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Background: National health surveys linked to vital statistics and health care information provide a growing source of individual-level population health data. Pooling linked surveys across jurisdictions would create comprehensive datasets that are larger than most existing cohort studies, and that have a unique international and population perspective. This paper's objectives are to examine the feasibility of pooling linked population health surveys from three countries, facilitate the examination of health behaviours, and present useful information to assist in the planning of international population health surveillance and research studies., Data and Methods: The design, methodologies and content of the Canadian Community Health Survey (2003 to 2008), the United States National Health Interview Survey (2000, 2005) and the Scottish Health Survey (SHeS) (2003, 2008 to 2010) were examined for comparability and consistency. The feasibility of creating common variables for measuring smoking, alcohol consumption, physical activity and diet was assessed. Sample size and estimated mortality events were collected., Results: The surveys have comparable purposes, designs, sampling and administration methodologies, target populations, exclusions, and content. Similar health behaviour questions allow for comparable variables to be created across the surveys. However, the SHeS uses a more detailed risk factor evaluation for alcohol consumption and diet data. Therefore, comparisons of alcohol consumption and diet data between the SHeS and the other two surveys should be performed with caution. Pooling these linked surveys would create a dataset with over 350,000 participants, 28,424 deaths and over 2.4 million person-years of follow-up., Discussion: Pooling linked national population health surveys could improve population health research and surveillance. Innovative methodologies must be used to account for survey dissimilarities, and further discussion is needed on how to best access and analyze data across jurisdictions.

Background: Routinely collected data from large population health surveys linked to chronic disease outcomes create an opportunity to develop more complex risk-prediction algorithms. We developed a predictive algorithm to estimate 5-year risk of incident cardiovascular disease in the community setting., Methods: We derived the Cardiovascular Disease Population Risk Tool (CVDPoRT) using prospectively collected data from Ontario respondents of the Canadian Community Health Surveys, representing 98% of the Ontario population (survey years 2001 to 2007; follow-up from 2001 to 2012) linked to hospital admission and vital statistics databases. Predictors included body mass index, hypertension, diabetes, and multiple behavioural, demographic and general health risk factors. The primary outcome was the first major cardiovascular event resulting in hospital admission or death. Death from a noncardiovascular cause was considered a competing risk., Results: We included 104 219 respondents aged 20 to 105 years. There were 3709 cardiovascular events and 818 478 person-years follow-up in the combined derivation and validation cohorts (5-year cumulative incidence function, men: 0.026, 95% confidence interval [CI] 0.025-0.028; women: 0.018, 95% 0.017-0.019). The final CVDPoRT algorithm contained 12 variables, was discriminating (men: C statistic 0.82, 95% CI 0.81-0.83; women: 0.86, 95% CI 0.85-0.87) and was well-calibrated in the overall population (5-year observed cumulative incidence function v. predicted risk, men: 0.28%; women: 0.38%) and in nearly all predefined policy-relevant subgroups (206 of 208 groups)., Interpretation: The CVDPoRT algorithm can accurately discriminate cardiovascular disease risk for a wide range of health profiles without the aid of clinical measures. Such algorithms hold potential to support precision medicine for individual or population uses. Study registration: ClinicalTrials.gov, no. NCT02267447., Competing Interests: Competing interests: None declared., (© 2018 Joule Inc. or its licensors.)

Results from the Joint Canada/United States Survey of Health (2002-2003) reveal that health status is relatively similar in the two countries, but income-related health disparities exist. Americans in the poorest income quintile are more likely to have poor health than their Canadian counterparts; there were no differences between the rich. In general, Canadians were more like insured Americans regarding access to services, and Canadians experienced fewer unmet needs overall. Despite higher U.S. levels of spending on health care, residents in the two countries have similar health status and access to care, although there are higher levels of inequality in the United States.

Introduction: The Canadian Community Health Survey (CCHS) - Nutrition 2004 (n=35,107; interview dates from January 2004 to January 2005) linked to the Canadian Vital Statistics - Death Database (CVSD) (2011) represents a novel linkage of a population-based, nationally representative nutrition survey with routinely collected mortality records (including date and cause of death). The linkage was done through individual tax data in Canada, and contains longitudinal records for 29,897 Canadians aged 0 years and older--1,753 of whom died--in the 10 provinces of Canada. The median follow-up time was 7.49 years, with 102,953 personyears among males and 114,876 person-years among females (unweighted), and included a special sampling survey weight (for linked data) to account for those who did not agree to share and link their information. The CCHS - Nutrition 2004 linked to CVSD has been used to evaluate associations between lifestyle and sociodemographic characteristics and mortality. Using these data, statistical methods have been developed and tested to control random and systematic measurement errors when evaluating the relationship between different dietary exposures (evaluated using repeated 24-hour dietary recalls) and health outcomes. The linked data are available through Statistics Canada's Research Data Centres. [ABSTRACT FROM AUTHOR]

Background: Modern health surveillance and planning requires an understanding of how preventable risk factors impact population health, and how these effects vary between populations. In this study, we compare how smoking, alcohol consumption, diet and physical activity are associated with all-cause mortality in Canada and the United States using comparable individual-level, linked population health survey data and identical model specifications.Methods: The Canadian Community Health Survey (CCHS) (2003-2007) and the United States National Health Interview Survey (NHIS) (2000, 2005) linked to individual-level mortality outcomes with follow up to December 31, 2011 were used. Consistent variable definitions were used to estimate country-specific mortality hazard ratios with sex-specific Cox proportional hazard models, including smoking, alcohol, diet and physical activity, sociodemographic indicators and proximal factors including disease history.Results: A total of 296,407 respondents and 1,813,884 million person-years of follow-up from the CCHS and 58,232 respondents and 497,909 person-years from the NHIS were included. Absolute mortality risk among those with a 'healthy profile' was higher in the United States compared to Canada, especially among women. Adjusted mortality hazard ratios associated with health behaviours were generally of similar magnitude and direction but often stronger in Canada.Conclusion: Even when methodological and population differences are minimal, the association of health behaviours and mortality can vary across populations. It is therefore important to be cautious of between-study variation when aggregating relative effect estimates from differing populations, and when using external effect estimates for population health research and policy development. [ABSTRACT FROM AUTHOR]

Background: This study summarizes the linkage of the Canadian Community Health Survey (CCHS) and the Canadian Mortality Database (CMDB), which was performed to examine relationships between social determinants, health behaviours and mortality in the household population. Data and methods: The 2000/2001-to-2011 Canadian Community Health Surveys were linked to the 2000-to-2011 CMDB using probabilistic methods based on common identifiers (names, date of birth, postal code and sex) for eligible respondents (85%; n = 614,774). Mortality records from January 1, 2000 through December 31, 2011 for people aged 12 or older were eligible for linkage (n = 2.774 million). The linkage was enhanced with information from the Historical Tax Summary File. Quality assessment consisted of internal and external validation. Cox survival analysis (age-adjusted) was conducted to estimate hazard ratios (HRs) associated with selected health behaviours. Results: Overall, 5.3% of eligible CCHS respondents linked to a mortality record; false positive and false negative rates were 0.04% and 2.43%, respectively. Linkage rates were higher among males (5.8%) and people aged 75 or older (20.2%), reflecting known mortality risks. Survival analyses confirmed elevated mortality risk associated with heavy (HR 2.36, CI 1.84, 2.89) and light smoking (HR 1.91, CI 1.52, 2.33), compared with not smoking; underweight and obesity, compared with normal and overweight; low fruit and vegetable consumption; and lack of physical activity. Interpretation: Linking health behaviour information from the CCHS to mortality data from the CMDB allows for a greater understanding of modifiable determinants of mortality. [ABSTRACT FROM AUTHOR]

Background: Refugees arrive in Canada with settlement challenges different from those faced by other immigrants, including a higher risk of poor health. This study reports hospitalization rates for the three fiscal years from 2006/2007 through 2008/2009 for immigrants who arrived during the 1980-to-2006 period, with a focus on three refugee groups. Methods: Information from two linked databases was used to estimate age-standardized hospitalization rates (ASHRs) per 10,000 population aged 30 or older for all causes (excluding pregnancy) and for leading causes, by immigrant category and by refugee subcategory. The analysis focused on refugees from Poland, Vietnam and the Middle East, whose hospitalization rates were compared with those of the Canadian-born population and/or economic class immigrants from the same source areas. Results: Immigrants aged 30 or older, including refugees, had significantly lower all-cause ASHRs than did the Canadian-born population. All-cause ASHRs were 470 per 10,000 for immigrants overall and 494 for refugees, compared with 891 for the Canadian-born. Of the three source areas, immigrants and refugees from Vietnam had lower ASHRs. The circulatory disease-specific ASHR for government-assisted refugees from the Middle East was similar to that of the Canadian-born population (142 and 158, respectively). Except for those from Poland, refugees typically had higher ASHRs than did their economic class counterparts. Interpretation: Refugees, like other immigrants, generally had lower hospitalization rates than did the Canadian-born population, but some subgroups were particularly susceptible to hospitalization for specific chronic diseases. [ABSTRACT FROM AUTHOR]

Background: Behaviours such as smoking, poor diet, physical inactivity, and unhealthy alcohol consumption are leading risk factors for death. We assessed the Canadian burden attributable to these behaviours by developing, validating, and applying a multivariable predictive model for risk of all-cause death.Methods: A predictive algorithm for 5 y risk of death-the Mortality Population Risk Tool (MPoRT)-was developed and validated using the 2001 to 2008 Canadian Community Health Surveys. There were approximately 1 million person-years of follow-up and 9,900 deaths in the development and validation datasets. After validation, MPoRT was used to predict future mortality and estimate the burden of smoking, alcohol, physical inactivity, and poor diet in the presence of sociodemographic and other risk factors using the 2010 national survey (approximately 90,000 respondents). Canadian period life tables were generated using predicted risk of death from MPoRT. The burden of behavioural risk factors attributable to life expectancy was estimated using hazard ratios from the MPoRT risk model.Findings: The MPoRT 5 y mortality risk algorithms were discriminating (C-statistic: males 0.874 [95% CI: 0.867-0.881]; females 0.875 [0.868-0.882]) and well calibrated in all 58 predefined subgroups. Discrimination was maintained or improved in the validation cohorts. For the 2010 Canadian population, unhealthy behaviour attributable life expectancy lost was 6.0 years for both men and women (for men 95% CI: 5.8 to 6.3 for women 5.8 to 6.2). The Canadian life expectancy associated with health behaviour recommendations was 17.9 years (95% CI: 17.7 to 18.1) greater for people with the most favourable risk profile compared to those with the least favourable risk profile (88.2 years versus 70.3 years). Smoking, by itself, was associated with 32% to 39% of the difference in life expectancy across social groups (by education achieved or neighbourhood deprivation).Conclusions: Multivariable predictive algorithms such as MPoRT can be used to assess health burdens for sociodemographic groups or for small changes in population exposure to risks, thereby addressing some limitations of more commonly used measurement approaches. Unhealthy behaviours have a substantial collective burden on the life expectancy of the Canadian population. [ABSTRACT FROM AUTHOR]

Background: To comprehensively examine the cardiovascular health of Canadians, we developed the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) health index. We analyzed trends in health behaviours and factors to monitor the cardiovascular health of the Canadian population. Methods: We used data from the Canadian Community Health Survey (2003-2011 [excluding 2005]; response rates 70%-81%) to examine trends in the prevalence of 6 cardio vascular health factors and behaviours (smoking, physical activity, fruit and vegetable consumption, overweight/obesity, diabetes and hypertension) among Canadian adults aged 20 or older. We defined ideal criteria for each of the 6 health metrics. The number of ideal metrics was summed to create the CANHEART health index; values range from 0 (worst) to 6 (best or ideal). A separate CANHEART index was developed for youth age 12-19 years; this index included 4 health factors and behaviours (smoking, physical activity, fruit and vegetable consumption and overweight/obesity). We determined the prevalence of ideal cardiovascular health and the mean CANHEART health index score, stratified by age, sex and province. Results: During the study period, physical activity and fruit and vegetable consumption increased and smoking decreased among Canadian adults. The prevalence of overweight/obesity, hypertension and diabetes increased. In 2009-2010, 9.4% of Canadian adults were in ideal cardiovascular health, 53.3% were in intermediate health (4-5 healthy factors or behaviours), and 37.3% were in poor cardiovascular health (0-3 healthy factors or behaviours). Twice as many women as men were in ideal cardiovascular health (12.8% vs. 6.1%). Among youth, the prevalence of smoking decreased and the prevalence of over- weight/obesity increased. In 2009-2010, 16.6% of Canadian youth were in ideal cardiovascular health, 33.7% were in intermediate health (3 healthy factors or behaviours), and 49.7% were in poor cardiovascular health (0-2 healthy factors or behaviours). Interpretation: Fewer than 1 in 10 Canadian adults and 1 in 5 Canadian youth were in ideal cardiovascular health from 2003 to 2011. Intensive health promotion activities are needed to meet the Heart and Stroke Foundation of Canada's goal of improving the cardio-vascular health of Canadians by 10% by 2020 as measured by the CANHEART health index. [ABSTRACT FROM AUTHOR]

Background This study validates cut-points for a frailty index (FI) to identify seniors at risk of a hospital-related event and estimates the number of frail seniors living in the community. The FI developed by Rockwood and Mitnitski defines levels of frailty based on scores of 0 to 1.0. Data and methods The cut-point validation was conducted using Stratum-Specific Likelihood Ratios applied to combined 2003 and 2005 Canadian Community Health Survey (CCHS) data, linked to hospital records from the Discharge Abstract Database (2002 to 2007). Based on the validated cut-points, frailty prevalence was estimated using 2009/2010 CCHS data. Results Seniors scoring more than 0.21 on the FI were considered to be at elevated risk of hospital-related events. Four additional frailty levels were identified: non-frail (0 to ⩽0.1), pre-frail (>0.1 to ⩽0.21), more frail (>0.30 to ⩽0.35) (women only), and most frail (frail-group subset) (0.45 or more). The number of community-dwelling seniors considered to be frail was estimated at about 1 million (24%) in 2009/2010; another 1.4 million (32%) could be considered pre-frail. Frailty prevalence rose with age; was higher among women than among men; and varied by geographic location. Interpretation A cut-point of more than 0.21 can be used to identify frail seniors living in the community. [ABSTRACT FROM AUTHOR]

Background Statistics Canada has initiated a series of data linkages of Census of Population long form and health outcome data. These linked data lack risk factor information. This study assesses the feasibility of using statistical modelling techniques to assign smoking status to census respondents. Data and methods The 2000/2001 Canadian Community Health Survey (CCHS) was used to develop age-/ sex-specific predictive models to model smoking status based on variables available on the 1991 Census. The 2002/2003 CCHS was used to validate the modelled variable. Data from the 2002/2003 CCHS linked to data from the Hospital Morbidity Database (2001/2002 to 2004/2005) were used to evaluate the use of modelled versus self-reported smoking status on smoking-related hospitalizations. Results For the current daily smoker models, income, education, marital status, dwelling ownership and region of birth were significant predictors. For the never smoker models, marital status, dwelling ownership, Aboriginal identity and region of birth were significant predictors. Modelled current daily smoker status was associated with increased odds of smoking-related hospitalization, compared with being a never smoker, even when adjusting for covariates. Interpretation This study demonstrates the feasibility of using statistical modelling techniques to assign smoking status to census data, provided socio-economic and identity information is available. [ABSTRACT FROM AUTHOR]

Background Waiting for specialist consultations can represent a substantial component of overall waiting time in the continuum of care. However, relatively little is known about the factors associated with how long patients wait for an initial specialist consultation. Data and methods The analysis is based on a subsample of 5,515 respondents aged 15 or older to the 2007 Canadian Community Health Survey who had consulted a specialist about a new condition in the previous 12 months and reported a waiting time. Multivariate logistic regression models were used to identify patient- and provider-related factors associated with waiting time. Results Female patients were less likely than male patients to see a specialist within a month. The nature of the new condition and the source of referral were significantly associated with waiting time. Compared with those referred by a family physician, patients referred by another specialist or a health care provider other than a physician, or who did not require a referral, were more likely to have a shorter waiting time. For men, but not women, household income and immigrant status were associated with waiting time. Interpretation This analysis suggests that factors beyond medical need are associated with how long patients wait to see a specialist. More research could usefully explore decision-making and communication processes between primary care physicians and specialists to better understand how urgency is assessed, how patients are triaged for specialist consultations, and how these patterns differ among various groups of patients. [ABSTRACT FROM AUTHOR]