Table of Contents

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Table of Contents
Slides
Sources ................................................................................... 3
Background ........................................................................... 45
Methodology .......................................................................... 67
Key Findings Degenerative joint disease (osteoarthritis)..................... Ischemic heart disease (IHD) ........................................... Arrhythmia ......................................................................... Chronic obstructive pulmonary disease (COPD) .......... Cerebrovascular disease .................................................. 819 2031 3243 4456 5768
Interpretative Cautions ......................................................... 6970
3
Sources

• Breezing AM, Watson DE, Black C. Chronic
  conditions and co-morbidity among residents of
  British Columbia. Vancouver Centre for Health
  Services and Policy Research 2005.
• Johns Hopkins Bloomberg School of Public Health.
  The Johns Hopkins Adjusted Clinical Groups (ACG)
  Case-Mix System Reference Manual. Version 7.0.
  Baltimore The Johns Hopkins University 2005.
• Johns Hopkins Bloomberg School of Public Health.
  The Johns Hopkins Adjusted Clinical Groups (ACG)
  Case-Mix System Technical User Guide. Version
  7.0. Baltimore The Johns Hopkins University
  2005.

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Background

• Chronic diseases
• affect a significant number of Canadians
• account for a large proportion of health care
  service utilization and associated direct and
  indirect health care costs
• are more common with increasing age and lower
  socioeconomic status
• are often associated with modifiable risk factors
  such as tobacco use, unhealthy diet and lack of
  physical activity
• are subject to delayed onset and
• are often considered to be preventable.
• Centre for Health Services and Policy Research
  (CHSPR) at the University of British Columbia
  identified eleven high-impact and/or
  high-prevalence chronic conditions.
• Combinationprevalence and impacthas important
  implications for the planning and allocation of
  health care resources.

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Background (contd)

• Used the Expanded Diagnosis Clusters (EDCs)
• Johns Hopkins ACG Case-Mix System (version 7.0)
  tool
• Estimated treated prevalence in Ontario for
  2006/07 for 5 of the 11 high-impact and/or
  high-prevalence chronic diseases, including
• Degenerative joint disease (osteoarthritis)
• Ischemic heart disease (IHD)
• Cardiac arrhythmia
• Chronic obstructive pulmonary disease (COPD)
• Cerebrovascular disease
• Prevalence rates for other chronic conditions
  (diabetes, asthma, cancer, congestive heart
  failure and hypertension) not reported using the
  ACG System ? already being measured, or will be
  measured in the near future, using validated
  algorithms developed by ICES and Cancer Care
  Ontario.

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Methodology

• Fiscal year 2006/07
• Cohort Ontarians (derived from the Registered
  Persons Database RPDB)
• EDC algorithm applied to Canadian Institute for
  Health Informations Discharge Abstract Database
  (CIHI-DAD) and Ontario Health Insurance Plan
  (OHIP) records over a two-year period (April 1,
  2005 to March 31, 2007)
• Algorithm mapped CIHI-DAD and OHIP to the
  following EDCs
• Degenerative joint disease MUS03
• Ischemic heart disease (excluding acute
  myocardial infarction) CAR03
• Cardiac arrhythmia CAR09
• Emphysema, chronic bronchitis, COPD RES04
• Cerebrovascular disease NUR05

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Methodology (contd)

• Exclusions
• Persons less than 20 years of age (less than 35
  years of age for calculation of COPD rates)
• Out-of-province residents
• Records with missing/invalid age, sex, and/or
  LHIN information
• Individuals who died or whose date of last
  contact with the health care system was greater
  than 5 years
• Population estimates (as of April 1, 2006) were
  calculated using the RPDB.
• Age- and sex-adjusted prevalence rates were
  standardized using Ontarios 2001 census
  population.
• Neighbourhood median household income ranked by
  quintiles (obtained from Statistics Canada census
  data) used as estimate of socioeconomic status
  (SES)

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Osteoarthritis (degenerative joint disease)

• Most common form of arthritis
• Causes breakdown of cartilage (covers and
  protects the ends of bones in joints)
• Commonly affects joints in the hands, feet and
  spine and large weight-bearing joints (hips and
  knees) causing pain, swelling, stiffness, reduced
  range of joint motion, disability in everyday
  living activities and mobility
• Greater risk for individuals that are older,
  overweight, have a family history of
  osteoarthritis and/or previous joint injury
• No cure treatments (e.g., medication, exercise,
  physiotherapy, weight loss) can increase joint
  mobility and decrease pain and disability. In
  severe cases, surgery may be performed to replace
  the entire joint, especially the hip or knee.

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Key FindingsOsteoarthritis

• Overall prevalence rates (2006/07)
• In 2006/07, little variation in prevalence rates
  among LHINs
• Twelve out of 14 LHIN prevalence rates were
  within 10 of the Ontario rate (9.3 per 100
  persons).
• Highest (11.3 per 100 persons) and lowest (7.6
  per 100 persons) rates were observed in the Erie
  St. Clair and Waterloo Wellington LHINs,
  respectively.

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Age- and sex-adjusted prevalence rate of
osteoarthritis per 100 Ontarians aged 20 years
and older, 2006/07
By Local Health Integration Network (LHIN) in
Ontario
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Age- and sex-adjusted prevalence rate of
osteoarthritis per 100 Ontarians aged 20 years
and older, by sub-LHIN planning area,
2006/07 LHIN 9 (Central East) vs. Ontario
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Key Findings (contd) Osteoarthritis

• Prevalence rates by sex and/or age group
  (2006/07)
• Rates for men and women in Ontario increased with
  age, leveling off after 74 years of age.
• For women, those aged 7584 had highest
  prevalence rates for men, rates were highest in
  the 85 age group.
• For both men and women, 5064 age group had
  highest volume (number of cases).
• Across all age groups, prevalence rates
  consistently higher in women than in men at the
  Ontario level and in most of the LHINs.
• Disparity was greatest in the 5064 age group
  where the rates for women were 51 higher than
  those for men.

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Prevalence rate of osteoarthritis per 100
Ontarians aged 20 years and older, by sex and
age group, 2006/07
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Prevalence rate of osteoarthritis per 100
Ontarians aged 20 years and older, by sex and age
group, 2006/07 LHIN 9 (Central East) vs. Ontario
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Age-adjusted prevalence rate of
osteoarthritis per 100 Ontarians aged 20 years
and older, by sex and sub-LHIN planning area,
2006/07 LHIN 9 (Central East) vs. Ontario
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Key Findings (contd) Osteoarthritis

• Prevalence rates by neighbourhood income quintile
  (2006/07)
• At the provincial level, prevalence rates
  increased as neighbourhood income level
  decreased.
• Among the LHINs, prevalence rates in the middle
  income quintiles (Q2Q4) often had overlapping
  confidence intervals however, in every LHIN
  (except the North West LHIN), prevalence rates in
  the lowest income quintile (Q1) were
  significantly higher than those in the highest
  income quintile (Q5).

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Age- and sex-adjusted prevalence rate of
osteoarthritis per 100 Ontarians aged 20 years
and older, by neighbourhood income quintile,
2006/07
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Age- and sex-adjusted prevalence rate of
osteoarthritis per 100 Ontarians aged 20 years
and older, by neighbourhood income quintile,
2006/07 LHIN 9 (Central East) vs. Ontario
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Ischemic heart disease (IHD)

• Heart problems caused by the narrowing of heart
  arteries, leading to a reduction in blood flow
  and oxygen to the heart muscle term often used
  interchangeably with coronary artery disease
  and coronary heart disease.
• Risk increases with age, smoking, high
  cholesterol levels, high blood pressure, obesity,
  diabetes and family history of certain heart
  conditions.
• IHD can be present without symptoms (silent
  ischemia), but more often causes chest pain
  (angina pectoris).
• stable (i.e., occurs under predictable
  circumstances, such as physical exertion or
  stress, and subsides with medication or rest)
• unstable (i.e., sudden onset becoming
  increasingly worse can be a warning sign of
  heart attack)
• Individuals with IHD may have had previous heart
  attack (old myocardial infarction).
• Treatment involves use of medication, surgery and
  lifestyle changes.

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Key FindingsIschemic heart disease (IHD)

• Overall prevalence rates (2006/07)
• In 2006/07, prevalence rates varied across LHINs
  
• Less than half of LHINs had overall prevalence
  rates within 10 of the Ontario rate (6.2 per 100
  persons).
• Overall rate in the Central East LHIN (7.8 per
  100 persons) was 66 higher than the overall rate
  in the Waterloo Wellington LHIN (4.7 per 100
  persons).

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Age- and sex-adjusted prevalence rate of ischemic
heart disease (IHD) per 100 Ontarians aged 20
years and older, 2006/07
By Local Health Integration Network (LHIN) in
Ontario
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Age- and sex-adjusted prevalence rate of ischemic
heart disease (IHD) per 100 Ontarians aged 20
years and older, by sub-LHIN planning area,
2006/07 LHIN 9 (Central East) vs. Ontario
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Key Findings (contd) Ischemic heart disease
(IHD)

• Prevalence rates by sex and/or age group
  (2006/07)
• Rates for men and women in Ontario increased with
  age.
• Rates increased two- to three-fold up to 75 years
  of age.
• Prevalence rates were highest in the oldest age
  group (85 years) for both men and women.
• For women, the 7584 age group had the highest
  volume (number of cases) for men, volume was
  highest in the 5064 age group.
• At the provincial and LHIN levels, after 34 years
  of age, men had significantly higher rates than
  women.
• Disparity between men and women increased with
  age groups until 5064 years at which point the
  disparity was greatestrates for men were almost
  twice as high as those for women from 65 years
  old and onward, the gap in rates between men and
  women narrowed through to age 85 years.

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Prevalence rate of ischemic heart disease
(IHD) per 100 Ontarians aged 20 years and older,
by sex and age group, 2006/07
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Prevalence rate of ischemic heart disease
(IHD) per 100 Ontarians aged 20 years and
older, by sex and age group, 2006/07 LHIN 9
(Central East) vs. Ontario
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Age-adjusted prevalence rate of ischemic heart
disease (IHD) per 100 Ontarians aged 20 years and
older, by sex and sub-LHIN planning area,
2006/07 LHIN 9 (Central East) vs. Ontario
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Key Findings (contd) Ischemic heart disease
(IHD)

• Prevalence rates by neighbourhood income quintile
  (2006/07)
• At the provincial level, prevalence rates
  increased as neighbourhood income level
  decreased.
• Throughout all LHINs, prevalence rates in the
  lowest income quintile (Q1) were significantly
  higher than those in the highest income quintile
  (Q5).

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Age- and sex-adjusted prevalence rate of ischemic
heart disease (IHD) per 100 Ontarians aged 20
years and older, by neighbourhood income
quintile, 2006/07
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Age- and sex-adjusted prevalence rate of ischemic
heart disease (IHD) per 100 Ontarians aged 20
years and older, by neighbourhood income
quintile, 2006/07 LHIN 9 (Central East) vs.
Ontario
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Arrhythmia

• An abnormal rhythm of the hearteither beating
  too quickly (tachycardia), too slowly
  (bradycardia), or irregularly.
• Caused by an abnormality in the generation or
  movement of electrical activity through the
  heart.
• Treatment ranges
• lifestyle changes, drug therapy, implantation of
  a permanent pacemaker or an implantable
  cardioverter-defibrillator
• Some forms of arrhythmia life-threatening if not
  promptly and properly treated.

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Key FindingsArrhythmia

• Overall prevalence rates (2006/07)
• In 2006/07, little variation in prevalence rates
  among LHINs
• Eleven out of 14 LHIN prevalence rates were
  within 10 of the Ontario rate (3.6 per 100
  persons).
• Highest (4.2 per 100 persons) and lowest (3.1 per
  100 persons) rates were observed in the Central
  and Waterloo Wellington LHINs, respectively.

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Age- and sex-adjusted prevalence rate of
arrhythmia per 100 Ontarians aged 20 years and
older, 2006/07
By Local Health Integration Network (LHIN) in
Ontario
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Age- and sex-adjusted prevalence rate of
arrhythmia per 100 Ontarians aged 20 years and
older, by sub-LHIN planning area, 2006/07 LHIN 9
(Central East) vs. Ontario
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Key Findings (contd) Arrhythmia

• Prevalence rates by sex and/or age group
  (2006/07)
• Prevalence rates for men and women in Ontario
  increased with age, with rates doubling between
  age groups 3549, 5064, 6574 and 7584 years.
• For both men and women, prevalence rates were
  highest in the oldest age group (85 years)
  7584 age group had highest volume (number of
  cases).
• At the provincial level and for most LHINs, in
  the younger age groups (2034, 3549), prevalence
  rates of arrhythmia were slightly higher in women
  than in men. After age 49, however, rates of
  arrhythmia in men became higher than those in
  women.
• Greatest disparity in rates in the 6574 age
  group where men had rates that were 34 higher
  than those in women.

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Prevalence rate of arrhythmia per 100 Ontarians
aged 20 years and older, by sex and age group,
2006/07
39
Prevalence rate of arrhythmia per 100 Ontarians
aged 20 years and older, by sex and age group,
2006/07 LHIN 9 (Central East) vs. Ontario
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Age-adjusted prevalence rate of arrhythmia per
100 Ontarians aged 20 years and older, by sex and
sub-LHIN planning area, 2006/07 LHIN 9 (Central
East) vs. Ontario
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Key Findings (contd) Arrhythmia

• Prevalence rates by neighbourhood income quintile
  (2006/07)
• Prevalence rates of arrhythmia remained steady
  across neighbourhood income quintiles in
  Ontarioan unusual finding because low
  socioeconomic status (SES) has traditionally been
  considered a risk factor for cardiovascular
  disease in general.
• Recent study1 also noted unexpected relationship
  between atrial fibrillation (most common form of
  arrhythmia) and SES prevalence of atrial
  fibrillation decreased with decreasing SES.
• Association might be related to better screening
  (more diagnoses) for those living in more
  affluent areas, and perhaps to poorer survival of
  those patients with atrial fibrillation who
  resided in less affluent neighbourhoods.
• 1Murphy NF, Simpson CR, Jhund PS, et al. A
  national survey of the prevalence, incidence,
  primary care burden and
• treatment of atrial fibrillation in Scotland.
  Heart. 2007 93(5)606612.

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Age- and sex-adjusted prevalence rate of
arrhythmia per 100 Ontarians aged 20 years and
older, by neighbourhood income quintile, 2006/07
43
Age- and sex-adjusted prevalence rate of
arrhythmia per 100 Ontarians aged 20 years and
older, by neighbourhood income quintile,
2006/07 LHIN 9 (Central East) vs. Ontario
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Chronic Obstructive Pulmonary Disease (COPD)

• A slow-developing chronic lung disease
  characterized by airflow limitation due to airway
  damage, resulting in shortness of breath
  (dyspnea), wheezing, increased mucus production
  and coughing.
• COPD includes both chronic bronchitis and
  emphysema.
• Most COPD caused by cigarette smoking other
  contributing causes are heredity, second-hand
  smoke, prolonged exposure to airway irritants
  (dust, chemicals, pollution) and a history of
  lung infections during childhood.
• No cure treatment is largely to treat and
  prevent symptoms and involves lifestyle changes,
  medication, pulmonary rehabilitation and, in some
  severe cases, surgery.

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Key FindingsChronic Obstructive Pulmonary
Disease (COPD)

• Overall prevalence rates (2006/07)
• In 2006/07, prevalence rates varied among LHINs
• Only 4 out of 14 LHIN rates were within 10 of
  the Ontario rate (3.6 per 100 persons).
• Erie St. Clair and North East LHINs had the
  highest rates (5.2 per 100 persons), while the
  Central West, Mississauga Halton and Central
  LHINs had the lowest rates (2.6 per 100 persons).
  

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Age- and sex-adjusted prevalence rate of chronic
obstructive pulmonary disease (COPD) per 100
Ontarians aged 35 years and older, 2006/07
By Local Health Integration Network (LHIN) in
Ontario
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Age- and sex-adjusted prevalence rate of chronic
obstructive pulmonary disease (COPD) per 100
Ontarians aged 35 years and older, by sub-LHIN
planning area, 2006/07 LHIN 9 (Central East) vs.
Ontario
49
Key Findings (contd) Chronic Obstructive
Pulmonary Disease (COPD)

• Prevalence rates by sex and/or age group
  (2006/07)
• Prevalence rates for men and women in Ontario
  increased with age, with rates increasing two- to
  three-fold between 3574 years of age.
• For both men and women, prevalence rates were
  highest in the oldest age group (85 years)
  5064 age group had highest volume (number of
  cases).
• At the provincial level, after age 64, prevalence
  rates were markedly higher in men than in women
  this disparity increased with age.
• At the LHIN level, prevalence rates tended to be
  similar in many LHINs between men and women up to
  age 64, after which rates consistently followed
  Ontario level trends (i.e., rates higher in men
  vs. women, disparity increasing with age).

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Prevalence rate of chronic obstructive pulmonary
disease (COPD) per 100 Ontarians aged 35 years
and older, by sex and age group, 2006/07
51
Prevalence rate of chronic obstructive pulmonary
disease (COPD) per 100 Ontarians aged 35 years
and older, by sex and age group, 2006/07 LHIN 9
(Central East) vs. Ontario
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Age-adjusted prevalence rate of chronic
obstructive pulmonary disease (COPD) per 100
Ontarians aged 35 years and older, by sex and
sub-LHIN planning area, 2006/07 LHIN 9 (Central
East) vs. Ontario
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Key Findings (contd) Chronic Obstructive
Pulmonary Disease (COPD)

• Prevalence rates by neighbourhood income quintile
  (2006/07)
• At the provincial level, prevalence rates of COPD
  increased as neighbourhood income level
  decreased this association was also quite
  consistent at the LHIN level.

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Age- and sex-adjusted prevalence rate of chronic
obstructive pulmonary disease (COPD) per 100
Ontarians aged 35 years and older, by
neighbourhood income quintile, 2006/07
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Age- and sex-adjusted prevalence rate of chronic
obstructive pulmonary disease (COPD) per 100
Ontarians aged 35 years and older, by
neighbourhood income quintile, 2006/07 LHIN 9
(Central East) vs. Ontario
56
Key Findings (contd) Chronic Obstructive
Pulmonary Disease (COPD)

• Interpretative caution for COPD1,2
• COPD believed under-diagnosed in primary care,
  especially in younger age groups (less than 60
  years old).
• Development of COPD is subtle yet gradually
  cumulative.
• Individual may satisfy respiratory function
  criteria for diagnosis (e.g., spirometry) before
  complaining of noticeable symptoms (e.g.,
  wheezing).
• In a recent study, close to half the population
  of general practice patients at high risk for
  COPD had a diagnosis of COPD ? approximately
  two-thirds of them were newly diagnosed through a
  case-finding programme (i.e., spirometric
  testing) vs. through complaint of noticeable
  symptoms (e.g., wheezing).
• 1Upshur REG, Wang L, Luo J, Maaten S, Leong A.
  Primary care for respiratory diseases. In
  Jaakkimainen L,
• Upshur R, Klein-Geltink JE, Leong A, Maaten S,
  Schultz SE, Wang L, editors. Primary Care in
  Ontario ICES Atlas.
• Toronto Institute for Clinical Evaluative
  Sciences 2006.
• 2Vandevoorde J, Verbanck S, Gijssels L, et al.
  Early detection of COPD a case finding study in
  general practice.
• Respir Med. 2007 101(3)525530.

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Cerebrovascular Disease (including stroke)

• Encompasses broad grouping of brain dysfunctions
  related to bleeding in, or lack of oxygen to, the
  brain.
• Acute stroke is the most common cerebrovascular
  disease.
• Other conditions (e.g., asymptomatic narrowing of
  blood vessels, subdural hematoma, late sequalae
  of stroke) also included in this grouping of
  dysfunctions.
• Stroke occurs when the blood flow to the brain is
  interrupted if blood flow is stopped for more
  than several seconds, death to brain cells can
  occur, causing permanent damage.
• The majority of strokes are ischemic, where a
  blood clot blocks or plugs a blood vessel in the
  brain.
• Strokes can also be hemorrhagic, where a blood
  vessel may break and bleed into the brain.
• If the blood supply to the brain is only briefly
  interrupted, it is referred to as a transient
  ischemic attack (TIA or mini-stroke).

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Key FindingsCerebrovascular Disease (including
stroke)

• Overall prevalence rates (2006/07)
• In 2006/07, modest variation in prevalence rates
  among LHINs
• Eight out of 14 LHIN prevalence rates were within
  10 of the Ontario rate (1.9 per 100 persons).
• South East LHIN had the highest rate (2.5 per 100
  persons), while the Mississauga Halton and
  Central LHINs had the lowest rates (1.6 per 100
  persons).

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Age- and sex-adjusted prevalence rate of
cerebrovascular disease per 100 Ontarians aged 20
years and older, 2006/07
By Local Health Integration Network (LHIN) in
Ontario
61
Age- and sex-adjusted prevalence rate of
cerebrovascular disease per 100 Ontarians aged 20
years and older, by sub-LHIN planning area,
2006/07 LHIN 9 (Central East) vs. Ontario
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Key Findings (contd) Cerebrovascular Disease
(including stroke)

• Prevalence rates by sex and/or age group
  (2006/07)
• Prevalence rates for men and women in Ontario
  increased with age.
• For both men and women, prevalence rates were
  highest in the oldest age group (85 years)
  7584 age group had highest volume (number of
  cases).
• At the provincial and LHIN levels, prevalence
  rates were slightly higher in men than in women
  for those 50 years and older for those younger
  than 50 years of age, rates were similar.

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Prevalence rate of cerebrovascular disease per
100 Ontarians aged 20 years and older, by sex
and age group, 2006/07
64
Prevalence rate of cerebrovascular disease per
100 Ontarians aged 20 years and older, by sex and
age group, 2006/07 LHIN 9 (Central East) vs.
Ontario
65
Age-adjusted prevalence rate of cerebrovascular
disease per 100 Ontarians aged 20 years and
older, by sex and sub-LHIN planning area,
2006/07 LHIN 9 (Central East) vs. Ontario
66
Key Findings (contd) Cerebrovascular Disease
(including stroke)

• Prevalence rates by neighbourhood income quintile
  (2006/07)
• At the provincial level, prevalence rates
  increased as neighbourhood income level
  decreased this association was not observed in
  all the LHINs, although for most of the LHINs,
  prevalence rates in the lowest income quintile
  (Q1) were significantly higher than those in the
  highest income quintile (Q5).

67
Age- and sex-adjusted prevalence rate of
cerebrovascular disease per 100 Ontarians aged 20
years and older, by neighbourhood income
quintile, 2006/07
68
Age- and sex-adjusted prevalence rate of
cerebrovascular disease per 100 Ontarians aged 20
years and older, by neighbourhood income
quintile, 2006/07 LHIN 9 (Central East) vs.
Ontario
69
Interpretative Cautions

• Ontario Health Insurance Plan (OHIP) physician
  billings and hospital discharge abstracts (DAD)
  used to identify treated prevalence.
• Some patient visits not captured using these
  sources (e.g., visits to community health centres
  CHCs for which shadow billings are not
  submitted to OHIP) however, CHCs generally each
  contain only a small number of full-time
  equivalent physicians, so for this study OHIP
  billings offered a robust measure of prevalence
  rates.
• OHIP billings linked to RPDB ? derive
  denominators for rates
• RPDB contains a number of outdated addresses and
  loses accuracy at extremes of age nonetheless,
  ICES-linked RPDB provides acceptable population
  estimates.
• ACG software required RPDB-derived population
  cohort.
• Inflated population estimates from RPDB (compared
  to census) in some locations may lead to
  underestimation of true prevalence.
• Prevalence rates based upon residential locations
  of patients, not locations where patients access
  health services.

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Interpretative Cautions (contd)

• Comparison of prevalence rates with other studies
  may not be appropriate due to differences in
  methodology, for example
• Different data sources (e.g., Canadian Community
  Health Survey CCHS data vs. administrative
  data)
• Different standard populations (e.g., Ontario
  2001 vs. Canada 1991)
• Different disease groupings (different ICD codes
  assigned to a particular disease)
• Each approach, with accompanying strengths and
  limitations depending on the chronic condition,
  should be taken into account for more
  comprehensive picture of the burden of illness.
• Caution should be used when interpreting data at
  the sub-LHIN level.
• Smaller populations and resulting case volumes
  will experience greater rate fluctuation.
• Reference to confidence intervals should be made
  to assist with interpretation.