-post design cohort study using national practice-based research network data.

OBJECTIVE: The objective was to analyse how the pandemic affected primary care access and comprehensiveness in chronic disease management by comparing primary care patterns before and during the early COVID-19 pandemic. DESIGN: We conducted a quasi-experimental pre-post design cohort study and reported indicators for the 21 months before and after the onset of the COVID-19 pandemic. SETTING: We used electronic medical record data from primary care clinics enrolled in the Canadian Primary Care Sentinel Surveillance Network from 1 January 2018 to 31 December 2021. POPULATION: The study population included patients (n=919 928) aged 18 years or older with at least one primary care contact from 12 March 2018 to 12 March 2020, in Canada. OUTCOME MEASURES: The study indicators included three indicators measuring access to primary care (encounters, blood pressure measurements and lab tests) and three for comprehensiveness (diagnoses, non-COVID-19 vaccines administered and referrals). RESULTS: 67.3% of the cohort was aged ≥40 years, 56.4% were female and 53.5% were from Ontario, Canada. Fewer patients received an encounter during the pandemic (91.5% to 81.5%), while the median (IQR) number of encounters remained the same (5 (2-1)) for those with access. Fewer patients received a blood pressure measurement (47.9% to 31.8%), and patients received fewer measurements during the pandemic (2 (1-4) to 1 (0-2)). CONCLUSIONS: Encounters with primary care remained consistent during the pandemic, but in-person care, such as lab tests and blood pressure measurements, decreased. In-person care indicators followed temporally to national COVID-19 case counts during the pandemic.

Validation of adult asthma case definitions for primary care sentinel surveillance.

BACKGROUND: Most asthma diagnoses and patient care take place in primary care settings. Electronic medical records (EMRs) offer an opportunity to utilize technology to improve asthma diagnosis and care. The purpose of this study was to create and validate separate case definitions for suspected and confirmed asthma in primary care EMRs, to enable surveillance, benchmarking, and quality improvement in primary care settings. The objective of this study was to develop a case definition for suspected and confirmed asthma for use in a primary care sentinel surveillance system. METHODS: A single chart abstractor conducted a manual audit of 776 randomly selected patient charts from an academic primary care practice EMR in Kingston, Ontario. Following the single chart abstractor classification, a consensus on chart classification as "not asthma", "suspected asthma", or "confirmed asthma" was achieved between the abstractor, a family physician, and a respirologist using Canadian Thoracic Society (CTS) criteria. Case definition algorithms based on billing codes, clinical data elements and medications were applied to the site's Canadian Primary Care Sentinel Surveillance Network (CPCSSN) data for the same charts and compared to abstractor classifications to determine each algorithm's measurement properties. RESULTS: The prevalence of suspected and confirmed asthma were 7.3% (n = 54) and 2.4% (n = 18), respectively. None of the proposed case definitions could differentiate between suspected and confirmed asthma. One algorithm consisting of billing, clinical, and medication elements had the highest Youden's Index for either suspected or confirmed asthma. The algorithm had a sensitivity of 81%, a specificity of 96%, positive predictive value of 71%, negative predictive value of 98%, and a Youden's Index of 0.77 for combined suspected or confirmed asthma cases. CONCLUSION: An EMR case definition for suspected or confirmed adult asthma has been validated for use in CPCSSN. Implementation of this case definition will enable the development of a surveillance electronic tool (eTool) for adult asthma that can foster quality improvement.

Effects of the COVID-19 Pandemic on Primary Health Care for Chronic Conditions in Canada: Protocol for a Retrospective Pre-Post Study Using National Practice-Based Research Network Data.

BACKGROUND: Since the COVID-19 pandemic began, there have been concerns that interruptions to the health care system may have led to changes in primary care, especially for care of chronic conditions such as diabetes and heart failure. Such changes may have longer term implications for population health. OBJECTIVE: This study aims to describe the impacts of the COVID-19 pandemic on indicators of primary care access, comprehensiveness, and appropriateness among adult patients, as well as on specific indictors of chronic conditions. Additionally, this study aims to determine whether any identified changes were associated with patient sociodemographic characteristics and multimorbidity. METHODS: This is a retrospective, single-arm, pre-post study using Canadian Primary Care Sentinel Surveillance Network (CPCSSN) data. CPCSSN is a research network supported by a primary care electronic medical record database, comprising over 1500 physicians and nearly 2 million patients. We are examining changes in care (eg, frequency of contacts, laboratory tests and investigations, referrals, medications prescribed, etc) among adults. We will also examine indicators specific to evidence-based recommendations for care in patients with diabetes and those with heart failure. We will compare rates of outcomes during key periods of the pandemic between March 13, 2020, and December 31, 2022, with equal time periods before the pandemic. Differences will be examined among specific subgroups of adults, including by decade of age, number of comorbidities, and socioeconomic status. Regression models appropriate to outcome distributions will be used to estimate changes, adjusting for potential confounders. This analysis is part of a mixed-methods study with a qualitative component investigating how patients with diabetes with or without concurrent heart failure perceived the impact of the pandemic on access to primary care and health care-related decisions. This study was approved by the Hamilton Integrated Research Ethics Board (14782-C). RESULTS: The start date of this study was October 5, 2022, and the prospective end date is January 31, 2024. As of May 2023, the study cohort (n=875,934) is defined, data cleaning is complete, and exploratory analyses have begun. Extended analyses using 2022 data are planned once the new data becomes available. We will disseminate results through peer-reviewed publications and academic conference, as well as creating evidence briefs, infographics, and a video for policy maker and patient audiences. CONCLUSIONS: This study will investigate whether the COVID-19 pandemic has resulted in changes in the provision of primary care in Canada and whether these potential changes have led to gaps in care. This study will also identify patient-level characteristics associated with changes in care patterns across the COVID-19 pandemic. Indicators specific to chronic conditions, namely diabetes and heart failure, will also be explored to determine whether there were changes in care of these conditions. TRIAL REGISTRATION: ClinicalTrials.gov NCT05813652; https://clinicaltrials.gov/ct2/show/NCT05813652. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/49131.

Validation of a primary care electronic medical records case definition for eczema: retrospective cross-sectional study.

BACKGROUND: To validate case definitions for eczema using primary care Electronic Medical Record (EMR) data from the Canadian Primary Care Sentential Surveillance Network (CPCSSN). METHODS: This study used EMR data from 1,574 primary care providers in seven Canadian provinces, representing 689,301 patients. Using a subset of patient records seven medical students or family medicine residents created a reference set of 1,772 patients. A total of 23 clinician-informed case definitions were validated against the reference. We assessed agreement using sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV) and overall accuracy. The case definitions with the best agreement statistics were deployed to estimate the prevalence of eczema in the CPCSSN. RESULTS: Case definition 1 had the highest SE (92.1%,85.0-96.5) but a lower SP (88.5%,86.7-90.1) and PPV (36.6%,33.1-40.3). Case definition 7 was the most specific case definition with a SP (99.8%, 99.4-100) and PPV (84.2%,61.2-94.7) but low SE (15.8%,9.3-24.5). Case definition 17 had a SE (75.3%, 65.7-83.3), SP (93.8%, 91.5-94.3) and PPV 43.7% (38.3-49.2). When we applied the most specific and most sensitive case definitions, we estimate the prevalence of eczema to be between 0.8 and 15.1%. Case definition 17 suggests an eczema prevalence estimate of 8.2% (8.08-8.21%). CONCLUSIONS: We validated EMR-based eczema case definitions to estimate the prevalence of clinician-documented eczema. Future studies may choose to apply one or more of these definitions' dependent on their studies objectives to inform disease surveillance as well as explore burden of illness or interventions related to eczema care in Canada.

Integrating User Preferences for Asthma Tools and Clinical Guidelines Into Primary Care Electronic Medical Records: Mixed Methods Study.

BACKGROUND: Asthma is a chronic respiratory disease that poses a substantial burden on individuals and the health care system. Despite published national guidelines for the diagnosis and management of asthma, considerable care gaps exist. Suboptimal adherence to asthma diagnosis and management guidelines contributes to poor patient outcomes. The integration of electronic tools (eTools) into electronic medical records (EMRs) represents a knowledge translation opportunity to support best practices. OBJECTIVE: The purpose of this study was to determine how best to integrate evidence-based asthma eTools into primary care EMRs across Ontario and Canada to improve adherence to guidelines as well as measure and monitor performance. METHODS: In total, 2 focus groups comprising physicians and allied health professionals who were considered experts in primary care, asthma, and EMRs were convened. One focus group also included a patient participant. Focus groups used a semistructured discussion-based format to consider the optimal methods for integrating asthma eTools into EMRs. Discussions were held on the web via Microsoft Teams (Microsoft Corp). The first focus group discussed integrating asthma indicators into EMRs using eTools, and participants completed a questionnaire evaluating the clarity, relevance, and feasibility of collecting asthma performance indicator data at the point of care. The second focus group addressed how to incorporate eTools for asthma into a primary care setting and included a questionnaire evaluating the perceived utility of various eTools. Focus group discussions were recorded and analyzed using thematic qualitative analysis. The responses to focus group questionnaires were assessed using descriptive quantitative analysis. RESULTS: Qualitative analysis of the 2 focus group discussions revealed 7 key themes: designing outcome-oriented tools, gaining stakeholder trust, facilitating open lines of communication, prioritizing the end user, striving for efficiency, ensuring adaptability, and developing within existing workflows. In addition, 24 asthma indicators were rated according to clarity, relevance, feasibility, and overall usefulness. In total, 5 asthma performance indicators were identified as the most relevant. These included smoking cessation support, monitoring using objective measures, the number of emergency department visits and hospitalizations, assessment of asthma control, and presence of an asthma action plan. The eTool questionnaire responses revealed that the Asthma Action Plan Wizard and Electronic Asthma Quality of Life Questionnaire were perceived to be the most useful in primary care. CONCLUSIONS: Primary care physicians, allied health professionals, and patients consider that eTools for asthma care present a unique opportunity to improve adherence to best-practice guidelines in primary care and collect performance indicators. The strategies and themes identified in this study can be leveraged to overcome barriers associated with asthma eTool integration into primary care EMRs. The most beneficial indicators and eTools, along with the key themes identified, will guide future asthma eTool implementation.

Primary care asthma surveillance: a review of knowledge translation tools and strategies for quality improvement.

BACKGROUND: Viable knowledge translation (KT) strategies are increasingly sought to improve asthma diagnosis, particularly in primary care. Despite this understanding, practical KT tools to support primary care practitioners are not widely available. Electronic medical records (EMRs) offer an opportunity to optimize the diagnosis and surveillance of chronic diseases such as asthma, and support quality improvement initiatives that increase adherence to guideline-recommended care. This review aims to describe the current state of electronic KT electronic tools (eTools) and surveillance systems for asthma and identify opportunities to increase adherence to asthma diagnostic guidelines by implementing digital KT eTools. METHODS: Systematic literature searches were conducted on Ovid MEDLINE that included the search terms: asthma, asthma diagnosis, asthma surveillance, electronic health records, translational medical research, quality improvement, professional practice gaps, and primary health care published in the previous 10 years. In total, the searches returned 971 articles, 163 of which were considered relevant and read in full. An additional 28 articles were considered after reviewing the references from selected articles. 75 articles were included in this narrative review. RESULTS: Established KT eTools for asthma such as electronic questionnaires, computerized clinical decision support systems (CDSS), chronic disease surveillance networks, and asthma registries have been effective in improving the quality of asthma diagnosis and care. As well, chronic disease surveillance systems, severe asthma registries, and workplace asthma surveillance systems have demonstrated success in monitoring asthma outcomes. However, lack of use and/or documentation of objective measures of lung function, challenges in identifying asthma cases in EMRs, and limitations of data sources have created barriers in the development of KT eTools. Existing digital KT eTools that overcome these data quality limitations could provide an opportunity to improve adherence to best-practice guidelines for asthma diagnosis and management. CONCLUSION: Future initiatives in the development of KT eTools for asthma care should focus on strategies that assist healthcare providers in accurately diagnosing and documenting cases of asthma. A digital asthma surveillance system could support adherence to best-practice guidelines of asthma diagnosis and surveillance by prompting use of objective methods of confirmation to confirm an asthma diagnosis within the EMR.

Characterizing primary care patients with posttraumatic stress disorder using electronic medical records: a retrospective cross-sectional study.

BACKGROUND: Posttraumatic stress disorder (PTSD) has significant morbidity and economic costs. This study describes the prevalence and characteristics of patients with PTSD using primary care electronic medical record (EMR) data. METHODS: This retrospective cross-sectional study used EMR data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). This study included 1,574 primary care providers located in 7 Canadian provinces. There were 689,301 patients that visited a CPCSSN provider between 1 January 2017 and 31 December 2019. We describe associations between PTSD and patient characteristics using descriptive statistics, chi-square, and multiple logistic regression models. RESULTS: Among the 689,301 patients included, 8,817 (1.3%, 95% CI 1.2-1.3) had a diagnosis of PTSD. On multiple logistic regression analysis, patients with depression (OR 4.4, 95% CI 4.2-4.7, P < 0.001), alcohol abuse/dependence (OR 1.7, 95% CI 1.6-1.9, P < 0.001), and/or drug abuse/dependence (OR 2.6, 95% CI 2.5-2.8, P < 0.001) had significantly higher odds of PTSD compared with patients without those conditions. Patients residing in community areas considered the most material deprived (OR 2.1, 95% CI 1.5-2.1, P < 0.001) or the most socially deprived (OR 2.8, 95% CI 2.7-5.3, P < 0.001) had higher odds of being diagnosed with PTSD compared with patients in the least deprived areas. CONCLUSIONS: The prevalence of PTSD in Canadian primary care is 1.3% (95% CI 1.25-1.31). Using EMR records we confirmed the co-occurrence of PTSD with other mental health conditions within primary care settings suggesting benefit for improved screening and evidence-based resources to manage PTSD.

Posttraumatic stress disorder (PTSD) is a mental health disorder with symptoms presenting after having experienced or witnessed a traumatic event. PTSD symptoms continue for more than 1 month after the event and negatively impact the health and social wellbeing of an individual. Primary care, including family doctors, nurse practitioners, and community paediatricians, are often the first point of healthcare for an individual. This study found that PTSD is diagnosed and managed in primary care. Patients with PTSD had comorbidities, substance use, and visited their primary care provider more frequently. Additionally, patients with PTSD often live in a community area that is experiencing high material and social deprivation. The presence of PTSD in primary care suggests the need for new and additional evidence-based resources to assist in managing this complex condition.

Comprehensiveness of care for women with depression: Association between primary care use and cervical cancer screening.

OBJECTIVE: To explore comprehensiveness of care in patients with depression by examining associations between a diagnosis of depression, frequency of primary care visits, and Papanicolaou test completion. DESIGN: Cross-sectional retrospective survey using electronic medical record data from the Canadian Primary Care Sentinel Surveillance Network. SETTING: Primary care practices in Ontario. PARTICIPANTS: Women aged 21 to 69 eligible to receive Pap tests in 2015. MAIN OUTCOME MEASURES: Associations between 2 predictors (depression and number of primary care visits in 2015) and Pap test completion were measured. RESULTS: Overall, 125,258 women were included: 20.5% completed a Pap test and 16.4% had a diagnosis of depression. Having a diagnosis of depression was associated with lower likelihood of Pap test completion (adjusted odds ratio [AOR]=0.92, 95% CI 0.88 to 0.95). A greater number of primary care visits was associated with a higher likelihood of Pap test completion; this association was stronger in women with a diagnosis of depression (AOR=4.9, 95% CI 4.16 to 5.69) than in those without (AOR=3.4, 95% CI 3.25 to 3.60). CONCLUSION: While depression was associated with fewer completed Pap tests, women with depression who saw their family doctors more often were more likely to be screened for cervical cancer. More primary care visits for depression treatment may be associated with an improved likelihood of screening for cervical cancer.

Primary care provider diagnosed eczema within electronic medical records from seven canadian provinces.

Context: Most epidemiological research on eczema has largely relied on patient survey data. With the increasing use of electronic medical records (EMR) in primary care, there has been a shift in epidemiological research towards the use of validated case definitions to study disease. Objective: Apply a validated case definition for eczema to EMR data from primary care providers participating in the Canadian Primary Care Sentential Surveillance Network (CPCSSN) to determine the prevalence of diagnosed eczema in Canada and describe patient's characteristics including risk factors and comorbidities. Study Design: Cross-sectional study. Dataset: EMR data from 1,574 primary care providers in seven Canadian provinces. Population Studied: Patient records were examined for those with at least one encounter with a family physician, nurse practitioner or community pediatrician participating in CPCSSN between January 1, 2017, and December 31, 2019 (N= 689,301 patients). Outcome Measures: Primary outcome was lifetime prevalence of eczema. Secondary outcomes were demographics of eczema patients and the association between eczema and various comorbidities. Results: Descriptive statistics revealed a lifetime prevalence of documented eczema of 11.6% overall, 15.1% in those <19 years, and 11.5% in those >19 years. Patients with eczema were more likely to be smokers. Using the Material and Social Deprivation Index we found eczema was more prevalent among the least materially and socially deprived quintiles. In logistic regression, female patients (OR, 1.29; 95% CI, 1.27-1.32) and patients <19 years (OR, 1.27; 95% CI, 1.19-1.35) had higher odds of eczema compared to male patients and patients aged >19 years. Patients with comorbidities such as rhinitis (OR, 2.11; 95% CI, 2.06-2.17), asthma (OR, 1.4; 95% CI, 1.37-1.43), any allergy (OR, 1.09, 95% CI 1.06-1.11), COPD (OR, 1.1; 95% CI, 1.06-1.14) and anxiety (OR, 1.66; 95% CI, 1.63-1.69) had higher odds of eczema compared to patients without these comorbidities. Depression (OR, 0.96; 95% CI, 0.94-0.98) and obesity (OR, 0.96; 95% CI, 0.94-0.98) were negatively associated with a diagnosis of eczema. Conclusion: This is the first study in Canada to determine the prevalence of primary care provider documented eczema using EMR data. This study can inform and improve disease surveillance as well as future studies exploring burden of illness, trends or interventions related to eczema care in Canada.

Characterizing posttraumatic stress disorder in primary care using electronic medical records: a retrospective cohort study.

Context: Posttraumatic stress disorder (PTSD) is a chronic mental health disorder associated with significant morbidity and economic cost. Primary care providers are frequently involved in the ongoing management of patients experiencing PTSD, as well as related comorbid conditions. Despite recognized need to enhance PTSD management in primary care settings, knowledge regarding its prevalence in these settings is limited. Objective: To apply a validated case definition of PTSD to electronic medical records (EMRs) of family physicians and nurse practitioners participating in the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). Study Design: Retrospective cross-sectional study. Dataset: This study accessed de-identified EMR from 1,574 primary care providers participating in the CPCSSN. Population Studied: The study population included all patients with at least one visit to a primary care provider participating in the CPCSSN between January 1, 2017 and December 31, 2019 (N = 689,301). Outcome Measures: We identified patients with PTSD and described associations between PTSD and patient characteristics (including sex, age, geography, depression, anxiety, medical comorbidities, substance use and social and material deprivation) using multivariable logistic regression models. Results: Among the 689,301 patients meeting inclusion criteria, 8,213 (1.2%) had a diagnosis of PTSD. Patients with PTSD were significantly more likely to reside in an urban location (84.9% vs. 80.4%; p-value <.0001) and have one or more comorbid conditions (90.8% vs. 70.2%; p-value <.0001). On multivariable logistic regression analysis, patients with depression (OR 4.8; 95%CI 4.6-5.1) and anxiety (OR 2.2; 95%CI 2.1-2.3) had increased odds of having PTSD compared to patients without depression or anxiety. Patients with alcohol (OR 1.8; 95%CI 1.6-1.9) and drug (OR 3.1; 95%CI 2.9-3.3) use disorders had significantly higher odds of PTSD compared to patients without these disorders. Patients in the most deprived neighborhoods based on census data had 4.2 times higher odds of have PTSD (95%CI 3.2-5.43) compared to patients in the least deprived areas. Conclusions: This is the first study to describe PTSD prevalence in a large Canadian sample of primary care patients using an EMR-based case definition. Characterizing patients with PTSD in primary care may improve disease surveillance and inform the interdisciplinary care required to manage PTSD symptoms.

A cross-sectional study evaluating cardiovascular risk and statin prescribing in the Canadian Primary Care Sentinel Surveillance Network database.

BACKGROUND: Cardiovascular disease (CVD) is a major cause of morbidity and mortality in Canada. Assessment and management of CVD risk is essential in reducing disease burden. This includes both clinical risk factors and socioeconomic factors, though few studies report on socioeconomic status in relation to CVD risk and treatment. The primary objective of this study was to estimate the cardiovascular risk of patients attending primary care practices across Canada; secondly, to evaluate concordance with care indicators suggested by current clinical practice guidelines for statin prescribing according to patients' cardiovascular risk and socioeconomic status. METHODS: This cross-sectional observational study used the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) database, which is comprised of clinical data from primary care electronic medical records. Patients aged 35-75y with at least one visit to their primary care provider between 2012 and 2016 were included. Patients were assigned to a CVD risk category (high, medium, low) and a deprivation quintile was calculated for those with full postal code available. Descriptive analyses were used to determine the proportion of patients in each risk category. Logistic regression was used to evaluate the consistency of statin prescribing according to national clinical guidelines by risk category and deprivation quintile. RESULTS: A total of 324,526 patients were included. Of those, 116,947 (36%) of patients were assigned to a high CVD risk category, primarily older adults, males, and those with co-morbidities. There were statistically significant differences between least (quintile 1) and most (quintile 5) deprived socioeconomic quintiles, with those at high CVD risk disproportionately in Q5 (odds ratio 1.4). Overall, 48% of high-risk patients had at least one statin prescription in their record. Patients in the lower socioeconomic groups had a higher risk of statin treatment which deviated from clinical guidelines. CONCLUSIONS: Primary care patients who are at high CVD risk are more often male, older, have more co-morbidities and be assigned to more deprived SES quintiles, compared to those at low CVD risk. Additionally, patients who experience more challenging socioeconomic situations may be less likely to receive CVD treatment that is consistent with care guidelines.

Screening patterns and identification of non-alcoholic fatty liver disease in obese children in canadian primary care.

Context. Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in children. There is no epidemiological data on rates of pediatric NAFLD in Canada. Primary care physicians (PCPs) are often the first contact healthcare professionals to manage potential pediatric patients with NAFLD. Objective: Evaluate patterns of screening and identification of pediatric NAFLD in Canadian primary care using administrative health care database. Study Design: Cross-sectional observational study. Dataset: The Canadian Primary Care Sentinel Surveillance Network (CPCSSN), a repository of clinical electronic medical record data drawn from primary care practices across Canada. Population Studied: Children aged 9-18 years old between July 1, 2018 and December 31, 2019. Outcome Measures: The proportion of children eligible for screening (BMI≥95th percentile) as per NASPGHAN guidelines using ALT levels. Logistic Regression was used to evaluate the predictors for screening. Suspected NAFLD was defined as elevated ALT (>22 U/L for girls and > 26 U/L for boys) in the absence of viral hepatitis, metabolic conditions, alcohol use, hepatotoxic medications. Results: The study sample consisted of 66,872 children, of which 15.8% (n=10,539) had a BMI≥95th percentile and only 10.1% (n=1,067/10539) were screened in the last year using ALT. Children were more likely to get screened if they were a) older (13-18 year vs 9-12 year, OR=1.63, 95% CI 1.38-1.93); b) living in an urban setting (OR=1.34, 95% CI 1.0-1.63); and c) had a higher BMI (≥99th percentile vs 95th-98th, OR=1.34, 95% CI 1.14, 1.56). We identified 855 cases of suspected NAFLD, most children (78.5%) were older (13-18 years), male (55.0%), and lived in an urban setting (71.5%). A significant proportion (40.4%) had a BMI in the 99th percentile and 60.3% had at least one comorbidity, and 35.9% were prescribed a psychotropic, antidiabetic or antihypertensive medications. Only 19.9% were referred to a specialist (pediatrician, gastroenterologist). Conclusions: This is the first study to estimate the screening patterns of pediatric NAFLD in primary care in Canada at a national level. The study revealed low screening rates in primary care, these results will help facilitate prioritization of care and future work that could evaluate successful implementation strategies while emphasizing the role of PCPs in screening and managing pediatric NAFLD in Canadian health care setting.

Screening Patterns of Nonalcoholic Fatty Liver Disease in Children with Obesity in Canadian Primary Care: A Cross-Sectional Study.

Background: Nonalcoholic fatty liver disease (NAFLD) is the most common pediatric chronic liver disease, and children with a body mass index (BMI) ≥95th percentile are recommended to be screened for NAFLD by liver enzymes. Objectives: This study aimed to determine the frequency and predictors of screening for NAFLD among children with obesity in Canada and to evaluate a sample of children with suspected NAFLD. Methods: This cross-sectional study used data from the Canadian Primary Care Sentinel Surveillance Network, a repository of electronic medical record data from Canadian primary care practices. Results: Of n = 110,827 children aged 9-18 years, 13.9% (n = 9,888) had a BMI ≥95th percentile. Only 8.7% (n = 859) of these patients were screened for NAFLD in the last year, and 23.6% (n = 2336) were ever screened. Using logistic regression, screening in the last year was associated with demographic and clinical characteristics, including previous liver enzyme assessment, prior antidiabetic prescription, and prior anxiolytic prescription. Among children with suspected NAFLD (n = 1,046), 34.7% had a BMI ≥99th percentile and approximately 8% were at increased risk of significant liver disease. Conclusion: The study revealed low screening rates for NAFLD in Canadian primary care and highlighted the important role of primary care providers in identifying and managing pediatric NAFLD.

Detecting Patients With Nonvalvular Atrial Fibrillation and Atrial Flutter in the Canadian Primary Care Sentinel Surveillance Network: First Steps.

BACKGROUND: A recent feasibility assessment of quality indicators for nonvalvular atrial fibrillation/atrial flutter (NVAF/AFL) identified the Canadian Primary Care Sentinel Surveillance Network, a national outpatient electronic medical record (EMR) system, as a data source for measurement. As a first step, we adapted and validated an existing EMR case definition. METHODS: A diagnosis of NVAF/AFL was defined using International Classification of Disease, 9th Revision, Clinical Modification codes (427.3) in either the physician billing, encounter diagnosis, or health condition fields. We identified all presumed cases in a single clinical site with the algorithm and selected a random sample of those who were presumed NVAF/AFL negative with the same algorithm. A chart audit diagnosis of "definite" NVAF/AFL was confirmed by electrocardiogram and nonvalvular diagnosis confirmed after echocardiogram, attending physician, or specialist letter review. To demonstrate face validity, clinical characteristics were compared for patients with and without NVAF/AFL. RESULTS: The case definition identified a possible 184 patients with and 184 without NVAF/AFL. The case validation resulted in a sensitivity of 100% (95% confidence interval [CI], 100-100), specificity of 84.3% (95% CI, 78.8-89.9), and positive and negative predictive value of 74.7% (95% CI, 66.4-83.2) and 100% (95% CI 100-100), respectively. Patients with NVAF/AFL were older (63 vs 42 years) and had a higher proportion of cardiovascular comorbidities and relevant medications. CONCLUSIONS: We think it is possible that with further validation work, NVAF/AFL can be accurately identified using this large pan-Canadian EMR system and used as a future tool to measure quality of care in the outpatient setting.

CONTEXTE: Dans le cadre d'une étude récente visant à déterminer s'il est possible d'utiliser des indicateurs de qualité pour évaluer les soins prodigués en cas de fibrillation auriculaire (FA) non valvulaire/flutter auriculaire, le Réseau canadien de surveillance sentinelle en soins primaires, un système national regroupant des données provenant des dossiers médicaux électroniques (DME) de patients vus en contexte de soins ambulatoires, a été retenu comme source de données pour une telle évaluation. Dans un premier temps, nous avons adapté et validé une définition de cas existante dans les DME. MÉTHODOLOGIE: On considérait qu'il y avait diagnostic de FA non valvulaire/flutter auriculaire si le code de la Classification internationale des maladies (9e révision, Modification clinique) correspondant (code 427.3) figurait dans un des champs de facturation des actes médicaux, des diagnostics de consultation ou des problèmes de santé du DME. Nous avons relevé tous les cas de FA non valvulaire/flutter auriculaire présumés d'une même clinique à l'aide de l'algorithme établi et constitué un échantillon aléatoire de patients qui, selon le même algorithme, ne présentaient pas de FA non valvulaire/flutter auriculaire. On a ensuite vérifié les dossiers pour confirmer le diagnostic; le cas de FA non valvulaire/flutter auriculaire était « certain ¼ si le dossier comprenait un électrocardiogramme positif et un diagnostic confirmé par échocardiographie, ou une note du médecin traitant ou d'un spécialiste confirmant le diagnostic. Pour démontrer la validité apparente de l'algorithme, les caractéristiques cliniques des patients atteints de FA non valvulaire/flutter auriculaire ont été comparées à celles des patients sans FA non valvulaire/flutter auriculaire. RÉSULTATS: La définition de cas a permis de repérer 184 patients ayant possiblement une FA non valvulaire/flutter auriculaire, et 184 autres patients sans FA non valvulaire/flutter auriculaire. À l'issue de la validation, la sensibilité de la définition de cas s'établissait à 100 % (intervalle de confiance [IC] à 95 % : 100 à 100), sa spécificité, à 84,3 % (IC à 95 % : 78,8 à 89,9), et ses valeurs prédictives positive et négative, à respectivement 74,7 % (IC à 95 % : 66,4 à 83,2) et 100 % (IC à 95 % : 100 à 100). Les patients atteints de FA non valvulaire/flutter auriculaire étaient plus âgés (63 vs 42 ans) et recevaient un traitement pour des affections cardiovasculaires concomitantes dans une plus forte proportion. CONCLUSIONS: Nous croyons qu'en approfondissant les travaux de validation, il serait possible de repérer avec précision les cas de FA non valvulaire/flutter auriculaire à partir des données de ce système pancanadien de surveillance des DME et de les utiliser pour évaluer la qualité des soins aux patients vus en contexte ambulatoire.

Data quality in healthcare: A report of practical experience with the Canadian Primary Care Sentinel Surveillance Network data.

Data quality (DQ) is the degree to which a given dataset meets a user's requirements. In the primary healthcare setting, poor quality data can lead to poor patient care, negatively affect the validity and reproducibility of research results and limit the value that such data may have for public health surveillance. To extract reliable and useful information from a large quantity of data and to make more effective and informed decisions, data should be as clean and free of errors as possible. Moreover, because DQ is defined within the context of different user requirements that often change, DQ should be considered to be an emergent construct. As such, we cannot expect that a sufficient level of DQ will last forever. Therefore, the quality of clinical data should be constantly assessed and reassessed in an iterative fashion to ensure that appropriate levels of quality are sustained in an acceptable and transparent manner. This document is based on our hands-on experiences dealing with DQ improvement for the Canadian Primary Care Sentinel Surveillance Network database. The DQ dimensions that are discussed here are accuracy and precision, completeness and comprehensiveness, consistency, timeliness, uniqueness, data cleaning and coherence.

Characteristics associated with pediatric growth measurement collection in electronic medical records: a retrospective observational study.

BACKGROUND: Complete growth measurements are an essential part of pediatric care providing a proxy for a child's overall health. This study describes the frequency of well-child visits, documented growth measurements, and clinic and provider factors associated with measurement. METHODS: Retrospective cross-sectional study utilizing electronic medical records (EMRs) from primary care clinics between 2015 and 2017 in Manitoba, Canada. This study assessed the presence of recorded height, weight and head circumference among children (0-24 months) who visited one of 212 providers participating in the Manitoba Primary Care Research Network. Descriptive and multivariable logistic regression analyses assessed clinic, provider, and patient factors associated with children having complete growth measurements. RESULTS: Our sample included 4369 children. The most frequent growth measure recorded was weight (79.2% n = 3460) followed by height (70.8% n = 3093) and head circumference (51.4% n = 2246). 67.5% of children (n = 2947) had at least one complete growth measurement recorded (i.e. weight, height and head circumference) and 13.7% (n = 599) had complete growth measurements at all well-child intervals attended. Pediatricians had 2.7 higher odds of documenting complete growth measures within well-child intervals compared to family physicians (95% CI 1.8-3.8). Additionally, urban located clinics (OR 1.7, 95% CI 1.2-2.5), Canadian trained providers (OR 2.3, 95% CI 1.4-3.7), small practice size (OR 1.6, 95% CI 1.2-2.2) and salaried providers (OR 3.4, 95% CI 2.2-5.2) had higher odds of documented growth measures. CONCLUSIONS: Growth measurements are recorded in EMRs but documentation is variable based on clinic and provider factors. Pediatric growth measures at primary care appointments can improve primary prevention and surveillance of child health outcomes.

Validation of an EMR algorithm to measure the prevalence of ADHD in the Canadian Primary Care Sentinel Surveillance Network (CPCSSN).

BACKGROUND: Building and validating electronic algorithms to identify patients with specific disease profiles using health data is becoming increasingly important to disease surveillance and population health management. The aim of this study was to develop and validate an algorithm to find patients with ADHD diagnoses within primary care electronic medical records (EMR); and then use the algorithm to describe the epidemiology of ADHD from 2008 to 2015 in a Canadian Primary care sample. METHODS: This was a cross sectional time series that used data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN), a repository of primary care EMR data. A sample of electronic patient charts from one local clinic were manually reviewed to determine the positive predictive value (PPV) and negative predictive value (NPV) of an ADHD case-finding algorithm. In each study year a practice population was determined, and the algorithm was used to measure an observed prevalence of ADHD. The observed prevalence was adjusted for misclassification, as measured by the validity indices, to obtain an estimate of the true prevalence. Estimates were calculated by age group (4-17 year olds, 18 to 34 year olds, and 35 to 64 year olds) and gender, and compared over time. RESULTS: The EMR algorithm had a PPV of 98.0% (95% CI [92.5, 99.5]) and an NPV of 95.0% (95% CI [92.9, 98.6]). After adjusting for misclassification, it was determined that the prevalence of patients with a clinical diagnosis of ADHD has risen in all age groups between 2008 and 2015, most notably in children and young adults (6.92, 95% CI [5.62, 8.39] to 8.57, 95% CI [7.32, 10.00]; 5.73, 95% CI [4.40, 7.23] to 7.33, 95% CI [6.04, 8.78], respectively). The well-established gender gap persisted in all age groups across time but was considerably smaller in older adults compared to children and young adults. CONCLUSION: Overall, the ADHD case-finding algorithm was found to be a valid tool to assess the epidemiology of ADHD in Canadian primary care practice. The increased prevalence of ADHD between 2008 and 2015 may reflect an improvement in the recognition and treatment of this disorder within primary care.

Detection of alpha-1 antitrypsin deficiency: the past, present and future.

BACKGROUND: Most patients with alpha-1 antitrypsin deficiency remain undiagnosed and therefore do not benefit from current therapies or become eligible for research studies of new treatments under development. Improving the detection rate for AATD is therefore a high priority for the Alpha-1 Foundation. A workshop was held on June 23, 2019 in Orlando, Florida during which stakeholders from the research, pharmaceutical, and patient communities focused on the topic of alpha-1 antitrypsin deficiency detection. RESULTS: A variety of detection strategies have been explored in the past and new approaches are emerging as technology advances. Targeted detection includes patients with chronic obstructive pulmonary disease, unexplained chronic liver disease, and family members of affected individuals. Newborn screening, electronic medical record data mining, and direct-to-consumer testing remain options for future detection strategies. CONCLUSION: These meeting proceedings can serve as a basis for innovative approaches to the detection of alpha-1 antitrypsin deficiency.

Recent Trends in the Prescribing of ADHD Medications in Canadian Primary Care.

Objective: The aim of this study was to describe the prevalence and incidence of ADHD medication prescribing, by age and gender, from 2005 to 2015 in Canadian primary care. Method: A population-based retrospective cohort study was conducted to evaluate the prescribing of ADHD medications between 2005 and 2015 using electronic medical record data. Yearly prevalence and incidence of ADHD medication prescribing were calculated for preschoolers (up to 5 years old), school-aged children (6-17 years old), and adults (18-65 years old) along with a description of the types of ADHD medications prescribed between 2005 and 2015. Results: Between 2005 and 2015, there was a 2.6-fold increase in the prevalence of ADHD medication prescribing to preschoolers, a 2.5-fold increase in school-aged children, and a fourfold increase in adults. There was a corresponding rise in incidence of prescribing although this rise was moderate and estimates were much lower compared with prevalence. The most commonly prescribed medication was Methylphenidate (65.0% of all ADHD medications prescribed). Conclusion: Although the prevalence of ADHD has remained stable over time, this study found an increase in the prescribing of ADHD medications in all age groups between 2005 and 2015. Incidence of new prescriptions was small relative to prevalence, suggesting that longer term treatments are being adopted.