Emergency Department Use in Patients with Cancer: A Population-Based Study

Introduction Emergency Department (ED) visits in cancer patients represent a significant burden to both patients and the health care system. Emergency Care of cancer patients is complex compared to the population. There is lack of knowledge regarding the pattern and reasons for ED visits in this population. Objectives and Approach We sought to identify factors and patterns associated with ED use among cancer patients, in the first year after diagnosis. Adult cancer patients diagnosed between 2011 and 2013 were identified from the Alberta Cancer Registry. This was linked with cancer related treatments extracted from medical records system at provincial cancer centers. ED visits and outpatient clinics were acquired from National Ambulatory Care Reporting System (NACRS). Databases were linked by unique patient identification number. Previous cancer patients were defined by having at least one cancer related diagnosis in NACRS before. The other patients were treated as non-cancer patients. Results Cancer patients accounted for 6.7% of ED visits and 10\% of ED hours. They had higher male percentage (53% vs. 49%), higher admission rate (23% vs. 10%), ambulance usage (20% vs. 12%) and longer stay (LOS) (171 vs. 131 mins) compared to non-cancer patients. 24% of cancer patients had 4 or more ED visits/year and accounted for 59% of visits. Lung and liver cancer patients had higher ED utilization than patients with other cancers. Breast cancer patients had more after-treatment-ED-visits (41% within a week vs. 26% in lung cancer). Use of ED was highest within 1 month of diagnosis for all types except breast cancer, which was highest at 2 months after. Differences were observed between urban and rural area for numbers reported above. Conclusion/Implications These data suggest high ED utilization by cancer patients, and variation in utilization by cancer type. Identifying the timing and risk factors of ED visit for each cancer type, especially on frequent ED users presents opportunities to improve care in oncology clinics and ED

Facilitating Patient Recruitment Process for Research

Introduction The Assessing outcomes of enhanced Chronic disease Care through patient Education and a value-based formulary Study (ACCESS) conducted from the University of Calgary trial is seeking 4700 low-income Albertans over the age of 65 years at high risk for cardiovascular morbidity and mortality. Recruitment efforts using advertising, conventional methods including posters and brochures in pharmacies have been challenging. The use of admail was attempted but fewer than 260 people (out of nearly 122,000 letters mailed) were enrolled. Objectives and Approach The objective was to determine if linking data collected by Alberta Health Service (AHS) could identify eligible patients and facilitate recruitment for the study. We extracted cohorts of data based ICD codes. These patient’s data were linked with Admission, Discharge and Transfer (ADT) and Master Patient Index (MPI) data to pull patient’s names, addresses and postal codes. Deceased and previously contacted patients were eliminated. The final patient name-list from the Analytics team was merged with a notification letter from Research Administration and sent by the data communication team to candidate patients. Interested patients contacted the researchers. Once informed consent was obtained, the data communication team sent the study questionnaire to the patients directly. Results 30,343 eligible patients were identified in Calgary and 23,305 in Edmonton. Out of 13825 people contacted, 304 people were enrolled into the study – a significantly higher rate than using other mail-based methods. Conclusion/Implications By linking various health administrative data, we assisted researchers to identify potential participants who would otherwise be inaccessible and geographically dispersed across Alberta. This effectively facilitated the recruitment process and enabled patients from across the province to participate with minimal investments

Identifying Knowledge Gaps with Administrative Health Data: A Cohort Study of Traumatic and Non-Traumatic Spinal Cord Injury in Alberta

Introduction The Spinal Cord Injury (SCI) population consists of two main sub-groups: traumatic (TSCI) and non-traumatic (NTSCI). TSCI has been studied; however less attention has been given to NTSCI. It is important to understand both SCI sub-groups for identification of knowledge gaps and subsequent health service planning. Objectives and Approach The goal is to study the SCI population (both TSCI and NTSCI) in Alberta, Canada, leveraging recent administrative health data. It is difficult to identify NTSCI patients for their heterogeneous conditions, and relatively low prevalence. Consequently, we followed a validated algorithm using particular ICD-10-CA codes, to identify (and index) adult SCI patients from Ambulatory and Inpatient records between April 1, 2006 and March 31, 2016. Indexed patients were linked to various databases (inpatient, ambulatory, physician claims, provincial insurance registry), and analyzed in multiple perspectives such as demographics patterns, deaths, resource and cost utilization, geographic distribution, and care equity between groups. Results Through 10 years of data we have identified 5217 SCI patients (3309 TSCI; 1908 NTSCI). 68.7% TSCI and 58.6% NTSCI are male. NTSCI patients are approximately 10 years older (46.3 TSCI; 54.5 NTSCI), and have a 3-point higher Charlson score. 1-year mortality in NTSCI is approximately 2.4 times the TSCI group. Hospitalizations, ER visits, critical care time have also been examined. Patients with NTSCI had a higher median index LOS (14 days IQR (4-51)) compared to the traumatic group who had much higher variability (11 days IQR (11-65.5)). Noted 13.7% NTSCI patients and 19.5% TSCI do not have hospitalizations after index (a diverse characteristic of SCI). Resource Intensity Weights, physician billing, rural-urban area utilization have also been compared between the sub-groups. Conclusion/Implications With the use of administrative databases and a validated algorithm, we described a diverse patient cohort with two main sub-groups (TSCI/NTSCI). Both groups were analyzed upon multiple topics and showed variations. Our results have provided updated knowledge of a comprehensive SCI population in Alberta, Canada, and may lead to improvements on care-giving model

Development of an automated system for clinical study recruitment

Introduction The AFTER AKI study was developed to evaluate implementation of a clinical decision support initiative for acute kidney injury patients. Recruitment relies on staff observing changes in serum creatinine, discussing the study with patients, and then alerting study personnel for consenting patients – a process that misses many eligible patients. Objectives and Approach To improve the efficiency of patient recruitment, we sought to develop an automated system to alert nurses on participating wards when patients on their wards met the study criteria with minimal risk of a data breech. To accomplish this, data from several databases were linked: • Calgary Laboratory Services (CLS; a subsidiary of Alberta Health Services (AHS)) • Data refreshed daily to capture serum creatinine labs • AHS Analytics Data Warehouse • Admission/Discharge/Transfer (ADT) data to determine patient location in hospital on previous day • Discharge Abstract Database (DAD) to exclude patients with prior renal transplant Results The data were linked using the following process: • Daily procedure scheduled to flag patients who met the lab criteria on the previous day using CLS laboratory data. • The identified patients were located by hospital and ward using ADT data, and to exclude patients with a prior renal transplant. Only non-transplant patients located one of the study wards were retained. • Cumulative patient list updated with new patients and dates. • Tableau report created and securely released to ward clerk to enable clerk to view new patients each day for their assigned wards and discuss study with them as an impartial third party. • Consenting patients can then be approached by study personnel to discuss in more detail. Conclusion/Implications A system was successfully created to enable an automated process for patient identification in a clinical trial. Patient privacy was protected by applying user-level security when disseminating reports to ensure that only health care providers within a patient’s ‘circle of care’ had access to necessary information

Early Childhood Respiratory Morbidity and Health Services Utilization in Children Born Preterm or Small and Large for Gestational Age

Introduction Alterations in duration of gestation and fetal growth such as preterm birth (PTB) or small and large for gestational age (SGA, LGA) have long-term consequences on respiratory health. The risk of health services use for respiratory conditions in infants born PTB, SGA or LGA in Canada needs to be evaluated. Objectives and Approach We evaluated the association between PTB, SGA and LGA and health services utilization for respiratory diseases in early childhood. We linked three administrative health databases to identify all singleton live births in Alberta between 2005-2010. We obtained data on the number of hospital admissions and emergency department (ED) visits in the first five years of life for acute upper respiratory infections, acute lower respiratory infections, wheezing disorders, bronchopulmonary dysplasia, and influenza and pneumonia. Odds ratios (OR) of health services use for PTB, SGA, LGA were calculated adjusting for important covariates (e.g., maternal age, sex, socioeconomic status, total antepartum risk score). Results The cohort contained 206,994 infants of whom 9.1% were PTB, 8.5% were SGA and 9.4% were LGA. Babies born prematurely (PTB) were more likely to have a respiratory disease in the first five years of life than babies experienced fetal growth alterations (SGA or LGA). PTB increased significantly the odds of acute lower respiratory infections by 30 to 90%, of wheezing disorders by 40 to 70%, of influenza and pneumonia by 30 to 60%, and of acute upper respiratory infections by 10 to 50%. By contrast, SGA increased the odds of bronchopulmonary dysplasia by 3 to 300%, and LGA increased the odds of acute upper respiratory infections by 11 to 18% and of acute lower respiratory infections by 8 to 11%. Conclusion/Implications Prematurity and alterations in fetal growth are associated with increased hospital and ED admissions in early childhood. The patterns differ for PTB, SGA, and LGA. Linkage of administrative health data provides useful epidemiological evidence to inform the burden of early childhood respiratory diseases resulting from adverse birth outcomes

The Use of Long-Acting Injectable Antipsychotic Therapy for Schizophrenia

Introduction Antipsychotic medications form the cornerstone of schizophrenia treatment. However, only a minority of patients adhere to their initial antipsychotic regimen. It’s expected that Long-Acting Injectable (LAI) antipsychotics improves patient adherence to treatment, however previous research comparing the use of first generation LAI’s against oral antipsychotics reported results that were inconclusive. Objectives and Approach Explore the effectiveness of the use of LAI’s in the delivery of mental health services in Alberta. Using linked data from AHS Analytics: • Physician claims • National Ambulatory Care Reporting System (NACRS), • Discharge Abstract database (DAD) • Pharmacy Information Network (PIN) • Alberta Provincial Registry data • Define a cohort of patients on antipsychotic medications. • Explore and contrast outcomes related to the use of LAIs against other antipsychotic medication types. Specifically using linked data to define: • Treatment Adherence • Utilization of LAI vs. other medication • Demographic differences • Outcomes pre- and post-LAI treatment Results A patient cohort was established containing only cases from April 1, 2013 to March 31, 2015. Additional data was used to perform a two year washout and a one year follow-up. Case and medication definitions were determined by a team of psychiatric clinicians. Patient comorbidity information was extracted using previously validated methods. Overall, 6349 incident cases were identified. Preliminary analysis indicate: • Overall patient cohort is older than expected • Use of additional medication types is correlated with greater health services utilization after diagnosis • Patients on only oral medications appear to have lower treatment adherence • Males seem to have higher treatment adherence than females • No significant differences were found between patients with rural vs. urban postal codes Conclusion/Implications We faced significant challenges when defining cases, medication use and outcomes. However, the linkage of a large number of data sources gives us powerful and multi-faceted insight into the use of antipsychotic medication use in Alberta. Future work will include work on definition validations and deeper analysis of outcomes

Cost analysis and efficacy of recruitment strategies used in a large pragmatic community-based clinical trial targeting low-income seniors: a comparative descriptive analysis

Abstract Objective One of the most challenging parts of running clinical trials is recruiting enough participants. Our objective was to determine which recruitment strategies were effective in reaching specific subgroups. Study design and setting We assessed the efficacy and costs of the recruitment strategies used in the Assessing Outcomes of Enhanced Chronic Disease Care Through Patient Education and a Value-based Formulary Study (ACCESS) in Alberta, Canada. Results Twenty percent of the study budget ($354,330 CAD) was spent on recruiting 4013 participants, giving an average cost per enrolled of$88 CAD. Pharmacies recruited the most participants (n = 1217), at a cost of $128/enrolled. ”Paid media” had the highest cost ($806/enrolled), whereas ”word of mouth” and ”unpaid media” had the lowest (~$3/enrolled). Participants enrolled from ”seniors outreach” had the lowest baseline quality of life and income, while participants from ”word of mouth” had the lowest educational attainment. Conclusion The ”health care providers” strategies were especially successful — at a moderate cost per enrolled. The "media" strategies were less effective, short lasting, and more costly. No strategy was singularly effective in recruiting our targeted groups, emphasizing the importance of utilizing a variety of strategies to reach recruitment goals. Trial registration ClinicalTrials.gov, NCT02579655 . Registered on 19 October 2015