Stakeholder Perspectives of Attributes and Features of Context Relevant to Knowledge Translation in Health Settings: A Multi-Country Analysis.

BACKGROUND: Context is recognized as important to successful knowledge translation (KT) in health settings. What is meant by context, however, is poorly understood. The purpose of the current study was to elicit tacit knowledge about what is perceived to constitute context by conducting interviews with a variety of health system stakeholders internationally so as to compile a comprehensive list of contextual attributes and their features relevant to KT in healthcare. METHODS: A descriptive qualitative study design was used. Semi-structured interviews were conducted with health system stakeholders (change agents/KT specialists and KT researchers) in four countries: Australia, Canada, the United Kingdom, and the United States. Interview transcripts were analyzed using inductive thematic content analysis in four steps: (1) selection of utterances describing context, (2) coding of features of context, (3) categorizing of features into attributes of context, (4) comparison of attributes and features by: country, KT experience, and role. RESULTS: A total of 39 interviews were conducted. We identified 66 unique features of context, categorized into 16 attributes. One attribute, Facility Characteristics, was not represented in previously published KT frameworks. We found instances of all 16 attributes in the interviews irrespective of country, level of experience with KT, and primary role (change agent/KT specialist vs. KT researcher), revealing robustness and transferability of the attributes identified. We also identified 30 new context features (across 13 of the 16 attributes). CONCLUSION: The findings from this study represent an important advancement in the KT field; we provide much needed conceptual clarity in context, which is essential to the development of common assessment tools to measure context to determine which context attributes and features are more or less important in different contexts for improving KT success.

Comorbidities do not limit improvement in pain and physical function after total knee arthroplasty in patients with knee osteoarthritis: the BEST-Knee prospective cohort study.

OBJECTIVE: To assess the relationship between comorbidities and amount of improvement in pain and physical function in recipients of total knee arthroplasty (TKA) for knee osteoarthritis (OA). DESIGN: Prospective cohort study. SETTING: Two provincial central intake hip and knee centres in Alberta, Canada. PARTICIPANTS: 1051 participants (278 in 6-minute walk test (6MWT) subset), ≥30 years of age with primary knee OA referred for consultation regarding elective primary TKA; assessed 1 month prior and 12 months after TKA. PRIMARY AND SECONDARY OUTCOME MEASURES: Pre-post TKA change in knee OA pain (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), physical function (Knee injury and Osteoarthritis Outcome Score (KOOS) Physical Function Short-Form) and 6MWT walking distance; and the reporting of an acceptable symptom state (Patient Acceptable Symptom State (PASS)) at 12 months after TKA. RESULTS: Mean participant age was 67 years (SD 8.8), 59% were female and 85% reported at least one comorbidity. Individuals with a higher number of comorbidities had worse pre-TKA and post-TKA scores for pain, physical function and 6MWT distance. At 12-month follow-up, mean changes in pain, function and 6MWT distance, and proportion reporting a PASS, were similar for those with and without comorbidities. In multivariable regression analysis, adjusted for potential confounders and clustering by surgeon, no specific comorbidities nor total number of comorbidities were associated with less improvement in pain, physical function or 6MWT distance at 12 months after TKA. Patients with diabetes (OR 0.64, 95% CI 0.44 to 0.94) and a higher number of lower extremity troublesome joints (OR 0.85, 95% CI 0.76 to 0.96) had lower odds of reporting a PASS. CONCLUSION: For individuals with knee OA, comorbid conditions do not limit improvement in pain, physical function or walking ability after TKA, and most conditions do not impact achieving an acceptable symptom state.

A co-designed framework to support and sustain patient and family engagement in health-care decision making.

BACKGROUND: Patient and family engagement in health care has emerged as a critical priority. Understanding engagement, from the perspective of the patient and family member, coupled with an awareness of how patient and family members are motivated to be involved, is an important component in increasing the effectiveness of patient engagement initiatives. The purpose of this research was to co-design a patient and family engagement framework. METHODS: Workshops were held to provide additional context to the findings from a survey. Participants were recruited using a convenience sampling strategy. Workshop data collected were analysed using a modified constant comparative technique. The core research team participated in a workshop to review the findings from multiple inputs to inform the final framework and participated in a face validity exercise to determine that the components of the framework measured what they were intended to measure. RESULTS: The framework is organized into three phases of engagement: why I got involved; why I continue to be involved; and what I need to strengthen my involvement. The final framework describes seven motivations and 24 statements, arranged by the three phases of engagement. CONCLUSION: The results of this research describe the motivations of patient and family members who are involved with health systems in various roles including as patient advisors. A deeper knowledge of patient and family motivations will not only create meaningful engagement opportunities but will also enable health organizations to gain from the voice and experience of these individuals, thereby enhancing the quality and sustainability of patient and family involvement.

Improving the quality of care with a single-entry model of referral for total joint replacement: a preimplementation/postimplementation evaluation.

OBJECTIVES: We assessed: (1) waiting time variation among surgeons; (2) proportion of patients receiving surgery within benchmark and (3) influence of the Winnipeg Central Intake Service (WCIS) across five dimensions of quality: accessibility, acceptability, appropriateness, effectiveness, safety. DESIGN: Preimplementation/postimplementation cross-sectional design comparing historical (n=2282) and prospective (n=2397) cohorts. SETTING: Regional, provincial health authority. PARTICIPANTS: Patients awaiting total joint replacement of the hip or knee. INTERVENTIONS: The WCIS is a single-entry model (SEM) to improve access to total hip replacement (THR) or total knee replacement (TKR) surgery, implemented to minimise variation in total waiting time (TW) across orthopaedic surgeons and increase the proportion of surgeries within 26 weeks (benchmark). Impact of SEMs on quality of care is poorly understood. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes related to 'accessibility': waiting time variation across surgeons, waiting times (Waiting Time 2 (WT2)=decision to treat until surgery and TW=total waiting time) and surgeries within benchmark. Analysis included descriptive statistics, group comparisons and clustered regression. RESULTS: Variability in TW among surgeons was reduced by 3.7 (hip) and 4.3 (knee) weeks. Mean waiting was reduced for TKR (WT2/TW); TKR within benchmark increased by 5.9%. Accessibility and safety were the only quality dimensions that changed (post-WCIS THR and TKR). Shorter WT2 was associated with post-WCIS (knee), worse Oxford score (hip and knee) and having medical comorbidities (hip). Meeting benchmark was associated with post-WCIS (knee), lower Body Mass Index (BMI) (hip) and worse Oxford score (hip and knee). CONCLUSIONS: The WCIS reduced variability across surgeon waiting times, with modest reductions in overall waits for surgery. There was improvement in some, but not all, dimensions of quality.

Existing comorbidities in people with osteoarthritis: a retrospective analysis of a population-based cohort in Alberta, Canada.

OBJECTIVES: The purpose of this study is to estimate the prevalence of comorbidities among people with osteoarthritis (OA) using administrative health data. DESIGN: Retrospective cohort analysis. SETTING: All residents in the province of Alberta, Canada registered with the Alberta Health Care Insurance Plan population registry. PARTICIPANTS: 497 362 people with OA as defined by 'having at least one OA-related hospitalization, or at least two OA-related physician visits or two ambulatory care visits within two years'. PRIMARY OUTCOME MEASURES: We selected eight comorbidities based on literature review, clinical consultation and the availability of validated case definitions to estimate their frequencies at the time of diagnosis of OA. Sex-stratified age-standardised prevalence rates per 1000 population of eight clinically relevant comorbidities were calculated using direct standardisation with 95% CIs. We applied χ2 tests of independence with a Bonferroni correction to compare the percentage of comorbid conditions in each age group. RESULTS: 54.6% (n=2 71 794) of people meeting the OA case definition had at least one of the eight selected comorbidities. Females had a significantly higher rate of comorbidities compared with males (standardised rates ratio=1.26, 95% CI 1.25 to 1.28). Depression, chronic obstructive pulmonary disease (COPD) and hypertension were the most prevalent in both females and males after age-standardisation, with 40% of all cases having any combination of these comorbidities. We observed a significant difference in the percentage of comorbidities among age groups, illustrated by the youngest age group (<45 years) having the highest percentage of cases with depression (24.6%), compared with a frequency of 16.1% in those >65 years. CONCLUSIONS: Our findings highlight the high frequency of comorbidity in people with OA, with depression having the highest age-standardised prevalence rate. Comorbidities differentially affect females, and vary by age. These factors should inform healthcare programme and delivery.

Understanding the motivations of patients: A co-designed project to understand the factors behind patient engagement.

BACKGROUND: Large-scale transformation depends on effective engagement of diverse stakeholders. With the evolution of the role of the 'patient partner' in health-care decision making, understanding the motivations of these individuals is essential to the success of engagement initiatives. This study reports on motivational factors associated with patient engagement in health care. METHODS: Patient co-investigators and a researcher co-designed and conducted this study. A survey was administered to patients and family members. Key informant interviews and previous research informed the development of the survey tool. The survey data were analysed using exploratory factor analysis to identify the underlying dimensions in the data. Cronbach's alpha was used to determine reliability. RESULTS: A total of 1449 individuals participated in the survey. Of these, 543 completed and 427 partially completed the survey (67% complete rate). The mean age of the respondents was 54 years. The majority of participants were female, well-educated, retired, married and lived in an urban centre. Seven motivational factors explained 65% of the total variance. Analysis of internal consistency revealed acceptable reliability for all items. The seven motivations were as follows: Self-fulfillment, Improving Healthcare, Compensation, Influence, Learning New Things, Conditional and Perks. CONCLUSION: The results of this research describe a sample of patient and family members currently engaged with health systems. We identified seven motivational factors underlying their engagement. A deeper knowledge of volunteer motivations will not only create meaningful engagement opportunities for patients, but also enable health organizations to gain from the experience of these individuals, thereby enhancing quality and sustainability of patient engagement programmes.

Understanding context: A concept analysis.

AIMS: To conduct a concept analysis of clinical practice contexts (work environments) in health care. BACKGROUND: Context is increasingly recognized as important to the development, delivery, and understanding of implementation strategies; however, conceptual clarity about what comprises context is lacking. DESIGN: Modified Walker and Avant concept analysis comprised of five steps: (1) concept selection; (2) determination of aims; (3) identification of uses of context; (4) determination of its defining attributes; and (5) definition of its empirical referents. METHODS: A wide range of databases were systematically searched from inception to August 2014. Empirical articles were included if a definition and/or attributes of context were reported. Theoretical articles were included if they reported a model, theory, or framework of context or where context was a component. Double independent screening and data extraction were conducted. Analysis was iterative, involving organizing and reorganizing until a framework of domains, attributes. and features of context emerged. RESULT: We identified 15,972 references, of which 70 satisfied our inclusion criteria. In total, 201 unique features of context were identified, of these 89 were shared (reported in two or more studies). The 89 shared features were grouped into 21 attributes of context which were further categorized into six domains of context. CONCLUSION: This study resulted in a framework of domains, attributes and features of context. These attributes and features, if assessed and used to tailor implementation activities, hold promise for improved research implementation in clinical practice.

Attributes of context relevant to healthcare professionals' use of research evidence in clinical practice: a multi-study analysis.

BACKGROUND: To increase the likelihood of successful implementation of evidence-based practices, researchers, knowledge users, and healthcare professionals must consider aspects of context that promote and hinder implementation in their setting. The purpose of the current study was to identify contextual attributes and their features relevant to implementation by healthcare professionals and compare and contrast these attributes and features across different clinical settings and healthcare professional roles. METHODS: We conducted a secondary analysis of 145 semi-structured interviews comprising 11 studies (10 from Canada and one from Australia) investigating healthcare professionals' perceived barriers and enablers to their use of research evidence in clinical practice. The data was collected using semi-structured interview guides informed by the Theoretical Domains Framework across different healthcare professional roles, settings, and practices. We analyzed these data inductively, using constant comparative analysis, to identify attributes of context and their features reported in the interviews. We compared these data by (1) setting (primary care, hospital-medical/surgical, hospital-emergency room, hospital-critical care) and (2) professional role (physicians and residents, nurses and organ donor coordinators). RESULTS: We identified 62 unique features of context, which we categorized under 14 broader attributes of context. The 14 attributes were resource access, work structure, patient characteristics, professional role, culture, facility characteristics, system features, healthcare professional characteristics, financial, collaboration, leadership, evaluation, regulatory or legislative standards, and societal influences. We found instances of the majority (n = 12, 86%) of attributes of context across multiple (n = 6 or more) clinical behaviors. We also found little variation in the 14 attributes of context by setting (primary care and hospitals) and professional role (physicians and residents, and nurses and organ donor coordinators). CONCLUSIONS: There was considerable consistency in the 14 attributes identified irrespective of the clinical behavior, setting, or professional role, supporting broad utility of the attributes of context identified in this study. There was more variation in the finer-grained features of these attributes with the most substantial variation being by setting.

Understanding patient engagement in health system decision-making: a co-designed scoping review.

BACKGROUND: With healthcare striving to shift to a more person-centered delivery model, patient and family involvement must have a bigger role in shaping this. While many initiatives involving patients and family members focus on self-care, a broader understanding of patient participation is necessary. Ensuring a viable and sustainable critical number of qualified patients and family members to support this shift will be of utmost importance. The purpose of this study was to understand how health systems are intentionally investing in the training and skill development of patients and family members. METHODS: Patient co-investigators and researchers conducted a scoping review of the existing literature on methods adopted by healthcare systems to build the skills and capacity of patients to participate in healthcare decision-making using a recognized methodological framework. Six electronic databases were searched to identify studies. Two independent reviewers screened titles and abstracts and full-text papers for inclusion. The research team independently extracted data. Any disagreements were resolved by achieving consensus through discussion. Quantitative and qualitative content synthesis, as well as a quality assessment, was conducted. RESULTS: After eliminating duplicates, the search resulted in 9428 abstracts. Four hundred fifty-eight articles were reviewed and 15 articles were included. Four themes emerged: forums (33%), patient instructors (20%), workshops (33%), and co-design (13%). Four of the identified studies measured the impact and overall effectiveness of the respective programs. Examples of how patient and family members were supported (invested in) included advocacy training to support future involvement in engagement activities, a training program to conduct patient-led research, involvement in an immersive experience-based co-design initiative, and involvement in training pharmacy students. Overall, these studies found positive outcomes when patients and family members were recipients of these opportunities. CONCLUSIONS: The results of this scoping review demonstrate that an evidence base around programs to advance patient engagement is largely absent. An opportunity exists for further research to identify strategies and measures to support patient engagement in healthcare decision-making.

Enhancing the uptake of systematic reviews of effects: what is the best format for health care managers and policy-makers? A mixed-methods study.

BACKGROUND: Systematic reviews are infrequently used by health care managers (HCMs) and policy-makers (PMs) in decision-making. HCMs and PMs co-developed and tested novel systematic review of effects formats to increase their use. METHODS: A three-phased approach was used to evaluate the determinants to uptake of systematic reviews of effects and the usability of an innovative and a traditional systematic review of effects format. In phase 1, survey and interviews were conducted with HCMs and PMs in four Canadian provinces to determine perceptions of a traditional systematic review format. In phase 2, systematic review format prototypes were created by HCMs and PMs via Conceptboard©. In phase 3, prototypes underwent usability testing by HCMs and PMs. RESULTS: Two hundred two participants (80 HCMs, 122 PMs) completed the phase 1 survey. Respondents reported that inadequate format (Mdn = 4; IQR = 4; range = 1-7) and content (Mdn = 4; IQR = 3; range = 1-7) influenced their use of systematic reviews. Most respondents (76%; n = 136/180) reported they would be more likely to use systematic reviews if the format was modified. Findings from 11 interviews (5 HCMs, 6 PMs) revealed that participants preferred systematic reviews of effects that were easy to access and read and provided more information on intervention effectiveness and less information on review methodology. The mean System Usability Scale (SUS) score was 55.7 (standard deviation [SD] 17.2) for the traditional format; a SUS score < 68 is below average usability. In phase 2, 14 HCMs and 20 PMs co-created prototypes, one for HCMs and one for PMs. HCMs preferred a traditional information order (i.e., methods, study flow diagram, forest plots) whereas PMs preferred an alternative order (i.e., background and key messages on one page; methods and limitations on another). In phase 3, the prototypes underwent usability testing with 5 HCMs and 7 PMs, 11 out of 12 participants co-created the prototypes (mean SUS score 86 [SD 9.3]). CONCLUSIONS: HCMs and PMs co-created prototypes for systematic review of effects formats based on their needs. The prototypes will be compared to a traditional format in a randomized trial.

Behaviour modification interventions to optimise red blood cell transfusion practices: a systematic review and meta-analysis.

OBJECTIVE: To assess the impact of behaviour modification interventions to promote restrictive red blood cell (RBC) transfusion practices. DESIGN: Systematic review and meta-analysis. SETTING, PARTICIPANTS, INTERVENTIONS: Seven electronic databases were searched to January 2018. Published randomised controlled trials (RCTs) or non-randomised studies examining an intervention to modify healthcare providers' RBC transfusion practice in any healthcare setting were included. PRIMARY AND SECONDARY OUTCOMES: The primary outcome was the proportion of patients transfused. Secondary outcomes included the proportion of inappropriate transfusions, RBC units transfused per patient, in-hospital mortality, length of stay (LOS), pretransfusion haemoglobin and healthcare costs. Meta-analysis was conducted using a random-effects model and meta-regression was performed in cases of heterogeneity. Publication bias was assessed by Begg's funnel plot. RESULTS: Eighty-four low to moderate quality studies were included: 3 were RCTs and 81 were non-randomised studies. Thirty-one studies evaluated a single intervention, 44 examined a multimodal intervention. The comparator in all studies was standard of care or historical control. In 33 non-randomised studies, use of an intervention was associated with reduced odds of transfusion (OR 0.63 (95% CI 0.56 to 0.71)), odds of inappropriate transfusion (OR 0.46 (95% CI 0.36 to 0.59)), RBC units/patient weighted mean difference (WMD: -0.50 units (95% CI -0.85 to -0.16)), LOS (WMD: -1.14 days (95% CI -2.12 to -0.16)) and pretransfusion haemoglobin (-0.28 g/dL (95% CI -0.48 to -0.08)). There was no difference in odds of mortality (OR 0.90 (95% CI 0.80 to 1.02)). Protocol/algorithm and multimodal interventions were associated with the greatest decreases in the primary outcome. There was high heterogeneity among estimates and evidence for publication bias. CONCLUSIONS: The literature examining the impact of interventions on RBC transfusions is extensive, although most studies are non-randomised. Despite this, pooled analysis of 33 studies revealed improvement in the primary outcome. Future work needs to shift from asking, 'does it work?' to 'what works best and at what cost?' PROSPERO REGISTRATION NUMBER: CRD42015024757.

Identifying the domains of context important to implementation science: a study protocol.

BACKGROUND: There is growing recognition that "context" can and does modify the effects of implementation interventions aimed at increasing healthcare professionals' use of research evidence in clinical practice. However, conceptual clarity about what exactly comprises "context" is lacking. The purpose of this research program is to develop, refine, and validate a framework that identifies the key domains of context (and their features) that can facilitate or hinder (1) healthcare professionals' use of evidence in clinical practice and (2) the effectiveness of implementation interventions. METHODS/DESIGN: A multi-phased investigation of context using mixed methods will be conducted. The first phase is a concept analysis of context using the Walker and Avant method to distinguish between the defining and irrelevant attributes of context. This phase will result in a preliminary framework for context that identifies its important domains and their features according to the published literature. The second phase is a secondary analysis of qualitative data from 13 studies of interviews with 312 healthcare professionals on the perceived barriers and enablers to their application of research evidence in clinical practice. These data will be analyzed inductively using constant comparative analysis. For the third phase, we will conduct semi-structured interviews with key health system stakeholders and change agents to elicit their knowledge and beliefs about the contextual features that influence the effectiveness of implementation interventions and healthcare professionals' use of evidence in clinical practice. Results from all three phases will be synthesized using a triangulation protocol to refine the context framework drawn from the concept analysis. The framework will then be assessed for content validity using an iterative Delphi approach with international experts (researchers and health system stakeholders/change agents). DISCUSSION: This research program will result in a framework that identifies the domains of context and their features that can facilitate or hinder: (1) healthcare professionals' use of evidence in clinical practice and (2) the effectiveness of implementation interventions. The framework will increase the conceptual clarity of the term "context" for advancing implementation science, improving healthcare professionals' use of evidence in clinical practice, and providing greater understanding of what interventions are likely to be effective in which contexts.

Understanding context in knowledge translation: a concept analysis study protocol.

AIM: To conduct a concept analysis of clinical practice contexts (work environments) that facilitate or militate against the uptake of research evidence by healthcare professionals in clinical practice. This will involve developing a clear definition of context by describing its features, domains and defining characteristics. BACKGROUND: The context where clinical care is delivered influences that care. While research shows that context is important to knowledge translation (implementation), we lack conceptual clarity on what is context, which contextual factors probably modify the effect of knowledge translation interventions (and hence should be considered when designing interventions) and which contextual factors themselves could be targeted as part of a knowledge translation intervention (context modification). DESIGN: Concept analysis. METHODS: The Walker and Avant concept analysis method, comprised of eight systematic steps, will be used: (1) concept selection; (2) determination of aims; (3) identification of uses of context; (4) determination of defining attributes of context; (5) identification/construction of a model case of context; (6) identification/construction of additional cases of context; (7) identification/construction of antecedents and consequences of context; and (8) definition of empirical referents of context. This study is funded by the Canadian Institutes of Health Research (January 2014). DISCUSSION: This study will result in a much needed framework of context for knowledge translation, which identifies specific elements that, if assessed and used to tailor knowledge translation activities, will result in increased research use by nurses and other healthcare professionals in clinical practice, ultimately leading to better patient care.

Outcomes of elderly survivors of intensive care: a review of the literature.

An increasing proportion of critically ill patients are elderly (ie, >or= 65 years of age). This poses complex challenges and choices for the management of elderly patients. Outcome following admission to the ICU has been traditionally concerned with mortality. Beyond mortality, outcomes such as functional status and health-related quality of life (HRQOL) have assumed greater importance. This article reviews the literature, published in English from 1990 to December 2003, pertaining to HRQOL and functional status outcomes of elderly patients. Functional status and HRQOL of elderly survivors of ICUs has been underinvestigated. There is no agreement as to the optimal instrument choice, and differences between studies preclude meaningful comparison or pooling of results.

A model for non-communicable disease surveillance in Canada: the prairie pilot diabetes surveillance system.

The Prairie Pilot Diabetes Surveillance Project was organized to design and test a prototype population-based surveillance system, using administrative data, for a chronic disease exemplar - diabetes mellitus. The Canadian model of a public health surveillance system for chronic conditions described here specifies a process by which administrative and claims data arising from provincial health insurance programs are merged into an annual person-level summary file (APLSF), yielding one summary record for each person insured within each province. The APLSF is the basis for a variety of estimates, including incidence, prevalence, mortality, complication rates and health services utilization. The model was used to produce comparable interprovincial estimates of several parameters with respect to diabetes for the entire population in the provinces of Alberta, Manitoba and Saskatchewan. All processing of identifiable health data occurred within the provinces where the data were generated. Combining results across provinces was based on further aggregation of the summary data from each province and not by pooling of identifiable person-level data. On the basis of preliminary outputs for diabetes mellitus, the model appears to provide coherent estimates of key diabetes parameters and reflects anticipated differences in health services and outcomes, by disease state. Three characteristics of the model recommend it as a resource for non-communicable disease surveillance in Canada: a) it maximizes the utility of existing data; b) it includes both those with and those without the disease in question; and c) it respects provincial legislation regarding personal health data, yet permits reporting of multi-provincial, population-based data.

Uptake of validated clinical practice guidelines: experience with implementing the Ottawa Ankle Rules.

This study examined whether emergency physicians (EPs) exposed to multiple dissemination strategies for the Ottawa Ankle Rules (OARs) would reduce extremity radiography use. We conducted a prospective cohort study comparing intervention (n = 2) with control (n = 2) hospitals over a 2-year period. All EPs received the paper-based rules during the run-in phase; EPs in the intervention hospitals were also subjected in sequence to valid dissemination approaches. Provincewide dissemination of the OARs did not decrease radiography during the run-in period (92% vs. 93%; P =.36). Sequential directed education and personalized feedback strategies failed to reduce radiographic ordering rates (P =.54) or the ordering of both foot and ankle radiographs (P =.11) over time. The use of radiography did not decrease despite the use of a variety of dissemination strategies. Additional research is required to determine the most effective methods of incorporating guidelines into emergency practice.

Incident cerebrovascular disease in rural and urban Alberta.

STUDY OBJECTIVE: This study examines the pattern of incidence and health service utilisation of cerebrovascular disease cases in urban and rural areas within a publicly funded health care system. DESIGN: A population-based study covering a large geographic region, using population-wide administrative health data. Age- and sex-standardised incidence and mortality rates were calculated for rural and urban areas. Final status (discharge or death), place of service and place of residence were reported for all cases across several different subsets of cerebrovascular disease. SETTING: The province of Alberta, located in western Canada. PARTICIPANTS: Incident cases of cerebrovascular disease (stroke and transient ischaemic attack) and 4 different definitions of incident stroke were identified from data on emergency department admissions in the 1999/2000 fiscal year. MAIN RESULTS: The rate of cerebrovascular disease per 10,000 was similar between urban (13.24) and rural (13.82) areas. Rural residents frequently reported their incident episode to urban emergency departments. Although the mortality is similar between urban and rural residents, rural dwellers die more frequently in the emergency department setting than urban dwellers, who die more often as in-patients. CONCLUSIONS: Overall mortality is similar between urban and rural residents. A large proportion of rural residents receive diagnoses and treatment for cerebrovascular disease in urban areas. Location of service and location of death differs between rural and urban cases of cerebrovascular disease.

Regional comparisons of inpatient and outpatient patterns of cerebrovascular disease diagnosis in the province of Alberta.

The diagnosis of cerebrovascular disease (CBVD) from administrative data has been critically examined by epidemiologists in recent years. Much of the existing literature suggests that hospital discharge diagnoses based on ICD-9-CM codes are an unreliable source of information for determining a diagnosis of stroke, particularly when four- and five-digit codes are used. We examined how diagnoses for CBVD in hospital inpatient and outpatient facilities vary between rural and urban areas and among the 16 administrative health regions. Our analysis revealed differences in diagnostic patterns between the two sources of data, differences between rural and urban areas, and variation across most of the regions. Geographic variation in health service utilization, diagnostic practices, specialty of the physician making the diagnosis, and disease burden may explain our findings. Our results suggest that the diagnosis of patients attending rural facilities are either coded differently (and less precisely) than those of urban residents or are coded more precisely only after the patients attend urban facilities. Regional differences in coding practices show that any CBVD surveillance system based on administrative data requires a large-scale (in this case, province-wide) and person-oriented approach.