Using funnel plots in public health surveillance

<p>Abstract</p> <p>Background</p> <p>Public health surveillance is often concerned with the analysis of health outcomes over small areas. Funnel plots have been proposed as a useful tool for assessing and visualizing surveillance data, but their full utility has not been appreciated (for example, in the incorporation and interpretation of risk factors).</p> <p>Methods</p> <p>We investigate a way to simultaneously focus funnel plot analyses on direct policy implications while visually incorporating model fit and the effects of risk factors. Health survey data representing modifiable and nonmodifiable risk factors are used in an analysis of 2007 small area motor vehicle mortality rates in Alberta, Canada.</p> <p>Results</p> <p>Small area variations in motor vehicle mortality in Alberta were well explained by the suite of modifiable and nonmodifiable risk factors. Funnel plots of raw rates and of risk adjusted rates lead to different conclusions; the analysis process highlights opportunities for intervention as risk factors are incorporated into the model. Maps based on funnel plot methods identify areas worthy of further investigation.</p> <p>Conclusions</p> <p>Funnel plots provide a useful tool to explore small area data and to routinely incorporate covariate relationships in surveillance analyses. The exploratory process has at each step a direct and useful policy-related result. Dealing thoughtfully with statistical overdispersion is a cornerstone to fully understanding funnel plots.</p

German evidence-based guidelines for the treatment of Psoriasis vulgaris (short version)

Psoriasis vulgaris is a common and chronic inflammatory skin disease which has the potential to significantly reduce the quality of life in severely affected patients. The incidence of psoriasis in Western industrialized countries ranges from 1.5 to 2%. Despite the large variety of treatment options available, patient surveys have revealed insufficient satisfaction with the efficacy of available treatments and a high rate of medication non-compliance. To optimize the treatment of psoriasis in Germany, the Deutsche Dermatologische Gesellschaft and the Berufsverband Deutscher Dermatologen (BVDD) have initiated a project to develop evidence-based guidelines for the management of psoriasis. The guidelines focus on induction therapy in cases of mild, moderate, and severe plaque-type psoriasis in adults. The short version of the guidelines reported here consist of a series of therapeutic recommendations that are based on a systematic literature search and subsequent discussion with experts in the field; they have been approved by a team of dermatology experts. In addition to the therapeutic recommendations provided in this short version, the full version of the guidelines includes information on contraindications, adverse events, drug interactions, practicality, and costs as well as detailed information on how best to apply the treatments described (for full version, please see Nast et al., JDDG, Suppl 2:S1–S126, 2006; or http://www.psoriasis-leitlinie.de)

The health equity measurement framework: a comprehensive model to measure social inequities in health

Abstract Background Despite the wealth of frameworks on social determinants of health (SDOH), two current limitations include the relative superficial description of factors affecting health and a lack of focus on measuring health equity. The Health Equity Measurement Framework (HEMF) addresses these gaps by providing a more encompassing view of the multitude of SDOH and drivers of health service utilisation and by guiding quantitative analysis for public health surveillance and policy development. The objective of this paper is to present the HEMF, which was specifically designed to measure the direct and indirect effects of SDOH to support improved statistical modelling and measurement of health equity. Methods Based on a framework synthesis, the HEMF development involved initially integrating theoretical components from existing SDOH and health system utilisation frameworks. To further develop the framework, relevant publications on SDOH and health equity were identified through a literature review in major electronic databases. White and grey literatures were critically reviewed to identify strengths and gaps in the existing frameworks in order to inform the development of a unique health equity measurement framework. Finally, over a two-year period of consultation, scholars, health practitioners, and local policy influencers from municipal and provincial governments provided critical feedback on the framework regarding its components and causal relationships. Results This unified framework includes the socioeconomic, cultural, and political context, health policy context, social stratification, social location, material and social circumstances, environment, biological factors, health-related behaviours and beliefs, stress, quality of care, and healthcare utilisation. Alongside the HEMF’s self-exploratory diagram showing the causal pathways in-depth, a number of examples are provided to illustrate the framework’s usefulness in measuring and monitoring health equity as well as informing policy-making. Conclusions The HEMF highlights intervention areas to be influenced by strategic public policy for any organisation whose purview has an effect on health, including helping non-health sectors (such as education and labour) to better understand how their policies influence population health and perceive their role in health equity promotion. The HEMF recognises the complexity surrounding the SDOH and provides a clear, overarching direction for empirical work on health equity

Impact of Socioeconomic Status and Residence Distance on Infant Heart Disease Outcomes in Canada

Background Socioeconomic status (SES) impacts clinical outcomes associated with severe congenital heart disease (sCHD). We examined the impact of SES and remoteness of residence (RoR) on congenital heart disease (CHD) outcomes in Canada, a jurisdiction with universal health insurance. Methods and Results All infants born in Canada (excluding Quebec) from 2008 to 2018 and hospitalized with CHD requiring intervention in the first year were identified. Neighborhood level SES income quintiles were calculated, and RoR was categorized as residing 300 km from the closest of 7 cardiac surgical programs. In‐hospital mortality at 300 km, respectively. Although SES and RoR had no impact on sCHD mortality, infants with mCHD living >300 km had a higher risk of mortality relative to those living <100 km (adjusted odds ratio [aOR], 1.43 [95% CI, 1.11–1.84]). Infants with mCHD within the lowest SES quintile and living farthest away had the highest risk for mortality (aOR, 1.74 [95% CI, 1.08–2.81]). Conclusions In Canada, neither RoR nor SES had an impact on outcomes of infants with sCHD. Greater RoR, however, may contribute to higher risk of mortality among infants with mCHD

Associations between social determinants of health and weight status in preschool children: a population-based study

IntroductionSocial determinants of health (SDH) may influence children’s weight status. Our objective was to examine relationships between SDH and preschoolers’ weight status. MethodsThis retrospective cohort study included 169 465 children (aged 4–6 years) with anthropometric measurements taken at immunization visits from 2009 to 2017 in Edmonton and Calgary, Canada. Children were categorized by weight status based on WHO criteria. Maternal data were linked to child data. The Pampalon Material and Social Deprivation Indexes were used to assess deprivation. We used multinomial logistic regression to generate relative risk ratios (RRRs) to examine associations between ethnicity, maternal immigrant status, neighbourhood-level household income, urban/ rural residence and material and social deprivation with child weight status. ResultsChildren of Chinese ethnicity were less likely than those in the General Population to have overweight (RRR = 0.64, 95% CI: 0.61–0.69) and obesity (RRR = 0.51, 0.42–0.62). Children of South Asian ethnicity were more likely than those in the General Population to have underweight (RRR = 4.14, 3.54–4.84) and more likely to have obesity (RRR = 1.39, 1.22–1.60). Children with maternal immigrant status were less likely than those without maternal immigrant status to have underweight (RRR = 0.72, 0.63–0.82) and obesity (RRR = 0.71, 0.66–0.77). Children were less likely to have overweight (RRR = 0.95, 0.94–0.95) and obesity (RRR = 0.88, 0.86–0.90) for every CAD 10 000 increase in income. Relative to the least deprived quintile, children in the most materially deprived quintile were more likely to have underweight (RRR = 1.36, 1.13–1.62), overweight (RRR = 1.52, 1.46–1.58) and obesity (RRR = 2.83, 2.54–3.15). Relative to the least deprived quintile, children in the most socially deprived quintile were more likely to have overweight (RRR = 1.21, 1.17–1.26) and obesity (RRR = 1.40, 1.26–1.56). All results are significant to p $lt; 0.001. ConclusionOur findings suggest the need for interventions and policies to address SDH in preschoolers to optimize their weight and health

Associations entre les déterminants sociaux de la santé et le statut pondéral des enfants d’âge préscolaire : une étude de population

IntroductionLes déterminants sociaux de la santé peuvent avoir une incidence sur le poids des enfants. Notre objectif était d’étudier les relations entre les déterminants sociaux de la santé et le poids des enfants d’âge préscolaire. MéthodologieCette étude de cohorte rétrospective portait sur 169 465 enfants (âgés de 4 à 6 ans) dont les mesures anthropométriques ont été prises lors de rendez-vous de vaccination de 2009 à 2017 à Edmonton et à Calgary (Canada). Les enfants ont été classés par statut pondéral sur la base des critères de l’Organisation mondiale de la santé (OMS). Les données sur les mères ont été jumelées aux données sur les enfants. Les indices de défavorisation matérielle et sociale de Pampalon ont été utilisés pour évaluer la défavorisation. Nous avons utilisé une régression logistique multinomiale pour générer des rapports de risque relatif (RRR) afin d’étudier les associations entre, d’une part, le groupe ethnique, le statut d’immigration de la mère, le revenu des ménages du quartier, la résidence en milieu urbain ou rural et la défavorisation matérielle et sociale et, d’autre part, le statut pondéral de l’enfant. RésultatsLes enfants d’origine chinoise risquaient moins que ceux de la population générale de faire de l’embonpoint (RRR = 0,64, IC à 95 % : 0,61 à 0,69) ou de l’obésité (RRR = 0,51, 0,42 à 0,62). Les enfants d’origine sud-asiatique risquaient plus que ceux de la population générale d’être en situation d’insuffisance pondérale (RRR = 4,14, 3,54 à 4,84) ou d’obésité (RRR = 1,39, 1,22 à 1,60). Les enfants de mère immigrante risquaient moins que les autres à être en situation d’insuffisance pondérale (RRR = 0,72, 0,63 à 0,82) ou d’obésité (RRR = 0,71, 0,66 à 0,77). La probabilité que les enfants fassent de l’embonpoint (RRR = 0,95, 0,94 à 0,95) ou de l’obésité (RRR = 0,88, 0,86 à 0,90) diminuait avec chaque passage à la tranche de revenu de 10 000 $CA supérieure. Par rapport au quintile le moins défavorisé, les enfants du quintile le plus défavorisé sur le plan matériel risquaient plus de présenter une insuffisance pondérale (RRR = 1,36, 1,13 à 1,62), un surpoids (RRR = 1,52, 1,46 à 1,58) ou de l’obésité (RRR = 2,83, 2,54 à 3,15). Par rapport au quintile le moins défavorisé, les enfants du quintile le plus socialement défavorisé risquaient plus de présenter un surpoids (RRR = 1,21, 1,17 à 1,26) ou de l’obésité (RRR = 1,40, 1,26 à 1,56). Tous les résultats sont significatifs à p$lt; 0,001. ConclusionNos constatations indiquent qu’il est nécessaire de mettre en place des interventions et des politiques qui tiennent compte des déterminants sociaux de la santé chez les enfants d’âge préscolaire afin d’optimiser leur poids et leur santé

Trends in Uptake and Adherence to Oral Anticoagulation for Patients With Incident Atrial Fibrillation at High Stroke Risk Across Health Care Settings

Background Oral anticoagulation (OAC) therapy prevents morbidity and mortality in nonvalvular atrial fibrillation; whether location of diagnosis influences OAC uptake or adherence is unknown. Methods and Results Retrospective cohort study (2008–2019), identifying adults with incident nonvalvular atrial fibrillation across health care settings (emergency department, hospital, outpatient) at high risk of stroke. OAC uptake and adherence via proportion of days covered for direct OACs and time in therapeutic range for warfarin were measured. Proportion of days covered was categorized as low (0–39%), intermediate (40–79%), and high (80–100%). Warfarin control was defined as time in therapeutic range ≥65%. All‐cause mortality was examined at a 3‐year landmark. Among 75 389 patients with nonvalvular atrial fibrillation (47.0% women, mean 77.4 years), 19.7% were diagnosed in the emergency department, 59.1% in the hospital, and 21.2% in the outpatient setting. Ninety‐day OAC uptake was 51.6% in the emergency department, 50.9% in the hospital, and 67.9% in the outpatient setting (P<0.0001). High direct OAC adherence increased from 64.9% to 80.3% in the emergency department, 64.3% to 81.7% in the hospital, and 70.9% to 88.6% in the outpatient setting over time (P values for trend <0.0001). Warfarin control was 40.3% overall and remained unchanged. In multivariable analysis, outpatient diagnosis compared with the hospital was associated with greater OAC uptake (odds ratio [OR], 1.79; [95% CI, 1.72–1.87]) and direct OAC (OR, 1.42; [95% CI, 1.27–1.59]) and warfarin (OR, 1.49; [95% CI, 1.36–1.63]) adherence. Varying or persistently low adherence was associated with a poor prognosis, especially for warfarin. Conclusions Locale of nonvalvular atrial fibrillation diagnosis is associated with varying OAC uptake and adherence. Interventions specific to health care settings are needed to improve stroke prevention

The Challenges of Identifying Patients With Peripheral Artery Disease Utilizing Administrative Databases

Peripheral artery disease (PAD) carries a high burden of morbidity when identified in patients with coronary artery disease (CAD). However, identification of patients with concomitant CAD and PAD remains challenging. Using linked administrative databases of 207,026 individuals with CAD between 2002 and 2019 (median follow-up, 4.7 years), a model for PAD was applied to identify baseline PAD and the development of PAD during follow-up. Both baseline PAD and future PAD models demonstrated poor calibration and discrimination (c-statistic 0.618 and 0.583). In the absence of additional variables, the present models are unable to identify patients with concomitant CAD and PAD. Résumé: La maladie artérielle périphérique (MAP) impose un lourd fardeau de morbidité lorsqu’elle est diagnostiquée chez les patients atteints de coronaropathie. Toutefois, il reste difficile de repérer les patients atteints à la fois de coronaropathie et de MAP. À partir de bases de données administratives liées comptant 207 026 personnes atteintes de coronaropathie entre 2002 et 2019 (suivi médian de 4,7 ans), un modèle pour la MAP a été appliqué afin de repérer une MAP initiale et l’apparition d’une MAP au cours du suivi. Les modèles de MAP initiale et de MAP future ont tous deux été associés à un calibrage et à une capacité de distinction insatisfaisants (statistique C de 0,618 et 0,583). En l’absence d’autres variables, les modèles actuels sont incapables de repérer les patients atteints de coronaropathie et de MAP concomitantes