Public Health Epidemiology in Ontario and Statistics Canada – Opportunities / Challenges / Questions Michael Wolfson Statistics Canada October 15, 2007

Statistics Canada Provides: a wide variety of data geographic data infrastructure various summary indicators analytical studies and reports record linkage capacity simulation modeling tools

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Ontario Government Tools “The Health Analysts Toolkit” “Ontario Health Planning Survey Guide” “Ontario Health Planning Data Guide” produced by Health Systems Intelligence Project of the Ontario MOHLTC – Jan 2006 provides an excellent review of many data sets, including those from Statistics Canada

Champlain LHIN - Map

Champlain / NW LHINs - Pop

Champlain LHIN - SES

Champlain LHIN - HS

Champlain LHIN - RFs

Champlain LHIN - Chronic

Definitions cross-sectional survey (CCHS etc.) >provides a “snapshot” of a population at a certain point in time longitudinal survey (NPHS) >surveys the same group of people repeatedly over time >provides dynamic information on the “trajectories” followed by a population >Permits examination of cause-effect relationships

CCHS “.1’s” – Objectives Support pan-Canadian health surveillance >nationally-comparable population health data for provinces and health regions Support health research on small populations and rare characteristics Make information readily available to a diversified user community in a timely fashion Offer a flexible survey instrument, including a rapid response option for emerging issues

CCHS “.1” Design large sample: originally ~ 130,000 respondents per year, every other year >Stratified to produce estimates for sub-provincial health regions, provinces, territories & Canada >Residents of private households aged 12+ mix of personal and telephone interviews >Interview of minutes broad range of content

household basics – demography, SES common content (30 minutes) >asked of all respondents >Core content (20 minutes) included in questionnaire every year >Theme content (10 minutes) rotates according to consensus-based long-term plan optional content (10 minutes) CCHS “.1’s” – Content

CCHS “.1” Example Results - Smoking

Example of optional content selection CCHS 2.1

Example of optional content selection CCHS 2.1 (cont’d)

CCHS “.1” - Survey Redesign Continuous collection >started in Jan >~65,000 respondents per year, every year >non-overlapping 2-month collection periods Questionnaire / Content >Common content split into theme and core content >Long-term plan for theme content >Maintain optional content >Capacity to include a maximum of 2 min. of extra content “on the fly” (Rapid Response) Data will be available more often >Annual data release

CCHS “.1” Theme Content Long-term plan Health Services Access Chronic Disease Screening TBD Health LivingInjury PreventionMental Well-Being CORE CONTENT OPTIONAL CONTENT OPTIONAL CONTENT OPTIONAL CONTENT Rapid Response - $ (max of 2 minutes)

CCHS “.2” – Objectives (originally in intervening years) support in-depth research on specific topics or themes >cycle 1.2 (2002) → Mental Health and Well-being >cycle 2.2 (2004) → Nutrition >(cycle 3.2 → CHMS) >cycle 4.2 (2008) → Healthy Aging provincial level (only) detail

CCHS Cycle 1.2 (2002) Mental Health & Well-being – Objectives estimate prevalence in the general population of selected mental health disorders provide information on the utilization of mental health services and perceived health needs provide data on the disability / impact associated with mental health problems to both individuals and society examine links between mental health and social, demographic, geographic and economic characteristics

CCHS Cycle 1.2 (2002) – Design Target population: >persons aged 15+ living in private dwellings in the ten provinces (excludes territories) Sample size ~37,000 respondents Personal interview >limited (14%) telephone follow-up >telephone, non-proxy only Five mental health disorders assessed >major depression, mania disorder, panic disorder, social phobia and agoraphobia >as well as alcohol and illicit drug dependence Supplement on Canadian Forces >also assessed GAD and PTSD >active members and reserves

CCHS Mental Health & Well Being Alcohol use & dependence Chronic Conditions Distress Eating troubles Gambling General health Height & weight Illicit drug use & dependence Medication use Physical activities Psychological well-being Restriction of activities Services Social support Spirituality Stress Two-week disability Work stress Screening (diagnostic modules) Depression Mania Panic disorder Social phobia Agoraphobia Administration Income Labour force Socio-demographics

Results from the CCHS Cycle 1.2 (2002) - Measured Mental Disorders or Substance Dependence / Past 12 Months Population Aged 15+ Covered in CCHS 1.225,000,000% Major depression1,200, Mania disorder240, Panic disorder380, Agoraphobia180, Social anxiety disorder (Social phobia)750, Alcohol dependence640, Illicit drugs dependence190, Total - Any measured disorder or substance dependence2,700,

CCHS Cycle 2.2 (2004) Nutrition – Objectives estimate the distribution of usual dietary intake >in terms of food groups, dietary supplements, nutrients and eating patterns through a dietary recall computer application >for a representative sample of Canadians at provincial and national levels measure the prevalence of household food insecurity among various population groups in Canada gather anthropometric measurements >body height and weight collect correlate information >physical activity >selected health conditions >socio-demographic characteristics

CCHS Cycle 2.2 (2004) Nutrition – Design Target population >persons of all ages living in private dwellings in the ten provinces (excluding the territories) Sample size ~35,000 1/3 of respondents asked second dietary recall to provide information on usual intake >personal interview for the 1 st interview >telephone interview for the 2 nd recall interview Stratified by 10 provinces and 15 age-sex groups corresponding to Dietary Reference Intake groupings

CCHS Cycle 2.2 (2004) Nutrition – Content Food consumption 24-hour dietary recall >USDA Automated Multiple Pass Methodology >Modified for Canadian marketplace >All foods and beverages >5 steps - improve chances of recalling all foods eaten 1.Quick List 2.Forgotten Foods 3.Time and Occasion 4.Detail Cycle 5.Final Probe 2 nd interview >10,000 of 35,000 respondents >24-hour recall only Other topics Alcohol Consumption (age 12+) Children’s Physical Activity (age 6 to 11) Chronic Conditions (all) Fruit and Vegetable Consumption (age 6 mo.+) General Health (age 12+) Household Food Security (all) Measured Height and Weight (age 2+) Physical Activity (age 12+) Sedentary Activity (age 12 – 17) Self Reported Height and Weight (10% sample, age 18+) Smoking (age 12+) Vitamin and Mineral Supplements (all) Women’s Health (women age 9+) Socio-Demographics (all) Labour Force (age 15 – 75) Income (all)

Results from CCHS Cycle 2.2 (2004) % above upper end of recommended range of total calories from fat, by age group and sex, population aged 4+, Canada excluding territories 2. Significantly different from estimate for previous age group of same sex (p < 0.05) Notes : Estimates of energy intake include calories from alcoholic beverages. Based on usual consumption. Excludes women who were pregnant or breastfeeding. E = use with caution / F = too unreliable to be published Data source : 2004 Canadian Community Health Survey: Nutrition

Results from CCHS Cycle 2.2 (2004) distribution of BMI, population aged 12 to 17, Canada excluding territories, 1978/79 and 2004

CCHS Cycle 4.2 Healthy Aging Objectives factors, influences and processes that contribute to healthy aging health, social and economic determinants Design respondents aged 55+ sample size – to be determined collection July 2008 to May 2009 computer Assisted Personal Interview (CAPI) possible link to CLSA / longitudinal survey

Health Services Access Survey (HSAS) Fill gap in “Quality of service” indicator area >Access to 24/7 first contact health services >Waiting times for key diagnostic and treatment services HSAS 2001 >Collected as follow-up supplement to CCHS (.1) >14,210 respondents >representative national-level estimates >sample buy-ins (P.E.I., Alta., B.C.) HSAS 2003 & 2005 >Integrated in CCHS (.1): sub-sample of 32,000+ respondents >representative provincial-level estimates HSAS 2007 >CCHS (.1) 2007 annual theme >Asked of a sub-sample of 32,000+ respondents Future uncertain….

Joint Canada / United States Survey of Health (JCUSH) - Objectives Objectives Examine Canada-US differences in health status and use of health care services Identify possible areas for collaboration in questionnaire design / development Design Conducted jointly by Statistics Canada (STC) and the National Center for Health Statistics (NCHS) Target population 18+ in private dwellings Collection: fall 2002 to spring 2003 All interviews by telephone, conducted from STC regional offices Sample size ~3,500 Canada / ~5,200 US Standard approach across both countries

Canadian Health Measures Survey (CHMS) – Background high-priority topics – e.g. environmental toxins, metabolic syndrome, physical fitness, other CHD risk factors – can only be assessed through direct physical measures other high priority health information collected through self-report surveys or administrative records is subject to reporting error – e.g. obesity, hypertension directly measured attributes can be measured more precisely / reported on continuous scales

estimate the numbers of individuals in Canada with selected health conditions, characteristics, and elevated levels of major risk factors estimate the distributional patterns of selected diseases, risk factors and protective characteristics monitor trends, based to the extent possible on available historical data ascertain relationships among risk factors, protective behaviours, and health status explore emerging public health issues and new measurement technologies assess the validity of prevalence estimates based on self- and proxy- reported information collect a nationally representative sample of genetic material and other covariates for future genetic research provide a potential platform and infrastructure for ongoing physical measures surveys and add-on studies share our experience with others CHMS – Objectives

combination of household interview + direct measures completed in mobile exam clinic national estimates, n = 5,000 over 2 years atypical sample design – 15 clusters selected from 97% of population (due to cost, logistics) Ages 6-79 (6-11, 12-19, 20-39, 40-59, 60-79) in the field CHMS – Parameters

National Population Health Survey (NPHS) – Objectives Support research into the dynamic processes of health >Provide data for analytical studies that will assist in understanding the determinants of health Evaluate the relationships between socio- economic and demographic characteristics of individuals with their health status and its evolution over time Aid in the development of public health policy

NPHS – Household Component Main component of NPHS >persons in private households in the ten provinces >first cycle in → every two years Cross-sectional sample >served cross-sectional purposes: 1994, 1996, 1998 subset of questionnaire – all members of household detailed health information – selected household respondent Longitudinal sample >same selected household respondent revisited each cycle >17,276 respondents initially >detailed health information from selected respondent >socio-demographic information on household each cycle including household composition, income, education

NPHS – Other Components Intended to complement main NPHS household component Institutions component >Residents of long-term care institutions (4+ beds) in the ten provinces >5 cycles of data: → every two years to >Sample ~2,200 respondents → national level data >High mortality: ~1/3 of respondents each cycle North component >Household residents in each territory >3 cycles of data, → every two years to >Sample ~2,000 respondents → territorial level data >Territories covered by the CCHS “.1’s” since 2000

Cross-sectional vs longitudinal findings Shift work and the health of males. Source: NPHS N. B. bars represent 95% confidence intervals; colour change occurs at mean relative risk Cross-sectional results: The odds of having been diagnosed with a chronic disease did not differ for men who worked shift compared with those working a regular daytime schedule Longitudinal results: Working shift was associated with increased health risks over time. Working a non-standard schedule in 94/95 was predictive of developing chronic diseases over the next 4 years.

Some Other Survey Data Sets population census – disability screener major surveys >HALS / PALS – Health / Participation and Activity Limitations Surveys (post-censal) >NLSCY – National Longitudinal survey of Children and Youth related surveys >SHS/FAMEX – Survey of Household Spending, formerly FAMily EXpenditure survey >GSS – General Social Survey

Cancer Registration In Canada Originated at varying times across country Provincial level 1 st : 1935 BC & Sask NCIRS: at Statistics Canada 1992 : CCR established – new standards

Canadian Cancer Registry (CCR) Key Features Reference Year Person Oriented Data Set - Person & Tumor Records - Data Definitions/Standards National Coverage Internal Duplicate Protocol CMDB Linkage & Clearance

CCR: How it is used Calculate cancer incidence and survival statistics Occupational, environmental and other medical follow-up studies Production of the Canadian Cancer Statistics monograph Research programs i.e. tobacco control, product safety, workplace health and safe environments Assess the impact of new technologies and treatments

self health a 5

self health b 6

type of smokerecumen mapcchs type of smokerecumene map

An Almost Familiar World Map cartogram algorithm: Mark Newman

Area Proportional to Population

Area Proportional to GDP 2002

Area Proportional to HIV (prevalence ages 15 – 49)

Area Proportional to “Unhealthy Life”(LE – HALE)

Health Indicators joint Statistics Canada / CIHI set >equity dimension – needs development Performance Indicators pursuant to First Ministers’ Health Accords >FPT process – moribund note Ontario Indicators QUESTION: what others?

Data Access print publications web site – tables, studies, maps microdata files (sometimes) >public use >via remote job submission >via the Research Data Centres >via the Ontario MOHLTC QUESTION: what modes of access would be most useful

Challenges small area estimates hypothesis testing choice of content areas measuring health status and health outcomes comparability – beyond Canada? beyond monitoring? (to causality / modeling)

Definition - Health Outcome health status “before” health status “after” health intervention other factors change in health status attributable to a health intervention (for an individual)

Changes in Life Expectancy (LE) and Health-Adjusted Life Expectancy (HALE) by Cause, Canada (Source: Manuel et al, ICES and Health Canada, NPHS) HALELE

Example of NPHS Analysis Using LifePaths / POHEM LifePaths and POHEM ( = Statistics Canada’s POpulation HEalth Model) – microsimulation-based projection tools projecting disability prevalence >in the context of population aging, and >declining fertility rates, >rising divorce rates, >and recent trends in the levels of disability >  who will look after future frail elderly

Disability Definitions – Motivation define disability severity levels in terms of likely predictors of need for services focus on activities commonly associated with use of home care services, e.g. everyday housework, grocery shopping, meal preparation, and personal care use projections of these disability levels as rough proxy for inferred “population at risk” for service needs such as home care – if not from close relatives, then either purchased or from government

Disability Definitions – Specifics (based on McMaster HUI3, most severe level) >No disability >Mild disability Mobility problem but do not need any help Dexterity problem but do not need any help from someone else (may or may not use special equipment) Somewhat forgetful and little difficulty in thinking Moderate and/or severe pain prevents performing some or few activities >Moderate disability Requires wheel chair or mechanical support to walk Dexterity problem and need help to perform some tasks Very forgetful and a lot of difficulty in thinking Severe pain prevents performing most activities >Severe disability Can not walk or need help from others to walk Dexterity problem and need help for most or all tasks Unable to remember or think

Estimation of Disability Dynamics data source: 1994, 1996, 1998 and 2000 waves of longitudinal NPHS (n = 287 to 12,733) look at pairs of “triples” for dynamics – two overlapping sets of 3 waves for each individual >1994 – 1996 – 1998, and 1996 – >recognizes a degree of duration dependence (i.e. nests and tests naïve first order Markov assumption) >allows assessment of unobserved person-specific factors look at improvements or deteriorations only >not a limiting assumption given modeling in continuous time use cross-validation to assess choice of specification (opportunistic, given bootstrap weights)

Disability Status Transition Matrix NoneMildModSevereInst’nDeadn obs None ,401 Mild ,783 Moderate ,255 Severe

Disability Transition Hazard Regressions – Functional Forms age (cubic spline), prior disability + (A) simple individual level variance + (B) individual level variance covariates (education, nuptiality, immigration) + (C) other covariates (year, sex, education, nuptiality, immigration) results: >prior disability matters (i.e. 2 nd order Markov) >(A) and (B) matter; (C) not how to assess: use replicated “out of sample predictions” based on 500 bootstrap weight vectors

Sub-Sample of 100 Simulated Life Paths 4 life paths 95 life paths vertical axis = 1.0 x years without disability x years with mild x moderate x severe x institutionalized horizontal axis = 1.0 x years of age

Projected Canadian Disability Prevalences from 2001 to 2021 darker blue = more severe disability, and ultimately institutionalization triangles indicate (roughly) total 65+ population, and “healthy” 65+

Concluding Comments Statistics Canada has a great deal of data Ontario appears to be using much of it well There are important areas of new development >evolution of CCHS >new CHMS >linkage of major surveys to provincial health care records There are also questions >accessibility of data >priority content needs >potential of new tools – e.g. mapping, simulation models