Disordered gambling among higher-frequency gamblers: who is at risk?

BACKGROUND: When gambling opportunities are made available to the public in a given jurisdiction, some individuals participate occasionally and others more frequently. Among frequent gamblers, some individuals develop problematic involvement and some do not. This study addresses the association among demographic and social risk factors, frequency of gambling and gambling disorders. METHOD: Data from an adult community sample (n=1372) were used to identify risk factors for higher-frequency gambling and disordered gambling involvement. RESULTS: Individuals with higher intelligence, older individuals and more religious individuals were less frequent gamblers. Males, single individuals and those exposed to gambling environments (friends and family who gamble) and those who started to gamble at a younger age were more frequent gamblers. Excitement-seeking personality traits were also higher among more frequent gamblers. A different set of risk factors was associated with the likelihood of gambling disorder among these higher-frequency gamblers. These variables included mental health indicators, childhood maltreatment and parental gambling involvement. Among higher-frequency gamblers, individuals who smoke cigarettes, those with a diagnosis of alcohol or drug dependence or obsessive-compulsive disorder, those with higher anxiety or depression and those with higher impulsivity and antisocial personality traits were more likely to report gambling-related problems. These individuals were also more likely to report gambling on electronic gambling machines (e.g. slot machines). CONCLUSIONS: These data suggest a model in which higher-frequency gambling, particularly with electronic gambling machines, when combined with any type of emotional vulnerability increased the likelihood of gambling disorder.

Using administrative data to understand the geography of case ascertainment.

We examined the geographic variability of information generated from different case definitions of childhood asthma derived from administrative health data used in Alberta, Canada. Our objective was to determine if analyses based on different case ascertainment algorithms identify geographic clusters in the same region of the study area. Our study group was based on a closed cohort of asthmatic children born in 1988. We used a spatial scan statistic to identify variations in the approximate location of geographic clusters of asthma based on different case definitions. Our results indicate that the geographic patterns are not greatly affected by the case ascertainment algorithm or the source of data. For example, asthmatics identified from medical claims data showed similar clustering to asthmatics defined through hospitalization and emergency department data. However, estimates of prevalence and incidence require careful consideration and validation against other data sources.

Health disparities in chickenpox or shingles in Alberta?

OBJECTIVE: Exploring for evidence of socio-economic health disparities in chickenpox and shingles in Alberta, Canada. METHODS: Chickenpox and shingles cases were identified from administrative data from Alberta's universal health care insurance system for 1994-2002. Incident cases were those with the earliest dated utilization of a health service (chickenpox: ICD9-CM 052/ICD10-CA B01; shingles: ICD9-CM 053/ ICD10-CA B02). Crude and age-specific rates were estimated for each year by an indicator of socio-demographic status based upon the nature of the payer and eligibility for health care premium subsidy (SES-proxy) for the provincial health care insurance system. RESULTS: Among young children there is a gradient of disparity in chickenpox rates prior to the year in which publicly funded vaccination programs were implemented. After this point, disparities decline but less so for First Nations children than for others. There was no evidence of disparity by SES-proxy for shingles. CONCLUSION: Publicly funded vaccination programs may effectively contribute to reduction in disease disparities for vaccine-preventable diseases. Further study is required to ascertain why disparities continue for First Nations children.

Prevalence of mental disorders in children living in Alberta, Canada, as determined from physician billing data.

BACKGROUND: The prevalence of mental disorders is often assessed using survey techniques. Although providing good estimates of prevalence, these techniques are time-consuming and expensive. OBJECTIVE: To estimate the prevalence of mental disorders among children aged 0 to 17 years living in Alberta, Canada, using health care administrative data. DESIGN: This was a cross-sectional study. International Classification of Diseases, Ninth Revision, Clinical Modification chapter 5 diagnostic codes from physician billing data were used. Codes were grouped into 10 categories. Prevalence rates for each category were calculated, stratified by age, sex, and premium subsidy status (a proxy for socioeconomic status). The age pattern, times of greatest risk, and the effect of sex on type and prevalence of mental disorder were estimated. SETTING: All fee-for-service health care venues in Alberta between April 1, 1995, and March 31, 1996, providing services to children registered with the Alberta Health Care Insurance Commission on March 31, 1996. RESULTS: Prevalence of mental disorders varied by disorder category, age, sex, and premium subsidy status. For boys, maximum prevalence of 9.5% occurred at age 10 years; for girls, maximum prevalence of 12.0% occurred at age 17 years. Mental disorders were most common in young boys and adolescent girls and among children receiving welfare. Distinct patterns of disorder were evident and comorbidity was common. CONCLUSIONS: Administrative data can be used to estimate the prevalence of mental disorders in a pediatric population. The estimates made are lower than those obtained by using surveys of similar populations, perhaps indicating the difference between treated and untreated prevalence. Strengths of this study are that the estimates reflect the entire population, are more easily and obtained at less cost, and are useful for the planning of mental health services.

Between intention and behavior: an application of community pharmacists' assessment of pharmaceutical care.

A new practice philosophy for pharmacists, pharmaceutical care, encourages pharmacists to ensure that medication-related health outcomes are optimized. However, its adoption by community pharmacists has been slow due to numerous barriers including the economic structure of retail pharmacy, interprofessional conflicts, information limitations, gaps in pharmacy training and uneven patient demand. The specific study objectives were to (1) describe self-efficacy, beliefs, evaluations and perceived behavioral control in the provision of pharmaceutical care, (2) quantify intention and behavior to provide pharmaceutical care in a period of two weeks and (3) examine the relationships between intention and behavior. A 20% sample of Alberta community pharmacists received an attitude survey followed in two weeks by a behavior survey. Both surveys were developed for this study. Of the 320 pharmacists receiving the attitude survey, 230 completed surveys were obtained (71.9%). The behavior survey was received from 182 of those completing the attitude survey (79.1%). A causal model was constructed predicting pharmaceutical care behavior/s from pharmacists' self-efficacy, beliefs, evaluations and behavioral control. Behavioral control exerted its effect upon behavior via three pathways and its direct effect on belief was strongest. The only direct predictor of behavior was self-efficacy. The chi2 measure indicated that the model was not a perfect fit (chi2 = 99.24, df = 67, p<0.006), but the goodness of fit index (0.931), adjusted goodness of fit index (0.876), and root mean squared error (0.067) fall within acceptable ranges. Thus, it appears that pharmaceutical care implementation programs which address individual factors singly in providing pharmaceutical care will not be successful. The control pharmacists' perceive over their patient care behaviors in their practice environment is critical. Programs which help pharmacists assess their work environment and determine strategies to impact or reconstruct their environments are required.

Secular trends in the epidemiology of shingles in Alberta.

Varicella vaccine was licensed in Canada in 1998, and a publicly funded vaccination programme introduced in the province of Alberta in 2001. In theory the vaccination programme might increase the burden of disease from shingles, making it important to develop baseline data against which future comparisons can be made. The study's aim was to describe the epidemiology of non-fatal cases of shingles for which publicly funded health services were utilized for the period 1986-2002. Shingles cases were identified from the records of Alberta's universal, publicly funded health-care insurance system for 1986-2002. The earliest dated health service utilizations for ICD-9-CM codes of 053 or ICD-10-CA codes of B02 were classified as incident. Diagnostic codes at least 180 days after the first were classified as recurrent episodes. Denominators for rates were estimated using mid-year population estimates from the Alberta Health Care Insurance Plan Registry. Annual age- and sex-specific rates were estimated. We explored the pattern of rates for sex, age and year effects and their interactions. Shingles rates increased between 1986 and 2002. There was a sex effect and evidence of an age-sex interaction. Females had higher rates than males at every age; however, the difference between females and males was greatest for the 50-54 years age group and declined for older age groups. The increased rate of shingles in Alberta began before varicella vaccine was licensed or publicly funded in Alberta, and thus cannot be attributed to vaccination.

Pain, medication, and injury in older farmers.

BACKGROUND: Agricultural work continues to be a dangerous occupation. Older farmers experience high risks for work-related injury. The purpose of this research was to determine if there is a relationship between medication use and injury among older male farmers in Alberta. METHODS: Using probabilistic linkage between an Alberta Agriculture government registry of farm operators and the Alberta Health Plan registry file, older farmers (aged 66 and older) were identified. Farm related injuries were identified using an E-code search of both hospitalization and emergency department separations for a 3-year period. Cases were matched to controls on age, geographic health region, and index injury date at a ratio of 1:5. Co-morbidity and medication use for each of the cases and controls were derived from population based health system utilization files. Conditional logistic regression was used to determine which medications were related to injury. RESULTS: Overall, a total of 282 farm related injuries were suffered by the linked group. Controlling for co-morbidity, farmers who had stopped taking narcotic pain killers (OR = 9.37 [95% CI:4.95, 17.72]) and non-steroidal anti-inflammatories (OR = 2.40 [95% CI:1.43, 4.03]) 30 days prior to the date of injury were at risk of injury. Those farmers taking sedatives up until the date of injury were also at risk (OR = 3.01 [95 CI:1.39, 6.52]). In addition, those suffering from incontinence/urinary tract disorders (OR = 2.95 [95% CI:1.30, 6.71]), and prior injury (OR = 1.42 [95% CI:1.04, 1.95]) were also at greater risk of injury. CONCLUSIONS: The relationship of medication use and injury in this population is different from those observed in studies of falls in older persons. We hypothesize that distraction from either pain or co-morbidity may play an important role in the etiology of injuries suffered in this active older working population. Further investigations in this area are required to confirm these findings.

The changing epidemiology of chickenpox in Alberta.

BACKGROUND: Varicella vaccine was licensed in Canada in 1998. The province of Alberta introduced a universal publicly funded varicella vaccination program in 2001. PURPOSE: To describe the epidemiology of non-fatal cases of chickenpox for which publicly funded health services were utilized for the period 1986-2002. METHODS: We used the records of Alberta's universal, publicly funded health care insurance system to identify cases of chickenpox for the period 1986-2002. The earliest dated utilization of a health service for which there was an ICD9-CM code of 052.xx or an IC10-CA code of B01.xx was used as the date of illness onset. Denominators for rates were estimated using mid-year population estimates from the Alberta Health Care Insurance Registry. Age-specific rates were estimated for each year. RESULTS: The crude incidence of chickenpox significantly declined over the period 1994-2002, most steeply after the year 2000. The incidence of chickenpox varied by age group and year and there was evidence of age-group-year interaction. Among those aged 5-19 years, chickenpox incidence began to decline prior to vaccine licensure in Canada. Among those aged less than one year and those aged 1-4 years, the incidence increased until 1999 when a decline began. Over the period 0.8% of cases were hospitalized. CONCLUSION: Chickenpox rates began to decline prior to the introduction of the publicly funded vaccination program; however the declines in rates among the youngest age-groups are consistent with a vaccination program effect.

Doctors, patients and influenza-like illness: clinicians or patients at risk?

BACKGROUND: Healthcare providers can transmit influenza and influenza-like illness (ILI) to patients and vice versa. However, the magnitude of this problem in the healthcare system as a whole is unknown. Using population-based administrative health data, we tested the hypothesis of a temporal association of ILI diagnosis among clinicians and their patients. METHODS: Healthcare providers under study included physicians (85%) and a variety of other medical professionals (such as chiropractors, dentists and optometrists). Cases of ILI were defined as having an ICD-9 code of influenza (487), pneumonia (480-486) or bronchitis (466 and 490) in a province-wide healthcare-provider billing system. Rates of ILI among persons who saw a sick (case) and non-sick (control) doctor were calculated and compared. RESULTS: The rate of ILI was lower among providers than among patients for every year of the study. The mean number of exposures to patients diagnosed with ILI was higher among case providers than among control providers (P = 0.044). However, exposure to case providers did not significantly increase the risk of ILI diagnosis among patients (OR=1.11; 95% confidence intervals 0.85-1.36). INTERPRETATION: Our findings are consistent with the hypothesis of patient-to-provider transmission. However, we may have underestimated the association and magnitude of this effect. Our results do not support the hypothesis that infectious doctors transmit disease to their patients, although this may be partly accounted for by the lower rates of ILI among the provider population in general.

The high risk of stroke immediately after transient ischemic attack: a population-based study.

BACKGROUND: The risk of stroke is elevated in the first 48 hours after TIA. Previous prognostic models suggest that diabetes mellitus, age, and clinical symptomatology predict stroke. The authors evaluated the magnitude of risk of stroke and predictors of stroke after TIA in an entire population over time. METHODS: Administrative data from four different databases were used to define TIA and stroke for the entire province of Alberta for the fiscal year (April 1999-March 2000). The age-adjusted incidence of TIA was estimated using direct standardization to the 1996 Canadian population. The risk of stroke after a diagnosis of TIA in an Alberta emergency room was defined using a Kaplan-Meier survival function. Cox proportional hazards modeling was used to develop adjusted risk estimates. Risk assessment began 24 hours after presentation and therefore the risk of stroke in the first few hours after TIA is not captured by our approach. RESULTS: TIA was reported among 2,285 patients for an emergency room diagnosed, age-adjusted incidence of 68.2 per 100,000 population (95% CI 65.3 to 70.9). The risk of stroke after TIA was 9.5% (95% CI 8.3 to 10.7) at 90 days and 14.5% (95% CI 12.8 to 16.2) at 1 year. The risk of combined stroke, myocardial infarction, or death was 21.8% (95% CI 20.0 to 23.6) at 1 year. Hypertension, diabetes mellitus, and older age predicted stroke at 1 year but not earlier. CONCLUSIONS: Although stroke is common after TIA, the early risk is not predicted by clinical and demographic factors. Validated models to identify which patients require urgent intervention are needed.

Tools used to help community pharmacists implement comprehensive pharmaceutical care.

OBJECTIVE: To describe the tools and processes used in the practice enhancement program (PEP) of the Pharmaceutical Care Research and Education Project to enable community pharmacists to acquire the necessary skills, knowledge, and attitudes to deliver comprehensive pharmaceutical care to elderly ambulatory patients. SETTING: Independent community pharmacies in Alberta. PRACTICE DESCRIPTION: The PEP was designed to allow self-directed learning in a problem-based environment. The intent was for pharmacists to apply the knowledge they gained to improve drug therapy outcomes. PRACTICE INNOVATION: As a systematic approach to providing care, several tools were adapted to help pharmacists execute tasks required by the nine steps of the pharmaceutical care process proposed by Helper and Strand. These tools and processes facilitated (1) self-directed learning about diseases and drugs, (2) acquisition of relevant patient data, (3) a consistent and stepwise approach to the identification and resolution of drug-related problems, (4) documentation of care provided, and (5) continuity of care. RESULTS: To help pharmacists in the PEP acquire the necessary competency to provide pharmaceutical care, they were required to use the tools and processes described herein to work up and resolve patient problems. Initially, patient problems were presented as paper cases covering a range of acute and chronic problems, including topics applicable to geriatric patients. This was followed by a practicum phase wherein patient problems represented individuals from among their clientele. CONCLUSION: The tools and processes used in the project increased community pharmacists' competency for providing pharmaceutical care, by helping them develop the needed skills, knowledge, and attitudes.

Utilization of health services following spinal cord injury: a 6-year follow-up study.

STUDY DESIGN: Cohort study with 6-years follow-up. OBJECTIVE: To describe the utilization of health services by persons with spinal cord injury (SCI) and compare it with that of the general population. SETTING: Alberta, Canada. METHODS: All persons who sustained an SCI in Alberta between April 1992 and March 1994 were followed from date of injury to 6 years postinjury. Cases were matched (1:5) with controls randomly selected from the general population and matched for age, gender, and region of residence. Administrative data from centralized health care databases were compiled to provide a complete picture of health care use, including hospitalizations, physician contacts, long-term care admissions, home care services, and the occurrence of secondary complications. RESULTS: In all, 233 individuals with SCI and 1165 matched controls were followed for 6 years. Compared with the control group, persons with SCI were rehospitalized 2.6 times more often, spent 3.3 more days in hospital, were 2.7 times more likely to have a physician contact, and required 30 times more hours of home care services. Of those with SCI, 47.6% were treated for a urinary tract infection, 33.8% for pneumonia, 27.5% for depression, and 19.7% for decubitus ulcer. CONCLUSION: SCI places a heavy burden on the health care system. Persons with SCI have greater rates of contact with the health system compared with the general population. Secondary complications continue to affect persons with SCI long after the acute trauma.