Using administrative data to measure the extent to which practitioners work together: "interconnected" care is common in a large cohort of family physicians.

BACKGROUND: Health care practitioners in jurisdictions around the world are encouraged to work in groups. The extent to which they actually do so, however, is not often measured. The purpose of this paper is to demonstrate the potential for administrative data to measure how practitioners are interconnected through their care of patients. Our example examined the interconnected care provided by family physicians. METHODS: We defined a physician as being "interconnected" with another physician if these 2 physicians provided at least 1% of their clinic visits over a 2-year period to the same patients. We examined a cohort of 2945 primary care physicians in 309 Family Health Networks and Family Health Groups in Ontario, Canada, in 2005/06. In total, 9.3 million physician visits for 2.1 million patients were studied. For each group practice we calculated the number of interconnected physicians. RESULTS: Physicians had, on average, 2.2 interconnected physician partners (median=1; 25th and 75th percentile: 0, 3). Physicians saw mainly their own listed patients, and 7.9% (median=5.9%; 25th and 75th percentile: 2.4%, 11.6%) of their visits were provided to patients of their interconnected partners. The number of interconnected physicians was higher in group practices that had more physicians, but levelled to 2.5 interconnected physicians in practices with 8 or 9 physicians. INTERPRETATION: Routinely collected administrative data can be used to examine how health care is organized and delivered in groups or networks of practitioners. This study's concept of interconnected care provided by primary care physicians within groups could be expanded to include other practitioners and, indeed, entire health care systems using more complex network analysis methods.

Predictors of universal influenza vaccination uptake in grades 1 and 2 Toronto school children: effective vaccination strategies should not end with at risk children.

The first population-based survey to determine predictors of influenza vaccination among children in a major metropolitan city with access to publicly funded health care and a universal influenza immunization program (UIIP). Previously collected demographic and health related data from 5619 school children aged 5-9 in Toronto, in 2006 were used to predict influenza vaccination. Vaccination was more likely in children with current asthma (OR 1.44, 95%CL 1.19-1.75), a high volume of contacts with a health service provider (OR 1.37, 95%CL 1.14-1.65), foreign born children (OR 1.20, 95%CL 1.01-1.42) and those with the lowest income adequacy (OR 1.37, 95%CL 1.12-1.68). Data from this study will be helpful in designing future influenza vaccination strategies to improve vaccination rates in the entire population.

School-based influenza vaccine delivery, vaccination rates, and healthcare use in the context of a universal influenza immunization program: an ecological study.

Influenza vaccines are universally funded in Ontario, Canada. Some public health units (PHUs) vaccinate children in schools. We examined the impact of school-based delivery on vaccination rates and healthcare use of the entire population over seven influenza seasons (2000-2007) using population-based survey and health administrative data. School-based vaccination was associated with higher vaccination rates in school-age children only. Doctors' office visits were lower for PHUs with school-based vaccination for children aged 12-19 but not for other age groups. Emergency department use and hospitalizations were similar between the two groups. In the context of universal influenza vaccination, school-based delivery is associated with higher vaccination rates and modest reductions in healthcare use in school-age children.

The effect of universal influenza immunization on antibiotic prescriptions: an ecological study.

The Canadian province of Ontario introduced universal influenza immunization in 2000, offering free vaccines to the entire population. We compared changes in rates of influenza-associated respiratory antibiotic prescriptions before and after universal immunization in Ontario with corresponding changes in other provinces. Universal influenza immunization is associated with reduced influenza-associated antibiotic prescriptions.

Influenza vaccination rates in Ontario children: implications for universal childhood vaccination policy.

The aims of this study were to estimate influenza vaccination coverage for children during the 2006-2007 influenza season in Ontario, Canada, where universal vaccination is available, and to compare the rate among children aged 6-23 months with corresponding rates from other Canadian provinces that specifically target this high-risk group. We conducted a telephone survey of caregivers of children aged 6 months-11 years that included 4854 children from 3029 households. Ontario's vaccination rate (complete and partial coverage combined) for children aged 2-11 years was 28.3% (95% CI 26.3-30.5%) for healthy children and 36.8% (95% CI 31.4-42.5%) for those with chronic conditions. Immunization coverage of children aged 6-23 months was 24.0% (95% CI 20.6-27.7%) in Ontario, similar to Manitoba's rate of 24.1% but lower than rates in other provinces: Nova Scotia (35.5%), Quebec (41.8% for 1 year olds and 37.7% for 2 year olds during the 2005-2006 season), Saskatchewan (32.5%) and Alberta (52.2%). Universal vaccination in Ontario has achieved modest coverage in children aged 2-11 years, but has been less successful than targeted programs in vaccinating infants aged 6-23 months.

Financial and work satisfaction: impacts of participation in primary care reform on physicians in ontario.

Governments in Ontario have promised family physicians (FPs) that participation in primary care reform would be financially as well as professionally rewarding. We compared work satisfaction, incomes and work patterns of FPs practising in different models to determine whether the predicted benefits to physicians really materialized. Study participants included 332 FPs in Ontario practising in five models of care. The study combined self-reported survey data with administrative data from ICES and income data from the Canada Revenue Agency. FPs working in non-fee-for-service (FFS) models had higher levels of work satisfaction than those in FFS models. Incomes were similar across groups prior to the advent of primary care reform. Incomes of family health network FPs rose by about 30%, while family health group FPs saw increases of about 10% and those in FFS experienced minimal changes or decreases. Self-reported change in income was not reliable, with only 47% of physicians correctly identifying whether their income remained stable, increased or decreased. The availability of a variety of FFS- and non-FFS-based payment options, each designed to accommodate physicians with different types or styles of practice, may be a useful tool for governments as they grapple with issues of physician recruitment and retention.

Chronic disease risk factors associated with health service use in the elderly.

BACKGROUND: To examine the association between number and combination of chronic disease risk factors on health service use. METHODS: Data from the 1995 Nova Scotia Health Survey (n = 2,653) was linked to provincial health services administrative databases. Multivariate regression models were developed that included important interactions between risk factors and were stratified by sex and at age 50. Negative-binomial regression models were estimated using generalized estimating equations assuming an autoregressive covariance structure. RESULTS: As the number of chronic disease risk factors increased so did the number of annual general practitioner visits, specialist visits and days spent in hospital in people aged 50 and older. This was not seen among individuals under age 50. Comparison of smokers, people with high blood pressure and people with high cholesterol showed no significantly different impact on health service use. CONCLUSION: As the number of chronic disease risk factors increased so did health service use among individuals over age 50 but risk factor combination had no impact.

The 2006 Canadian dyslipidemia guidelines will prevent more deaths while treating fewer people--but should they be further modified?

BACKGROUND: When clinical guidelines affect large numbers of individuals or substantial resources, it is important to understand their benefits, harms and costs from a population perspective. Many countries' dyslipidemia guidelines include these perspectives. OBJECTIVE: To compare the effectiveness and efficiency of the 2003 and 2006 Canadian dyslipidemia guidelines for statin treatment in reducing deaths from coronary artery disease (CAD) in the Canadian population. METHODS: The 2003 and 2006 Canadian dyslipidemia guidelines were applied to data from the Canadian Heart Health Survey (weighted sample of 12,300,000 people), which includes information on family history and physical measurements, including fasting lipid profiles. The number of people recommended for statin treatment, the potential number of CAD deaths avoided and the number needed to treat to avoid one CAD death with five years of statin therapy were determined for each guideline. RESULTS: Compared with the 2003 guidelines, 1.4% fewer people (20 to 74 years of age) are recommended statin treatment, potentially preventing 7% more CAD deaths. The number needed to treat to prevent one CAD death over five years decreased from 172 (2003 guideline) to 147 (2006 guideline). CONCLUSIONS: From a population perspective, the 2006 Canadian dyslipidemia recommendations are an improvement of earlier versions, preventing more CAD events and deaths with fewer statin prescriptions. Despite these improvements, the Canadian dyslipidemia recommendations should explicitly address issues of absolute benefit and cost-effectiveness in future revisions.

Inequitable access for mentally ill patients to some medically necessary procedures.

BACKGROUND: Although universal health care aims for equity in service delivery, socioeconomic status still affects death rates from ischemic heart disease and stroke as well as access to revascularization procedures. We investigated whether psychiatric status is associated with a similar pattern of increased mortality but reduced access to procedures. We measured the associations between mental illness, death, hospital admissions and specialized or revascularization procedures for circulatory disease (including ischemic heart disease and stroke) for all patients in contact with psychiatric services and primary care across Nova Scotia. METHODS: We carried out a population-based record-linkage analysis of related data from 1995 through 2001 using an inception cohort to calculate rate ratios compared with the general public for each outcome (n = 215,889). Data came from Nova Scotia's Mental Health Outpatient Information System, physician billings, hospital discharge abstracts and vital statistics. We estimated patients' income levels from the median incomes of their residential neighbourhoods, as determined in Canada's 1996 census. RESULTS: The rate ratio for death of psychiatric patients was significantly increased (1.34), even after adjusting for potential confounders, including income and comorbidity (95% confidence interval [CI] 1.29-1.40), which was reflected in the adjusted rate ratio for first admissions (1.70, 95% CI 1.67-1.72). Their chances of receiving a procedure, however, did not match this increased risk. In some cases, psychiatric patients were significantly less likely to undergo specialized or revascularization procedures, especially those who had ever been psychiatric inpatients. In the latter case, adjusted rate ratios for cardiac catheterization, percutaneous transluminal coronary angioplasty and coronary artery bypass grafts were 0.41, 0.22 and 0.34, respectively, in spite of psychiatric inpatients' increased risk of death. CONCLUSIONS: Psychiatric status affects survival with and access to some procedures for circulatory disease, even in a universal health care system that is free at the point of delivery. Understanding how these disparities come about and how to reduce them should be a priority for future research.

Mortality in individuals who have had psychiatric treatment: population-based study in Nova Scotia.

BACKGROUND: Most studies of mortality in psychiatric patients have investigated in-patients rather than those attending out-patient clinics or primary care, where most receive treatment. AIMS: To evaluate the mortality risk in mental illness for patients in contact with psychiatric services or primary care (n=221 048) across Nova Scotia (population 936 025). METHOD: A population-based record-linkage analysis was made of the period 1995-2000, using an inception cohort to calculate mortality rate ratios. RESULTS: The mortality rate was 1.74, with increased ratios for all major causes of death. Male mortality was almost double that of females after controlling for demographic factors, treatment setting and place of residence. Patients of lower income, in specialist psychiatric settings, and with dementia or psychoses were also at greater risk. However, in absolute numbers, 72% of deaths occurred in patients who had only seen their general practitioner. CONCLUSIONS: Mortality risk is increased in all psychiatric patients, not just those who have received in-patient treatment.