Cohort profile: the British Columbia COVID-19 Cohort (BCC19C)-a dynamic, linked population-based cohort

Purpose

The British Columbia COVID-19 Cohort (BCC19C) was developed from an innovative, dynamic surveillance platform and is accessed/analyzed through a cloud-based environment. The platform integrates recently developed provincial COVID-19 datasets (refreshed daily) with existing administrative holdings and provincial registries (refreshed weekly/monthly). The platform/cohort were established to inform the COVID-19 response in near "real-time" and to answer more in-depth epidemiologic questions.

Participants

The surveillance platform facilitates the creation of large, up-to-date analytic cohorts of people accessing COVID-19 related services and their linked medical histories. The program of work focused on creating/analyzing these cohorts is referred to as the BCC19C. The administrative/registry datasets integrated within the platform are not specific to COVID-19 and allow for selection of "control" individuals who have not accessed COVID-19 services.

Findings to date

The platform has vastly broadened the range of COVID-19 analyses possible, and outputs from BCC19C analyses have been used to create dashboards, support routine reporting and contribute to the peer-reviewed literature. Published manuscripts (total of 15 as of July, 2023) have appeared in high-profile publications, generated significant media attention and informed policy and programming. In this paper, we conducted an analysis to identify sociodemographic and health characteristics associated with receiving SARS-CoV-2 laboratory testing, testing positive, and being fully vaccinated. Other published analyses have compared the relative clinical severity of different variants of concern; quantified the high "real-world" effectiveness of vaccines in addition to the higher risk of myocarditis among younger males following a 2nd dose of an mRNA vaccine; developed and validated an algorithm for identifying long-COVID patients in administrative data; identified a higher rate of diabetes and healthcare utilization among people with long-COVID; and measured the impact of the pandemic on mental health, among other analyses.

Future plans

While the global COVID-19 health emergency has ended, our program of work remains robust. We plan to integrate additional datasets into the surveillance platform to further improve and expand covariate measurement and scope of analyses. Our analyses continue to focus on retrospective studies of various aspects of the COVID-19 pandemic, as well as prospective assessment of post-acute COVID-19 conditions and other impacts of the pandemic.

Systematic review and meta-analysis of disease clustering in multimorbidity: a study protocol

INTRODUCTION

Multimorbidity is defined as the presence of two or more chronic diseases. Co-occurring diseases can have synergistic negative effects, and are associated with significant impacts on individual health outcomes and healthcare systems. However, the specific effects of diseases in combination will vary between different diseases. Identifying which diseases are most likely to co-occur in multimorbidity is an important step towards population health assessment and development of policies to prevent and manage multimorbidity more effectively and efficiently. The goal of this project is to conduct a systematic review and meta-analysis of studies of disease clustering in multimorbidity, in order to identify multimorbid disease clusters and test their stability.

METHODS AND ANALYSIS

We will review data from studies of multimorbidity that have used data clustering methodologies to reveal patterns of disease co-occurrence. We propose a network-based meta-analytic approach to perform meta-clustering on a select list of chronic diseases that are identified as priorities for multimorbidity research. We will assess the stability of obtained disease clusters across the research literature to date, in order to evaluate the strength of evidence for specific disease patterns in multimorbidity.

ETHICS AND DISSEMINATION

This study does not require ethics approval as the work is based on published research studies. The study findings will be published in a peer-reviewed journal and disseminated through conference presentations and meetings with knowledge users in health systems and public health spheres.

PROSPERO REGISTRATION NUMBER

CRD42023411249.

Risk of hospital admission and death from first-ever SARS-CoV-2 infection by age group during the Delta and Omicron periods in British Columbia, Canada

BACKGROUND

Population-based cross-sectional serosurveys within the Lower Mainland, British Columbia, Canada, showed about 10%, 40% and 60% of residents were infected with SARS-CoV-2 by the sixth (September 2021), seventh (March 2022) and eighth (July 2022) serosurveys. We conducted the ninth (December 2022) and tenth (July 2023) serosurveys and sought to assess risk of severe outcomes from a first-ever SARS-CoV-2 infection during intersurvey periods.

METHODS

Using increments in cumulative infection-induced seroprevalence, population census, discharge abstract and vital statistics data sets, we estimated infection hospitalization and fatality ratios (IHRs and IFRs) by age and sex for the sixth to seventh (Delta/Omicron-BA.1), seventh to eighth (Omicron-BA.2/BA.5) and eighth to ninth (Omicron-BA.5/BQ.1) intersurvey periods. As derived, IHR and IFR estimates represent the risk of severe outcome from a first-ever SARS-CoV-2 infection acquired during the specified intersurvey period.

RESULTS

The cumulative infection-induced seroprevalence was 74% by December 2022 and 79% by July 2023, exceeding 80% among adults younger than 50 years but remaining less than 60% among those aged 80 years and older. Period-specific IHR and IFR estimates were consistently less than 0.3% and 0.1% overall. By age group, IHR and IFR estimates were less than 1.0% and up to 0.1%, respectively, except among adults aged 70-79 years during the sixth to seventh intersurvey period (IHR 3.3% and IFR 1.0%) and among those aged 80 years and older during all periods (IHR 4.7%, 2.2% and 3.5%; IFR 3.3%, 0.6% and 1.3% during the sixth to seventh, seventh to eighth and eighth to ninth periods, respectively). The risk of severe outcome followed a J-shaped age pattern. During the eighth to ninth period, we estimated about 1 hospital admission for COVID-19 per 300 newly infected children younger than 5 years versus about 1 per 30 newly infected adults aged 80 years and older, with no deaths from COVID-19 among children but about 1 death per 80 newly infected adults aged 80 years and older during that period.

INTERPRETATION

By July 2023, we estimated about 80% of residents in the Lower Mainland, BC, had been infected with SARS-CoV-2 overall, with low risk of hospital admission or death; about 40% of the oldest adults, however, remained uninfected and at highest risk of a severe outcome. First infections among older adults may still contribute substantial burden from COVID-19, reinforcing the need to continue to prioritize this age group for vaccination and to consider them in health care system planning.

Changes in emergency department use in British Columbia, Canada, during the first 3 years of the COVID-19 pandemic

BACKGROUND

Previous studies have shown reductions in the volume of emergency department visits early in the COVID-19 pandemic, but few have evaluated the pandemic's impact over time or stratified analyses by reason for visits. We aimed to quantify such changes in British Columbia, Canada, cumulatively and during prominent nadirs, and by reason for visit, age and acuity.

METHODS

We included data from the National Ambulatory Care Reporting System for 30 emergency departments across BC from January 2016 to December 2022. We fitted generalized additive models, accounting for seasonal and annual trends, to the monthly number of visits to estimate changes throughout the pandemic, compared with the expected number of visits in the absence of the pandemic. We determined absolute and relative differences at various times during the study period, and cumulatively since the start of the pandemic until the overall volume of emergency department visits returned to expected levels.

RESULTS

Over the first 16 months of the pandemic, the volume of emergency department visits was reduced by about 322 300 visits, or 15% (95% confidence interval 12%-18%), compared with the expected volume. A sharp drop in pediatric visits accounted for nearly one-third of the reduction. The timing of the return to baseline volume of visits differed by subgroup. The largest and most sustained decreases were in respiratory-related emergency department visits, visits among children, visits among oldest adults and non-urgent visits. Later in the pandemic, we observed increased volumes of highest-urgency visits, visits among children and visits related to ear, nose and throat.

INTERPRETATION

We have extended evidence that the impact of the COVID-19 pandemic and associated mitigation strategies on emergency department visits in Canada was substantial. Both our findings and methods are relevant in public health surveillance and capacity planning for emergency departments in pandemic and nonpandemic times.

COVID-19 hospitalisations in immunocompromised individuals in the Omicron era: a population-based observational study using surveillance data in British Columbia, Canada

Background

People with immune dysfunction are at higher risk of severe outcomes from COVID-19 infection, but relatively little epidemiologic information is available for mostly vaccinated population in the Omicron era. This population-based study compared relative risk of breakthrough COVID-19 hospitalisation among vaccinated people identified as clinically extremely vulnerable (CEV) vs non-CEV individuals before treatment became more widely available.

Methods

COVID-19 cases and hospitalisations reported to the British Columbia Centre for Disease Control (BCCDC) between January 7, 2022 and March 14, 2022 were linked with data on their vaccination and CEV status. Case hospitalisation rates were estimated across CEV status, age groups and vaccination status. For vaccinated individuals, risk ratios for breakthrough hospitalisations were calculated for CEV and non-CEV populations matched on sex, age group, region, and vaccination characteristics.

Findings

Among CEV individuals, a total of 5591 COVID-19 reported cases were included, among which 1153 were hospitalized. A third vaccine dose with mRNA vaccine offered additional protection against severe illness in both CEV and non-CEV individuals. However, 2- and 3-dose vaccinated CEV population still had a significantly higher relative risk of breakthrough COVID-19 hospitalisation compared with non-CEV individuals.

Interpretation

Vaccinated CEV population remains a higher risk group in the context of circulating Omicron variant and may benefit from additional booster doses and pharmacotherapy.

Funding

BC Centre for Disease Control and Provincial Health Services Authority.

Comparison of influenza and COVID-19 hospitalisations in British Columbia, Canada: a population-based study

INTRODUCTION

We compared the population rate of COVID-19 and influenza hospitalisations by age, COVID-19 vaccine status and pandemic phase, which was lacking in other studies.

METHOD

We conducted a population-based study using hospital data from the province of British Columbia (population 5.3 million) in Canada with universal healthcare coverage. We created two cohorts of COVID-19 hospitalisations based on date of admission: annual cohort (March 2020 to February 2021) and peak cohort (Omicron era; first 10 weeks of 2022). For comparison, we created influenza annual and peak cohorts using three historical periods years to capture varying severity and circulating strains: 2009/2010, 2015/2016 and 2016/2017. We estimated hospitalisation rates per 100 000 population.

RESULTS

COVID-19 and influenza hospitalisation rates by age group were 'J' shaped. The population rate of COVID-19 hospital admissions in the annual cohort (mostly unvaccinated; public health restrictions in place) was significantly higher than influenza among individuals aged 30-69 years, and comparable to the severe influenza year (2016/2017) among 70+. In the peak COVID-19 cohort (mostly vaccinated; few restrictions in place), the hospitalisation rate was comparable with influenza 2016/2017 in all age groups, although rates among the unvaccinated population were still higher than influenza among 18+. Among people aged 5-17 years, COVID-19 hospitalisation rates were lower than/comparable to influenza years in both cohorts. The COVID-19 hospitalisation rate among 0-4 years old, during Omicron, was higher than influenza 2015/2016 and 2016/2017 and lower than 2009/2010 pandemic.

CONCLUSIONS

During first Omicron wave, COVID-19 hospitalisation rates were significantly higher than historical influenza hospitalisation rates for unvaccinated adults but were comparable to influenza for vaccinated adults. For children, in the context of high infection levels, hospitalisation rates for COVID-19 were lower than 2009/2010 H1N1 influenza and comparable (higher for 0-4) to non-pandemic years, regardless of the vaccine status.

Risk factors for COVID-19 hospitalization after COVID-19 vaccination: a population-based cohort study in Canada

OBJECTIVES

With the uptake of COVID-19 vaccines, there is a need for population-based studies to assess risk factors for COVID-19-related hospitalization after vaccination and how they differ from unvaccinated individuals.

METHODS

We used data from the British Columbia COVID-19 Cohort, a population-based cohort that includes all individuals (aged ≥18 years) who tested positive for SARS-CoV-2 by real-time reverse transcription-polymerase chain reaction from January 1, 2021 (after the start of vaccination program) to December 31, 2021. We used multivariable logistic regression models to assess COVID-19-related hospitalization risk by vaccination status and age group among confirmed COVID-19 cases.

RESULTS

Of the 162,509 COVID-19 cases included in the analysis, 8,546 (5.3%) required hospitalization. Among vaccinated individuals, an increased odds of hospitalization with increasing age was observed for older age groups, namely those aged 50-59 years (odds ratio [OR] = 2.95, 95% confidence interval [CI]: 2.01-4.33), 60-69 years (OR = 4.82, 95% CI: 3.29, 7.07), 70-79 years (OR = 11.92, 95% CI: 8.02, 17.71), and ≥80 years (OR = 24.25, 95% CI: 16.02, 36.71). However, among unvaccinated individuals, there was a graded increase in odds of hospitalization with increasing age, starting at age group 30-39 years (OR = 2.14, 95% CI: 1.90, 2.41) to ≥80 years (OR = 41.95, 95% CI: 35.43, 49.67). Also, comparing all the age groups to the youngest, the observed magnitude of association was much higher among unvaccinated individuals than vaccinated ones.

CONCLUSION

Alongside a number of comorbidities, our findings showed a strong association between age and COVID-19-related hospitalization, regardless of vaccination status. However, age-related hospitalization risk was reduced two-fold by vaccination, highlighting the need for vaccination in reducing the risk of severe disease and subsequent COVID-19-related hospitalization across all population groups.

Mental health-related healthcare service utilisation and psychotropic drug dispensation trends in British Columbia during COVID-19 pandemic: a population-based study

Background

The impact of the COVID-19 pandemic on the population's mental health is vital for informing public health policy and decision-making. However, information on mental health-related healthcare service utilisation trends beyond the first year of the pandemic is limited.

Aims

We examined mental health-related healthcare service utilisation patterns and psychotropic drug dispensations in British Columbia, Canada, during the COVID-19 pandemic compared with the prepandemic period.

Methods

We conducted a retrospective population-based secondary analysis using administrative health data to capture outpatient physician visits, emergency department visits, hospital admissions and psychotropic drug dispensations. We examined time trends of mental health-related healthcare service utilisation and psychotropic drug dispensations between January to December 2019 (prepandemic period) and January 2020 to December 2021 (pandemic period). In addition, we calculated age-standardised rates and rate ratios to compare mental health-related healthcare service utilisation before and during the first two years of the COVID-19 pandemic, stratified by year, sex, age and condition.

Results

By late 2020, except for emergency department visits, utilisation of healthcare services recovered to prepandemic levels. Between 2019 and 2021, the monthly average rate for overall mental health-related outpatient physician visits, emergency department visits and psychotropic drug dispensations increased significantly by 24%, 5% and 8%, respectively. Notable and statistically significant increases were observed among 10-14 year-olds (44% in outpatient physician visits, 30% in emergency department visits, 55% in hospital admissions and 35% in psychotropic drug dispensations) and 15-19 year-olds (45% in outpatient physician visits, 14% in emergency department visits, 18% in hospital admissions and 34% in psychotropic drug dispensations). Additionally, these increases were more prominent among females than males, with some variation for specific mental health-related conditions.

Conclusions

The increase in mental health-related healthcare service utilisation and psychotropic drug dispensations during the pandemic likely reflects significant societal consequences of both the pandemic and pandemic management measures. Recovery efforts in British Columbia should consider these findings, especially among the most affected subpopulations, such as adolescents.

Long-term trends in population-based hospitalisation rates for myocardial infarction in England: a national database study of 3.5 million admissions, 1968-2016

AIM

To analyse the timing and scale of temporal changes in rates of hospitalised myocardial infarction (MI) in England by age and sex from 1968 to 2016.

METHODS

MI admissions for adults aged 15-84 years were identified from electronic hospital data. We calculated age-standardised and age-specific rates, and examined trends using joinpoint.

RESULTS

From 1968 to 2016, there were 3.5 million admissions for MI in England (68% men). Rates increased in the early years of the study in both men and women, peaked in the mid-1980s (355 per 100 000 population in men; 127 in women) and declined by 38.8% in men and 37.4% in women from 1990 to 2011. From 2012, however, modest increases were observed in both sexes. Long-term trends in rates over the study period varied by age and sex, with those aged 70 years and older having the greatest and most sustained increases in the early years (1968-1985). During subsequent years, rates decreased in most age groups until 2010-2011. The exception was younger women (35-49 years) and men (15-34 years) who experienced significant increases from the mid-1990s to 2007 (range +2.1%/year to 4.7%/year). From 2012 onwards, rates increased in all age groups except the oldest, with the most marked increases in men aged 15-34 years (7.2%/year) and women aged 40-49 (6.9%-7.3%/year) .

CONCLUSION

Despite substantial declines in hospital admission rates for MI in England since 1990, the burden of annual admissions remains high. Continued surveillance of trends and coronary disease preventive strategies are warranted.

Mental Health and Substance Use Associated with Hospitalization among People with COVID-19: A Population-Based Cohort Study

This study identified factors associated with hospital admission among people with laboratory-diagnosed COVID-19 cases in British Columbia. The study used data from the BC COVID-19 Cohort, which integrates data on all COVID-19 cases with data on hospitalizations, medical visits, emergency room visits, prescription drugs, chronic conditions and deaths. The analysis included all laboratory-diagnosed COVID-19 cases in British Columbia to 15 January 2021. We evaluated factors associated with hospital admission using multivariable Poisson regression analysis with robust error variance. Of the 56,874 COVID-19 cases included in the analysis, 2298 were hospitalized. Factors associated with increased hospitalization risk were as follows: male sex (adjusted risk ratio (aRR) = 1.27; 95% CI = 1.17–1.37), older age (p-trend < 0.0001 across age groups increasing hospitalization risk with increasing age [aRR 30–39 years = 3.06; 95% CI = 2.32–4.03, to aRR 80+ years = 43.68; 95% CI = 33.41–57.10 compared to 20–29 years-old]), asthma (aRR = 1.15; 95% CI = 1.04–1.26), cancer (aRR = 1.19; 95% CI = 1.09–1.29), chronic kidney disease (aRR = 1.32; 95% CI = 1.19–1.47), diabetes (treated without insulin aRR = 1.13; 95% CI = 1.03–1.25, requiring insulin aRR = 5.05; 95% CI = 4.43–5.76), hypertension (aRR = 1.19; 95% CI = 1.08–1.31), injection drug use (aRR = 2.51; 95% CI = 2.14–2.95), intellectual and developmental disabilities (aRR = 1.67; 95% CI = 1.05–2.66), problematic alcohol use (aRR = 1.63; 95% CI = 1.43–1.85), immunosuppression (aRR = 1.29; 95% CI = 1.09–1.53), and schizophrenia and psychotic disorders (aRR = 1.49; 95% CI = 1.23–1.82). In an analysis restricted to women of reproductive age, pregnancy (aRR = 2.69; 95% CI = 1.42–5.07) was associated with increased risk of hospital admission. Older age, male sex, substance use, intellectual and developmental disability, chronic comorbidities, and pregnancy increase the risk of COVID-19-related hospitalization.

Using Reproducible Data Visualizations to Augment Decision-Making During Suppression of Small Counts

IntroductionWhen reporting disease rates to the public, a health system must take precaution to protect released data from re-identification risks. While specific guidelines and methods vary across data systems and governances 1 , redaction of cells with small values is a key component in any approach for preparing data for public release. These preparations, when conducted manually, have proven to be arduous, time consuming, and prone to human error. Although finding a “small” value (e.g. “< 5 ” ) is straightforward, detecting conditions in which suppressed values could be recalculated from related cells involves human judgement. Objectives and ApproachGuided by the real-world objective to reports the rates of chronic diseases in British Columbia, we aimed to design a reproducible workflow that would augment human decision-making and offer a nimble quality control tool, approachable by epidemiologists without technical background. Our workflow (1) splits data into disease-by-year data frames of a specific form, (2) applies a sequence of algorithms trained to recognize conditions that made recalculation of suppressed values possible and (3) prints a graph for each case of suggested automatic redaction to be confirmed by a human. ResultsThe augmented suppression system was successfully integrated into the maintenance of Chronic Disease Dashboard, an online reporting tool of the Observatory for Population and Public Health designed to address the gap in surveillance of chronic diseases in British Columbia. Anticipating the evolution of suppression logic, we isolated the logical tests responsible for redaction and provided several options to vary the degree of preserved information. Conclusion / ImplicationsInstead of employing a complex generalizable solution, we make a case for organizing the procedure for small cell redaction as a data visualization task, allowing for straightforward quality control of suppression decision and thus more approachable to a non-technical audience, as well as for employing such learning devices as workflow maps and function dependency trees for structuring applied projects and ensuring their reproducibility.

Effects of the new prescribing standards in British Columbia on consumption of opioids and benzodiazepines and z drugs

OBJECTIVE

To evaluate the effects of the 2016 College of Physicians and Surgeons of British Columbia's (CPSBC's) opioid and benzodiazepine and z drug prescribing standards on the use of these medications in British Columbia.

DESIGN

Interrupted time-series analysis of community-prescribing records over a 30-month period: January 2015 to June 2017.

SETTING

British Columbia.

PARTICIPANTS

Random sample of British Columbia residents with filled prescriptions during the study period.

INTERVENTION

Introduction of CPSBC's opioid and benzodiazepine and z drug prescribing standards on June 1, 2016.

MAIN OUTCOME MEASURES

Total weekly consumption of opioids (measured in morphine equivalents) and benzodiazepines and z drugs (measured in diazepam equivalents); and total monthly users of each class of medication.

RESULTS

Total consumption of both medication classes began to decline in late 2015, and the rate of decrease did not statistically significantly change following the implementation of the CPSBC standards in June 2016. In contrast, introduction of the standards was associated with an immediate 2% decrease in the number of monthly users of opioids for pain (P < .001), culminating in a 9% decrease over the course of the following year (P < .001). This trend was driven largely by a decrease in the number of continuing users; minimal change was seen in the number of new users during the study period. Trends in monthly users of benzodiazepines and z drugs mirrored those seen for opioids for pain.

CONCLUSION

Implementation of the 2016 CPSBC standards did not change a pre-existing downward trend in consumption of opioids or benzodiazepines and z drugs that began 6 months earlier. However, the standards did have a small effect on the number of monthly users of these medications, with a decrease in opioid prescribing among continuing users. Given the risk of destabilization of patients who are discontinued from opioid therapy, future research should assess how patient health outcomes are related to changing prescribing practices.

Area-based socioeconomic disparities in mortality due to unintentional injury and youth suicide in British Columbia, 2009-2013

INTRODUCTION

The association between health outcomes and socioeconomic status (SES) has been widely documented, and mortality due to unintentional injuries continues to rank among the leading causes of death among British Columbians. This paper quantified the SES-related disparities in the mortality burden of three British Columbia's provincial injury prevention priority areas: falls among seniors, transport injury, and youth suicide.

METHODS

Mortality data (2009 to 2013) from Vital Statistics and dissemination area or local health area level socioeconomic data from CensusPlus 2011 were linked to examine age-standardized mortality rates (ASMRs) and disparities in ASMRs of unintentional injuries and subtypes including falls among seniors (aged 65+) and transport-related injuries as well as the intentional injury type of youth suicide (aged 15 to 24). Disparities by sex and geography were examined, and relative and absolute disparities were calculated between the least and most privileged areas based on income, education, employment, material deprivation, and social deprivation quintiles.

RESULTS

Our study highlighted significant sex differences in the mortality burden of falls among seniors, transport injury, and youth suicide with males experiencing significantly higher mortality rates. Notable geographic variations in overall unintentional injury ASMR were also observed across the province. In general, people living in areas with lower income and higher levels of material deprivation had increasingly higher mortality rates compared to their counterparts living in more privileged areas.

CONCLUSION

The significant differences in unintentional and intentional injury-related mortality outcomes between the sexes and by SES present opportunities for targeted prevention strategies that address the disparities.

Development and characteristics of the Provincial Overdose Cohort in British Columbia, Canada

Introduction

British Columbia (BC), Canada declared a public health emergency in April 2016 for opioid overdose. Comprehensive data was needed to identify risk factors, inform interventions, and evaluate response actions. We describe the development of an overdose cohort, including linkage strategy, case definitions, and data governance model, and present the resulting characteristics, including data linkage yields and case overlap among data sources.

Methods

Overdose events from hospital admissions, physician visits, poison centre and ambulance calls, emergency department visits, and coroner’s data were grouped into episodes if records were present in multiple sources. A minimum of five years of universal health care records (all prescription dispensations, fee-for-service physician billings, emergency department visits and hospitalizations) were appended for each individual. A 20% random sample of BC residents and a 1:5 matched case-control set were generated. Consultation and prioritization ensured analysts worked to address questions to directly inform public health actions.

Results

10,456 individuals suffered 14,292 overdoses from January 1, 2015 to Nov 30, 2016. Only 28% of overdose events were found in more than one dataset with the unique contribution of cases highest from ambulance records (32%). Compared with fatal overdoses, non-fatal events more often involved females, younger individuals (20 to 29 years) and those 60 or older. In 78% of illegal drug deaths, there was no associated ambulance response. In the year prior to first recorded overdose, 60% of individuals had at least one ED visit, 31% at least one hospital admission, 80% at least one physician visit, and 87% had filled at least one prescription in a community pharmacy.

Conclusion

While resource-intensive to establish, a linked cohort is useful for characterizing the full extent of the epidemic, defining sub-populations at risk, and patterns of contact with the health system. Overdose studies in other jurisdictions should consider the inclusion of multiple data sources.

Patterns and history of prescription drug use among opioid-related drug overdose cases in British Columbia, Canada, 2015-2016

BACKGROUND

British Columbia is the epicenter of the current fentanyl-related overdose crisis in Canada. Our study characterizes prescribing histories of people who had an opioid-related overdose compared to matched controls.

METHODS

We examined linked administrative data for individuals who overdosed between January 1, 2015 and November 30, 2016. Past prescriptions over five years were assessed for opioids for pain, opioid agonist therapy, benzodiazepines/z-drugs, antidepressants, antipsychotics, gabapentinoids, mood stabilizers and anti-epileptics, muscle relaxants, and other sedating medications. Prescribing history of 9964 cases was compared with that of 49,820 matched controls.

RESULTS

Overdose cases were more likely to be prescribed opioids for pain and to have used prescription opioids on a long-term basis in the previous five years compared to controls. However, at the time of overdose, 92% of men and 86% of women did not have an active opioid for pain prescription, and approximately half had not filled one in the past five years. Those who overdosed tended to have more prescriptions for psychotropic substances than controls. Fewer than 10% of cases had an active prescription for opioid agonist therapy and most were not on treatment in the past.

CONCLUSIONS

Low prevalence of active prescriptions for opioids for pain at the time of overdose suggests that opioid prescribing plays a limited short-term impact in the current fentanyl-related crisis of overdoses. While liberal opioid prescribing practices may have contributed to the development of the current overdose crisis, regulation and enforcement of clinicians' prescribing practices will likely have limited impact in reducing overdoses.

Development and Characteristics of the Provincial Overdose Cohort in British Columbia, Canada

IntroductionBritish Columbia has the highest rate of opioid overdose in Canada, driven by the use of illegal opioids such as fentanyl. In addition to ongoing surveillance, there is a need for more comprehensive data to identify risk factors, inform the development of interventions, and evaluate the public health emergency response. Objectives and ApproachThe Provincial Overdose Cohort is a linked administrative dataset based on information from hospital admissions, physician visits, prescription dispensations, poison centre calls, ambulance, emergency department, coroner’s data, and First Nations Client File. Overdoses in the province were identified for the period January 2015-November 2016. Overdoses occurring within a 24 hour period across data sources were grouped as a single episode. For identified cases and for a control population (a 20% random sample of the BC residents), health care and prescribing history was appended dating back to 2010. Initial analyses were conducted based on a prioritization process with knowledge users. ResultsIntegration of distinct data sources about overdose events provided a more complete understanding of the extent of the opioid crisis than use of a single dataset alone. Between January 1, 2015 and November 30, 2016 10,456 overdoses occurred in BC. Overdose deaths represented only 13% of individuals overdosing; 54% of all overdoses were captured through ambulance records and 46\% through emergency and hospital records, with some overlap between the datasets. Most cases had contact with the health care system in the year before overdose suggesting opportunities for intervention. Some demographic differences were noted when comparing fatal and non-fatal overdoses, but few differences in health or prescribing histories were identifiable using administrative data. Conclusion/ImplicationsThe Provincial Overdose Cohort is a uniquely comprehensive dataset in a jurisdiction at the forefront of the opioid overdose response. Jurisdictions developing surveillance systems should consider the inclusion of ambulance, emergency room and hospital data in order to more completely characterize the population at risk.

Linkage of Chronic Disease Data from Provincial Sources for Strategic Decision Support and Population Health Surveillance in British Columbia (BC)

IntroductionBC Ministry of Health (MoH)’s health administrative data holdings for a variety of general health care data are not readily linked with various data registries maintained by specialized care agencies of the Provincial Health Services Authority (PHSA). These provincial data sources have rich chronic disease information for BC residents. Objectives and ApproachThe objective of this project is to develop a system for cross-agency linkage of provincial level chronic disease data to improve chronic disease information that would support the BC’s health system, MoH and PHSA agencies in particular, in healthcare delivery and chronic disease prevention planning. We aim to achieve linkage of data from various provincial chronic disease data sources of the MoH and PHSA, with further potential to link with variety of other external databases such as Census data for socio-economic determinants of health. We are reporting here the outcome of the first phase of this project. ResultsThe outcomes from the project to date were as follows: Data linkage between the MoH’s administrative databases, Chronic Disease Registries (CDRs) in particular and Census based socio-economic status (SES) data was achieved, providing the population level evidence of health outcomes such as health inequity, comorbidities and multimorbidities (sub-project # 1). Preliminary results on data quality and health outcomes by SES will be presented. This was followed by completion of securing approval to ensure data security compliance for data linkages of CDRs with the Provincial Renal Agency’s Registry called “PROMIS” (sub-project # 2), Cardiac Services BC’s Registry called “HEARTis” ((sub-project # 3), and BC Cancer Agency’s Registry and BC Generations Project data (sub-project # 4), for implementation to answer agency specific research questions. Conclusion/ImplicationsThis data linkage project to consolidate information from chronic disease and socio-economic databases for providing answers to various analytic questions posed will improve decision support and enhanced population health surveillance. The lessons learned from this multi-agency collaboration and their implications for other jurisdictions will be addressed.

Is cardiovascular risk reduction therapy effective in South Asian, Chinese and other patients with diabetes? A population-based cohort study from Canada

OBJECTIVES

Guidelines recommend ACE inhibitors (ACEi), angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs) and diuretics in all patients with diabetes mellitus. However, the effectiveness of these agents in South Asian and Chinese populations is unknown. We sought to determine whether ACEi, ARB, CCB and diuretics are associated with reduced mortality in South Asian, Chinese and other patients with diabetes.

DESIGN

Population-based cohort study using administrative health databases.

SETTING

Province of British Columbia, Canada (2006-2013).

PARTICIPANTS

Patients aged ≥35 years with incident diabetes.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was all-cause mortality for each medication class compared with untreated patients within each ethnicity. Treatment effect was assessed using inverse probability of treatment weighted Cox proportional hazards models. Medication adherence effect on mortality was also evaluated.

RESULTS

208 870 patients (13 755 South Asian, 22 871 Chinese, 172 244 other Canadian) were included. ACEi reduced mortality in other patients (HR=0.88, 0.84-0.91), but power was insufficient to evaluate for benefit in Chinese and South Asian patients. ARB and diuretics reduced mortality in Chinese (ARB HR=0.64, 0.50-0.82; diuretics HR=0.77, 0.62-0.96) and other patients (ARB HR=0.69, 0.64-0.74; diuretics HR=0.66, 0.63-0.69) compared with untreated patients. No mortality benefit was observed among South Asians for any drug class or for CCB among all ethnicities. Higher medication adherence was associated with lower mortality for other patients only (HR=0.79, 0.72-0.86).

CONCLUSIONS

Effectiveness of cardiovascular risk reduction therapy on mortality varies considerably by ethnicity. Further study is needed to evaluate the mortality benefit of antihypertensive agents in South Asians. Inclusion of these ethnic groups in future clinical trials is essential to examine for differential responses.

Long-term sedative use among community-dwelling adults: a population-based analysis

BACKGROUND

Chronic use of benzodiazepines and benzodiazepine-like sedatives (z-drugs) presents substantial risks to people of all ages. We sought to assess trends in long-term sedative use among community-dwelling adults in British Columbia.

METHODS

Using population-based linked administrative databases, we examined longitudinal trends in age-standardized rates of sedative use among different age groups of community-dwelling adults (age ≥ 18 yr), from 2004 to 2013. For each calendar year, we classified adults as nonusers, short-term users, or long-term users of sedatives based on their patterns of sedative dispensation. For calendar year 2013, we applied cross-sectional analysis and estimated logistic regression models to identify health and socioeconomic risk factors associated with long-term sedative use.

RESULTS

More than half (53.4%) of long-term users of sedatives in British Columbia are between ages 18 and 64 years (young and middle-aged adults). From 2004 to 2013, long-term sedative use remained stable among adults more than 65 years of age (older adults) and increased slightly among young and middle-aged adults. Although the use of benzodiazepines decreased during the study period, the trend was offset by equal or greater increases in long-term use of z-drugs. Being an older adult, sick, poor and single were associated with increased odds of long-term sedative use.

INTERPRETATION

Despite efforts to stem such patterns of medication use, long-term use of sedatives increased in British Columbia between 2004 and 2013. This increase was driven largely by increased use among middle-aged adults. Future deprescribing efforts that target adults of all ages may help curb this trend.

Patterns and trends in long-term opioid use for non-cancer pain in British Columbia, 2005-2012

OBJECTIVES

We aimed to calculate trends in incidence and prevalence rates of long-term opioid use for non-cancer pain, as well as to describe the characteristics of long-term opioid users and their patterns of opioid use.

METHODS

We used population-based linked health care and socio-demographic administrative data for British Columbia (BC) between 2005 and 2012. We included individuals who had at least one episode of long-term opioid use during the study period and who were not cancer or palliative care patients.

RESULTS

Long-term users comprised only 10% of all individuals prescribed opioids for non-cancer pain, but accounted for 64% of all opioid prescriptions and 87% of all morphine equivalents dispensed in BC during this period. While the incidence rate did not significantly change, the prevalence rate increased by 27% for men and 22% for women. In 2012, there were 3.80 (3.72-3.88) new long-term opioid users per 1,000 men and 4.42 (4.34-4.51) new users per 1,000 women. At the same time, there were 18.3 (95% CI 18.1-18.5) existing long-term users per 1,000 men and 21.7 users (95% CI 21.5-21.9) per 1,000 women. Overall, 2.4% of BC residents were long-term users of prescription opioids in 2012. Most long-term users had one continuous episode of use spanning multiple years. Almost two thirds took opioids every other day or more frequently.

CONCLUSION

There is a growing population of long-term opioid users for non-cancer pain in BC, with higher incidence and prevalence rates observed among women than among men.

Assessing the external validity of model-based estimates of the incidence of heart attack in England: a modelling study

BACKGROUND

The DisMod II model is designed to estimate epidemiological parameters on diseases where measured data are incomplete and has been used to provide estimates of disease incidence for the Global Burden of Disease study. We assessed the external validity of the DisMod II model by comparing modelled estimates of the incidence of first acute myocardial infarction (AMI) in England in 2010 with estimates derived from a linked dataset of hospital records and death certificates.

METHODS

Inputs for DisMod II were prevalence rates of ever having had an AMI taken from a population health survey, total mortality rates and AMI mortality rates taken from death certificates. By definition, remission rates were zero. We estimated first AMI incidence in an external dataset from England in 2010 using a linked dataset including all hospital admissions and death certificates since 1998. 95 % confidence intervals were derived around estimates from the external dataset and DisMod II estimates based on sampling variance and reported uncertainty in prevalence estimates respectively.

RESULTS

Estimates of the incidence rate for the whole population were higher in the DisMod II results than the external dataset (+54 % for men and +26 % for women). Age-specific results showed that the DisMod II results over-estimated incidence for all but the oldest age groups. Confidence intervals for the DisMod II and external dataset estimates did not overlap for most age groups.

CONCLUSION

By comparison with AMI incidence rates in England, DisMod II did not achieve external validity for age-specific incidence rates, but did provide global estimates of incidence that are of similar magnitude to measured estimates. The model should be used with caution when estimating age-specific incidence rates.

Mortality and Cardiovascular Risk of Sulfonylureas in South Asian, Chinese and Other Canadians with Diabetes

OBJECTIVES

Sulfonylureas have been inconsistently associated with increased cardiovascular mortality in patients with type 2 diabetes mellitus. However, there are no existing studies of long-term risk in South Asian and Chinese populations. Our objective was to determine whether sulfonylureas are associated with increased mortality or cardiovascular disease in a population cohort of South Asian, Chinese and other Canadian patients with incident diabetes.

METHODS

We studied a population-based cohort of adults 35 years of age or older who had diabetes and had been diagnosed between April 2004 and March 2014 by using administrative databases from British Columbia. The primary outcome was time to death from any cause or from a major cardiovascular event (MACE) with sulfonylurea treatment within each ethnicity. Propensity score modelling was applied using inverse probability of treatment weights. Results were stratified by agent and adjusted for age, sex, comorbidities, income and other medications.

RESULTS

We included 208 870 patients: 13 755 South Asians, 22 871 Chinese, 172 244 other Canadians. Mortality and MACEs were higher in other Canadian patients for whom sulfonylureas had been prescribed (adjusted HR = 2.0; 95% confidence interval 1.9 to 2.2; and HR = 1.9, 1.7 to 2.2). Among Chinese and South Asian patients who had been prescribed sulfonylureas, mortality (HR = 2.6, 2.0 to 3.5; and HR = 2.4, 1.7 to 3.4, respectively) and MACEs (HR = 2.3; 1.4 to 4.0; and HR = 2.0, 1.2 to 3.2, respectively) were elevated.

CONCLUSIONS

Considering the widespread use of sulfonylureas, there is a significant signal for increased mortality in all patients. In particular, increased mortality and MACEs were observed in South Asian and Chinese patients. These results should be confirmed in other studies, and patients of Asian descent should be included in clinical trials concerning diabetes.

Sex differences in the risk of receiving potentially inappropriate prescriptions among older adults

Objectives: to measure sex differences in the risk of receiving potentially inappropriate prescription drugs and to examine what are the factors that contribute to these differences.

Design: a retrospective cohort study.

Setting: community setting of British Columbia, Canada.

Participants: residents of British Columbia aged 65 and older (n = 660,679).

Measurements: we measured 2013 period prevalence of prescription dispensations satisfying the American Geriatrics Society's 2012 version of the Beers Criteria for potentially inappropriate medication use in older adults. We used logistic regressions to test for associations between this outcome and a number of clinical and socioeconomic factors.

Results: a larger share of women (31%) than of men (26%) filled one or more potentially inappropriate prescription in the community. The odds of receiving potentially inappropriate prescriptions are associated with several clinical and socioeconomic factors. After controlling for those factors, community-dwelling women were at 16% higher odds of receiving a potentially inappropriate prescription than men (adjusted odds ratio = 1.16, 95% confidence interval = 1.12–1.21). Much of this sex difference stemmed from women's increased odds of receiving potentially inappropriate prescriptions for benzodiazepines and other hypnotics, for tertiary tricyclic antidepressants and for non-selective NSAIDs.

Conclusion: there are significant sex differences in older adults' risk of receiving a potentially inappropriate prescription as a result of complex intersections between gender and other social constructs. Appropriate responses will therefore require changes in the information, norms and expectations of both prescribers and patients.

High-Cost Users of Prescription Drugs: A Population-Based Analysis from British Columbia, Canada

Objective

To examine variation in pharmaceutical spending and patient characteristics across prescription drug user groups.

Data Sources

British Columbia's population‐based linked administrative health and sociodemographic databases (N = 3,460,763).

Study Design

We classified individuals into empirically derived prescription drug user groups based on pharmaceutical spending patterns outside hospitals from 2007 to 2011. We examined variation in patient characteristics, mortality, and health services usage and applied hierarchical clustering to determine patterns of concurrent drug use identifying high‐cost patients.

Principal Findings

Approximately 1 in 20 British Columbians had persistently high prescription costs for 5 consecutive years, accounting for 42 percent of 2011 province‐wide pharmaceutical spending. Less than 1 percent of the population experienced discrete episodes of high prescription costs; an additional 2.8 percent transitioned to or from high‐cost episodes of unknown duration. Persistent high‐cost users were more likely to concurrently use multiple chronic medications; episodic and transitory users spent more on specialized medicines, including outpatient cancer drugs. Cluster analyses revealed heterogeneity in concurrent medicine use within high‐cost groups.

Conclusions

Whether low, moderate, or high, costs of prescription drugs for most individuals are persistent over time. Policies controlling high‐cost use should focus on reducing polypharmacy and encouraging price competition in drug classes used by ordinary and high‐cost users alike.

Postpartum domperidone use in British Columbia: a retrospective cohort study

BACKGROUND

Domperidone is commonly used off-label to stimulate milk production in mothers who have low milk supply. The aim of this study was to describe trends, patterns and determinants of postpartum domperidone use.

METHODS

This is a retrospective, population-based study involving all women with a live birth between Jan. 1, 2002, and Dec. 31, 2011, in the province of British Columbia. We examined administrative data sets containing person-specific information on filled prescriptions and use of medical services, and we used logistic regression to examine associations between domperidone use and maternal characteristics.

RESULTS

The study population consisted of 225 532 women with 320 351 live births. The prevalence of postpartum domperidone use more than doubled between 2002 and 2011. In 2011, 1 in 3 women with a preterm birth and 1 in 5 women with a full-term birth were prescribed domperidone in the first 6 months postpartum. Women who were older, had a higher body mass index, had a chronic disease, were first-time mothers, delivered more than 1 baby (multiple pregnancy), had a preterm birth or had a cesarian delivery were more likely to fill a postpartum domperidone prescription.

INTERPRETATION

We found an increase in postpartum domperidone use over a 10-year period. More research is needed on maternal and infant health outcomes.

Sensitivity and specificity of administrative mortality data for identifying prescription opioid-related deaths

BACKGROUND

Comprehensive systems for surveilling prescription opioid-related harms provide clear evidence that deaths from prescription opioids have increased dramatically in the United States. However, these harms are not systematically monitored in Canada. In light of a growing public health crisis, accessible, nationwide data sources to examine prescription opioid-related harms in Canada are needed. We sought to examine the performance of 5 algorithms to identify prescription opioid-related deaths from vital statistics data against data abstracted from the Office of the Chief Coroner of Ontario as a gold standard.

METHODS

We identified all prescription opioid-related deaths from Ontario coroners' data that occurred between Jan. 31, 2003, and Dec. 31, 2010. We then used 5 different algorithms to identify prescription opioid-related deaths from vital statistics death data in 2010. We selected the algorithm with the highest sensitivity and a positive predictive value of more than 80% as the optimal algorithm for identifying prescription opioid-related deaths.

RESULTS

Four of the 5 algorithms had positive predictive values of more than 80%. The algorithm with the highest sensitivity (75%) in 2010 improved slightly in its predictive performance from 2003 to 2010.

INTERPRETATION

In the absence of specific systems for monitoring prescription opioid-related deaths in Canada, readily available national vital statistics data can be used to study prescription opioid-related mortality with considerable accuracy. Despite some limitations, these data may facilitate the implementation of national surveillance and monitoring strategies.

Sex Disparities in Post-Acute Myocardial Infarction Pharmacologic Treatment Initiation and Adherence: Problem for Young Women

BACKGROUND

The prevalence of the use of secondary prevention cardiovascular medications is lower among women than men, but it is unclear if this is a result of lower treatment initiation among women or lower treatment adherence. We aimed to map the treatment pathway for survivors of acute myocardial infarction (AMI) by sex and age.

METHODS AND RESULTS

This retrospective population-based cohort study used linked administrative data sets in British Columbia (2004-2011), which include health care, prescription drugs, sociodemographic, and mortality information. The study cohort included all individuals admitted to hospital for AMI in 2007-2009 and survived for 1 year after hospital discharge. Patients were evaluated for whether they initiated and then subsequently filled prescriptions angiotensin-converting enzyme inhibitors, β-blockers, and statins. More than two thirds of AMI survivors initiated treatment on all appropriate medications, given their contraindications, within 2 months of discharge. Younger men were significantly more likely than younger women to initiate appropriate treatment (adjusted odds ratio, 1.38; 95% confidence interval, 1.10-1.75). By the end of 1 year after discharge, only one third of all AMI survivors filled all appropriate prescriptions for at least 80% of the year. There was no significant difference in adherence to medication therapy between women and men.

CONCLUSIONS

The majority of AMI survivors either discontinue treatment or do not refill their prescriptions consistently. Women <55 years are significantly less likely to be on optimal therapy by the end of 1 year after discharge, which is driven by a sex disparity in treatment initiation and not treatment adherence.

Risk of dementia in patients hospitalised with type 1 and type 2 diabetes in England, 1998-2011: a retrospective national record linkage cohort study

AIMS/HYPOTHESIS

Type 2 diabetes increases the risk of subsequent dementia. Our objective was to determine whether a similar risk of subsequent dementia is associated with type 1 diabetes in a large defined population.

METHODS

This retrospective cohort study examined national administrative record-linked statistical data on hospital care and mortality in England, 1998-2011. Cohorts of people admitted to hospital when aged 30 or over were constructed: 343,062 people with type 1 diabetes; 1,855,141 people with type 2 diabetes; and a reference cohort. Results were expressed as rate ratios (RR) comparing each diabetes cohort with the control cohort.

RESULTS

The overall RR for dementia in people admitted to hospital with type 1 diabetes was 1.65 (95% CI 1.61, 1.68), and for people admitted to hospital with type 2 diabetes was 1.37 (1.35, 1.38). Young age at admission for diabetes appeared to confer a greater rate of subsequent dementia; the RR for dementia in people admitted to hospital with type 1 diabetes aged 30-39 years was 7.10 (4.65, 10.6), which reduced to 4.40 (3.55, 5.40) in those aged 40-49 at admission, and further reduced with increasing age to 1.16 (1.11, 1.20) in those aged 80 or over at admission. A similar pattern was seen with type 2 diabetes.

CONCLUSIONS/INTERPRETATION

Type 1 diabetes, as well as type 2 diabetes, may be associated with an elevated risk of subsequent dementia. The risk of dementia varies with age at admission to hospital with diabetes, and appears to be much greater in the young.

The drivers of overspending on prescription drugs in Quebec

According to data from the most recent edition of the Canadian Rx Atlas, Quebec was the province with the highest total spending per capita on prescription drugs. The difference between Quebec and the rest of Canada was 35%, which translates into $1.5 billion dollars of extra spending. This analysis explores the economic cost drivers of the higher level of pharmaceutical spending in Quebec. While much of the additional spending was driven by a higher volume of drugs being prescribed overall, the factors contributing to higher spending differed greatly within particular therapeutic categories. The results and their implications are discussed in the context of pharmaceutical policy environment.

Long-Term Survival and Recurrence After Acute Myocardial Infarction in England, 2004 to 2010

Background—

There are limited population-based national data on prognosis in survivors of acute myocardial infarction (AMI), particularly on long-term survival and the risk of recurrence.

Methods and Results—

Record linkage of hospital and mortality data identified 387 452 individuals in England who were admitted to hospital with a main diagnosis of AMI between 2004 and 2010 and who survived for at least 30 days. Seven years after an AMI, the risk of death from any cause in survivors of first or recurrent AMI was, respectively, 2 and 3 times higher than that in the English general population of equivalent age. For all survivors of a first AMI, the risk of a second AMI was highest during the first year and the cumulative risk increased more gradually thereafter. For men, 1- and 7-year cumulative risks were 5.6% (95% confidence interval [CI], 5.5–5.7) and 13.9% (95% CI, 13.7–14.1); for women, they were 7.2% (95% CI, 7.1–7.4) and 16.2% (95% CI, 16.0–16.5). Older age, higher deprivation, no revascularization procedures, and presence of comorbidities were associated with higher recurrence risk.

Conclusions—

Survivors of both first and recurrent AMI remained at a significantly higher risk of death compared with the general population for at least 7 years after the event. For survivors of first AMI, the influence of predisposing factors for second AMI lessened with time after the initial event. The results reinforce the importance of acute clinical care and secondary prevention in improving long-term prognosis of hospitalized AMI patients.

Determinants of the decline in mortality from acute myocardial infarction in England between 2002 and 2010: linked national database study

OBJECTIVE

To report trends in event and case fatality rates for acute myocardial infarction and examine the relative contributions of changes in these rates to changes in total mortality from acute myocardial infarction by sex, age, and geographical region between 2002 and 2010.

DESIGN

Population based study using person linked routine hospital and mortality data.

SETTING

England.

PARTICIPANTS

840,175 people of all ages who were admitted to hospital for acute myocardial infarction or died suddenly from acute myocardial infarction.

MAIN OUTCOME MEASURES

Acute myocardial infarction event, 30 day case fatality, and total mortality rates.

RESULTS

From 2002 to 2010 in England, the age standardised total mortality rate fell by about half, whereas the age standardised event and case fatality rates both declined by about one third. In men, the acute myocardial infarction event, case fatality, and total mortality rates declined at an average annual rate of, respectively, 4.8% (95% confidence interval 3.0% to 6.5%), 3.6% (3.4% to 3.7%), and 8.6% (5.4% to 11.6%). In women, the corresponding figures were 4.5% (1.7% to 7.1%), 4.2% (4.0% to 4.3%), and 9.1% (4.5% to 13.6%). Overall, the relative contributions of the reductions in event and case fatality rates to the decline in acute myocardial infarction mortality rate were, respectively, 57% and 43% in men and 52% and 48% in women; however, the relative contributions differed by age, sex, and geographical region.

CONCLUSIONS

Just over half of the decline in deaths from acute myocardial infarction during the 2000s in England can be attributed to a decline in event rate and just less than half to improved survival at 30 days. Both prevention of acute myocardial infarction and acute medical treatment have contributed to the decline in deaths from acute myocardial infarction over the past decade.

Incidence and 30-day case fatality for acute myocardial infarction in England in 2010: national-linked database study

Background: There are limited national population-based epidemiological data on acute myocardial infarction (AMI) in England, making the current burden of disease, and clinical prognosis, difficult to quantify. The aim of this study was to provide national estimates of incidence and 30-day case fatality rate (CFR) for first and recurrent AMI in England. Methods: Population-based study using person-linked routine hospital and mortality data on 79 896 individuals of any age, who were admitted to hospital for AMI or who died suddenly from AMI in 2010. Results: Of 82 252 AMI events in 2010, 83% were first. Age-standardized incidence of first AMI per 100 000 population was 130 (95% CI 129–131) in men and 55.9 (95% CI 55.3–56.6) in women. Age-standardized 30-day overall CFRs including sudden AMI deaths for men and women, respectively, were 32.4% (95% CI 32.0–32.9) and 30.3% (95% CI 29.8–30.9) for first AMI and 29.7% (95% CI 28.7–30.7) and 26.7% (95% CI 25.5–27.9) for recurrent AMI. Age-standardized hospitalized 30-day CFR was 12.0% (95% CI 11.6–12.3) for men and 12.3% (95% CI 11.9–12.7) for women. Conclusions: While the majority of AMIs are not fatal, of those that are, two-thirds occur as sudden AMI deaths. About one in six of all AMIs are recurrent events. These findings reinforce the importance of primary and secondary prevention in reducing AMI morbidity and mortality.