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
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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
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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
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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.
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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
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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
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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.
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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
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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.
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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/
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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
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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
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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
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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
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Brand Name Lotensin Capoten, Captotec, Captril Inhibace, Inhibase Vasotec Monopril Zestril, Prinivil Coversyl Accupril, Accupro Altace Mavik
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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,
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Aldactazide, Spirozide, Spirozine Dyazide, Maxzide, Diazide, Pro Triazide, Triamzide, Riva-Zide, Triazide, Hydro-Triam
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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.
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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.
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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
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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
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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.
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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.
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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
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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.
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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
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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
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Brand Name lithium Lamictal Tegretol Epival Depakene Vraylar Abilify Seroquel Invega Zyprexa Risperdal Zeldox Saphris
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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.
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