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Objectives: Implementation of the International Statistical Classification of Disease and Related Health Problems, 10th Revision (ICD-10) coding system presents challenges for using administrative data. Recognizing this, we conducted a multistep process to develop ICD-10 coding algorithms to define Charlson and Elixhauser comorbidities in administrative data and assess the performance of the resulting algorithms. Methods: ICD-10 coding algorithms were developed by \"translation\" of the ICD-9-CM codes constituting Deyo's (for Charlson comorbidities) and Elixhauser's coding algorithms and by physicians' assessment of the face-validity of selected ICD-10 codes. The process of carefully developing ICD-10 algorithms also produced modified and enhanced ICD-9-CM coding algorithms for the Charlson and Elixhauser comorbidities. We then used data on in-patients aged 18 years and older in ICD-9-CM and ICD-10 administrative hospital discharge data from a Canadian health region to assess the comorbidity frequencies and mortality prediction achieved by the original ICD-9-CM algorithms, the enhanced ICD-9-CM algorithms, and the new ICD-10 coding algorithms. Results: Among 56,585 patients in the ICD-9-CM data and 58,805 patients in the ICD-10 data, frequencies of the 17 Charlson comorbidities and the 30 Elixhauser comorbidities remained generally similar across algorithms. The new ICD-10 and enhanced ICD-9-CM coding algorithms either matched or outperformed the original Deyo and Elixhauser ICD-9-CM coding algorithms in predicting in-hospital mortality. The C-statistic was 0.842 for Deyo's ICD-9-CM coding algorithm, 0.860 for the ICD-10 coding algorithm, and 0.859 for the enhanced ICD-9-CM coding algorithm, 0.868 for the original Elixhauser ICD-9-CM coding algorithm, 0.870 for the ICD-10 coding algorithm and 0.878 for the enhanced ICD-9-CM coding algorithm. Conclusions: These newly developed ICD-10 and ICD-9-CM comorbidity coding algorithms produce similar estimates of comorbidity prevalence in administrative data, and may outperform existing ICD-9-CM coding algorithms.

In sub-Saharan Africa, a shortage of trained health professionals and limited geographical access to health facilities present major barriers to the expansion of antiretroviral therapy (ART). We tested the utility of a health centre (HC)/community-based approach in the provision of ART to persons living with HIV in a rural area in western Uganda. The HIV treatment outcomes of the HC/community-based ART program were evaluated and compared with those of an ART program at a best-practice regional hospital. The HC/community-based cohort comprised 185 treatment-naïve patients enrolled in 2006. The hospital cohort comprised of 200 patients enrolled in the same time period. The HC/community-based program involved weekly home visits to patients by community volunteers who were trained to deliver antiretroviral drugs to monitor and support adherence to treatment, and to identify and report adverse reactions and other clinical symptoms. Treatment supporters in the homes also had the responsibility to remind patients to take their drugs regularly. ART treatment outcomes were measured by HIV-1 RNA viral load (VL) after two years of treatment. Adherence was determined through weekly pill counts. Successful ART treatment outcomes in the HC/community-based cohort were equivalent to those in the hospital-based cohort after two years of treatment in on-treatment analysis (VL≤400 copies/mL, 93.0% vs. 87.3%, p = 0.12), and in intention-to-treat analysis (VL≤400 copies/mL, 64.9% and 62.0%, p = 0.560). In multivariate analysis patients in the HC/community-based cohort were more likely to have virologic suppression compared to hospital-based patients (adjusted OR = 2.47, 95% CI 1.01-6.04). Acceptable rates of virologic suppression were achieved using existing rural clinic and community resources in a HC/community-based ART program run by clinical officers and supported by lay volunteers and treatment supporters. The results were equivalent to those of a hospital-based ART program run primarily by doctors.

To explore the impact of a physician non-accompanying pediatric critical care transport program, and to identify factors associated with the selection of specific transport team compositions. Children transported to a Canadian academic children's hospital were included. Two eras (Physician-accompanying Transport (PT)-era: 2000–07 when physicians commonly accompanied the transport team; and Physician-Less Transport (PLT)-era: 2010–15 when a physician non-accompanying team was increasingly used) were compared with respect to transport and PICU outcomes. Transport and patient characteristics for the PLT-era cohort were examined to identify factors associated with the selection of a physician accompanying team, with multivariable logistic regression with triage physicians as random effects. In the PLT-era (N=1177), compared to the PT-era (N=1490) the probability of PICU admission was significantly lower, and patient outcomes including mortality were not significantly different. Associations were noted between the selection of a physician non-accompanying team and specific transport characteristics. There was appreciable variability among the triage physicians for the selection of a physician non-accompanying team. No significant differences were observed with increasing use of a physician non-accompanying team. Selection of transport team compositions was influenced by clinical and system factors, but appreciable variation still remained among triage physicians. •There were no significant differences in patient outcomes in increasing use of a PLT team in a Canadian pediatric retrieval system.•Selection of transport team composition is influenced by clinical and system factors.•An appreciable variation among triage physicians exists even after adjusting for them.

Ordinal scales often generate scores with skewed data distributions. The optimal method of analyzing such data is not entirely clear. The objective was to compare four statistical multivariable strategies for analyzing skewed health-related quality of life (HRQOL) outcome data. HRQOL data were collected at 1 year following catheterization using the Seattle Angina Questionnaire (SAQ), a disease-specific quality of life and symptom rating scale. In this methodological study, four regression models were constructed. The first model used linear regression. The second and third models used logistic regression with two different cutpoints and the fourth model used ordinal regression. To compare the results of these four models, odds ratios, 95% confidence intervals, and 95% confidence interval widths (i.e., ratios of upper to lower confidence interval endpoints) were assessed. Relative to the two logistic regression analysis, the linear regression model and the ordinal regression model produced more stable parameter estimates with smaller confidence interval widths. A combination of analysis results from both of these models (adjusted SAQ scores and odds ratios) provides the most comprehensive interpretation of the data.

Mycobacterium tuberculosis Beijing strains are frequently associated with tuberculosis outbreaks and drug resistance. However, contradictory evidence and limited study generalizability make it difficult to foresee if the emergence of Beijing strains in high-income immigrant-receiving countries poses an increased public health threat. The purpose of this study was to determine if Beijing strains are associated with high risk disease presentations relative to other strains within Canada. This was a retrospective population-based study of culture-confirmed active TB cases in a major immigrant-receiving province of Canada in 1991 through 2007. Of 1,852 eligible cases, 1,826 (99%) were successfully genotyped. Demographic, clinical, and mycobacteriologic surveillance data were combined with molecular diagnostic data. The main outcome measures were site of disease, lung cavitation, sputum smear positivity, bacillary load, and first-line antituberculosis drug resistance. A total of 350 (19%) patients had Beijing strains; 298 (85%) of these were born in the Western Pacific. Compared to non-Beijing strains, Beijing strains were significantly more likely to be associated with polyresistance (aOR 1.8; 95% CI 1.0-3.3; p = 0.046) and multidrug-resistance (aOR 3.4; 1.0-11.3; p = 0.049). Conversely, Beijing strains were no more likely than non-Beijing strains to be associated with respiratory disease (aOR 1.3; 1.0-1.8; p = 0.053), high bacillary load (aOR 1.2; 0.6-2.7), lung cavitation (aOR 1.0; 0.7-1.5), immediately life-threatening forms of tuberculosis (aOR 0.8; 0.5-1.6), and monoresistance (aOR 0.9; 0.6-1.3). In subgroup analyses, Beijing strains only had a significant association with multidrug-resistant tuberculosis (aOR 6.1; 1.2-30.4), and an association of borderline significance with polyresistant tuberculosis (aOR 1.8; 1.0-3.5; p = 0.062), among individuals born in the Western Pacific. Other than an increased risk of polyresistant or multidrug-resistant tuberculosis, Beijing strains appear to pose no more of a public health threat than non-Beijing strains within a high-income immigrant-receiving country.

The purpose of this study was to examine gender differences in mortality for human immunodeficiency virus (HIV) patients in rural Western Uganda after six months of highly active antiretroviral therapy (HAART). Three hundred eighty five patients were followed up for six months after initiating HAART. Statistical analysis included descriptive, univariate and multivariate methods, using Kaplan-Meier estimates of survival distribution and Cox proportional hazards regression. Mortality in female patients (9.0%) was lower than mortality in males (13.5%), with the difference being almost statistically significant (adjusted hazard ratio for females 0.55; 95% confidence interval [CI]: 0.28-1.07; P = 0.08). At baseline, female patients had a significantly higher CD4+ cell count than male patients (median 147 cells/μL vs 120 cells/μL; P < 0.01). A higher CD4+ cell count and primary level education were strongly associated with better survival. The higher CD4+ cell count in females may indicate that they accessed HAART services at an earlier stage of their disease progression than males. A borderline statistically significant lower mortality rate in females shows that females fare better on treatment in this context than males. The association between lower mortality and higher CD4+ levels suggest that males are not accessing treatment early enough and that more concerted efforts need to be made by HAART programs to reach male HIV patients.

OBJECTIVE:The HIV/AIDS epidemic disproportionately involves socially vulnerable populations. Since 2001, the proportion of foreign-born patients served by the Northern Alberta HIV Program has increased. Our study aimed to evaluate antiretroviral therapy (ART) outcomes among HIV-infected foreign-born patients in northern Alberta, Canada, prescribed once-daily ART. METHODS:We utilized a two-part retrospective cohort study to compare ART outcomes of foreign-born and Canadian-born Aboriginal patients compared to Canadian-born non-Aboriginal patients. Part 1 utilized logistic regression to compare the odds of experiencing initial virological suppression of foreign-born (40%) and Canadian-born Aboriginal patients (27%) compared with Canadian-born non-Aboriginal patients (33%). Part 2 used survival analysis to compare the rate of ART failure by country of origin among patients who achieved initial virological suppression in Part 1. RESULTS:Our study sample included 322 treatment-naïve patients (122 foreign-born). For Part 1, 261 patients achieved initial virological suppression within six months of initiating ART. After controlling for age, treatment regimen, HIV risk exposure, and calendar year compared to Canadian-born non-Aboriginal patients, the odds of achieving initial virological suppression were significantly lower for Canadian-born Aboriginal patients (OR=0.44, 95% CI: 0.20-0.96); and similar for foreign-born patients (OR=0.76, 95% CI: 0.33-1.73). Part 2 included 261 patients who were followed for 635.1 person-years. Adjusting for age, sex, baseline CD4 cell count, and drug regimen, compared to Canadian-born non-Aboriginal patients, Canadian-born Aboriginal and foreign-born patients had similar rates of virological failure after achieving initial virological suppression (HR=1.54, 95% CI: 0.38-6.18; HR=0.49, 95% CI: 0.11-2.20, respectively). CONCLUSIONS:Our study indicated that ART outcomes among Alberta-based foreign-born patients are similar to those among Canadian-born non-Aboriginal patients. Our results, however, suggested that Canadian-born Aboriginal patients had poorer treatment outcomes compared to Canadian-born non-Aboriginal patients. It is imperative, therefore, that clinicians, researchers and community members better understand reasons for poor ART outcomes among Canadian-born Aboriginal patients in northern Alberta.

Background: Aboriginals are over-represented in Canada's HIV epidemic and are commonly infected with HIV via injection drug use (IDU); however, little is known about the impact of Aboriginal ethnicity on mortality after starting highly active antiretroviral therapy (HAART). Therefore, we compared mortality rates between Aboriginal and non-Aboriginal HIV patients and between IDU and non-IDU HIV patients after they initiated HAART. Methods: We conducted a retrospective cohort study of antiretroviral-naïve patients starting HAART January 1999-June 2005 (baseline), followed until December 2005. We constructed two Cox proportional hazards models, one to estimate all-cause and one to estimate HIV-related mortality hazard ratios (HRs), considering sex, and baseline age, CD4 cell count, HIV RNA level, calendar year, and HAART regimen as potential confounders. Results: The 548 study patients were followed for 1,889.8 person-years; 194 (35%) were Aboriginal, 255 (46%) were IDUs. We observed 55 deaths; 47% were HIV-related. In multivariable models, Aboriginals experienced higher all-cause (HR=1.85, 95% CI=1.05-3.26, p=0.034) and HIV-related (HR=3.47, 95% CI= 1.36-8.83, p=0.009) mortality rates compared to non-Aboriginals; and, compared to patients with other exposures, IDUs experienced higher all-cause (HR=2.45, 95% CI=1.31-4.57, p=0.005) but similar HIV-related (p=0.27) mortality rates. Conclusions: Compared to non-Aboriginals, Aboriginal HIV patients suffer higher all-cause and HIV-related mortality rates after starting HAART. The strongest and most significant predictor of higher all-cause mortality was IDU. Future research should examine reasons for the observed poorer survival of Aboriginal and IDU HIV patients after initiating HAART to develop interventions to improve the prognosis for these vulnerable populations. Contexte : Les Autochtones sont surreprésentés dans l'épidémie de VIH qui sévit au Canada, le plus souvent en raison de l'utilisation de drogues par injection (UDI); pourtant, on sait peu de choses sur l'impact de l'ethnicité autochtone sur la mortalité après le début d'une thérapie antirétrovirale hautement active (TAHA). C'est pourquoi nous avons comparé les taux de mortalité de patients autochtones et non autochtones atteints du VIH et ceux d'UDI et de non-UDI atteints du VIH après le début d'une TAHA. Méthode : Nous avons mené une étude de cohortes rétrospective auprès de patients naïfs de traitement antiretroviral ayant entamé une TAHA entre janvier 1999 et juin 2005 (groupe de référence), que nous avons suivis jusqu'en décembre 2005. Nous avons construit deux modèles de Cox (modèles des risques proportionnels), l'un pour estimer les coefficients de danger (QD) pour toutes les causes de mortalité et l'autre pour la mortalité liée au VIH, en tenant compte des facteurs confusionnels possibles (sexe, âge au départ, numération des lymphocytes CD4, niveaux d'ARN VIH, année civile et régime TAHA). Résultats : Les 548 patients à l'étude ont été suivis sur 1 889,8 personnes-années; 194 (35 %) étaient Autochtones, et 255 (46 %) étaient des UDI. Nous avons observé 55 décès, dont 47 % liés au VIH. Dans les modèles multivariés, les Autochtones affichaient des taux supérieurs pour la mortalité toutes causes confondues (QD=1,85, IC de 95 %=1,05-3,26, p=0,034) et la mortalité liée au VIH (QD=3,47, IC de 95 %=1,36-8,83, p=0,009) comparativement aux Non-Autochtones. Par rapport aux patients ayant d'autres expositions, les UDI affichaient des taux supérieurs de mortalité toutes causes confondues (QD=2,45, IC de 95 %=1, 31-4,57, p=0,005), mais leurs taux de mortalité liée au VIH étaient semblables (p=0,27). Conclusion : À comparer aux Non-Autochtones, les patients autochtones atteints du VIH ont des taux supérieurs de mortalité toutes causes confondues et de mortalité liée au VIH après le début d'une TAHA. La variable prédictive la plus forte et la plus significative de la mortalité toutes causes confondues était le statut d'UDI. Dans les futurs travaux de recherche, il faudrait se pencher sur les raisons des moins bons taux de survie observés chez les patients autochtones et les UDI atteints du VIH après le début d'une TAHA afin d'élaborer des interventions susceptibles d'améliorer le pronostic de ces populations vulnérables.

Background Improved availability of antiretroviral therapy in sub-Saharan Africa is intended to benefit all eligible HIV-infected patients; however in reality antiretroviral services are mainly offered in urban hospitals. Poor rural patients have difficulty accessing the drugs, making the provision of antiretroviral therapy inequitable. Initial tests of community-based treatment programs in Uganda suggest that home-based treatment of HIV/AIDS may equal hospital-based treatment; however the literature reveals limited experiences with such programs. The research This intervention study aimed to; 1) assess the effectiveness of a rural community-based ART program in a subcounty (Rwimi) of Uganda; and 2) compare treatment outcomes and mortality in a rural community-based antiretroviral therapy program with a well-established hospital-based program. Ethics approvals were obtained in Canada and Uganda. Results and outcomes Successful treatment outcomes after two years in both the community and hospital cohorts were high. All-cause mortality was similar in both cohorts. However, community-based patients were more likely to achieve viral suppression and had good adherence to treatment. The community-based program was slightly more cost-effective. Per capita costs in both settings were unsustainable, representing more than Uganda’s Primary Health Care Services current expenditures per person per year for all health services. The unpaid community volunteers showed high participation and low attrition rates for the two years that this program was evaluated. Challenges and successes Key successes of this study include the demonstration that antiretroviral therapy can be provided in a rural setting, the creation of a research infrastructure and culture within Kabarole’s health system, and the establishment of a research collaboration capable of enriching the global health graduate program at the University of Alberta. Challenging questions about the long-term feasibility and sustainability of a community-based ARV program in Uganda still remain. The partnership This project is a continuation of previous successful collaborations between the School of Public Health of Makerere University, the School of Public Health of University of Alberta, the Kabarole District Administration and the Kabarole Research and Resource Center.

Background: Bicycle trauma is a common cause of recreational death and disability and helmets have been shown to reduce fatal and non-fatal head and face injuries. This study evaluated the effect of mandatory bicycle helmet legislation for all ages in St. Albert, Alberta. Methods: We observed bicyclists from June to September of 2006 in St. Albert, a community subject to both provincial (<18 years old) and municipal (all ages) helmet legislation, and compared our results with observations taken in 2000 when no legislation existed. Helmet wearing and rider characteristics were recorded by trained observers. Poisson regression analysis was used to obtain helmet prevalence (HP) and prevalence ratio (PR) estimates. Results: HP increased from 45% to 92% (PR=2.03; 95% CI: 1.72-2.39) post-legislation. Controlling for other covariates, children were 53% (PR=1.53; 95% CI: 1.34-1.74) and adolescents greater than 6 times (PR=6.57; 95% CI: 1.39-31.0) more likely to wear helmets; however, adults (PR=1.26; 95% CI: 0.96-1.66) did not show a statistically significant change post-legislation. Restricting the analysis to high socio-economic status areas, adult helmet prevalence increased in St. Albert from 58% to 73% post-legislation compared with a 52% to 57% change across the province; this effect was not statistically significant. Conclusions: Helmet legislation in St. Albert was associated with a significant increase in helmet use among child and adolescent cyclists. A larger increase in HP was observed for adults in St. Albert than in other areas of the province; however, this difference was not statistically significant, which may reflect the small sample size or insufficient time passage after bylaw enactment. Contexte : Les traumatismes dus aux accidents de bicyclette sont une cause courante de mortalité et d'invalidité survenues dans le cadre d'activités de loisirs, et l'on sait que le port du casque réduit les blessures mortelles et non mortelles à la tête et au visage. Nous avons évalué l'effet des lois sur le port obligatoire du casque de cycliste à tout âge à St. Albert, en Alberta. Méthode : De juin à septembre 2006, nous avons observé des cyclistes à St. Albert, une municipalité assujettie à la fois à la loi provinciale (<18 ans) et à un règlement municipal (tous les âges) sur le port du casque, et nous avons comparé nos résultats aux observations effectuées en 2000, quand il n'existait encore aucune loi. Le port du casque et les caractéristiques des cyclistes ont été notés par des observateurs formés. Au moyen d'analyses de régression de Poisson, nous avons estimé la prévalence du port du casque (PPC) et les ratios de prévalence (RP). Résultats : La PPC est passée de 45 % à 92 % (RP=2,03; IC de 95 % = 1,72-2,39) après l'adoption des mesures législatives. Si l'on tient compte des effets d'autres covariables, les enfants étaient plus susceptibles dans une proportion de 53 % (RP=1,53; IC de 95 % = 1,34-1,74), et les adolescents plus de 6 fois plus susceptibles (RP=6,57; IC de 95 % = 1,39-31,0) de porter un casque; cependant, la loi ne semble pas avoir eu d'effet significatif sur le port du casque chez les adultes (RP=1,26; IC de 95 % = 0,96-1,66). En limitant notre analyse aux quartiers de statut socioéconomique élevé, la prévalence du port du casque chez les adultes a augmenté à St. Albert, passant de 58 % à 73 % après les mesures législatives; à l'échelle de la province, elle est passée de 52 % à 57 %; cet effet n'était pas statistiquement significatif. Conclusion : À St. Albert, les mesures législatives sur le port du casque étaient associées à une hausse significative du port du casque de cycliste chez les enfants et les adolescents. Une plus forte hausse de la PPC a été observée chez les adultes de St. Albert que dans d'autres parties de la province, mais cet écart n'était pas significatif, ce qui peut s'expliquer par la petite taille de l'échantillon ou par le fait qu'il ne s'était pas écoulé suffisamment de temps après l'adoption du règlement municipal.