UofT Family Medicine Report: Caring for Our Diverse Populations - UTOPIAN Technical Appendix

University of Toronto Family Medicine Report: Caring for our Diverse Populations UTOPIAN Technical Appendix

Authors Karen Tu Babak Aliarzadeh Tao Chen Sumeet Kalia

Table of Contents Introduction .................................................................................................................................................... 2 Data Inclusion Criteria ..................................................................................................................................... 3 Family physician criteria for inclusion .......................................................................................................... 3 Patient criteria for inclusion ........................................................................................................................ 3 Defining Office Visits ....................................................................................................................................... 5 Family physician office visits - OHIP billing service codes ............................................................................. 5 Special or focused practice office visits – OHIP billing service codes ............................................................. 6 Identifying Medications in the EMR ................................................................................................................. 7 Identifying Patients with Disease Conditions ................................................................................................... 8 Cumulative patient profiles in different EMRs.............................................................................................. 8 Family history .............................................................................................................................................. 8 Chapter 3: Caring for Children and Youth ........................................................................................................ 9 ‘Well’ vs ‘Sick’ visits ..................................................................................................................................... 9 Measuring zBMI in children ....................................................................................................................... 10 Chapter 4: Meeting the Needs of People Living with Chronic Disease ............................................................ 11 Identifying patients with depression and or anxiety ................................................................................... 11 Identifying patients with hypertension ...................................................................................................... 13 Identifying patients with diabetes.............................................................................................................. 18 Identifying patients with chronic kidney disease ........................................................................................ 21 Chapter 5 Recognizing the Complexity of Care for Older Adults ..................................................................... 22 Identifying mental health visits .................................................................................................................. 22 Chapter 8: Helping People with Severe Mental Illness ................................................................................... 24 Identifying patients with schizophrenia ..................................................................................................... 24 Identifying patients with bipolar affective disorder .................................................................................... 25 Classifying patients smoking status ............................................................................................................ 26

UTOPIAN Technical Appendix: November 19, 2020

1

Introduction

This is the Technical Appendix to accompany the 2020 University of Toronto Family Medicine Report: Caring for Our Diverse Populations. The intent of the appendix is to provide the technical details of the analysis of the UTOPIAN Data Safe Haven data provided in the report. This includes the processes for cleaning the data, identifying the relevant patients, identifying patients with disease conditions and other analytic and classification methods

UTOPIAN Technical Appendix: November 19, 2020

2

Data Inclusion Criteria Data is extracted from participating family physicians on Telus PS Suite EMR, Accuro EMR and OSCAR EMR software. Data is extracted on a quarterly basis and processed with quarterly cut-off dates (CutOffDate) for each yearly cycle of data extraction (Q1= March 31st, Q2= June 30th, Q3= September 30th, Q4= December 31st). Data used for this report were as of the March 31, 2019 Q1 cut off date.

Family physician criteria for inclusion Family physician data are included if their data meets our data quality assessment as follows: 1. The percent of rostered patients with a billing record in the year prior to the CutOffDate (Bills_ratio) is greater than or equal to 20% 2. The percent of rostered adult patients with a ‘selected’ lab test in the year prior to the CutOffDate (Lab_ratio) is greater than or equal to 20% 3. The percent of rostered adult patients with a medication record in the year prior to the CutOffDate (Medication_ratio) is greater than or equal to 20% 4. At least 200 rostered patients

Patient criteria for inclusion Patient data are included if their data meets all the following criteria: 1. Patient is registered under a family physician that meets family physician inclusion criteria.

2. Patient has sex recorded and a valid date of birth. Age is calculated as of the quarterly CutOffDate, using the middle of the birth month as the day of birth.

3. The electronic medical record (EMR) start date1 must be at least 1 year prior to the quarterly CutOffDate, unless age <1 year at the CutOffDate. If age < 1 year then must be rostered or have at least 1 Ontario Health Insurance Plan (OHIP) billing service code classified as a family physician office visit.2 4. a. Rostered to a participating physician OR b. Any periodic health exam (OHIP billing service code K017, K130, K131, K132) in the past 3 years OR c. An ‘active’ patient is defined as having two ‘visits’ in the past 3 years. Whereby a ‘visit’ is an OHIP billing service code family physician office visit OR a special or focused practice office visit, hospital visit (including hospital palliative care visit), emergency room visit, home visit or longterm care visit with a populated cumulative patient profile in the EMR

UTOPIAN Technical Appendix: November 19, 2020

3

Notes: 1EMR

start date defined as the earliest date of a: 1. of a family physician office visit OR 2. a special or focused practice office visit, hospital visit (including hospital palliative care visit), emergency room visit, home visit or long-term care visit with a populated cumulative patient profile in the EMR AND a family physician office visit less than 1 year prior to the CutOffDate

2OHIP

billing service codes with a frequency of 50 or more were classified into family physician office visits, special or focused practice office visits, specialist visits, hospital visits, hospital or office prenatal or obstetrical care visits, hospital or home palliative care visits, emergency room visits, home visits, long term care visits, telephone consultations, nurse practitioner visits, add on/premium codes, tracking codes and miscellaneous billing codes.

Data collected at each quarter with a frequency of 50 or more will be classified with each data collection in order to capture new OHIP billing service codes that may arise over time with each new data collection.

UTOPIAN Technical Appendix: November 19, 2020

4

Defining Office Visits Family physician office visits - OHIP billing service codes Code

Description

Code

Description

A001

minor assessment

K017

periodic health visit-child aft. 2nd birthday

A002

enhanced 18-month well baby visit

K022

hiv prim care individ care 1/2 hr or major part

A003

major assessment

K028

sexually transmitted disease (std) counseling

A004

general re-assessment

K030

diabetic management fee

A007

intermediate assessment

K032

gp-specific neurocognitive assessment

A008

mini assessment

K033

counselling - 1 pt/yr/unit

A071

complex medical specific re-assessment

K039

smoking cessation follow-up visit

A131

complex medical specific re-assessment

K130

periodic health visit - adolescent

A134

medical specific re-assessment

K131

periodic health visit - adult aged 18 to 64 inclusive

A624

medical specific re-assessment

K132

periodic health visit - adult 65 years of age and older

A888

partial assessment

K680

substance abuse - extended assessment

A903

pre-op assessment

P003

obs.-prenatal care-gen.assess-major prenatal visit

A920

medical management of early pregnancy, initial visit

P004

obs.-prenatal care-minor prenatal assess.subseq.prenat.vis.

K005

primary mental health

P005

antenatal health screen

K007

ind. psychotherapy per half hour - gp

P008

obs.-post-natal care in office

K013

counselling-one or more people-per 1/2hr

K037

fibromyalgia/chronic fatigue syndrome care

UTOPIAN Technical Appendix: November 19, 2020

5

Special or focused practice office visits â&#x20AC;&#x201C; OHIP billing service codes Code

Description

Code

Description

A005

consultation

K008

diagnostic interview and/or counselling with child and/or parent

A006

repeat consultation

K004

family psychotherapy-2 or more members in attendance at the same time

A133

medical specific assessment

K014

A680

addiction medicine initial assessment

K015

A905

limited consultation

K018

Sexual assault examination - female

A911

special family and general practice consultation

K029

intensive insulin therapy counseling

A912

comprehensive family and general practice consultation

K040

group counselling

A917

focused practice assessment - sports medicine

K041

group counselling- 2 or more patientsadditional units where >3 K013 or K040

A957

focused practice assessment - addiction medicine

K701

mental health out-patient case conference

A967

focused practice assessment - care of the elderly

K703

geriatric out-patient case conference

A996

special visit physician office - nights

C911

special family and general practice consultation

K002

family meeting, caregiver interview interviews-relatives on behalf of patient

C912

comprehensive family and general practice consultation subject

K003

Interviews with Childrenâ&#x20AC;&#x2122;s Aid Society or legal guardian on behalf of the patient

UTOPIAN Technical Appendix: November 19, 2020

counselling for transplant recipients, donors or families of recipients and donors counselling of relatives on behalf of catastrophic or terminally ill patient

6

Identifying Medications in the EMR Different EMR software have different ways of recording when a medication is discontinued.

In Telus PS Suite EMR, when a provider discontinues a medication, a new prescription record is generated that is marked as discontinued. Therefore, prescription records that are marked as discontinued are not counted as a prescription for a particular medication.

In Accuro EMR and OSCAR EMR when a provider discontinues a medication a new prescription does not get generated but rather the original prescription gets a flag. In Accuro EMR this flag is called ‘discontinued’, in OSCAR EMR it is called ‘past medication.’ Therefore, all prescriptions in Accuro EMR and OSCAR EMR are counted as a prescription for a particular medication, unless the prescription date and discontinuation date is the same date, in which case that prescription does not get counted as a prescription for a particular medication.

UTOPIAN Technical Appendix: November 19, 2020

7

Identifying Patients with Disease Conditions Cumulative patient profiles in different EMRs Although the principles and types of content in EMRs are similar, all EMRs are structured differently and therefore record similar information in different ways. One area of difference is how active problems and past medical history are recorded. Some EMRs provide drop down menus to populate the different variables of the cumulative patient profile, others are very free-text oriented. While some EMRs ‘force’ coding of diagnoses, in others coding of diagnoses is optional and therefore the coding of diagnoses is highly variable even amongst providers using the same EMR software. As a result, we focus on free text searches for identifying the presence of disease conditions as recorded in the cumulative patient profile of the EMR.

Family history We have found that some physicians document family history in the problem list portion of the cumulative patient profile list of health conditions or when a physician changes EMR software the old cumulative patient profile gets copied and pasted into the new EMR cumulative patient profile and not placed into the discrete fields of the cumulative patient profile. Therefore, we developed strategies to attempt to not erroneously attribute disease conditions in family members to patients. Whenever the algorithm detects a ‘key search term’ in the health condition’s table free-text entries, the algorithm searches for family words in the 5-word neighbourhood of the ‘key search term’ in the phrase where the search term is located. The list of family words that are searched for are as follows: grandp[a-z]+

grandf[a-z]+

grandm[a-z]+

grandson

granddaughter

parents

father

dad

mother

mom

brother

bro

sister

sis

wife

husband

aunt

uncle

pgp

pgf

aunt

uncle

pgp

pgf

pgm

mgf

mgm

mgp

family history

fam hx

famhx

Family hx

fhx

son

daughter

This strategy was applied for all free text searches for the occurrence of disease conditions documented in the past or present health conditions section of the cumulative patient profile Adapted from: Williamson T, Green ME, Birtwhistle R, Khan S, Garies S, Wong ST, Natarajan N, Manca D, Drummond N. Validating the 8 CPCSSN Case Definitions for Chronic Disease Surveillance in a Primary Care Database of Electronic Health Records. Ann Fam Med. 2014 Jul; 12(4): 367–372. doi: 10.1370/afm.1644

UTOPIAN Technical Appendix: November 19, 2020

8

Chapter 3: Caring for Children and Youth ‘Well’ vs ‘Sick’ visits ‘Well’ visits – Visits by children were classified as ‘well’ visits if: 1. The OHIP billing service code was: Code A002 K017 K130 K131

Description enhanced 18-month well baby visit periodic health visit-child age 2-15 years periodic health visit-adolescent age 16-17 years periodic health visit-adult age 18-64 years

OR 2. A family physician office visit with a vaccination (OHIP immunization code): Code G840 G841 G842 G843 G844 G845 G846 G847 G848 G538

Description Diphtheria, Tetanus, and acellular Pertussis vaccine/ Inactivated Poliovirus vaccine (DTaPIPV) - paediatric Diphtheria, Tetanus, acellular Pertussis, Inactivated Polio Virus, Haemophilus influenza type b (DTaP-IPV-Hib) - paediatric Hepatitis B (HB) Human Papillomavirus (HPV) Meningococcal C Conjugate (Men-C) Measles, Mumps, Rubella (MMR) Pneumococcal Conjugate Diphtheria, Tetanus, acellular Pertussis (Tdap) - adult Varicella (VAR) Other immunizing agents not listed above

OR 3. An office visit with an OHIP diagnostic code of 916-well baby visit, or 917-physical health exam

‘Sick’ visits – All other visits were deemed ‘sick’ visits.

Based on: Carsley S, Birken CS, Parkin PC, Pullenayegum E, Tu K. Completeness and accuracy of anthropometric measurements in electronic medical records for children attending primary care. J Innov Health Inform. 2018 Mar; 25(1):019–026. doi:10.14236/jhi.v25i1.963.

UTOPIAN Technical Appendix: November 19, 2020

9

Measuring zBMI in children We collect weight and height measurements on the same day, including numerical values and units, in the past year of the patients who are between 0-18 years old by March 31, 2019.

We compute the age at measurement and, convert inches to centimetres and pounds to kilograms, and use the R package from Daymont et al. (2017) to remove the implausible entries. We use the most recent measures and apply the two WHO R packages to compute zBMI for children from 0-60 months (Schumacher 2020) and 5-18 years old, (WHO 2013), respectively.

Based on: Daymont, C., Ross, M. E., Russell Localio, A., Fiks, A. G., Wasserman, R. C., & Grundmeier, R. W. (2017). Automated identification of implausible values in growth data from pediatric electronic health records. Journal of the American Medical Informatics Association, 24(6), 1080-1087.

Schumacher, D. (2020, May 21). Computation of the WHO Child Growth Standards [R package anthro version 0.9.3]. Retrieved October 16, 2020, from https://cran.rproject.org/web/packages/anthro/index.html WHO (2013, October 16). Growth reference data for 5-19 years. Retrieved October 16, 2020, from https://www.who.int/growthref/tools/en/

UTOPIAN Technical Appendix: November 19, 2020

10

Chapter 4: Meeting the Needs of People Living with Chronic Disease Identifying patients with depression and or anxiety Depression and anxiety symptoms often co-exist, antidepressant medications are used to treat both depression and anxiety and physicians often use billing codes for depression and anxiety interchangeably. Therefore, we elected to combine the identification of depression and/or anxiety into one category. Patients with a past or current history of depression and/or anxiety were identified using the following criteria: 1. Free text documentation of depression and/or anxiety in the past or present health condition section of the cumulative patient profile including the following terms: Depression

Anxiety

clinically depressed depression depressive disorder MDD/major depressive disorder MDE/major depressive episode Dysthymia SAD (not social anxiety disorder) unipolar affective disorder

anxiety GAD/generalized anxiety disorder panic disorder agoraphobia post-traumatic stress disorder PTSD acute (traumatic) stress disorder social phobia OCD/obsessive compulsive disorder somatoform disorder conversion disorder somatization psychosomatic phobia dissociative disorder hypochondriac hypochondriasis

OR 2. Presence of two 311-depression OHIP diagnosis codes in a year, or three 300-anxiety OHIP diagnosis codes in a year, at any point in time in the EMR record OR 3. A prescription for an antidepressant medication

UTOPIAN Technical Appendix: November 19, 2020

11

Antidepressant medications include: Class

SSRI

SNRI

Other

Generic

Brand Name

citalopram fluoxetine sertraline escitalopram paroxetine fluvoxamine duloxetine venlafaxine desvenlafaxine levomilnacipran bupropion* mirtazapine vortioxetine vilazodone agomelatine moclobemide

Celexa Prozac Zoloft Cipralex Paxil Luvox Cymbalta Effexor Pristiq Fetzima Wellbutrin* Remeron Trintellix Viibryd Valdoxan Mannerix

* Any patient who was only prescribed medications also used in smoking cessation (bupropion or Wellbutrin) and had an OHIP billing service code associated with â&#x20AC;&#x153;smoking cessationâ&#x20AC;? (E079-initial smoking cessation discussion, K039-follow up discussion of smoking cessation, Q042-add on code in addition to K039) or OHIP diagnosis code 305-tobacco abuse or 491-chronic bronchitis within +/- 30 days of the prescription were not counted as having a prescription for an antidepressant to identify patients with depression and/or anxiety.

OR 4. A prescription for a benzodiazepine medication with an OHIP diagnosis codes of 311-depression or 300-anxiety on the same day, at any point in time in the EMR record.

Benzodiazepine medications include: Generic

Brand Name

alprazolam bromazepam clonazepam chlordiazepoxide diazepam flurazepam lorazepam nitrazepam oxazepam temazepam triazolam

Xanax Lectopam Rivotril Librium Valium Dalmane Ativan Mogadon, Nitrazadon Serax, Oxpam Restoril Halcion, Apo-Triazo

UTOPIAN Technical Appendix: November 19, 2020

12

Identifying patients with hypertension 1. Free text documentation of hypertension in the past or present health condition section of the cumulative patient including the following terms: Include Hypertension Misspelling such as hyperrtension or hyepertension Hypertensive Htn

Do not include Hypertensive response Borderline Occular/ocular Maternal Gestation White coat Pulmonary Pregnancy induced/PIH

OR 2. The most recent blood pressure1 reading systolic blood pressure >=140 mmHg or diastolic blood pressure >= 90 mmHg a. Met Hypertension Canada2 criteria for the diagnosis of hypertension b. Do not include blood pressure readings during gestational period3 OR 3. Anti-hypertensive medication4 is prescribed in the last 18 months a. Met Hypertension Canada2 criteria for the diagnosis of hypertension at any point in time in their EMR record b. Do not include medications and blood pressure readings during pregnancy period3 OR 4. Anti-hypertensive medication4 is prescribed on the same day as an elevated blood pressure reading1 >= 140 mmHg or diastolic blood pressure >= 90 mmHg in the past 18 months a. Do not include medications and blood pressure readings during pregnancy period3

Notes: 1 Exclude

physiologically improbable blood pressure readings (White 2007) if: a. systolic blood pressure < 70 mmHg or >260 mmHg b. diastolic blood pressure < 40 or >150 mmHg c. diastolic blood pressure >= systolic blood pressure

UTOPIAN Technical Appendix: November 19, 2020

13

2 Taken

from Hypertension Canada (Neremberg 2018) (Note: the recording of home vs office blood pressure readings and 24-hour blood pressure readings are not documented with consistent nomenclature in the EMR, therefore all bp readings are presumed to be office blood pressure readings) criteria: 1.

2.

3.

4.

One BP reading of systolic blood pressure >=180 mmHg or diastolic blood pressure >= 110 mmHg OR Two consecutive BP readings that both are of systolic blood pressure >=140 mmHg or diastolic blood pressure >= 90 mmHg for diabetic and CKD patients OR Or an initial BP reading of systolic blood pressure >= 140mmHg or diastolic blood pressure >= 90 mmHg followed by three consecutive BP readings that are on average over systolic blood pressure >=160mmHg or diastolic blood pressure >=100mmHg OR Or five consecutive BP readings that the first reading is systolic blood pressure >=140 mmHg or diastolic blood pressure >=90 mmHg and the average of the subsequent readings are systolic blood pressure >=140 mmHg or diastolic blood pressure >=90 mmHg

3 Pregnancy

period (Note: patients may develop pregnancy induced hypertension which may resolve after delivery.

Therefore, we do not include blood pressure readings taken during the time of pregnancy): 1. Start time (the earliest of): a. The time when a female patient’s ß-hCG lab test >=5.0. (If more than one ß-hCG in a 100 day time period OR b. 30 weeks before a female patient‘s pregnancy related oral glucose tolerance test 2. End time (the latest of): a. 40 weeks after a female patient’s ß-hCG lab test >= 5.0 OR b. 20 weeks after a female patient‘s pregnancy related oral glucose tolerance test lab test

4 Anti-hypertensive

medications:

Class

Angiotensin-converting Enzyme (ACE) Inhibitors

Generic benazepril captopril cilazapril enalapril fosinopril lisinopril perindopril quinapril hcl ramipril trandolapril

UTOPIAN Technical Appendix: November 19, 2020

Brand Name Lotensin Capoten, Captotec, Captril Inhibace, Inhibase Vasotec Monopril Zestril, Prinivil Coversyl Accupril, Accupro Altace Mavik

14

Class

Angiotensin II Receptor Blockers

Renin Inhibitor

Beta-adrenergic Blockers

Alpha-2 Adrenergic Receptor Agonist

Calcium Channel Blockers

Potassium-sparing Diuretic

Generic

Brand Name

candesartan

Atacand

eprosartan

Teveten

irbesartan

Avapro

losartan

Cozaar

olmesartan

Olmetec

telmisartan

Micardis

valsartan

Diovan

aliskiren

Basilez

acebutolol

Monitan, Sectral, Rhotral

atenolol

Tenormin

bisoprolol

Monocor

labetalol

Trandate

metoprolol

Lopressor, Toprol, Betaloc

nadolol

Corgard

oxprenolol

Trasicor

pindolol

Visken

propranolol

Inderal, Detensol

methyldopa

Dopazide, Methazide, Doparil

amlodipine diltiazem

Norvasc Cardizem, Tiazac

felodipine

Renedil, Plendil

nicardipine

Cardene

nifedipine

Adalat

nimodipine

Minotop

verapamil triamterene

Isoptin, Veralan, Veramil Neo Diurex

chlorthalidone

Thiazide, Hygroton Oretic, Microzide, Diuchlor H, Esidrix, Hydro Aquil, Hydrodiuril, Neo Codema, Urozide, ApoHydro

hydrochlorothiazide

Thiazide and Thiazidelike Diuretics

indapamide

Lozide

amiloride amiloride & hydrochlorothiazide spironolactone & hydrochlorothiazide triamterene & hydrochlorothiazide

Midamor Amiloride HCTZ, Amihydro, Riva-Amilzide, Amilazide, Amilzide, Atenidone, Moduretic,

UTOPIAN Technical Appendix: November 19, 2020

Aldactazide, Spirozide, Spirozine Dyazide, Maxzide, Diazide, Pro Triazide, Triamzide, Riva-Zide, Triazide, Hydro-Triam

15

Class

Combination Agents

Generic benazepril & hydrochlorothiazide

Brand Name Lotensin

cilazapril & hydrochlorothiazide

Inhibace Plus

enalapril & hydrochlorothiazide

Vaseretic

hydrochlorothiazide & ramipril

Altace HCT

lisinopril & hydrochlorothiazide

Zestoretic/ Prinzide

perindopril & indapamide

Coversyl Plus

quinapril & hydrochlorothiazide

Accuretic

amlodipine & telmisartan

Twynsta

eprosartan & hydrochlorothiazide

Teveten Hct

candesartan & hydrochlorothiazide

Atacand

hydrochlorothiazide & irbesartan

Avalide

hydrochlorothiazide & losartan

Hyzaar

hydrochlorothiazide & olmesartan

Benicar HCT

hydrochlorothiazide & valsartan

Diovan HCT

losartan & hydrochlorothiazide

Hyzaar

telmisartan & hydrochlorothiazide

Micardis HCT, Micardis Plus

valsartan & hydrochlorothiazide

Diovan

atenolol & chlorthalidone

nadolol & bendroflumethiazide

Tenoretic Logimat, Mibloc, Mobloc, Logimax Forte And Mobloc Forte Corzide

pindolol & hydrochlorothiazide

Viskazide

propranolol hcl & hydrochlorothiazide

Inderide

timolol & hydrochlorothiazide

Timolide

felodipine & ramipril

Inotens, Unimest And Unitens

verapamil & trandolapril

Tarka

chlorthalidone & reserpine

Regroton

methyldopa & hydrochlorothiazide

Aldoclor

methyldopa & hydrochlorothiazide

Aldoril

reserpine & hydrochlorothiazide

Hydroserpine, Hydropres, Serpasil Esidrix Ser-Ap-ES, Serpazide, Uni Serp, Hydrap-Es, Diuretic-Ap-Es, Marpres, Serathide, Unipres, Serpex Dutoprol, Lopressor HCT Lopressidone, Logroton

felodipine & metoprolol

reserpine & hydrochlorothiazide & hydralazine hcl metoprolol & hydrochlorothiazide metoprolol & chlorthalidone

References: White WB, editor. Blood Pressure Monitoring in Cardiovascular Medicine and Therapeutics.

Towana, NJ: Humana Press; 2007 Aug 8.

UTOPIAN Technical Appendix: November 19, 2020

16

Nerenberg KA, Zarnke KB, Leung AA, Rabi DM, Daskalopoulou SS, et al. for Hypertension Canada.

Hypertension Canadaâ&#x20AC;&#x2122;s 2018 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children. Can J Cardiol. 2018 May; 34(5): E74-E81 doi:10.1016/j.cjca.2018.02.022

Adapted from: Tu K, Bevan L, Hunter K, Rogers J, Young J, Nesrallah G. Quality indicators for the detection and management of Chronic Kidney Disease in primary care in Canada derived from a ModifiedDelphi Panel Approach. CMAJ Open. 2017 Jan; 5(1): E74-E81.

UTOPIAN Technical Appendix: November 19, 2020

17

Identifying patients with diabetes 1. Free text documentation of diabetes in the past or present health condition section of the cumulative patient including the following terms: Include

Do Not Include

Diabetes

Insipid

Niddm

Chemical induced

Dm/Dm2/Dmii

Pregnancy

T2dm

Maternal

Iddm

Gestation

T1d/t1dm

Borderline

T2d/dka/type2dm

Pre-diabetes Prednisone

OR 2. Two most recent eligible labs that are less than two years apart. a. Eligible labs: i. HbA1c >= 6.5% ii. FBS >= 7.0 mmol/L iii. RBS >= 11.1 mmol/L b. Exclude labs during pregnancy period1 OR 3. Diabetes medication2 (oral hypoglycemic or insulin) in the 2 years prior to the cycle cutoff date a. Exclude metformin and insulin during pregnancy period1 b. Exclude metformin for female patients who are 50 years old or younger Notes: 1 Pregnancy

period (Note: patients may develop gestational diabetes which may resolve after delivery. Therefore we do not include diabetes lab tests readings taken during the time of pregnancy): 1.

2.

Start time (the earliest of): a. The time when a female patient’s ß-hCG lab test >=5.0. (If more than one ß-hCG in a 100 day time period use the date of the earliest one) OR b. 30 weeks before a female patient‘s pregnancy related oral glucose tolerance test End time (the latest of): a. 40 weeks after a female patient’s ß-hCG lab test >= 5.0 OR b. 20 weeks after a female patient‘s pregnancy related oral glucose tolerance test lab test

UTOPIAN Technical Appendix: November 19, 2020

18

2

Diabetes medications: Class

Generic

Brand Name

Biguanide

metformin

Glucophage, Glumetza, Glycon, Riomet

alogliptin

Nesina

linagliptin

Trajenta, Tradjenta

saxagliptin

Onglyza

sitagliptin

Januvia, Ristaben, Tesavel, Xelevia

albiglutide

Eperzan, Tanzeum

dulaglutide

Trulicity

exenatide

Bydureon, Bydureon Bcise, Byetta

liraglutide

Saxenda, Victoza

lixisenatide

Adlyxine, Adlyxin, Lyxumia

semaglutide

Ozempic, Rybelsus

canagliflozin

Invokana, Invokamet

dapagliflozin

Forxiga, Edistride, Farxiga

empagliflozin

Jardiance

ertugliflozin

Steglatro

acarbose

Glucobay, Mar-Acarbose, Precose Sulphated Insulin, Entuzity, Humulin, Iletin, Novolin, Novolinset, Velosulin, Hypurin, Lente Insulin, NPH Insulin, Regular Insulin

Incretin (Dipeptidyl Peptidase-4 inhibitors) (DPP-4)

Incretin (Glucagon-like Peptide-1 receptor agonists) (GLP-1)

SGLT-2 Inhibitors

Alpha-glucosidase Inhibitor

insulin

Insulin

Insulin secretagogue (Sulfonylureas)

insulin aspart

Fiasp, Novomix, Novorapid, Novolog

insulin degludec

Tresiba

insulin detemir

Levemir

insulin glargine

Basaglar, Lantus, Toujeo Abasaglar, Semglee

insulin glulisine

Apidra

insulin lispro

Admelog, Humalog, Liprolog, Lyumjev

acetohexamide

Dimelor

chlorpropamide

Diabinese, Novo-Propamide

glibenclamide gliclazide

Insulin secretagogue (Meglitinides)

Glyburide, Diabeta, Euglucon, Med Glybe, Mylan-Glybe, Glynase, Miconase Diamicron, Diamicron Mr, Glic, Amaryl, Glimepiride

tolbutamide

Mobenol, Novo-Butamide, Orinase

nateglinide

Starlix

repaglinide

Gluconorm

UTOPIAN Technical Appendix: November 19, 2020

19

Class

Thiazolidinediones

CombinationAgents

Generic

Brand Name

pioglitazone

Actos, Glustin

repaglinide

Gluconorm, Novonorm, Prandin

rosiglitazone

Avandia

metformin and ertugliflozin

Segluromet

ertugliflozin and sitagliptin

Steglujan

glimepiride and rosiglitazone

Avandaryl

insulin degludec and liraglutide

Xultophy

insulin glargine and lixisenatide

Soliqua

linagliptin and empagliflozin

Glyxambi

metformin and alogliptin

Kazano

metformin and canagliflozin

Invokamet

metformin and dapagliflozin

Xigduo

metformin and empagliflozin

Synjardy

metformin and linagliptin

Jentadueto

metformin and rosiglitazone

Avandamet

metformin and saxagliptin

Komboglyze

metformin and sitagliptin

Janumet, Velmetia

pioglitazone and alogliptin

Oseni, Incresync

saxagliptin and dapagliflozin

Qtern

Adapted from: Tu K, Manuel D, Lam K, Kavanagh D, Mitiku TF, Guo H. Diabetics can be identified in an electronic medical record using laboratory tests and prescriptions. J Clin Epidemiol. 2011 Apr; 64(4):431-5.

Ivers NM, Tu K, Young J, Francis JJ, Barnsley J, Shah BR, Upshur REG, Moineddin R, Grimshaw JM, Zwarenstein M. Feedback GAP: Pragmatic, cluster-randomized trial of goal setting and action plans to increase the effectiveness of audit and feedback interventions in primary care. Implementation Sci. 2013 Dec; 8:142.

UTOPIAN Technical Appendix: November 19, 2020

20

Identifying patients with chronic kidney disease Look for the most recent eGFR if (<60 ml/min/1.73m2) then look for the next most recent EGFR if (<60 ml/min/1.73m2) and > three months apart then classify as chronic kidney disease (CKD)

Adapted from: Tu K, Bevan L, Hunter K, Rogers J, Young J, Nesrallah G. Quality indicators for the detection and management of Chronic Kidney Disease in primary care in Canada derived from a Modified-Delphi Panel Approach. CMAJ Open. 2017 Jan; 5(1): E74-E81.

UTOPIAN Technical Appendix: November 19, 2020

21

Chapter 5 Recognizing the Complexity of Care for Older Adults Identifying mental health visits Mental health visits were identified as all mental health or addictions OHIP billing service codes: Code

Description

K005 K007 K623 A680 A957

primary mental health care psychotherapy assessment for involuntary admission initial assessment substance abuse addiction medicine focused practice assessment

OR Any family physician office visit or a special or focused practice office visit with an OHIP mental health diagnosis code: Psychotic Disorders: Code

Description

295 296 297 298 306 309 311

Schizophrenia manic-depressive psychoses, involutional melancholia other paranoid states other psychoses psychosomatic illness adjustment reaction depressive disorder

Non-Psychotic Disorders Code 300 301 302

Description anxiety neurosis, hysteria, neurasthenia, obsessive-compulsive neurosis, reactive depression personality disorders sexual deviations

Substance Use Disorders Code

Description

303 304

alcoholism drug dependence

UTOPIAN Technical Appendix: November 19, 2020

22

Social Problems Code

Description

897 898 899 900 901 902 904 905 906 909

economic problems marital difficulties parent-child problems problems with aged parents or in-laws family disruption/divorce education problems social maladjustment occupational problems legal problems other problems of social adjustment

Adapted from: Steele LH, Glazier RH, Lin E, Evans M. Using administrative data to measure ambulatory mental health service provision in primary care. Medical Care, 2004 Oct;42(10). 960-965.

UTOPIAN Technical Appendix: November 19, 2020

23

Chapter 8: Helping People with Severe Mental Illness Identifying patients with schizophrenia 1. Free text documentation of schizophrenia or schizoaffective disorder in the past or present health condition section of the cumulative patient profile including the following terms: schizop schizoa, OR 2. Any tracking code Q021 for schizophrenia OR 3. Any prescription for clozapine at any point in time in the EMR record OR 4. Presence of an OHIP diagnostic billing code of 295-schizophrenia or 298-psychoses AND A prescription for an antipsychotic*

* Antipsychotic medications for schizophrenia: Generic clozapine risperidone quetiapine paliperidone brexpiprazole olanzapine aripiprazole lurasidone ziprasidone asenapine

Brand Name Clozaril Risperdal Seroquel Invega Rexulti Zyprexa Abilify Latuda Zeldox Saphris

UTOPIAN Technical Appendix: November 19, 2020

24

Identifying patients with bipolar affective disorder 1. Free text documentation of bipolar affective disorder in the past or present health condition section of the cumulative patient profile including the following terms: Bipolar manic_depress OR 2. Any tracking code Q020 for bipolar affective disorder OR 3. Any prescription for lithium at any point in time in the EMR record OR 4. Presence of an OHIP diagnostic billing code of 296-bipolar disorder AND A prescription for a mood stabilizer*

* Mood stabilizer medications for bipolar affective disorder: Class Lithium Anticonvulsant

Antipsychotic medication

Generic lithium lamotrigine carbamazepine divalproex valproic acid cariprazine aripiprazole quetiapine paliperidone olanzapine risperidone ziprasidone asenapine

UTOPIAN Technical Appendix: November 19, 2020

Brand Name lithium Lamictal Tegretol Epival Depakene Vraylar Abilify Seroquel Invega Zyprexa Risperdal Zeldox Saphris

25

Classifying patients smoking status We used unstructured text or structured variable data from the cumulative patient profiles and billing data (OHIP billing service codes E079-initial discussion with patient re: smoking cessation, K039-smoking cessation follow-up visit, Q042-additonal smoking cessation follow-up, or OHIP diagnosis code 305tobacco abuse) to ascertain patient smoking status. Patients may have no information or multiple pieces of information re smoking status recorded in their chart.

The most recent relevant information was used to assign patients to one of these three categories: 1. Current smoker 2. Past smoker 3. Non-Smoker Or smoking status missing/unavailable

Note: Patients that were classified in the EMR as “Never” smoker and “Not current” smoker were grouped together into the single category non-smoker.

UTOPIAN Technical Appendix: November 19, 2020

26