Provincial Health Indicators Work Group (PHIWG)
Minutes of September 17-18, 2001 Meeting

Ministry of Health and Long-Term Care
5700 Yonge Street, Room M3 & M4, Toronto, Ontario

Mary-Anne Pietrusiak, Durham Region Health Department
Julie Stratton, Peel Regional Health Department
Brenda Guarda, Simcoe County District Health Unit
Sherri Ennis, Central East Health Information Partnership
Carol Paul, Health Information Products and Services Unit, MOHLTC
Jessie Wong, Health Information Products and Services Unit, MOHLTC
Chee Wong, Public Health Branch, MOHLTC
Brenda Coleman, Elgin-St. Thomas Health Unit
Nam Bains, Health Information Partnership, Eastern Ontario Region – by teleconference for selected parts
Ruth Sanderson, Middlesex-London Health Unit
Heather Schouten, Toronto Public Health
Jennifer Pennock, City of Ottawa – Public Health and Long-Term Care
Evelyn Crosse, Perth District Health Unit
Carla Troy, Centre for Surveillance Coordination, Health Canada
Catalina Yokingco, Toronto Public Health
Jo-Anne Peterson, PHRED – KFLA Kingston
Vic Sahai, Northern Health Information Partnership
Doug Manuel, Institute for Clinical Evaluative Sciences
Jane Hohenadel, Porcupine Health Unit
Susan Bondy, Institute for Clinical Evaluative Sciences

1. Introductions

2. Minutes of July 16-17, 2001
The minutes were accepted with no changes as moved by Brenda Guarda and seconded by Ruth Sanderson.

3. Business Arising from the Minutes

3.1 Terms of reference
Mary-Anne Pietrusiak did not yet edit the terms of reference. Discussion was deferred.

3.2 Template
The draft template had been distributed by e-mail earlier. Further suggestions and clarification:
  • A brief sentence will be included to explain when to use the crude rate vs. SMR vs. SRATE
  • Under “Data Sources”, the wording “Original source” will replace “Created by”.
  • Under “Analysis Check List”, include any syntax, variable names or wording for queries for the Data Warehouse, where appropriate. The HIUs can assist with this information.

3.3 Name for the indicators
After much discussion, the preferred name is: Core Indicators for Public Health in Ontario. This will hopefully shorten in conversation to the “Core Indicators”.

3.4 Web site search function
The Eastern Ontario Health Information Partnership is still working on the search function that we are hoping to use in our web site.

3.5 Help from public health librarians
Ruth discussed the project with Yvonne Tyml, librarian from Middlesex-London. She expressed interest in helping us, noting that the public health librarians meet on a regular basis. It was decided that we will ask the librarians to review the keywords in the draft report but that we will have a first go at formulating them using MeSH terms (for a MeSH browser, see the website of the U.S. National Library of Medicine:
Action: Ruth Sanderson to verify the process for the librarians to review the draft.

3.6 Citation for the PHPDB
Jessie Wong drafted a table of suggested citations for all of the indicators. There was a lot of discussion and it was recognized that we need to reference the original source as well as where we got the data from (data distributor). For HELPS and Cubes, the release dates should be documented. For the data warehouse, the date that the data were extracted should be documented as this is a good indication of which model was in use at that time.
Action: Ruth Sanderson to check with the public health librarians about any rules for citing the data, such as the order of the information.
Action: Carla Troy to check with Health Canada about how they are citing data sources for their national “data warehouse”.
Action: Jessie Wong will pull this information together to produce a second draft of citations.

3.7 ICD-10
Mary-Anne has been in contact with Jason Gilmore at Statistics Canada to find out what work they have done on determining the appropriate ICD-10 codes. Work was just beginning and he will pass the results on to Mary-Anne.

Chee informed the group that the roll out of HELPS2 will occur in October. Documentation will be on the web. File names will change to a new systematic format. Cancer data will hopefully include 1988-1998.

3.9 Standardization Sub-Group
Brenda Coleman has distributed files to the sub-group of Mary-Anne Pietrusiak, Sue Bondy, Julie Stratton, and Jennifer Pennock. She also pointed out to Statistics Canada that they are standardizing by both age and sex. They have acknowledged and adjusted their documentation. We need to do the same. Brenda’s files examine the standard errors and compare confidence interval calculations of Armitage vs. Chiang. The group has not had time to review the files. The question of the standard population was addressed: it will still be the 1991 Canadian population.
Action: The sub-group will develop recommendations about standardization methods.

4.0 Sub-Group Reports
    List of Data Gaps and Requests to Public Health Branch
  • Indoor air quality – mould
  • OBSP data need to be part of HELPS or sent out to health units from CCO in a systematic way.
  • Cervical screening – data from the program
  • Smoking in pregnancy – to be part of the Parkyn?
    Action: Mary-Anne will find out the status of the smoking question study on the Parkyn from Dr. Donna Reynolds.
  • Smoking in public places
  • Drinking and driving on boats and recreational vehicles
  • Nutrition variables
  • Developmental milestones at 18 months
  • Pre-schoolers well-nourished – development of a screening tool for nutrition needs of pre-schoolers
  • School readiness – part of National Longitudinal Survey on Children and Youth
  • Pediatric BMI – could be a derived variable on the CCHS
    Action: Julie to send URL for CDC’s calculation of pediatric BMI
    Action: Carol to look into derivation on CCHS
    Action: Mary-Anne will list data gaps and distribute to PHIWG members to aid in CCHS consultation.

4.1 Potential Years of Life Lost (Doug Manuel, Sherri Ennis)

4.2 Health-Related Quality of Life (Doug Manuel, Brian Laundry, Richard Alvarez)
Because Doug was ill and unable to attend the meeting, discussion was deferred.

4.3 Physical Environment and Health (Vic Sahai)

Since Vic has been unable to continue working on PHIWG, Mary-Anne has taken over the physical environment section.
    Air Quality Index (AQI)
  • Mary-Anne received very helpful feedback about this indicator from Jane Ying on behalf of the Health Promotion and Environmental Protection Office, Toronto Public Health.
  • Keep the indicator but add in other categories, including particulates and nitrogen oxides.
    Action: Heather will send Mary-Anne a City of Toronto document about environmental data sources.
    Ultraviolet (UV) Radiation Index
  • Because of the questionable nature of this indicator at the local level, it was dropped.
    Trihalomethanes (THMs) in Drinking Water
  • Expand indicator to consider other facets of drinking water such as microbiological safety (proportion of positive e-coli/coliform tests), fluoride.
    Posted Bathing Beaches
  • Expand commentary.
    New Indicators
  • Consider an indicator on boil water advisories, looking at number of person-days affected.
  • Consider RRFSS as a source of data – number of households on private wells.
  • Identify information on mould as a data gap.
    Action: Mary-Anne will consult with the Public Health Branch and the MOE on development of new indicators.
    Action: Carla will check with the Environmental Health Directorate of Health Canada for resources that might be useful.

4.4 Cancer Incidence and Early Detection of Cancer (Heather Schouten, Jennifer Pennock)
    Incidence of Selected Cancers
  • Keep
    Mortality from Selected Cancers
  • Keep
    PYLL from Selected Cancers
  • To be determined
    Hospital Separations for Selected Cancers
  • Keep
    OBSP Mammography Rates
  • Change description from ever screened to screened in past 2 years with ever screen as an “Other Category”.
  • Change age group to 50-74 years.
  • Add that diagnostic mammograms are not included under comments on OBSP data.
    Mammography Rates for Women Aged 50-69
  • Change age group to 50-74 years.
  • Consider pulling out screening mammograms – need to verify that this is feasible in CCHS.
    Clinical Breast Exam Rates
  • Keep
    Cervical Cancer Screening Rates
  • Keep

4.5 Smoking (Brenda Guarda, Carol Paul, Jessie Wong, Susan Bondy)
    Daily Cigarette Smoking
  • Keep
    Population Living in Smoke-Free Homes
  • Check wording on CCHS
    New Indicators
  • Smoke-free Public Places – considers workplaces, restaurants, bars that are 100% smoke-free. The Ontario
    Tobacco Research Unit is a possible source of data.
  • Minor Access to Tobacco – proportion of establishments that sell to minors according to health unit compliance checks.
  • Proportion of Non-Smokers Exposed to Second-Hand Smoke – CCHS

4.6 Alcohol (Brenda Guarda, Carol Paul, Jessie Wong, Susan Bondy)
    Proportion of Current Drinkers
  • Keep
    Proportion Consuming 15 or more alcoholic drinks per week
  • Drop since it is no longer an objective in the Mandatory Programs
    Proportion of Low-Risk Drinkers
  • Basic categories: low risk, at risk
    Frequency of Heavy Drinking Episodes
  • Same definition in CCHS.
    Prevalence of Drinking and Driving
  • Expand on caveats
    New Indicators
  • Add supplementary indicator of Drinking on Boats and Recreational Vehicles – RRFSS is source.

4.7 Physical Activity (Brenda Guarda, Carol Paul, Jessie Wong, Susan Bondy)
    Frequency of Physical Activity
  • Keep, check for consistent definition on CCHS
    Energy Expenditure
  • Rename to Physical Activity Index
  • Incorporate comments about Health Canada’s Physical Activity Guide
    New Indicators
  • Sedentary Activities – in leisure and at work

4.8 Nutrition (Brenda Guarda, Carol Paul, Jessie Wong, Susan Bondy)
    Body Mass Index
  • Be consistent with the National Indicators and the CCHS so the categories will be: under 20 (underweight), 20-24.9 (acceptable weight), 25-26.9 (some excess weight), 27 or higher (overweight)
  • In the current new draft of Mandatory, the overweight category should be BMI >= 27 not > 27.
    Action: Mary-Anne will contact Dr. Robert Kyle, Chair of Chronic Diseases Technical Review Committee about this adjustment.
  • An additional category of obese: BMI >= 30 will be added.
  • Discrepancies between some of these definitions and categories will be noted.
    Average Fat Intake as Percent of Energy
  • Drop since only source of data is the 1990 Ontario Health Survey.
    Percent of Population Consuming Five or More Servings of Vegetables and Fruit Daily
  • Rename to Fruit and Vegetable Consumption
  • Use CCHS data
    Percent of Adolescent Population Aged 12 to 17 Consuming Three or More Servings of Milk Products Daily
  • Drop since only source of data is the 1990 Ontario Health Survey.
    Percent of Population Aged 18 and Over Consuming Two or More Servings of Milk Products Daily
  • Drop since only source of data is the 1990 Ontario Health Survey.
    Percent of Population Aged 12 and Over Consuming Five or More Servings of Grain Products Daily
  • Drop since only source of data is the 1990 Ontario Health Survey.

4.9 Mental Health (Jessie Wong)
    Prevalence of Depression
  • Keep, national indicator
    Suicide Mortality Rate
  • Keep, national indicator
    Hospitalization for Attempted Suicide
  • Keep
    New Indicators
  • Suicidal Thoughts – optional from CCHS
  • Suicide Attempts – optional from CCHS
  • Work Stress – scale from CCHS
  • Self-Perceived Life Stress – from CCHS

4.10 Dental Portion of Child and Adolescent Health (Ruth Sanderson)
    DMF/def Index
  • In description, deleted “or tooth services” and replace “in kindergarten” with “at school entry”.
  • Add more caveats and detail about data quality, including the inconsistency across the province. Review with Dr. Sandra Bennett from the Public Health Branch.
    Proportion of Caries-Resistant Children
  • Rename to Proportion of Caries-Free Children and use that wording throughout.
  • Replace “in kindergarten” with “at time of survey”.
  • In comments, state that this indicator is a proxy for early childhood tooth decay, and that caries-free means current prevalence=0 and lifetime incidence=0.
    New Indicators
  • Proportion of Children with Treatment Needs – those requiring treatment, urgent and non-urgent.
  • Fluorosis
  • Fissure Sealants
Action: Ruth is to ask Dr. Bennett whether the indicator Percentage of High Risk Schools is a population indicator.

4.11 Sexual Health (Evelyn Crosse)
    Youth Sexual Activity
  • From CCHS
    Age of Sexual Debut
  • From CCHS
    Number of Sexual Partners
  • From CCHS
    Condom Frequency among those at Risk for STDs
  • From CCHS
  • Cross-reference to STD indicators in Infectious Diseases
  • Indicate in comments that for high non-response, report as separate category
    Condom Use the Last Time Among those at Risk for STDs
  • From CCHS

4.12 Reproductive Health (Brenda Coleman)

Brenda talked about follow-up to the teleconference on developing indicators from the ISCIS database that took place on July 12, 2001. The teleconference included Brenda, Ruth and Mary-Anne from PHIWG as well as Alanna Leffley from Grey Bruce Health Unit and Faye Brooks from Leeds, Grenville, Lanark HU, and staff from the Public Health Branch and Integrated Services for Children. A number of data issues need to be made clear as well as the type of indicators we would like to see from ISCIS. There is also a lot of urgency since Leann Wagner, Acting Manager of ISCIS, will soon be going on maternity leave. We would like her to begin the process of developing these indicators before she leaves so that the work can be continued by her replacement.
Action: Brenda Coleman will draft a letter to Leann Wagner. The draft will be reviewed by Sherri, Mary-Anne, Ruth and Elizabeth.
    Crude Birth Rate
  • Keep
    Age-Specific Fertility Rates and General Fertility Rate
  • Under alternative sources, list ISCIS and CIHI. The numbers obtained from CIHI, through the data warehouse, uses CMG codes. Sherri Ennis has done some analysis and is writing a report about the method used.
    Total Fertility Rate
  • Keep
    Age-Specific Therapeutic Abortion Rates
  • Keep
    Age-Specific Therapeutic Abortion Ratios
  • After lots of discussion, we decided to keep the indicator as is.
    Age-Specific Pregnancy Rates Including Teenage Pregnancy Rate
  • Keep
    Rate of Multiple Births
  • Keep
    Low Birth Weight Rate
  • Rename to Birth Weight Rate
  • Basic categories of preterm, singleton vs. multiple, large for gestational age
    Rate of Neural Tube Defects
  • Keep
    Stillbirth Rate
  • Include as a category under Perinatal Mortality Rate since the number at local level is small
    Perinatal Mortality Rate
  • Stillbirths under Basic Categories
    Infant Mortality Rate
  • Keep, cross-reference to Selected Cause of Death in Children and Adolescents
    New Indicators
  • Age of First Births – mean age and median age
  • Congenital Infections
  • Folic acid supplementation – from CCHS
  • Smoking during Pregnancy – cross-reference to smoking section
Note: Add maternal mortality to selected cause of mortality and cross-reference.

4.13 Seniors Health (Brenda Coleman)

It was decided to omit this section and move the indicators to other sections.
    Long-Term Care Bed Ratio
  • Drop, more of a concern for DHCs than public health.
    Population Projections for Seniors
  • Include in Population section
    Living Arrangements for Seniors
  • Include in Social Environment section
    Selected Causes of Hospitalization Among Seniors
  • This would already be covered under the Hospitalization section.
    Fall-Related Deaths Among Seniors
  • Include in the Injury section
    Fall-Related Hospitalizations Among Seniors
  • Include in the Injury section
    Activity Limitations Among Seniors
  • Include in the Health-Related Quality of Life Section

4.14 Use of Health Services and Medications (Nam Bains)

Rename to Use of Health Services
    Visits to General Practitioner
  • From CCHS
    Visits to Dentist
  • From CCHS
    Use of Emergency Services
  • Drop, this question is difficult to work with in the CCHS because of the skip patterns.
    Medication Use
  • Drop, too much mix of different medications that the indicator is not useful.
    Taking Three or More Medications in Past Two Days
  • Move this to the Injury section and change to include only those aged 65+
    Rate of Days of Hospitalization
  • Move to the Hospitalization section.
  • There were questions about how to use and interpret this indicator.
    Action: Nam and Sherri will take a closer look at this indicator to see how it can be used in public health.
    New Indicators
  • Add Average Length of Stay to Hospitalization section.

4.15 Appendices

Appendix 1: Members of PHIWG
  • Mary-Anne will list all members to date and include the dates they were on PHIWG.
Appendix 2: Direct standardization (SRATES)

Appendix 3: Indirect standardization (SMRs, SIRs)
  • The Sub-group on standardization will expand these.
Appendix 4: Standard population: Canada 1991
  • Will remain the same.
Appendix 5: PYLL calculation
  • Should be reviewed.
Appendix 6: Public health units and health areas sampled in the 1990 OHS and 1996/97 OHS
  • Add in CCHS.
Appendix 7: Methods for age standardizing the Ontario Health Survey
  • Information on bootstrapping will be added by Carol and Jessie.
Appendix 8: Avoidable mortality from specific diseases
  • Doug Manual will review to ensure it is up to date.
Appendix 9 How to calculate a moving average
  • Should be reviewed.
Appendix 10: Mandatory Health Programs and Services Guidelines: Objectives and Indicators
  • Needs to be updated.
Appendix 11: Summary of Notes on Data Sources
  • Needs to be updated
  • List each source separately (a, b, c, etc.) so that it is easier to search on one particular data source.
New Appendices
  • References
  • Methodology for life expectancy
  • National and Provincial Case Definitions for Infectious Diseases
  • Adverse Vaccine Events
  • Fact Sheet on RRFSS
  • Methodology for Life Expectancy

5.0 Next Steps

Each group is to edit the indicators they are responsible for using the new template. Mary-Anne will revise the template and send it out. The deadline for completing the indicators is February 1, 2002. Another meeting will then be scheduled to consider this next draft, with emphasis on reviewing the new indicators. The goal will be to hire a student in web design for the summer to overhaul the web site and put on the new indicators.