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This study aimed to determine whether higher intakes of Na, added sugars and saturated fat are prospectively associated with all-cause mortality and CVD incidence and mortality in a diverse population. The nationally representative Canadian Community Health Survey-Nutrition 2004 was linked with the Canadian Vital Statistics – Death Database and the Discharge Abstract Database (2004–2011). Outcomes were all-cause mortality and CVD incidence and mortality. There were 1722 mortality cases within 115 566 person-years of follow-up (median (interquartile range) of 7·48 (7·22–7·70) years). There was no statistically significant association between Na density or energy from saturated fat and all-cause mortality or CVD events for all models investigated. The association of usual percentage of energy from added sugars and all-cause mortality was significant in the base model with participants consuming 11·47 % of energy from added sugars having 1·34 (95 % CI 1·01, 1·77) times higher risk of all-cause mortality compared with those consuming 4·17 % of energy from added sugars. Overall, our results did not find statistically significant associations between the three nutrients and risk of all-cause mortality or CVD events at the population level in Canada. Large-scale linked national nutrition datasets may not have the discrimination to identify prospective impacts of nutrients on health measures. [ABSTRACT FROM AUTHOR]

Using 5 diet quality indexes, we estimated the mortality and life expectancy lost, at the national level, attributable to poor dietary patterns, which had previously been largely unknown. We used the Canadian Community Health Survey 2004, linked to vital statistics (n  = 16,212 adults; representing n  = 22,898,880). After a median follow-up of 7.5 years, 1,722 deaths were recorded. Population attributable fractions were calculated to estimate the mortality burden of poor dietary patterns (Dietary Guidelines for Americans Adherence Index 2015, Dietary Approaches to Stop Hypertension, Healthy Eating Index, Alternative Healthy Eating Index, and Mediterranean Style Dietary Pattern Score). Better diet quality was associated with a 32%–51% and 21%–43% reduction in all-cause mortality among adults aged 45–80 years and ≥20 years, respectively. Projected life expectancy at 45 years was longer for Canadians adhering to a healthy dietary pattern (average of 5.2–8.0 years (men) and 1.6–4.1 (women)). At the population level, 26.5%–38.9% (men) and 8.9%–22.9% (women) of deaths were attributable to poor dietary patterns. Survival benefit was greater for individuals with higher scores on all diet indexes, even with relatively small intake differences. The large attributable burden was likely from assessing overall dietary patterns instead of a limited range of foods and nutrients. [ABSTRACT FROM AUTHOR]

Background: As Canada continues to experience an opioid crisis, it is important to understand the intersection between the demographic, socioeconomic and service use characteristics of those experiencing opioid overdoses to better inform prevention and treatment programs. Data and methods: The Statistics Canada British Columbia Opioid Overdose Analytical File (BCOOAF) represents people's opioid overdoses between January 2014 and December 2016 (n = 13,318). The BCOOAF contains administrative health data from British Columbia linked to Statistics Canada data, including on health, employment, social assistance and police contacts. Cluster analysis was conducted using the k-prototypes algorithm. Results: The results revealed a six-cluster solution, composed of three groups (A, B and C), each with two distinct clusters (1 and 2). Individuals in Group A were predominantly male, used non-opioid prescription medications and had varying levels of employment. Individuals in Cluster A1 were employed, worked mostly in construction, had high incomes and had a high rate of fatal overdoses, while individuals in Cluster A2 were precariously employed and had varying levels of income. Individuals in Group B were predominantly female; were mostly taking prescription opioids, with about one quarter or less receiving opioid agonist treatment (OAT); mostly had precarious to no employment; and had low to no income. People in Cluster B1 were primarily middle-aged (45 to 65 years) and on social assistance, while people in Cluster B2 were older, more frequently used health services and had no social assistance income. Individuals in Group C were primarily younger males aged 24 to 44 years, with higher prevalence of having experienced multiple overdoses, were medium to high users of health care services, were mostly unemployed and were recipients of social assistance. Most had multiple contacts with police. Those in Cluster C1 predominantly had no documented use of prescription opioid medications, and all had no documented OAT, while all individuals in Cluster C2 were on OAT. Interpretation: The application of machine learning techniques to a multidimensional database enables an intersectional approach to study those experiencing opioid overdoses. The results revealed distinct patient profiles that can be used to better target interventions and treatment. [ABSTRACT FROM AUTHOR]

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 Canadian immigrants from countries where the hepatitis B virus (HBV) and hepatitis C virus (HCV) are endemic may be at higher risk of liver-related disease than Canadian-born residents. This study compared HBV- and HCV-related hospitalizations in Canadian immigrants (arriving from 1980 to 2013) and longterm residents (Canadian-born population and pre-1980 immigrants) and aimed to describe the burden of disease in both groups. Methods Based on the 2004/2005-to-2013/2014 hospital Discharge Abstract Database linked to the 1980-to-2013 Longitudinal Immigration Database, this descriptive cross-sectional study examined the distribution of HBV- and HCV-related hospitalizations, lengths of stay, comorbidities, and sequelae incurred by immigrants and long-term residents in Canada. With a linkage rate of 85%, 5,854,949 immigrants were included in the study. Proportions of HBV- and HCV-related hospitalizations attributable to immigrants were calculated. Results By birth country risk level, 22% of HBV-related hospital events among recent immigrants, and 20% of those related to HCV, were among people from high-risk countries. Proportionally, fewer immigrants had comorbidities than long-term residents. The top two hospital-related sequelae in both groups were cirrhosis and ascites, and liver cancer. While immigrants made up 16% of the Canadian population, they incurred 37% of HBV-related hospitalizations and 9% of HCVrelated hospitalizations, giving ratios of hepatitis-related hospitalizations relative to the population share of 2.3 (95% confidence interval [CI]: 2.2 to 2.5) and 0.5 (95% CI: 0.5 to 0.6) respectively. These ratios were higher among seniors, at 4.4 (95% CI: 3.9 to 4.9) and 2.3 (95% CI: 1.9 to 2.6), respectively. Interpretation Immigrants can require hospitalization for hepatitis in Canada, especially for HBV. These results may inform health screening for HBV or HCV in the Canadian immigration context. [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 The objective of this study was to create the Canadian Food Environment Dataset (Can-FED) and to demonstrate its validity. Data and methods Food outlet data were extracted from Statistics Canada's Business Register (BR) in 2018. Retail food environment access measures (both absolute and relative measures) were calculated using network buffers around the centroid of 56,589 dissemination areas in Canada. A k-medians clustering approach was used to create categorical food environment variables that were easy to use and amenable to dissemination. Validity of the measures was assessed by comparing the food environment measures from Can-FED with measures created using Enhanced Points of Interest data by DMTI Spatial Inc. and data from a municipal health inspection list. Validity was also assessed by calculating the geographic variability in food environments across census metropolitan areas (CMAs) and assessing associations between CMA-level food environments and CMA-level health indicators. Results Two versions of Can-FED were created: a researcher file that must be accessed within a secure Statistics Canada environment and a general-use file available online. Agreement between Can-FED food environment measures and those derived from a proprietary dataset and a municipal health inspection list ranged from rs=0.28 for convenience store density and rs=0.53 for restaurant density. At the CMA level, there is wide geographic variation in the food environment with evidence of patterning by health indicators. Interpretation Can-FED is a valid and accessible dataset of pan-Canadian food environment measures that was created from the BR, a data source that has not been explored fully for health research. [ABSTRACT FROM AUTHOR]

Background Reliance on the use of opioids to manage pain has increased over time, as have opioid-related morbidity and deaths. In 2018, 12.7% of Canadians reported having used opioid pain relief medications (OPRMs) in the previous year. Among these people, 9.6% had engaged in problematic use that could cause harm to their health. Though socioeconomic characteristics associated with opioid-related harms have previously been reported, population-level evidence based on administrative health data lacks important behavioural and psychosocial information. This analysis extends previous research by using modelling to report factors related to the problematic use of OPRMs for the household population aged 15 and older in Canada. Data and methods This analysis uses responses to the 2018 Canadian Community Health Survey to identify factors that are significantly associated, after adjustment using multivariate logistic regression models, with elevated odds of problematic use of OPRMs. Results The fully adjusted model confirmed that being male, being younger (ages 20 to 24), having fair or poor mental health, having unmet needs for help with mental or emotional health or substance problems, being a smoker, or being unattached and living with others were significantly related to problematic OPRM use. Interpretation Subjective perceptions significantly related to problematic OPRM use, independent of socioeconomic circumstances, were examined in this study. While previous research based on administrative health data has contributed much to knowledge about factors associated with opioid harms, modelled results revealed that self-reported experiential factors also warrant consideration as they are significantly associated with problematic use. Having fair or poor mental health, having unmet perceived needs for help, and being unattached in terms of household arrangement relationship were related to problematic use of OPRMs, even after adjustment for socioeconomic and other health covariates. This study suggests risk profiles that could be used to inform health care providers, and strategies to support safe pain management. [ABSTRACT FROM AUTHOR]

Background: Survivors of acute health events can experience lasting reductions in functional status and quality of life, as well as reduced ability to work and earn income. We aimed to assess the effect of acute myocardial infarction (MI), cardiac arrest and stroke on work and earning among working-age people.Methods: For this retrospective cohort study, we used the Canadian Hospitalization and Taxation Database, which contains linked hospital and income tax data, from 2005 to 2013 to perform difference-in-difference analyses. We matched patients admitted to hospital for acute MI, cardiac arrest or stroke with controls who were not admitted to hospital for these indications. Participants were aged 40-61 years, worked in the 2 years before the event and were alive 3 years after the event. Patients were matched to controls for 11 variables. The primary outcome was working status 3 years postevent. We also assessed earnings change attributable to the event. We matched 19 129 particpants who were admitted to hospital with acute MI, 1043 with cardiac arrest and 4395 with stroke to 1 820 644, 307 375 and 888 481 controls, respectively.Results: Fewer of the patients who were admitted to hospital were working 3 years postevent than controls for acute MI (by 5.0 percentage points [pp], 95% confidence interval [CI] 4.5-5.5), cardiac arrest (by 12.9 pp, 95% CI 10.4-15.3) and stroke (by 19.8 pp, 95% CI 18.5-23.5). Mean (95% CI) earnings declines attributable to the events were $3834 (95% CI 3346-4323) for acute MI, $11 143 (95% CI 8962-13 324) for cardiac arrest, and $13 278 (95% CI 12 301-14 255) for stroke. The effects on income were greater for patients who had lower baseline earnings, comorbid disease, longer hospital length of stay or needed mechanical ventilation. Sex, marital status or self-employment status did not affect income declines.Interpretation: Acute MI, cardiac arrest and stroke all resulted in substantial loss in employment and earnings that persisted for at least 3 years after the events. These outcomes have consequences for patients, families, employers and governments. Identification of subgroups at high risk for these losses may assist in targeting interventions, policies and legislation to promote return to work. [ABSTRACT FROM AUTHOR]

Background: National population information about the surgical treatment rate for primary cancers, including breast cancer, has remained a significant data gap in Canada. This gap has implications for cancer care planning and evaluating health system performance. New linkages between the Canadian Cancer Registry and hospital discharge records were conducted by Statistics Canada in 2016. Using already existing, routinely collected health administrative data, these linkages allow viable reporting of surgical cancer treatment for the first time for all provinces and territories (except Quebec). Data and methods: Hospital record information about type and date of surgical treatment of tumours was provided by information from linked data. These linked data reported 50,740 incident primary malignant breast tumours diagnosed between January 1, 2010, and December 31, 2012, among females aged 19 years or older. The unadjusted treatment rate for primary surgical intervention within one year was calculated as the proportion of total tumours that were linkable to hospital records. Results: For three combined years (2010, 2011 and 2012), 88.3% (N=44,780) of patients overall received at least one surgical treatment. Variations to the surgical rate occurred across jurisdictions, with the highest rate at 91-92% for Prince Edward Island, Newfoundland and Labrador, British Columbia and New Brunswick. Generally, there was an inverse gradient between surgical treatment rate and tumour stage. Interpretation: The surgical treatment rate of new primary breast cancers varied across provinces and territories from 2010 to 2012. New linked data could be used to further identify geographic and demographic inequities in terms of receiving surgical cancer treatment and contribute to the evaluation of cancer system performance and outcomes. [ABSTRACT FROM AUTHOR]

Background: While the incidence of active tuberculosis (TB) in Canada is among the lowest in the world, the rates of TB among immigrants and Indigenous people remain high. In fact, the majority of new active TB cases are disproportionately found among immigrants. This study profiles TB-related acute care hospitalizations among new immigrants to Canada by selected characteristics. Data and methods: This study is based on the 2000-to-2013 Longitudinal Immigration Database (IMDB) linked to the Canadian Institute for Health Information's Discharge Abstract Database (DAD) from 2001/2002 to 2013/2014. It examines the timing of first TB-related acute care hospitalization occurring from the fiscal year 2001/2002 to the fiscal year 2013/2014 among immigrants who landed in Canada from 2000 to 2013 outside of Quebec and the territories. Mean and median hospital days and the percentage of total TB hospitalizations incurred by these new immigrants are calculated to measure the burden of hospital care among recent immigrants. Results: From 2001/2002 to 2013/2014, 1,120 out of 2.7 million immigrants arriving between 2000 and 2013 were found to have, in total, 1,340 TB-related hospital discharges. The majority of cases (97%) were among immigrants from the Immigration, Refugees and Citizenship Canada (IRCC) designated country list for TB, in which about three quarters of the cases were from the World Health Organization (WHO) list of high TB-burden countries. Approximately half (45%) of immigrants hospitalized for TB were aged 18 to 34 at the time of hospitalization. Around 10% of all TB patients had been hospitalized before formally landing as immigrants. Mean and median length of hospital stay were 17 days and 11 days, respectively (22 days and 14 days, respectively, for the overall population in Canada). While new immigrants who landed between 2000 and 2013 represent 7% of the overall population of Canada, they incurred 17% of all TB-related hospital discharges occurring during this period. Interpretation: This paper demonstrates the value of linked administrative data to understanding immigrant health and is important for future work in this area. Current immigration protocols surrounding TB involve screening for active pulmonary TB and identifying some migrants with latent TB. Results of this study, linking TB-related hospitalizations to immigrant landing files, provide unique information that can inform public health action, as well as migration policy and program development to contribute to the efforts to eliminate TB. [ABSTRACT FROM AUTHOR]

Background: The aging of the Canadian population has increased attention on the future need for nursing home beds. Although current projections rely primarily on age and sex, other factors also contribute to the need for long-term care. This study seeks to identify additional factors to age and sex that contribute to Canadians transitioning from living at home to living in a seniors' residence or nursing home. Data and methods: As part of a larger record linkage project, three cycles of the Canadian Community Health Survey (CCHS) were linked to the 2011 Census of Population: Cycle 3.1 (2005/2006), Cycle 4.1 (2007/2008), and CCHS-Healthy Aging (2008/2009). The sample was limited to successfully linked CCHS respondents who were aged 60 years or older as of Census Day 2011 (May 10, 2011; n=81,411). Sex-specific generalized multinomial logistic regression models were conducted to examine the association between each respondent's characteristics and dwelling location (private dwelling, private dwelling with additional family, nursing home, or seniors' residence) on Census Day. Results: On Census Day, 1.4% of the study sample were living in a nursing home, 1.2% in a seniors' residence, 7.1% in a private dwelling with additional family, and 90.3% in a private dwelling. Women were more likely than men to be living in a nursing home (1.8% of women vs. 0.9% of men) or seniors' residence (1.7% of women vs. 0.7% of men). Regression models showed that, aside from age, there were increased odds of living in a nursing home or seniors' residence among individuals who lost their spouse or who were not married, who did not own their dwelling, who had poor self-rated health, or who had been diagnosed with dementia. The association of other factors with dwelling place differed according to sex and type of dwelling. Interpretation: Although age is strongly associated with living in a nursing home or seniors' residence, other demographic and health factors affect the likelihood of an individual transitioning to an institutional dwelling. Such factors could be considered when planning for the future housing and care needs of the Canadian population. [ABSTRACT FROM AUTHOR]

Background: In Canada, long waiting times for core specialized services have consistently been identified as a key barrier to access. Governments and organizations have responded with strategies for better access management, notably for total joint replacement (TJR) of the hip and knee. While wait time management strategies (WTMS) are promising, the factors which influence their sustainable implementation at the organizational level are understudied. Consequently, this study examined organizational and systemic factors that made it possible to sustain waiting times for TJR within federally established limits and for at least 18 months or more.Methods: The research design is a multiple case study of WTMS implementation. Five cases were selected across five Canadian provinces. Three success levels were pre-defined: 1) the WTMS maintained compliance with requirements for more than 18 months; 2) the WTMS met requirements for 18 months but could not sustain the level thereafter; 3) the WTMS never met requirements. For each case, we collected documents and interviewed key informants. We analyzed systemic and organizational factors, with particular attention to governance and leadership, culture, resources, methods, and tools.Results: We found that successful organizations had specific characteristics: 1) management of the whole care continuum, 2) strong clinical leadership; 3) dedicated committees to coordinate and sustain strategy; 4) a culture based on trust and innovation. All strategies led to relatively similar unintended consequences. The main negative consequence was an initial increase in waiting times for TJR and the main positive consequence was operational enhancement of other areas of specialization based on the TJR model.Conclusions: This study highlights important differences in factors which help to achieve and sustain waiting times. To be sustainable, a WTMS needs to generate greater synergies between contextual-level strategy (provincial or regional) and organizational objectives and constraints. Managers at the organizational level should be vigilant with regard to unintended consequences that a WTMS in one area can have for other areas of care. A more systemic approach to sustainability can help avoid or mitigate undesirable unintended consequences. [ABSTRACT FROM AUTHOR]

Background: Economic immigrants generally, and economic class principal applicants (ECPAs) specifically, tend to have better health than other immigrants, as well as the Canadian-born population. However, health outcomes vary among subcategories within this group, especially by sex. Methods: This study examines hospitalization rates among ECPAs aged 25 to 74 who arrived in Canada between 1980 and 2006 as skilled workers, business immigrants, or live-in caregivers. The analysis used two linked databases to estimate age-standardized hospitalization rates (ASHRs) overall and for leading causes by sex. ASHRs of ECPA subcategories were compared with each other and with those of the Canadian-born population. Logistic regression was used to derive odds ratios for hospitalization among ECPAs, by sex. Results: Male and female ECPAs aged 25 to 74 had significantly lower all-cause ASHRs than did the Canadian-born population in the same age range. This pattern prevailed for each ECPA subcategory and for each disease examined. Compared with skilled workers, business immigrants had lower odds of hospitalization; live-in caregivers who arrived after 1992 had higher odds. Adjustment for education, official language proficiency, and world region reduced the strength of or eliminated these associations. Interpretation: Compared with the Canadian-born population, ECPAs generally had lower hospitalization rates. Differences were apparent among ECPA subcategories. [ABSTRACT FROM AUTHOR]

Background: Respiratory diseases are among the leading causes of acute care hospitalization for First Nations people. Poor housing conditions are associated with respiratory disorders and may be related to the likelihood of hospitalization. This analysis examines whether First Nations identity is associated with higher odds of hospitalization for respiratory conditions relative to non-Aboriginal persons, and whether such differences in hospitalization rates remain after consideration of housing conditions. Data and methods: Data from the 2006 Census linked to the Discharge Abstract Database were used to analyze differences in hospitalization for respiratory tract infections and asthma between First Nations and non-Aboriginal people when housing conditions were taken into account. Results: Rural on-reserve First Nations people were more likely than non-Aboriginal people to be hospitalized for a respiratory tract infection (1.5% versus 0.5%) or for asthma (0.2% versus 0.1%). For respiratory tract infection hospitalizations, adjustment for housing conditions, household income and residential location reduced differences, but the odds remained nearly three times higher for on-reserve First Nations people (OR = 2.83; CI: 2.69 to 2.99) and two times higher for off-reserve First Nations people (OR = 2.03; CI: 1.87 to 2.21), compared with the non-Aboriginal cohort. For asthma hospitalizations, adjustment for household income reduced the odds more than did adjustment for housing conditions. Even with full adjustment, the odds of asthma hospitalization relative to non-Aboriginal people remained significantly higher for First Nations people. Interpretation: First Nations people are significantly more likely than non-Aboriginal people to be hospitalized for respiratory tract infections and asthma, even when housing conditions, household income and residential location are taken into account. While housing conditions are associated with such hospitalizations, household income may be more important. [ABSTRACT FROM AUTHOR]

Background: High-quality ambulatory care can reduce cardiovascular disease risk, but important gaps exist in the provision of cardiovascular preventive care. We sought to develop a set of key performance indicators that can be used to measure and improve cardiovascular care in the primary care setting. Methods: As part of the Cardiovascular Health in Ambulatory Care Research Team initiative, we established a 14-member multidisciplinary expert panel to develop a set of indicators for measuring primary prevention performance in ambulatory cardiovascular care. We used a 2-stage modified Delphi panel process to rate potential indicators, which were identified from the literature and national cardiovascular organizations. The top-rated indicators were pilot tested to determine their measurement feasibility with the use of data routinely collected in the Canadian health care system. Results: A set of 28 indicators of primary prevention performance were identified, which were grouped into 5 domains: risk factor prevalence, screening, management, intermediate outcomes and long-term outcomes. The indicators reflect the major cardiovascular risk factors including smoking, obesity, hypertension, diabetes, dyslipidemia and atrial fibrillation. All indicators were determined to be amenable to measurement with the use of population-based administrative (physician claims, hospital admission, laboratory, medication), survey or electronic medical record databases. Interpretation: The Cardiovascular Health in Ambulatory Care Research Team indicators of primary prevention performance provide a framework for the measurement of cardiovascular primary prevention efforts in Canada. The indicators may be used by clinicians, researchers and policy-makers interested in measuring and improving the prevention of cardiovascular disease in ambulatory care settings. [ABSTRACT FROM AUTHOR]

Background: Some patients with cardiovascular-related chronic diseases such as diabetes and heart disease report financial barriers to achieving optimal health. Previous surveys report that the perception of having a financial barrier is associated with self-reported adverse clinical outcomes. We sought to confirm these findings using linked survey and administrative data to determine, among patients with cardiovascular-related chronic diseases, if there is an association between perceived financial barriers and the outcomes of: (1) disease-related hospitalizations, (2) all-cause mortality and (3) inpatient healthcare costs.Methods: We used ten cycles of the nationally representative Canadian Community Health Survey (administered between 2000 and 2011) to identify a cohort of adults aged 45 and older with hypertension, diabetes, heart disease or stroke. Perceived financial barriers to various aspects of chronic disease care and self-management were identified (including medications, healthful food and home care) from the survey questions, using similar questions to those used in previous studies. The cohort was linked to administrative data sources for outcome ascertainment (Discharge Abstract Database, Canadian Mortality Database, Patient Cost Estimator). We utilized Poisson regression techniques, adjusting for potential confounding variables (age, sex, education, multimorbidity, smoking status), to assess for associations between perceived financial barriers and disease-related hospitalization and all-cause mortality. We used gross costing methodology and a variety of modelling approaches to assess the impact of financial barriers on hospital costs.Results: We identified a cohort of 120,752 individuals over the age of 45 years with one or more of the following: hypertension, diabetes, heart disease or stroke. One in ten experienced financial barriers to at least one aspect of their care, with the two most common being financial barriers to accessing medications and healthful food. Even after adjustment, those with at least one financial barrier had an increased rate of disease-related hospitalization and mortality compared to those without financial barriers with adjusted incidence rate ratios of 1.36 (95% CI: 1.29-1.44) and 1.24 (1.16-1.32), respectively. Furthermore, having a financial barrier to care was associated with 30% higher inpatient costs compared to those without financial barriers.Discussion: This study, using novel linked national survey and administrative data, demonstrates that chronic disease patients with perceived financial barriers have worse outcomes and higher resource utilization, corroborating the findings from prior self-report studies. The overall exposure remained associated with the primary outcome even in spite of adjustment for income. This suggests that a patient's perception of a financial barrier might be used in clinical and research settings as an additional measure along with standard measures of socioeconomic status (ie. income, education, social status).Conclusions: After adjusting for relevant covariates, perceiving a financial barrier was associated with increased rates of hospitalization and mortality and higher hospital costs compared to those without financial barriers. The demonstrable association with adverse outcomes and increased costs seen in this study may provide an impetus for policymakers to seek to invest in interventions which minimize the impact of financial barriers. [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]

Purpose: The objective of this study was to explore Canadian rural‐urban differences in the use of primary and secondary preventive diagnostic services for acute myocardial infarction (AMI)—a condition that is amenable to primary health care prevention efforts. Methods: We examined primary and secondary preventive care services utilized 2 years prior to a patient's first AMI in a cohort of 30,491 patients in Ontario, Canada, from 2010 to 2012. Using logistic regression, rural‐urban differences in lipid testing, glucose testing, stress testing, electrocardiograms, and echocardiograms in middle‐age and senior patients were examined. Findings: The odds of rural patients receiving care for primary preventive screening were more than 50% lower than the odds for urban patients, with rural seniors being the most affected. Lipid testing: middle‐age OR 0.519 (95% CI, 0.469‐0.574), senior OR 0.422 (0.386‐0.460); glucose testing: middle‐age OR 0.471 (0.426‐0.521), senior OR 0.359 (0.328‐0.394). The odds of rural patients receiving secondary preventive diagnostic care were also lower than the odds for urban patients, but differences between the age groups were not as apparent. Stress testing: middle‐age OR 0.745 (95%CI, 0.642‐0.866), senior OR 0.726 (0.643‐0.820); electrocardiogram: middle‐age OR 0.815 (0.737‐0.901), senior OR 0.724 (0.659‐0.795); echocardiogram: middle‐age OR 0.755 (0.655‐0.869), senior OR 0.746 (0.681‐0.818). Conclusions: Study results support ongoing concerns related to health care for rural Canadians by demonstrating underutilization of AMI preventive diagnostic care among rural patients. Rural seniors are most at risk. These results have implications for rural health care as well as seniors’ health policy in Canada. [ABSTRACT FROM AUTHOR]

While immigrants tend to be healthier especially when they first arrived, this healthy immigrant effect may not apply to vaccine-preventable diseases (VPD) especially among immigrants from countries without vaccination programs. There is therefore an important information gap regarding differential health outcome and hospitalization usage by immigrant status, landing cohort, world region and immigrant category. This study focused on acute-care hospitalization, and used two recently linked population-based databases in Canada, namely, the 2006 Census linked to the Hospital Discharge Abstract (DAD), and the Immigrant Landing File linked to the DAD (ILF-DAD) to estimate crude and age-standardized VPD-related hospitalization rates (ASHR) by the above-mentioned immigrant characteristics to be compared with that for overall Canadian-born reference population. Based on the 2006 Census-DAD linked database, VPD-specific ASHR for overall immigrants was significantly higher than that for the Canadian-born population (1.6, 95% CI, 1.5, 1.6 vs 1.2, 95% CI, 1.1, 1.2, respectively). VPD-specific ASHRs by landing cohorts also increased with years in Canada (e.g. 1.4, 95% CI, 1.3, 1.5 for the 1990–2006 cohort, and 1.6, 95% CI, 1.5, 1.7 for the pre-1980 cohort). Based on the 1980–2006 ILF-DAD, the VPD-specific ASHRs were highest among Southeast and East Asians (e.g. 2.1, 95% CI, 1.9, 2.3 for East Asia). Compared with the Canadian-born, economic class immigrants overall had significantly lower ASHR (1.4, 95% CI 1.2, 1.6), but the low rate was mainly due to the dependants (spouse or children) within this class (0.8, 95% CI 0.6, 1.1). Both family and refugee categories had significantly higher ASHRs (1.3, 95% CI, 1.2, 1.5 and 1.7, 95% CI, 1.4, 2.1, respectively), especially among those refugees assisted by government (2.0, 95% CI, 1.4, 2.6). With increasing immigration, changing source countries and emerging needs for refugee settlements in Canada, these newly linked datasets help to monitor VPD-related hospitalization pattern among Canadian immigrants. [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: Although immigrants tend to be healthier than the Canadian-born population when they arrive, subgroups, notably different immigration categories, may differ in health and health care use. Data limitations have meant the research has seldom focused on category of immigrant-economic, family or refugee. A newly linked database has made it possible to study acute care hospitalization by immigration category and source region. Data and methods: The Immigrant Landing File-Hospital Discharge Abstract Linked Database (n = 2.6 million) was used to derive sex-specific crude and age-standardized hospitalization rates (ASHRs) per 10,000 population for all-cause and leading causes of hospitalization during the 2006/2007-to-2008/2009 period. Results: Economic class immigrants had lower all-cause ASHRs than did their family class or refugee counterparts. Male refugees had high ASHRs overall and for circulatory diseases, digestive diseases, injury, and cancer. Female differences by immigrant class were less pronounced. All-cause ASHRs (excluding pregnancy) rose with years since arrival in Canada for male and female immigrants. Immigrants from East Asia had the lowest ASHRs; those from the United States, the highest. Interpretation: Although hospital use is an imperfect indicator of health status, this study supports an initial healthy immigrant effect and its subsequent decline. Marked differences emerged among immigrant subgroups with some, notably refugees and immigrants from the United States, having significantly higher hospitalization rates overall and for leading causes, compared with other groups. [ABSTRACT FROM AUTHOR]

Objectives. To estimate the risk of work loss due to illness or disability in a cohort of employed persons with OA compared with matched non-OA individuals. Methods. We performed a population-based cohort analysis using the last six cycles of the Canadian longitudinal National Population Health Survey from 2000 to 2010. OA cases and up to four age- and sex-matched non-OA individuals were selected. Discrete time hazard regression models were used to estimate the hazard of work loss due to illness or disability. To analyse the effect of a self-reported OA measure on the outcome, we performed a sensitivity analyses for case selection. Results. From 7273 employed individuals between the ages of 20 and 70 years in the National Population Health Survey, 659 OA cases were selected and matched to 2144 non-OA individuals. The proportion of OA cases who experienced work loss due to illness or disability during the follow-up period was 12.6%, compared with 9.3% for non-OA individuals (P < 0.001). OA cases had a 90% [hazard ratio (HR) 1.90 (95% CI 1.36, 3.23)] higher hazard of work loss due to illness or disability compared with their matched non-OA individuals after adjusting for sociodemographic, health and work-related status. The adjusted HRs were 1.61 (95% CI 1.13, 2.30) and 2.04 (95% CI 1.74, 4.75) for females and males, respectively. Conclusion. OA is independently associated with an increased risk of work loss due to illness or disability. Given the high prevalence of OA in the population of working age, future research may wish to investigate ways to improve occupational participation among OA patients. [ABSTRACT FROM AUTHOR]

Objective As rates of total joint arthroplasty (TJA) for osteoarthritis (OA) rise, there is a need to ensure appropriate use. We undertook this study to develop criteria for appropriate use of TJA. Methods In prior work, we used qualitative methods to separately assess OA patients' and arthroplasty surgeons' perceptions regarding appropriateness of patient candidates for TJA. The current study reviewed the appropriateness themes that emerged from each group, and a series of statements were developed to reflect each unique theme or criterion. A group of arthroplasty surgeons then indicated their level of agreement with each statement using electronic voting. Where ≤70% agreed or disagreed, the criterion was discussed and revised, and revoting occurred. In standardized telephone interviews, OA patient focus group participants indicated their level of agreement with each revised criterion. Results Qualitative research in 58 OA patients and 14 arthroplasty surgeons identified 11 appropriateness criteria. Member-checking in 15 surgeons (including 5 who had participated in the qualitative study) resulted in agreement on 6 revised criteria. These included evidence of arthritis on joint examination, patient-reported symptoms negatively impacting quality of life, an adequate trial of appropriate nonsurgical treatment, realistic patient expectations of surgery, mental and physical readiness of patient for surgery, and patient-surgeon agreement that potential benefits exceed risks. Thirty-six of the original 58 OA patient focus group participants (62.1%) participated in the member-check interviews and endorsed all 6 criteria. Conclusion Patients and surgeons jointly endorsed 6 criteria for assessment of TJA appropriateness in OA patients. Prospective validation of these criteria (assessed preoperatively) as predictive of postoperative patient-reported outcomes is under way and will inform development of a surgeon-patient decision-support tool for assessment of TJA appropriateness. [ABSTRACT FROM AUTHOR]

Background: Linking cancer registry and administrative data can reveal health care use patterns among cancer patients. The Canadian Cancer Registry (CCR) contains personal health insurance numbers (HINs) that facilitate linkage to hospitalization information in the Discharge Abstract Database (DAD). Data and methods: Valid HINs, captured in the CCR or obtained through probabilistic linkages to provincial health insurance registries, were used to deterministically link prostate, female breast, colorectal and lung cancers diagnosed from 2005 through 2008 with the DAD for iscal years 2004/2005 to 2010/2011. Results: At least 98% of tumours diagnosed from 2005 through 2008 had valid HINs in the CCR or obtained through probabilistic linkages. For provinces submitting day surgeries to the DAD, linkage rates to at least one DAD record were higher for female breast (95.6% to 98.1%), colorectal (96.9% to 98.7%) and lung cancers (92.8% to 96.3%) than for prostate cancers (77.2% to 91.6%). Among linked records, agreement was high for sex (99% or more) and complete date of birth (97% or more); the likelihood of a consistent diagnosis in the CCR and on at least one linked DAD record was higher for female breast (86.8% to 97.2%), colorectal (94.6% to 97.7%) and lung cancers (90.3% to 95.5%) than for prostate cancers (77.4% to 87.8%). Interpretation: Deterministically linking the CCR and DAD using personal HINs is a feasible and valid approach to obtaining hospitalization information about cancer patients. [ABSTRACT FROM AUTHOR]

Based on data from the 2007 to 2009 and 2009 to 2011 Canadian Health Measures Survey, this article provides national information about prescription medication use among community-dwelling Canadians. An estimated 41% of 6- to 79-year-olds who lived in private households reported taking at least one prescription medication in the past two days (current use). Generally, prescription drug use was higher among females and among people in poorer health, and increased with age. Approximately 11% of 45- to 64-year-olds and 30% of seniors aged 65 to 79 took at least five prescription medications concurrently. For adults aged 25 to 79, the leading prescription medication classes were lipid-lowering agents, ACE-inhibitors, peptic-ulcer and acid-reducers, beta-blockers (men), other analgesics and anti-pyretics (men), anti-depressants (women) and thyroid medication (women). Among children and young adults aged 6 to 24, the leading prescription medications were for attention deficit and hyperactivity disorder (males), depression, and hormonal contraception (females). [ABSTRACT FROM AUTHOR]

Background: Canadian households are spending an increasing share of their household income on health care not covered by public plans. This study investigates trends in out-of-pocket expenditures for health care services and products by household income quintile from 1997 to 2009. Data and methods: Biennial estimates from the Survey of Household Spending between 1997 and 2009 were used to examine changes in out-of-pocket health care expenditures by household income quintile. The statistical significance of these changes was assessed using linear and logistic regression. Results: In 2009, the percentage of after-tax household income spent on health care among low-income households (5.7%) was nearly twice that of highincome households (2.6%). Approximately 40% of households in the two lowest income quintiles spent more than 5% of their total after-tax income on health care services, compared with 14% of households in the highest income quintile. The increase in spending between 1997 and 2009 was greatest for households in the lowest income quintile (63%). Interpretation: Out-of-pocket health care expenditures have increased for households in all income quintiles, but the relative increase was greatest among households in lower income quintiles. [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 The widespread use of risk algorithms in clinical medicine is testimony to how they have helped transform clinical decision-making. Risk algorithms have a similar but underdeveloped potential to support decision-making for population health. Objective To describe the role of predictive risk algorithms in a population setting. Methods First, predictive risk algorithms and how clinicians use them are described. Second, the population uses of risk algorithms are described, highlighting the strengths of risk algorithms for health planning. Lastly, the way in which predictive risk algorithms are developed is discussed briefly and a guide for algorithm assessment in population health presented. Conclusion For the past 20 years, absolute and baseline risk has been a cornerstone of population health planning. The most accurate and discriminating method to generate such estimates is the use of multivariable risk algorithms. Routinely collected data can be used to develop algorithms with characteristics that are well suited to health planning and such data are increasingly available. The widespread use of risk algorithms in clinical medicine is testimony to how they have helped transform clinical decision-making. Risk algorithms have a similar but underdeveloped potential to support decision-making for population health. INSETS: Case example of risk prediction in clinical medicined algorithms.;Case example of population use of a clinical risk algorithm. [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]

Objectives. We examined income-related inequalities in self-reported health in the United States and Canada and the extent to which they are associated with individual-level risk factors and health care system characteristics. Methods. We estimated income inequalities with concentration indexes and curves derived from comparable survey data from the 2002 to 2003 Joint Canada-US Survey of Health. Inequalities were then decomposed by regression and decomposition analysis to distinguish the contributions of various factors. Results. The distribution of income accounted for close to half of income-related health inequalities in both the United States and Canada. Health care system factors (e.g., unmet needs and health insurance status) and risk factors (e.g., physical inactivity and obesity) contributed more to income-related health inequalities in the United States than to those in Canada. Conclusions. Individual-level health risk factors and health care system characteristics have similar associations with health status in both countries, but they both are far more prevalent and much more concentrated among lower-income groups in the United States than in Canada. (Am J Public Health. 2009;99: 1856-1863. doi:10.2105/AJPH.2007.129361) [ABSTRACT FROM AUTHOR]

In 2005, an estimated 1.3 million Canadians aged 12 or older (4.9% of the population of these ages) reported to the Canadian Community Health Survey (CCHS) that they had been diagnosed with diabetes. The Canadian Diabetes Association has published Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada, which recommend the type of care that should be provided to individuals with diabetes. According to the CCHS, and based on data from six of the provinces/territories (Newfoundland and Labrador, Prince Edward Island, New Brunswick, Ontario, Manitoba and Yukon Territory), almost three-quarters of diabetic respondents aged 18 or older reported having had their hemoglobin A1C checked by a health care professional at least once in the year before the survey, and those who had had the test were close to meeting the recommended frequency of every three months. The majority of diabetic respondents were also meeting the recommendation for eye examinations, but only half had the recommended annual foot examinations. Half the diabetic population reported that they or a family member had checked their glucose level every day. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Ophthalmology is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objectives To obtain patients’ perspectives on acceptable waiting times for hip or knee replacement surgery. Methods A questionnaire with both open- and close-ended items was mailed to 432 consecutive patients who had hip or knee replacement surgery 3–12 months previously in Saskatchewan, Canada. A content analysis was used to analyse the text data from the open-ended questions. Results The sample of 303 (response rate 70%) was 59% female with a mean age of 70 years (SD 11). The median waiting time from the decision date to surgery was 17 weeks. Individuals who rated their waiting time very acceptable (48%) had a median waiting time of 13 weeks compared with a median waiting time of 22 weeks for those who rated it unacceptable (23%). The two most common determinants of acceptability were patient expectations and pain and its impact on patient quality of life. The median maximum acceptable waiting time was 13 weeks and median ideal waiting time, 8.6 weeks. Seventy-nine per cent felt that those in greater need (higher severity) should go before them on the waiting list. Patient ratings of maximum acceptable waiting time were based on: pain and loss of mobility, time needed to prepare for surgery, and severity at the time of seeing the surgeon. In consideration of changing their surgeon to one with a shorter waiting list, 68% would not. Conclusions Patient views on waiting times are not only related to quality of life issues, but also to prior expectations and notions of fairness and priority. Understanding patient views on waiting for surgery has implications for better management of waiting times and experiences for joint replacement. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Examines trends in self-reported unmet health care needs among household populations in Canada. Data from the Canadian Community Health Survey from September 2000 through February 2001; Level of access to health care; Rate of unmet health care needs.

Offers a study that discusses differences in measurement approaches and a lack of awareness of the effectiveness of different approaches to managing waiting lists and waiting times and how they hamper progress in the Canadian health care system. Causes in the variability in perceptions of waiting lists; Public opinion.

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Hospitals tend to be among the destinations that make densely populated, well-connected neighbourhoods more conducive to active living. In this study, we determined whether living near a hospital distorts the association between living in favourable ALEs and hospitalization for physical inactivity-related cardiometabolic diseases. We used a record linkage of 442,345 respondents of the Canadian Community Health Survey and their hospitalization records for cardiometabolic disease. We then assessed respondents' neighbourhoods using the Canadian Active Living Environments measure (Can-ALE), a measure based on ≥3-way intersection density, residential density, and points of interest. We then calculated the distance in kilometers between the centroids of respondents' assigned dissemination areas and the nearest user-contributed location for hospitals from OpenStreetMap. We monitored changes in estimates for the association between ALEs and odds of cardiometabolic disease hospitalization using a series of logistic regressions with indicator variables for distances to hospital of 500 meters to 10 kilometers. We found that living between 500 meters and six kilometers of a hospital and was associated with modestly higher odds of cardiometabolic hospitalization (OR 1.10, 95% CI 1.02 to 1.18 for 500 meters; OR 1.05, 95% CI 1.01 to 1.09 for six kilometers). Living in more favourable ALEs was associated with lower odds of hospitalization (OR 0.79, 95% CI 0.68 to 0.91; comparing the most favourable to least favourable ALEs). Effect estimates between more favourable ALEs and lower odds of hospitalization were marginally strengthened when living within 2-6 kilometers to a hospital was accounted for. This study demonstrates the importance of disentangling interrelated geographic factors and underlines the potential for built environments to elicit reductions in health care. [ABSTRACT FROM AUTHOR]

Background: Small area estimation refers to statistical modelling procedures that leverage information or "borrow strength" from other sources or variables. This is done to enhance the reliability of estimates of characteristics or outcomes for areas that do not contain sufficient sample sizes to provide disaggregated estimates of adequate precision and reliability. There is growing interest in secondary research applications for small area estimates (SAEs). However, it is crucial to assess the analytic value of these estimates when used as proxies for individual-level characteristics or as distinct measures that offer insights at the area level. This study assessed novel area-level community belonging measures derived using small area estimation and examined associations with individual-level measures of community belonging and self-rated health., Data and Methods: SAEs of community belonging within census tracts produced from the 2016-2019 cycles of the Canadian Community Health Survey (CCHS) were merged with respondent data from the 2020 CCHS. Multinomial logistic regression models were run between area-level SAEs, individual-level sense of community belonging, and self-rated health on the study sample of people aged 18 years and older., Results: Area-level community belonging was associated with individual-level community belonging, even after adjusting for individual-level sociodemographic characteristics, despite limited agreement between individual- and area-level measures. Living in a neighbourhood with low community belonging was associated with higher odds of reporting being in fair or poor health, versus being in very good or excellent health (odds ratio: 1.53; 95% confidence interval: 1.22, 1.91), even after adjusting for other factors such as individual-level sense of community belonging, which was also associated with self-rated health., Interpretation: Area-level and individual-level sense of community belonging were independently associated with self-rated health. The novel SAEs of community belonging can be used as distinct measures of neighbourhood-level community belonging and should be understood as complementary to, rather than proxies for, individual-level measures of community belonging.

Background: The World Health Organization recommends a 10% total energy (TE%) limit for free sugars (i.e., added sugars and naturally occurring sugars in fruit juice, honey, and syrups) based on evidence linking higher intakes with overweight and dental caries. Evidence for cardiovascular disease (CVD) is limited. Impacts may differ by sex, age group, and solid vs. liquid sources; liquids may stimulate more adverse CVD profiles (due to their rapid absorption in the body along along with triggering less satiety). We examined associations of consuming total free sugars ≥ 10 TE% with CVD within four sex and age-defined groups. Given roughly equal free sugar intakes from solid and liquid sources, we also evaluated source-specific associations of free sugars ≥ 5 TE% thresholds., Methods: In this retrospective cohort study, we estimated free sugars from 24-h dietary recall (Canadian Community Health Survey, 2004-2005) in relationship to nonfatal and fatal CVD (Discharge Abstract and Canadian Mortality Databases, 2004-2017; International Disease Classification-10 codes for ischemic heart disease and stroke) through multivariable Cox proportional hazards models adjusted for overweight/obesity, health behaviours, dietary factors, and food insecurity. We conducted analyses in separate models for men 55 to 75 years, women 55 to 75 years, men 35 to 55 years, and women 35 to 55 years. We dichotomized total free sugars at 10 TE% and source-specific free sugars at 5 TE%., Results: Men 55 to 75 years of age had 34% higher CVD hazards with intakes of free sugars from solid sources ≥ 5 TE% vs. below (adjusted HR 1.34, 95% CI 1.05- 1.70). The other three age and sex-specific groups did not demonstrate conclusive associations with CVD., Conclusions: Our findings suggest that from a CVD prevention standpoint in men 55 to 75 years of age, there may be benefits from consuming less than 5 TE% as free sugars from solid sources., (© 2023. The Author(s).)

Background: Sugar-sweetened beverages have obesogenic and diabetogenic effects ascribed to free sugars. These include added sugars and naturally occurring sugars in juices. A meta-analysis indicates that some foods with added sugars are associated with lower type 2 diabetes rates. To expand the evidence relevant to free sugars from solid sources, we examined a young to middle-aged population with respect to overweight and gestational diabetes (GDM) outcomes., Methods: We studied female participants (12-50 years old) from the 2004-2005 Canadian Community Health Survey 2.2 (CCHS) with data linked to the hospital Discharge Abstract Database (DAD) until 2017, providing 13 years of follow-up. We estimated free sugars by solid and liquid sources from 24-h dietary recalls as percent total energy intake (TE%), and computed body mass index (BMI). We applied ICD-10 diagnostic codes for deliveries and GDM to DAD. We conducted multivariable logistic regression analyses to evaluate associations between free sugars with overweight at baseline (cross-sectional component) and, in those who delivered, with GDM during follow-up (nested case control component). We compared those with consumption above versus below various thresholds of intake for free sugars, considering solid and liquid sources separately (2.TE%, 5TE%, 10TE% and 15TE% thresholds)., Results: Among 6305 participants, 2505 (40%) were overweight, defined as BMI ≥ 85th percentile below 18 years and BMI ≥ 25 kg/m 2 for adults. Free sugars from solid sources were associated with lower odds of overweight above versus below the 2.5TE% (adjusted odds ratio [adjOR] 0.80, 95%CI 0.70-0.92), 5TE% (adjOR 0.89, 95%CI 0.79-0.99), and 10TE% (adjOR 0.86, 95%CI 0.75-0.97) thresholds. Free sugars from liquid sources were associated with greater odds of overweight across the 2.5TE% (adjOR 1.20, 95%CI 1.07-1.36), 10TE% (adjOR 1.17, 95%CI 1.02-1.34), and 15TE% (adjOR 1.43, 95%CI 1.23-1.67) thresholds. There were 113 cases of GDM among the 1842 women who delivered (6.1%). Free sugars from solid sources were associated with lower odds of GDM above versus below the 5TE% threshold (adjOR 0.56, 95%CI 0.36-0.85)., Conclusions: Our findings support limiting free sugars from liquid sources, given associations with overweight. We did not identify adverse associations of free sugars from solid sources across any of the thresholds examined., (© 2021. The Author(s).)

Importance: Traumatic injury disproportionately affects adults of working age. The ability to work and earn income is a key patient-centered outcome. The association of severe injury with work and earnings appears to be unknown., Objective: To evaluate the association of severe traumatic injury with subsequent employment and earnings in long-term survivors., Design, Setting, and Participants: This is a retrospective, matched, national, population-based cohort study of adults who had employment and were hospitalized with severe traumatic injury in Canada between January 2008 and December 2010. All acute care hospitalizations for severe injury were included if they involved adults aged 30 to 61 years who were hospitalized with severe traumatic injury, working in the 2 years prior to injury, and alive through the third calendar year after their injury. Patients were matched with unexposed control participants based on age, sex, marital status, province of residence, rurality, baseline health characteristics, baseline earnings, self-employment status, union membership, and year of the index event. Data analysis occurred from March 2019 to December 2019., Main Outcomes and Measures: Changes in employment status and annual earnings, compared with unexposed control participants, were evaluated in the third calendar year after injury. Weighted multivariable probit regression was used to compare proportions of individuals working between those who survived trauma and control participants. The association of injury with mean yearly earnings was quantified using matched difference-in-difference, ordinary least-squares regression., Results: A total of 5167 adults (25.6% female; mean [SD] age, 47.3 [8.8] years) with severe injuries were matched with control participants who were unexposed (25.6% female; mean [SD] age, 47.3 [8.8] years). Three years after trauma, 79.3% of those who survived trauma were working, compared with 91.7% of control participants, a difference of -12.4 (95% CI, -13.5 to -11.4) percentage points. Three years after injury, patients with injuries experienced a mean loss of $9745 (95% CI, -$10 739 to -$8752) in earnings compared with control participants, representing a 19.0% difference in annual earnings. Those who remained employed 3 years after injury experienced a 10.8% loss of earnings compared with control participants (-$6043 [95% CI, -$7101 to -$4986]). Loss of work was proportionately higher in those with lower preinjury income (lowest tercile, -18.5% [95% CI, -20.8% to -16.2%]; middle tercile, -11.5% [95% CI, -13.2% to -9.9%]; highest tercile, -6.0% (95% CI, -7.8% to -4.3%])., Conclusions and Relevance: In this study, severe traumatic injury had a significant association with employment and earnings of adults of working age. Those with lower preinjury earnings experienced the greatest relative loss of employment and earnings.

Objective: To evaluate sex-specific and age-specific associations of active living environments (ALEs) with premature cardiometabolic mortality., Design: Population-based retrospective cohort study., Setting: Residential neighbourhoods (1000-metre circular buffers from the centroids of dissemination areas) across Canada for which the Canadian ALE Measure was derived, based on intersection density, points of interest and dwelling density., Participants: 249 420 survey respondents from an individual-level record linkage between the Canadian Community Health Survey (2000-2010) and the Canadian Mortality Database until 2011, comprised of older women (65-85 years), older men (65-81 years), middle-aged women (45-64 years) and middle-aged men (45-64 years)., Primary Outcome Measures: Premature cardiometabolic mortality and average daily energy expenditure attributable to walking. Multivariable proportional hazards regression models were adjusted for age, educational attainment, dissemination area-level median income, smoking status, obesity, the presence of chronic conditions, season of survey response and survey cycle., Results: Survey respondents contributed a total of 1 451 913 person-years. Greater walking was observed in more favourable ALEs. Walking was associated with lower cardiometabolic death in all groups except for middle-aged men. Favourable ALEs conferred a 22% reduction in death from cardiometabolic causes (HR 0.78, 95% CI 0.63 to 0.97) for older women., Conclusions: On average, people walk more in favourable ALEs, regardless of sex and age. With the exception of middle-aged men, walking is associated with lower premature cardiometabolic death. Older women living in neighbourhoods that favour active living live longer., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Among older Canadians, we examined the influence of low social support, a weak sense of belonging, and living alone to understand their role on mortality risk in Canada., Methods: We conducted a retrospective cohort study of older Canadians surveyed in 2001 from the Canadian Community Health Survey and followed up with death events through December 31, 2011 from the Canadian Vital Statistics Database. Analyses were stratified by age: 55-64 and 65 and older. Social support was assessed using measures developed for the Medical Outcomes Study. A sense of belonging, a binary measure, measured community integration. Living alone was a binary measure. Survival analysis was applied using a Cox proportional hazards model, adjusted for age, sex, income, smoking, and frailty., Results: Among respondents 55-64 (n = 6822), low affection (HR = 1.37; 95% CI 1.07, 1.75), low emotional/informational support (HR = 1.36; 95% CI 1.06, 1.74), and low positive social interactions (HR = 1.36; 95% CI 1.06, 1.75) were associated with mortality risk. Among respondents 65 and older (n = 8966), low affection (HR = 1.17; 95% CI 1.04, 1.31), low positive social interactions (HR = 1.20; 95% CI 1.07, 1.34), low emotional/informational support (HR = 1.19; 95% CI 1.06, 1.33), and a weak sense of belonging (HR = 1.13; 95% CI 1.05, 1.22) were associated with mortality risk., Conclusion: Low social support and a weak sense of belonging are important risk factors among older Canadians and should be part of the dialogue in Canada about their roles in healthy aging.

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.