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Risk factors for avoidable hospitalizations in Canada using national linked data: A retrospective cohort study.

ABSTRACT: Hospitalizations for certain chronic conditions are considered avoidable for adult Canadians given effective and timely primary care management. Individual-level risk factors such as income and health behaviours are not routinely collected in most hospital databases and as a result, are largely uncharacterized for avoidable hospitalization at the national level. The aim of this study was to identify and describe demographic, socioeconomic, and health behavioural risk factors for avoidable hospitalizations in Canada using linked data. A national retrospective cohort study was conducted by pooling eight cycles of the Canadian Community Health Survey (2000/2001-2011) and linking to hospitalization records in the Discharge Abstract Database (1999/2000-2012/2013). Respondents who were younger than 18 years and older than 74 years of age, residing in Quebec, or pregnant at baseline were excluded yielding a final cohort of 389,065 individuals. The primary outcome measure was time-to index avoidable hospitalization. Sex-stratified Cox proportional hazard models were constructed to determine effect sizes adjusted for various factors and their associated 95% confidence intervals. Demographics, socioeconomic status, and health behaviours are associated with risk of avoidable hospitalizations in males and females. In fully adjusted models, health behavioural variables had the largest effect sizes including heavy smoking (Male HR 2.65 (95% CI 2.17-3.23); Female HR 3.41 (2.81-4.13)) and being underweight (Male HR 1.98 (1.14-3.43); Female HR 2.78 (1.61-4.81)). Immigrant status was protective in both sexes (Male HR 0.83 (0.69-0.98); (Female HR 0.69 (0.57-0.84)). Adjustment for behavioural and clinical variables attenuated the effect of individual-level socioeconomic status. This study identified several risk factors for time-to-avoidable hospitalizations by sex, using the largest national database of linked health survey and hospitalization records. The larger effect sizes of several modifiable risk factors highlights the importance of prevention in addressing avoidable hospitalizations in Canada.

SUBMITTER: Wallar LE

PROVIDER: S-EPMC7077875 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Risk factors for avoidable hospitalizations in Canada using national linked data: A retrospective cohort study.

Wallar Lauren E LE Rosella Laura C LC

PloS one 20200317 3

Hospitalizations for certain chronic conditions are considered avoidable for adult Canadians given effective and timely primary care management. Individual-level risk factors such as income and health behaviours are not routinely collected in most hospital databases and as a result, are largely uncharacterized for avoidable hospitalization at the national level. The aim of this study was to identify and describe demographic, socioeconomic, and health behavioural risk factors for avoidable hospit ...[more]

PMID: 32182242

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Project description:Introduction:Avoidable hospitalizations refer to acute care use for conditions that should normally be managed in primary care settings. Lower socioeconomic status that is often measured using area-based indicators (e.g. median household income) has been shown to increase risk of avoidable hospitalizations. However, both area- and individual-level socioeconomic status can contribute to hospitalization risk, but previous data limitations have prevented separate analyses. Further, the joint effect of individual and neighbourhood socioeconomic status has not been established in the Canadian population. To address this, this study links individual-level household income and neighbourhood-level material deprivation data within a population-based Canadian cohort. Objectives:To determine the individual and joint effect of individual-level household income and neighbourhood-level material deprivation on risk of hospitalization for a set of chronic ambulatory care sensitive conditions using linked health survey, hospital discharge, and census-derived data. Methods:A pooled cohort was created by linking sociodemographic and health information from eight cycles of the Canadian Community Health Survey (2000/2001 - 2010) to hospital discharge records and Canadian Marginalization Indices (2001, 2006) (N = 354,595). The primary outcome variable was risk of index hospitalization with a primary diagnosis of angina, asthma, congestive heart failure, chronic obstructive pulmonary disease, diabetes, epilepsy, or hypertension. The primary exposure variable was joint individual-level national household income quintile and neighbourhood-level material deprivation quintile. Relative risk (RR) was estimated by constructing modified Poisson regression models with robust error variance. Results:In fully adjusted models with income and deprivation considered separately, individuals in the lowest household income quintile and highest material deprivation quintile were at increased risk of hospitalization (Income RR: 1.82 (95% CI 1.56-2.13) Deprivation RR: 1.67 (1.44-1.95)). When income and deprivation were jointly considered, those with low individual income living in high deprivation neighbourhoods were at greatest risk of hospitalization (RR 1.83 (95% CI 1.63 - 2.05)). Conclusion:Both individual income and neighbourhood deprivation separately and jointly increase risk of avoidable hospitalizations. Additional research is needed to understand their mechanisms of action. However, both levels should be considered when designing effective policies and interventions to reduce avoidable hospitalizations.

Project description:Background:Hospitalizations of chronic dialysis patients have not been previously studied at a national level in Canada. Understanding the scope and variables associated with hospitalizations will inform measures for improvement. Objective:To describe the risk of all-cause and infection-related hospitalizations in patients on dialysis. Design:Retrospective cohort study using health care administrative databases. Setting:Provinces and territories across Canada (excluding Manitoba and Quebec). Patients:Incident chronic dialysis patients with a dialysis start date between January 1, 2005, and March 31, 2014. Patients with a prior history of kidney transplantation were excluded. Measurements:Patient characteristics were recorded at baseline. Dialysis modality was treated as a time-varying covariate. The primary outcomes of interest were all-cause and dialysis-specific infection-related hospitalizations. Methods:Crude rates for all-cause hospitalization and infection-related hospitalization were determined per patient year (PPY) at 7 and 30 days, and at 3, 6, and 12 months postdialysis initiation. A stratified, gamma-distributed frailty model was used to assess repeat hospital admissions and to determine the inter-recurrence dependence of hospitalizations within individuals, as well as the hazard ratio (HR) attributed to each covariate of interest. Results:A total of 38 369 incident chronic dialysis patients were included: 38 088 adults and 281 pediatric patients (age less than 18 years). There were 112 374 hospitalizations, of which 11.5% were infection-related hospitalizations. The all-cause hospitalization rate was similar for all adult age groups (age 65 years and older: 1.40, 1.35, and 1.18 admissions PPY at 7 days, 30 days, and 6 months, respectively). The all-cause hospitalization rate was higher for pediatric patients (1.67, 2.48, and 2.47 admissions PPY at 7 days, 30 days, and 6 months, respectively; adjusted HR: 2.73, 95% confidence interval [CI]: 2.37-3.15, referent age group: 45-64 years). Within the first 7 days after dialysis initiation, patients on peritoneal dialysis had a higher risk of all-cause hospitalization (HR: 1.27, 95% CI: 1.07-1.50) and infection-related hospitalization (HR: 2.05, 95% CI: 1.19-3.55) compared with patients on hemodialysis. Beyond 7 days, the risk did not differ significantly by dialysis modality. Female sex and Indigenous race were significant risk factors for all-cause hospitalization. Limitations:The cohort had too few home hemodialysis patients to examine this subgroup. The outcome of infection-related hospitalization was determined using diagnostic codes. Dialysis patients from Manitoba and Quebec were not included. Conclusions:In Canada, the rates of hospitalization were not influenced by dialysis modality beyond the initial 7-day period following dialysis initiation; however, the rate of hospitalization in pediatric patients was higher than in adults at every time frame examined.

Project description:BackgroundOpioids are a leading cause of adverse drug events in the hospital. Guidelines recommend that physicians assess the risks of opioids and discuss them with patients when considering opioid use. There are no studies examining patient- and prescribing-related risk factors for opioid-related adverse drug events (ORADEs) in hospitalized medical patients.ObjectiveTo identify independent risk factors for severe ORADEs in hospitalized medical patients.DesignRetrospective cohort study.PatientsMedical patients hospitalized at US, non-federal, and acute care facilities, with at least one pharmacy charge for an opioid during hospitalization. We excluded patients with metastatic malignancy, hospice, or palliative care billing codes.Main measuresWe used Cox proportional hazards modeling to identify risk factors for severe ORADEs, defined by a pharmacy charge for naloxone. Candidate risk factors were chosen a priori, based on clinical grounds and prior literature.Key resultsAmong 731,208 hospitalizations (median age 60, 56.5% female), a severe ORADE occurred in 2727 (0.4%). Independent risk factors included patient characteristics (advanced age, female gender), comorbidities (congestive heart failure, opioid abuse/dependence, non-opioid drug abuse/dependence, psychosis, depression, obstructive sleep apnea), organ failures on admission (respiratory failure, shock/hypotension, renal failure, hepatic failure, acidosis, and neurologic failure), medication co-administrations (antipsychotics and short-acting benzodiazepines), and characteristics of the opioid prescriptions themselves (total dose for the day, parenteral route of administration, and receipt of multiple types of opioids in a day). Although a risk prediction model derived from these factors performed well on stratified k-fold cross-validation (average c-statistics 0.68-0.71), the low incidence of the outcome limited the positive predictive value of the risk score.ConclusionsIn this national cohort of medical patients, we identified several risk factors for ORADEs that can be used to inform physician decision-making, conversations with patients about risk, and development and targeting of harm reduction strategies for at-risk populations.

Project description:BACKGROUND:Older adults who reside in long-term care facilities (LTCFs) are at particularly high risk for infection, morbidity and mortality from pneumonia and influenza (P&I) compared to individuals of younger age and those living outside institutional settings. The risk factors for P&I hospitalizations that are specific to LTCFs remain poorly understood. Our objective was to evaluate the incidence of P&I hospitalization and associated person- and facility-level factors among post-acute (short-stay) and long-term (long-stay) care residents residing in LTCFs from 2013 to 2015. METHODS:In this retrospective cohort study, we used Medicare administrative claims linked to Minimum Data Set and LTCF-level data to identify short-stay (<?100?days, index?=?admission date) and long-stay (100+ days, index?=?day 100) residents who were followed from the index date until the first of hospitalization, LTCF discharge, Medicare disenrollment, or death. We measured incidence rates (IRs) for P&I hospitalization per 100,000 person-days, and estimated associations with baseline demographics, geriatric syndromes, clinical characteristics, and medication use using Cox regression models. RESULTS:We analyzed data from 1,118,054 short-stay and 593,443 long-stay residents. The crude 30-day IRs (95% CI) of hospitalizations with P&I in the principal position were 26.0 (25.4, 26.6) and 34.5 (33.6, 35.4) among short- and long-stay residents, respectively. The variables associated with P&I varied between short and long-stay residents, and common risk factors included: advanced age (85+ years), admission from an acute hospital, select cardiovascular and respiratory conditions, impaired functional status, and receipt of antibiotics or Beers criteria medications. Facility staffing and care quality measures were important risk factors among long-stay residents but not in short-stay residents. CONCLUSIONS:Short-stay residents had lower crude 30- and 90-day incidence rates of P&I hospitalizations than long-stay LTCF residents. Differences in risk factors for P&I between short- and long-stay populations suggest the importance of considering distinct profiles of post-acute and long-term care residents in infection prevention and control strategies in LTCFs. These findings can help clinicians target interventions to subgroups of LTCF residents at highest P&I risk.

Project description:ObjectivesTo investigate whether retrofitting insulation into homes can reduce cold associated hospital admission rates among residents and to identify whether the effect varies between different groups within the population and by type of insulation.DesignA quasi-experimental retrospective cohort study using linked datasets to evaluate a national intervention programme.Participants994 317 residents of 204 405 houses who received an insulation subsidy through the Energy Efficiency and Conservation Authority Warm-up New Zealand: Heat Smart retrofit programme between July 2009 and June 2014.Main outcome measureA difference-in-difference approach was used to compare the change in hospital admissions of the study population post-insulation with the change in hospital admissions of the control population that did not receive the intervention over the same two timeframes. Relative rate ratios were used to compare the two groups.Results234 873 hospital admissions occurred during the study period. Hospital admission rates after the intervention increased in the intervention and control groups for all population categories and conditions with the exception of acute hospital admissions among Pacific Peoples (rate ratio 0.94, 95% confidence interval 0.90 to 0.98), asthma (0.92, 0.86 to 0.99), cardiovascular disease (0.90, 0.88 to 0.93), and ischaemic heart disease for adults older than 65 years (0.79, 0.74 to 0.84). Post-intervention increases were, however, significantly lower (11%) in the intervention group compared with the control group (relative rate ratio 0.89, 95% confidence interval 0.88 to 0.90), representing 9.26 (95% confidence interval 9.05 to 9.47) fewer hospital admissions per 1000 in the intervention population. Effects were more pronounced for respiratory disease (0.85, 0.81 to 0.90), asthma in all age groups (0.80, 0.70 to 0.90), and ischaemic heart disease in those older than 65 years (0.75, 0.66 to 0.83).ConclusionThis study showed that a national home insulation intervention was associated with reduced hospital admissions, supporting previous research, which found an improvement in self-reported health.

Project description:BACKGROUND:The annual rate of stillbirth in Sweden has remained largely unchanged for the past 30?years. In Sweden, there is no national audit system for stillbirths. The aim of the study was to determine if a regional multidisciplinary audit could help in identifying avoidable factors and delays associated with stillbirths. METHODS:Population-based retrospective cohort study. SETTINGS:Six labour wards in Stockholm County. PARTICIPANTS:Women delivering a stillbirth >?22?weeks of gestation in Stockholm during 2017. INTERVENTION:A multidisciplinary team was convened. Each team member independently assessed the medical chart of each case of stillbirth regarding causes and preventability, level of delay, the standard of healthcare provided, the investigation of maternal/foetal diseases and if any recommendations were given for the next pregnancy. A decision was based on the agreement of all five members. If no agreement was reached, a reassessment of the case was done and the medical record was scrutinized again until a mutual decision was made. Primary outcomes: The frequency of probably/possibly preventable factors associated with a stillbirth and the level of delay (patient/caregiver). SECONDARY OUTCOMES:The causes of death, the standard of antenatal/intrapartum/postpartum care, whether a summary of possible causes of the stillbirth was made and if any plans for future pregnancies were noted. RESULTS:Thirty percent of the stillbirths were assessed as probably/possibly preventable. More frequent ultrasound/clinical check-ups, earlier induction of labour and earlier interventions in line with current guidelines were identified as possibly preventable factors. A possibly preventable stillbirth was more common among non-Swedish-speaking women (p?=?0.03). In 15% of the cases, a delay by the healthcare system was identified. Having multiple caregivers, absence of continuity in terms of attending the antenatal clinic and not following the basic monitoring program for antenatal care were also identified as risk factors for a delay. CONCLUSION:A national/regional multidisciplinary audit group retrospectively identified factors associated with stillbirth. Access to good translation services or a more innovative approach to the problem regarding communication with mothers could be an important factor to decrease possible patient delays contributing to stillbirths. TRIAL REGISTRATION:NCT04281368 .

Project description:In August 2011, Ontario, Canada introduced a rotavirus immunization program using Rotarix™ vaccine. No assessments of rotavirus vaccine coverage have been previously conducted in Ontario.We assessed vaccine coverage (series initiation and completion) and factors associated with uptake using the Electronic Medical Record Administrative data Linked Database (EMRALD), a collection of family physician electronic medical records (EMR) linked to health administrative data. Series initiation (1 dose) and series completion (2 doses) before and after the program's introduction were calculated. To identify factors associated with series initiation and completion, adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) were calculated using logistic regression.A total of 12,525 children were included. Series completion increased each year of the program (73%, 79% and 84%, respectively). Factors associated with series initiation included high continuity of care (aOR = 2.15; 95%CI, 1.61-2.87), maternal influenza vaccination (aOR = 1.55; 95%CI,1.24-1.93), maternal immmigration to Canada in the last five years (aOR = 1.47; 95% CI, 1.05-2.04), and having no siblings (aOR = 1.62; 95%CI,1.30-2.03). Relative to the first program year, infants were more likely to initiate the series in the second year (aOR = 1.71; 95% CI 1.39-2.10) and third year (aOR = 2.02; 95% CI 1.56-2.61) of the program. Infants receiving care from physicians with large practices were less likely to initiate the series (aOR 0.91; 95%CI, 0.88-0.94, per 100 patients rostered) and less likely to complete the series (aOR 0.94; 95%CI, 0.91-0.97, per 100 patients rostered). Additional associations were identified for series completion.Family physician delivery achieved moderately high coverage in the program's first three years. This assessment demonstrates the usefulness of EMR data for evaluating vaccine coverage. Important insights into factors associated with initiation or completion (i.e. high continuity of care, smaller roster sizes, rural practice location) suggest areas for research and potential program supports.

Dataset Information

Risk factors for avoidable hospitalizations in Canada using national linked data: A retrospective cohort study.

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Risk factors for avoidable hospitalizations in Canada using national linked data: A retrospective cohort study.

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