Guttmann A, Nakhla M, Henderson M, To T, Daneman D, Cauch‐Dudek K, Wang X, Lam K, Hux J. Validation of a health administrative data algorithm for assessing the epidemiology of diabetes in Canadian ...children.
Objective: To validate a case definition of pediatric diabetes using administrative health data and describe trends in incidence and prevalence over time in Ontario, Canada.
Methods: We sampled hospital records of 700 children from 1994 to 2003 with a prior history of at least one outpatient or hospital record for diabetes mellitus and 300 randomly selected children with no diabetes records. We defined patients as having diabetes based on diagnoses and drug utilization from chart ion and compared sensitivity and specificity of a number of combinations of overall health care use using administrative data to develop a highly specific definition. We used Poisson regression to test changes in incidence over time (1994–2003).
Results: Use of four physician claims and no hospital records over a 2‐yr period yielded the most specific definition (83% sensitivity, 99% specificity). Using this definition overall age/sex standardized incidence per 100 000 was 32.3 95% confidence intervals (CI) 30.4, 34.4 and prevalence 241.5 per 100 000 (95% CI 236.2–249.9) in 2003/2004. Overall incidence differs by age, (peaking in 10–14 yr olds) but not significantly by sex. The overall incidence has increased on average by 3.1% per year since 1994 (95% CI 1.02–1.04), with no difference in the rate of increase by age.
Conclusions: Population‐based surveillance of diabetes in children is possible using administrative data. This will facilitate further study of trends in incidence but also in use of health services and outcomes. Further work to differentiate type 1 and 2 diabetes will be important.
Patients newly-diagnosed with diabetes require self-management education to help them understand and manage the disease. The goals of the study were to determine the frequency of diabetes ...self-management education program utilization by newly-diagnosed patients, and to evaluate whether there were any demographic or clinical disparities in utilization.
Using population-level health care data, all 46,553 adults who were diagnosed with any type of non-gestational diabetes in Ontario, Canada between January and June 2006 were identified. They were linked with a diabetes self-management education program registry to identify those who attended within 6 months of diagnosis. The demographic and clinical characteristics of attendees and non-attendees were compared.
A total of 9,568 (20.6%) patients attended a diabetes self-management education program within 6 months of diagnosis. Younger age, increasing socioeconomic status, and the absence of mental health conditions or other medical comorbidity were associated with attendance. Patients living in rural areas, where access to physicians may be limited, were markedly more likely to attend. Recent immigrants were 40% less likely to attend self-management education programs than longer-term immigrants or nonimmigrants.
Only one in five newly-diagnosed diabetes patients attended a diabetes self-management education program. Demographic and clinical disparities in utilization persisted despite a publicly-funded health care system where patients could access these services without direct charges. Primary care providers and education programs must ensure that more newly-diagnosed diabetes patients receive self-management education, particularly those who are older, poorer, sicker, or recent immigrants.
Ursodeoxycholic acid, a dihydroxyl bile acid normally present in human beings in minimal amounts, becomes incorporated into the bile salt pool when taken orally. In cholestasis, bile acids are ...retained in the liver and are hepatotoxic. Ursodeoxycholic acid is the least‐known hepatotoxic bile acid, has choleretic properties and is reported to benefit patients with chronic cholestasis. In a nationwide Canadian controlled trial, 222 patients with primary biliary cirrhosis were treated with ursodeoxycholic acid (14 mg/kg/body wt/day) or placebo for 24 mo. Only patients with a diagnosis confirmed by liver biopsy and serum positive for antimitochondrial antibodies were enrolled; 88% were symptomatic on entry. The primary outcome measure was percent change in total serum bilirubin from baseline to final follow‐up. Treated patients (111) and controls (111) were comparable with regard to age, gender, biochemical parameters and liver histological condition. Although treatment was not associated with any improvement in symptoms, ursodeoxycholic acid therapy caused the bilirubin to fall significantly within the first 3 mo of therapy (p<0.001). Significant falls in serum alkaline phosphatase, aminotransferases, cholesterol and IgM levels were also noted in the treated group. Improvement in some histological features was observed but there was no difference between the groups in the number of patients who reached the endpoints of death or liver transplantation. Ursodeoxycholic acid, given to patients with primary biliary cirrhosis, leads to an improvement in serum markers of cholestasis. A larger sample size is needed to determine whether ursodeoxycholic acid therapy has a beneficial effect on the survival of patients with primary biliary cirrhosis. (HEPATOLOGY 1994;19:1149–1156.)
Rationale, aims and objectives
The efficacy of diabetes self‐management education on glycaemic control, self‐care behaviour and knowledge has been established by short‐term studies in experimental ...settings. The objective of this study was to assess its effectiveness to improve quality of care and reduce the risk of long‐term diabetes complications in unselected older patients with recently diagnosed diabetes in routine clinical care.
Methods
Using population‐level health care administrative databases and registries, all patients aged ≥66 years in Ontario, Canada with diabetes for <5 years were identified. Self‐management education programme attendees (n = 8485) in 2006 were matched with non‐attendees using high‐dimensional propensity scores, creating extremely well‐balanced study arms. Quality of care measures and the long‐term risk of diabetes complications were compared.
Results
Self‐management programme attendees were more likely than non‐attendees to achieve process measures of quality of care such as retinal screening examinations (75.3% versus 70.3%, adjusted relative risk 1.05, 99% confidence interval 1.03–1.08), and ≥2 glycated haemoglobin tests (57.5% versus 53.3%, adjusted relative risk 1.08, 99% confidence interval 1.05–1.11). However, with a median follow‐up of 5.3 years, diabetes complications and mortality were not different between arms.
Conclusions
In real‐world clinical care, self‐management education for older patients with recently diagnosed diabetes was associated with modest improvements in quality of care, but no reductions in long‐term clinical events.
OBJECTIVE:Self-management education, supported by multidisciplinary health care teams, is essential for optimal diabetes management. We sought to determine whether acute diabetes complications or ...quality of care differed for patients in routine clinical care when their self-management education was delivered through group diabetes education classes versus individual counselling.
METHODS:With the use of population-level administrative and primary data, all diabetic patients in Ontario who attended a self-management education program in 2006 were identified and grouped according to whether they attended group classes (n=12,234), individual counselling (n=55,761) or a mixture of both (n=9,829). Acute complications and quality of care in the following year were compared among groups.
RESULTS:Compared with those attending individual counselling, patients who attended group classes were less likely to have emergency department visits for hypo/hyperglycemia (odds ratio 0.54, 95% confidence interval CI: 0.42–0.68), hypo/hyperglycemia hospitalizations (OR 0.49, CI: 0.32–0.75) or foot ulcers/cellulitis (OR 0.64, CI: 0.50–0.81). They were more likely to have adequate HbA1c testing (OR 1.10, CI: 1.05–1.15) and lipid testing (OR 1.25, CI: 1.19–1.32), and were more likely to receive statins (OR 1.22, CI: 1.07–1.39).
CONCLUSION:Group self-management education was associated with fewer acute complications and some improvements in processes of care. Group sessions can offer care to more patients with reduced human resource requirements. With increased pressure to find efficiencies in health care delivery, group diabetes education may provide an opportunity to deliver less resource-intensive care that simultaneously improves patient care.
Patients with primary biliary cirrhosis (PBC) may have additional features of autoimmune hepatitis (AIH). Corticosteroids usually contraindicated in PBC have been advocated for these patients. ...Patients with antimitochondrial antibody (AMA)-positive PBC from two previous randomized, controlled trials were assessed for features of AIH. Their biochemical, immunologic, and histologic responses to ursodeoxycholic acid (UDCA) versus placebo were compared with those without AIH features. The survival of patients testing positive or negative for antinuclear antibodies (ANA) was also examined. Features of AIH were defined by the presence of 2 or more of the following: 1) alanine transaminase (ALT) > 5× the upper limit of normal (ULN); 2) immunoglobulin G (IgG) > 2× ULN or positive anti-smooth muscle antibody (ASMA); and 3) moderate to severe lobular inflammation on pretreatment liver biopsy. Testing for AMA, ASMA, and ANA was done by immunofluorescence. The change in serum bilirubin, alkaline phosphatase (ALP), transaminases, IgM, and IgG from baseline to 2 years was compared. Of the 331 patients randomized, 16 (4.8%) had features of AIH (12 UDCA, 4 placebo). The median percent change in serum biochemistry and immunoglobulin values were similar in patients with PBC ± features of AIH after 2 years of therapy with UDCA. Over 2 years, little change in histologic features of AIH was observed. Survival was similar for patients with PBC with and without ANA. In conclusion, features of AIH in PBC may be transient and response to UDCA therapy similar to patients with PBC without features of AIH. (HEPATOLOGY .)
To determine primary care physician screening, treatment, and control rates for hypertension and to examine whether type of physician payment model affected these rates.
A cross-sectional chart ...abstraction study.
Community health centres (salary), primary care networks (capitation), or traditional fee-for-service practices in Ontario.
A total of 135 primary care physicians, 45 from each of the 3 different models of care. Data were abstracted from 28 adult patient charts randomly selected from each physician.
Screening rates were based on the presence of at least 1 blood pressure reading in the past 3 years, treatment rates on the number of patients with hypertension treated with antihypertensive medication, and control rates on the number of patients with hypertension whose most recent blood pressure readings were below 140/90 mm Hg, below 130/80 mm Hg for patients with diabetes, or below 120/75 mm Hg for patients with renal disease.
Overall, 92.5% of all patients were screened for hypertension, 86.4% of patients with hypertension were treated with antihypertensive medications, and 44.9% of patients with hypertension had their blood pressure controlled. Mean screening rates were 90.6%, 93.5%, and 93.3% (P = .22), and after adjusting for sociodemographic factors and comorbid conditions, mean treatment rates were 90.9%, 81.0%, and 87.4% (P < .05) and mean control rates were 54.5%, 38.6%, and 41.6% (P < .05) for capitation, salary, and fee-for-service physicians, respectively.
Our results showed that although screening rates were similar between all 3 models, there were differences in treatment and control rates, with capitation physicians having the best treatment and control rates. Further investigation into whether this type of payment model results in improved chronic disease management for other chronic diseases and preventative care maneuvers will give support to health care policy makers who are moving toward capitation-type payment models for primary care delivery.
Objective. To validate algorithms using administrative data that characterize ambulatory physician care for patients with a chronic disease.
Data Sources. Seven‐hundred and eighty‐one people with ...diabetes were recruited mostly from community pharmacies to complete a written questionnaire about their physician utilization in 2002. These data were linked with administrative databases detailing health service utilization.
Study Design. An administrative data algorithm was defined that identified whether or not patients received specialist care, and it was tested for agreement with self‐report. Other algorithms, which assigned each patient to a primary care and specialist physician, were tested for concordance with self‐reported regular providers of care.
Principal Findings. The algorithm to identify whether participants received specialist care had 80.4 percent agreement with questionnaire responses (κ=0.59). Compared with self‐report, administrative data had a sensitivity of 68.9 percent and specificity 88.3 percent for identifying specialist care. The best administrative data algorithm to assign each participant's regular primary care and specialist providers was concordant with self‐report in 82.6 and 78.2 percent of cases, respectively.
Conclusions. Administrative data algorithms can accurately match self‐reported ambulatory physician utilization.
Objectives To determine whether attending diabetes education is associated with blood glucose self‐monitoring among unselected older adults in routine clinical care.
Method A cross‐sectional ...population‐based study was carried out on 15 190 people with diabetes aged 65–79 years. Subjects were identified using a registry of doctor‐diagnosed diabetes derived from administrative data, and attendance at diabetes education centres (DECs) was determined from a separate registry of DEC utilization for 2006. Outcomes were derived using administrative data. The primary outcome was prescriptions filled for glucose self‐monitoring supplies. The secondary outcomes were prescriptions for antihypertensive drugs, prescriptions for lipid‐lowering drugs and eye examinations.
Results DEC attendance was associated with glucose self‐monitoring, after adjusting for baseline differences between attendees and non‐attendees (adjusted odds ratio 6.45, 95% confidence interval 5.61 to 7.42). All of the secondary outcomes were also independently associated with DEC attendance.
Conclusions This study suggests that diabetes education is associated with self‐management behaviour in real‐world clinical care. These findings support the effectiveness of self‐management education programmes to increase self‐care behaviours.
Abstract Objective The aim of this study was to describe the utilization of diabetes education centres by people not diagnosed with diabetes mellitus in real-world clinical care in Ontario. Methods ...Using population-level health administrative databases and registries, all people in Ontario, Canada, who attended a diabetes self-management education centre in 2006 were identified. The proportion of attendees without diagnosed diabetes at the time of their visit was determined, they were stratified by centre and health region, and their utilization of diabetes education centres was characterized. They were then followed up until 2010 for incident diabetes. Results Of 117 660 adults attending a diabetes education centre, 19 920 (16.9%) did not have diagnosed diabetes. There was a marked variation in the proportion of attendees without diagnosed diabetes between health regions and between individual centres. More attendees did not have diagnosed diabetes at centres based in community health centres (47.5%) or First Nations communities (22.1%) than those based in hospitals (13.9%) or other community settings (13.0%). Only 2741 attendees (13.8%) without diabetes attended group education classes; most attended individual counselling sessions. Diabetes incidence during follow up was 11.2 cases per 100 person years. Conclusions One in 6 people receiving care at a diabetes education centre in Ontario did not have diabetes, and the significant regional variations could represent inappropriate overuse or underuse. Although education and counselling for patients at risk for diabetes is clinically important, the volume of such persons served at Ontario diabetes education centres may detract from the centres' core function of supporting and managing patients already diagnosed with diabetes.
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