Winnipeg Quality of Life Project Phase One Report

This project addresses the lack of neighbourhood statistical data and survey information on the quality of life in the inner city available to community groups. Many organizations and individuals in Winnipeg’s inner city are working to enhance individual quality of life in the inner city and to raise the standard of living. However, there is no adequate way, at this time, to measure change occurring in neighbourhoods. Inner city organizations and larger governmental and non-governmental organizations collect data useful to measure outcomes of specific programs and general social trends; unfortunately these data and the survey instruments used are not standardized between organizations. It is difficult to use these data when measuring the community-wide impacts of programs, perceptions of residents, and the social or economic progress of neighbourhoods and communities

Evaluating area-based socioeconomic status predictors of pediatric health outcomes in Manitoba

Introduction Socioeconomic gradients in health exist in Canada. Although multiple Canadian area-based socioeconomic measures (ABSM) have been developed, none have been specifically validated against relevant pediatric outcomes. Our objective was to use key pediatric health outcomes and compare the strength of association with a number of ABSM, including income quintile. Objectives and Approach This is a retrospective cross-sectional assessment of the association between socioeconomic status (SES) measured by ABSM and key pediatric health outcomes at the population level. Data from the Manitoba Population Research Data Repository was used for residents aged 0-19y. The timeframe was 2010-2015. Outcomes included preterm births, birth weight, mortality, vaccination rates and teen pregnancy. Regressions used each outcome against various ABSM (e.g. CAN-Marg, SEFI2, INSPQ) or income quintile. Best model for each outcome was assessed by goodness of fit measure (AIC). Measures of inequality included SII (Slope Index of Inequality) and RII (Relative Index of Inequality, both RIImean and RIIratio). Results In our regression models, the 4 Can-Marg subcomponents consistently had about 15% lower AICs (best fit) across all 16 key pediatric outcomes compared to INSPQ (Raymond-Pampalon), income quintile or SEFI2 (Socioeconomic Factor Index - Version 2). Sex differences were small and inconsequential. Whether ABSMs were treated as continuous or categorical predictors was of little statistical consequence. Of note, 15 of the 16 outcomes had socioeconomic gradients identified by SII or RII on at least one of the ABSMs. Income quintile detected 12 of 15, CAN-Marg material deprivation detected 9; the combination of CAN-Marg material deprivation and ethnicity detected 13 of 15. SEFI2 detected only 3 and the National INSPQ detected 6. Conclusion/Implications There are significant health inequalities in pediatric outcomes in Manitoba (15 of 16 studied). Combining CAN-Marg measures of poverty (material deprivation) and ethnic concentration identified 13/15 cases of documented inequality and was the best ABSM for capturing pediatric health gradients; it was similar to income quintile alone

Prenatal care of women who give birth to Children with Fetal Alcohol Spectrum Disorder in a universal health care system: A retrospective cohort study utilizing linkable administrative data

Introduction Fetal Alcohol Spectrum Disorder (FASD) is a significant public health concern. Prenatal care (PNC) settings are integral to preventing prenatal alcohol exposure as physicians delivering PNC services are in a unique position to reduce alcohol consumption during pregnancy. However, few studies have investigated PNC use among women who drink during Objectives and Approach Analysis was conducted of women with children born in Manitoba between April 1, 1984 and Mach 31, 2012, with follow up till 2013 using linkable administrative and novel clinic data. Study group included women whose child(ren) were diagnosed with FASD from 1999 to 2012 (n=702) at a centralised FASD diagnostic clinic. Comparison group included women from the general population whose children who did not have an FASD diagnosis (n=2097), matched on the index child’s birthdate, postal code, and SES. Adequacy of PNC utilization was defined using the revised Graduated Index of Prenatal Care Utilization. Results This is the first population-based study to investigate rates of PNC usage of women who have given birth to children with FASD. Rates of inadequate PNC were higher among the study group (adjusted RR 2.47, 95% CI 2.08 to 2.94), as well as no PNC (adjusted RR 3.55, CI 2.42 to 5.22). Among the study group 63% accessed PNC, with 59% receiving intermediate, adequate, or intensive PNC. Conclusion/Implications Results represent opportunity for screening and brief intervention programs to be delivered in PNC health care settings, as well as outreach programs to facilitate the uptake of PNC among high risk women

Prescription Opioid Use and Concurrent Psychotropic Drug Use During Pregnancy: A Population-Based Retrospective Cohort Study Utilizing Linked Administrative Data

Introduction It is important to investigate the use of prescription opioids during pregnancy to gain insight into the potential impact of maternal opioid exposure during pregnancy on children. We report the prevalence of prescription opioid use and concurrent psychotropic drug use in a large, Canadian population-based cohort of pregnant women. Objectives and Approach Using population-level linked administrative data from a universal health care system, this study included all women with a live birth in Manitoba from 1996 to 2014. Dispensing of opioids was determined from prescription drug data. Patterns of prescription opioids dispensed to pregnant women were investigated by demographic characteristics, region of residence, and socioeconomic status. Concurrent psychotropic therapies were also measured. These data address limitations associated with re-call bias, cilitate longitudinal analaysis, and allow the investigation of rare outcomes, difficult to study using other data sources. Results In a large population level sample of pregnancies (N=245,784), 2.43% of pregnancies were exposed to 2+ dispensations of opioids. An additional 4.95% of pregnancies recorded at a single opioid dispensation. Compared to women who were not dispensed any opioid prescriptions, the proportion of opioid exposed pregnancies who were also prescribed anti-depressants (SSRI/SNRI) was sevenfold higher (22.5% vs 3.05%). The same pattern was found for anxiolytics (37.2% vs 1.5%) and antipsychotics (3.5% vs 0.34%). Conclusion/Implications These data demonstrate high proportions of women were dispensed opioids during pregnancy. Further research should be done on the short term and long term effects of these medications on infants and children. Moreover, these results highlight the need for further investigation into the effects of exposure to multiple psychotropic drug

In-Utero SSRI and SNRI Exposure and the Risk of Long Term Adverse Mental and Educational Outcomes in Children: A Population-Based Retrospective Cohort Study Utilizing Linked Administrative Data

Introduction Few studies are capable of investigating the impact of untreated maternal depression versus in-utero antidepressant exposure on long-term effects on children. Previous studies are limited by confounding by indication and are unable to follow children over time to accurately investigate long term outcomes present in childhood and adolescence. Objectives and Approach We utilize linkable administrative data to facilitate longitudinal analysis to investigate mental and educational outcomes in children exposed to in utero antidepressants. Using population-level linked administrative data from a universal health system, this study included all mother-newborn dyads in Manitoba (born 1996 to 2009, with follow-up through 2014). High Dimensional Propensity Scores and inverse probability treatment weighting were used to address confounding by indication and disease severity.Cox Proportional Hazard Regression models were used to estimate risk of mood and anxiety disorder in children and educational outcomes. Results Asymmetric trimming of the study cohort resulted in a total of 4998 mother-child dyads; 4159 children whose mothers did not use SSRIs/SNRIs during pregnancy and 839 children who were exposed to 2+ prescriptions in-utero. Use of SSRIs/SNRIs during pregnancy was not associated with an increased risk of mood/anxiety disorder in children HR 1.32 (95% CI 0.67 to 2.62). Initial results on the association between in-utero antidepressant use and early childhood development index (EDI) scores indicate no impact on school readiness (31.9% vs 29.3%), or scores on standardized tests of literacy and numeracy in Grade 3 (28.4% meeting expectation versus 31.4%) and in Grade 7 (68.8% versus 70.0%). Conclusion/Implications Administrative data facilitate investigation into an important clinical concern. These data provide robust evidence demonstrating in a large population based sample, in utero exposure to serotonergic antidepressants compared with no exposure does not increase risk of the onset of mood and anxiety disorders and adverse educational outcomes in children

Generating synthetic data from administrative health records for drug safety and effectiveness studies

Introduction Administrative health records (AHRs) are used to conduct population-based post-market drug safety and comparative effectiveness studies to inform healthcare decision making. However, the cost of data extraction, and the challenges associated with privacy and securing approvals can make it challenging for researchers to conduct methodological research in a timely manner using real data. Generating synthetic AHRs that reasonably represent the real-world data are beneficial for developing analytic methods and training analysts to rapidly implement study protocols. We generated synthetic AHRs using two methods and compared these synthetic AHRs to real-world AHRs. We described the challenges associated with using synthetic AHRs for real-world study. Methods The real-world AHRs comprised prescription drug records for individuals with healthcare insurance coverage in the Population Research Data Repository (PRDR) from Manitoba, Canada for the 10-year period from 2008 to 2017. Synthetic data were generated using the Observational Medical Dataset Simulator II (OSIM2) and a modification (ModOSIM). Synthetic and real-world data were described using frequencies and percentages. Agreement of prescription drug use measures in PRDR, OSIM2 and ModOSIM was estimated with the concordance coefficient. Results The PRDR cohort included 169,586,633 drug records and 1,395 drug types for 1,604,734 individuals. Synthetic data for 1,000,000 individuals were generated using OSIM2 and ModOSIM. Sex and age group distributions were similar in the real-world and synthetic AHRs. However, there were significant differences in the number of drug records and number of unique drugs per person for OSIM2 and ModOSIM when compared with PRDR. For the average number of days of drug use, concordance with the PRDR was 16% (95% confidence interval [CI]: 12%-19%) for OSIM2 and 88% (95% CI: 87%-90%) for ModOSIM. Conclusions ModOSIM data were more similar to PRDR than OSIM2 data on many measures. Synthetic AHRs consistent with those found in real-world settings can be generated using ModOSIM. Synthetic data will benefit rapid implementation of methodological studies and data analyst training

Using Administrative Data to Evaluate the Effectiveness of Home Visiting Programs for Improving the Well-Being of First Nations Children and Parents

Introduction The province-wide Families First Home Visiting Program (FFHV) provides home visiting to families with children living in conditions of risk. It remains unknown if First Nations families are benefiting from the program. Using existing administrative and population-wide data is an innovative practice to evaluate programs that have been scaled up. Objectives and Approach The objective is to determine FFHV’s effectiveness at improving outcomes for First Nations children and parents. The partnership with First Nations Health and Social Secretariat of Manitoba facilitated access to First Nations identifiers and provided guidance in conducting the study. Program data from 4,010 First Nations children and parents were linked at an individual-level to administrative data housed at the Manitoba Centre for Health Policy. We compared the predictive probability of outcomes of program and non-program families. Inverse probability of treatment weights were used to adjust for confounders related to both entry into FFHV and the outcomes under study. Results The cohort of First Nations children and parents was successfully linked through an individual scrambled health identifier. FFHV was associated with higher rates of child immunization at age one (71% versus 66%) and age two (47% versus 41%) and parental involvement in community support groups (21% versus 17%). It was also associated with lower rates of being in care of child welfare at age one (10% versus 14%) and age two (15% versus 19%); maltreatment-related hospitalizations at age three (0.4% versus 1.0%); and child victimization as measured by justice system records (1.7% versus 3.0%). However, there were no differences in being “not ready for school” between the two groups of children, nor between the groups of mothers in physician visits for mental health reasons. Conclusion/Implications Home visiting services can play a role in supporting healthy development of First Nations children by providing support to parents and connecting children to health and social services, however, there also remains an urgent need for long term strategies to address structural inequality and the ongoing effects of colonization

In-Utero SSRI and SNRI Exposure and the Risk of Neurodevelopmental Disorders in Children: A Population-Based Retrospective Cohort Study Utilizing Linked Administrative Data

Introduction Many studies demonstrating an association between in utero exposure to serotonergic antidepressants and higher risk of neurodevelopmental disorders in children are confounded by history of maternal depression and disease severity. We conducted a population-based analysis of women diagnosed with mood/anxiety disorder, a patient population for whom pharmacotherapy is clearly indicated. Objectives and Approach Using linked population-based administrative data, we identified all mother-newborn pairs in Manitoba (born 1996 to 2009, with follow-up through 2014). High dimensional propensity scores and inverse probability treatment weighting were used to address confounding by indication and disease severity. The final trimmed cohort consisted of mothers who were diagnosed with a mood/anxiety disorder from 90 days prior to conception until delivery (n=4995). Cox Proportional Hazard Regression models were used to estimate risk of Autism Spectrum Disorder, epilepsy and attention deficit hyperactivity disorder (ADHD) in offspring. In addition to clinical data, we used novel education data to define outcomes in children. Results Among the cohort of mothers diagnosed with a mood/anxiety disorder during pregnancy or up to 90 days before, 16.8% received at least two dispensations of an SSRI or SNRI during pregnancy. We did not observe an association between use of SSRIs/SNRIs during pregnancy and increased risk of Autism Spectrum Disorder (hazard ratio 0.92; 95% CI 0.42 to 2.03), epilepsy (hazard ratio 1.21; 95% CI 0.48 to 3.05), or ADHD (hazard ratio 1.13, 95% CI 0.78 to 1.64) among offspring. Conclusion/Implications In the absence of randomized control trials, large observation studies using sophisticated data analysis are the gold standard of evidence to help patients and clinicians making the decision to continue antidepressant use during pregnancy. Results of this study reassure women for whom the medication is clinically indicated

No Strings Attached: The Impact of an Unconditional Prenatal Income Supplement on First Nations Birth and Early Childhood Outcomes

Introduction In Manitoba, low-income pregnant women are eligible for the Healthy Baby Prenatal Benefit (HBPB), an unconditional income supplement provided during the second and third trimester of pregnancy. HBPB is associated with improved birth outcomes for Manitoba women; its association with birth outcomes for First Nations (Indigenous) women is unknown. Objectives and Approach To determine the association between HBPB and First Nations’ (FN) newborn and early childhood outcomes, we linked whole-population data from health, public health, family services and education. We included only FN women receiving income assistance during pregnancy (n=7074) to develop comparable treatment (received HBPB; n=5283) and comparison (no HBPB; n=1791) groups. Propensity score weighting adjusted for differences in maternal characteristics between groups. Multi-variable regressions compared groups on breastfeeding initiation, low birth weight, preterm birth, small- and large-for-gestational age, Apgar scores, complete immunizations at 1 and 2 years, and developmental vulnerability in kindergarten measured with the Early Development Instrument (EDI). Results Receipt of the HBPB was associated with reductions in low birth weight births (adjusted Relative Risk (aRR): 0.77; 95% CI: 0.63, 0.93) and preterm births (aRR: 0.78 (0.68, 0.90)), and increases in breastfeeding initiation (aRR: 1.05 (1.00, 1.09)) and large-for-gestational age births (aRR: 1.11 (1.01, 1.23)). HBPB receipt during pregnancy was also associated with increases in 1- and 2-year immunizations for FN children (aRR: 1.14 (1.09, 1.19), and aRR: 1.28 (1.19, 1.36), respectively). Reductions in the risk of being developmentally vulnerable in the language and cognitive domain of the EDI were also found for FN children whose mothers had received the HBPB during pregnancy (aRR: 0.85 (0.74, 0.97). Conclusion/Implications A modest unconditional income supplement during pregnancy was associated with improved birth outcomes, increased immunization rates, and improved language and cognitive development at kindergarten for children born to low-income First Nations women. Long-term strategies to address structural inequities and the ongoing effects of colonization are also needed