Provincial Health Indicators Work Group (PHIWG)
Minutes of July 16-17, 2001 Meeting
Ministry of Health and Long-Term Care
5700 Yonge Street, Room M3A/B, Toronto, Ontario


Attendants:
Mary-Anne Pietrusiak, Durham Region Health Department
Julie Stratton, Peel Regional Health Department
Elizabeth Rael, Public Health Branch, MOHLTC
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
Ruth Sanderson, Middlesex-London Health Unit
Jo-Anne Peterson, PHRED – KFLA Kingston
Heather Schouten, Toronto Public Health
Marene Gatali, Toronto Public Health (student)
Jennifer Pennock, City of Ottawa – Public Health and Long-Term Care
Jane Hohenadel, Porcupine Health Unit
Susan Bondy, Institute for Clinical Evaluative Sciences (July 17 only)
Regrets:
Evelyn Crosse, Perth District Health Unit
Carla Troy, Centre for Surveillance Coordination, Health Canada
Vic Sahai, Northern Health Information Partnership
Doug Manuel, Institute for Clinical Evaluative Sciences


1. Introductions

2. Minutes of January 25, 2001
The minutes were accepted with no changes. 
In reference to some of the action items:
  • New members from the North, Toronto and the East Regions have ensured appropriate geographical representation for PHIWG.
  • PHIWG members have provided some feedback related to Vital Statistics data quality priorities. Since the APHEO paper is not yet complete, the opportunity still exists for more input.
  • Mary-Anne obtained a copy of the Manitoba Health indicators report but since it is not useful to PHIWG at this point in the project, it will not be distributed.
  • Mary-Anne, Hyewon Lee-Han and Ruth Sanderson conducted a 1 ½ hour session on the indicators at the Ministry’s Spring Education Days, which was well-attended.
  • Mary-Anne did not submit an update to PHERO because the Ministry presentation seemed sufficient.
3. Indicator Project General

3.1 Terms of Reference

Mary-Anne circulated a revised Terms of Reference. PHIWG decided that further revisions were needed to reflect the ongoing nature of the work, the type of decision-making, the frequency of meeting, the volunteer nature of the membership and size of PHIWG.

Once Round 2 of the revisions is completed and the indicators move from draft to final version, the Work Group will move into committee mode and be renamed. This standing committee will develop a process for ongoing work and will ensure that the indicators are kept up-to-date.

PHIWG expressed the need for a definite name for the indicators, since there are a number of indicator projects occurring. Suggestions included: Ontario Health Status Indicators, Ontario Public Health Status Indicators. PHIWG will return to this issue to give people time for more suggestions.
Action: Mary-Anne will revise the terms of reference based on the discussion.

3.2 Revised structure and web-page

Mary-Anne circulated a new draft indicator with a revised format. She used the indicator “Selected Causes of Death in Children and Adolescents” as an example. The revised format is meant to facilitate moving the indicators to a more web-based design. The present website would need a complete overhaul, but the advantages would be that the indicators would be more accessible and easier to update and maintain. A student could be hired to complete some of this work. Sten Ardal at CEHIP expressed interest in helping with the project. Funds could come from the MOHLTC; CEHIP also offered funds if needed. Brenda Guarda mentioned that Georgian College has a post-graduate course on web design and that their health unit has hosted students in the past.

A search feature would make it easier to find indicators on a particular subject. Nam indicated that they hired consultants to develop this application for their website. The software could possibly be modified for PHIWG’s use.
Action: Nam will find out whether the search software is transferable and whether/what modifications are needed.

To make indicators easier to print from the web, it was suggested that a PDF format be available.

Indicator format changes:
  • No longer in table format.
  • Add “Keywords” section. Since public health librarians could help with this section, PHIWG will consult with the Middlesex-London librarian. The keywords should use MeSH terms as much as possible. A MeSH browser is available at the website of the U.S. National Library of Medicine: http://www.nlm.nih.gov/mesh/MBrowser.html
    Action: Ruth Sanderson to consult with Yvonne Tyml, librarian from Middlesex-London, for advice.
  • Add a section on “Corresponding Mandatory Objectives”
  • Drop the “Usage” section since the information was fairly arbitrary and the most useful piece was the Mandatory objectives.
  • Add “National Indicators” to list whether Statscan and CIHI have a corresponding indicator. List the indicator, the date of documentation, and a link to their web site.
  • Add “Other Indicators” to list corresponding indicators from RRFSS, WHO and any other key sources.
  • Move the “Indicator Comments” up so they are not at the end.
  • Remove the sections on specific data sources and standardization since these were redundant and any changes had to then be done throughout the whole document. Instead, provide a link to the relevant appendices. Important data comments would be put under “Indicator Comments”. The years that the data are available for that source would be listed in the Appendix.
  • Under “Data Sources” for both numerator and denominator, there would be the sub-sections of “Created by”, “Distributed by” and “Suggested Citation”. This would combine the two sections of "Data Sources" and "Data Distributor".
  • Add "Alternative Data Sources" where appropriate.
  • Add "Analysis Check List" section for cues to do certain things such as exclude out-of-province births. This is also where syntax or selection criteria would be included.
  • A proper citation is needed for the PHPDB.
    Action: Jessie to determine the proper citation for the PHPDB.
  • Change “Basic Categorizations” to “Basic Categories”.
  • The “Basic Categories” and “ICD-9 Codes” sections would move up after “Description”. Where possible words will also be used to describe basic categories. Proposed definitions: infants <1, Child 1-11, Adolescents 12-19. This would be consistent with OHS data but not death and hospitalization. More discussion needed.
  • Add “Cross-References to Other Sections” for related indicators that could be in either spot with a link option that would then take you to that indicator.
  • References should be in proper publication format (various source provide format, including the Canadian Journal of Public Health: http://www.cpha.ca/english/cjph/stylreq/style.htm) and should relate to the specific indicator only. General references will be moved to an appendix or the end of the Introduction.
  • Add “Date of Last Revision” for each indicator.
Action: Mary-Anne will revise new draft indicator and create blank template, and will distribute to PHIWG members.

3.3 HELPS

Elizabeth reported that the HELPS Advisory Committee has been reinstated and gave an update from the last meeting/teleconference. PHIWG thought that a link between PHIWG and the HELPS Advisory Committee is important. Brenda Guarda, Nam Bains and Jane Hohenadel belong to both groups. They will make regular reports at PHIWG meetings and communicate any relevant information.

4. Sub-Group Reports

4.0 General Issues: These issues arose throughout the sub-group reports but are grouped together to make them easier to understand and find.

    Population Estimates
  • Because there are numerous releases and versions of population estimates, comments in Appendix 11 will be expanded to describe the Statistics Canada cycle of producing population estimates. The citation for population estimates should be “Statistics Canada, Population Estimates [years], release date.
    Action: Carol Paul will expand population estimates comments.
    National Indicators
  • Since the National Indicators are calculated using a different denominator, a sentence should be included to highlight this difference.
    Action: Mary-Anne will consult with Carol and Jason Gilmore to develop the wording for this sentence to be included in each indicator that has a corresponding national indicator.
    ICD-10
  • PHIWG acknowledged that ICD-10 codes will need to be included but since we will not have data coded in ICD-10 for a few more years, there is no hurry to determine what the codes are.
  • Since the National Indicators project will need to determine the codes much earlier, we can obtain the information from Jason Gilmore.
    Rapid Risk Factor Surveillance System (RRFSS)
  • RRFSS will be identified as an additional data source, where appropriate.
  • If RRFSS is the only data source for an important indicator, the indicator will be a “Supplementary Indicator” rather than a “Core Indicator”. Supplementary Indicators will be at the end of the section. An appendix on Data Gaps will also highlight the need for data.
  • PHIWG felt it was important to include RRFSS indicators because: of the opportunity to influence CCHS content; their inclusion may encourage other health units to join RRFSS; and RRFSS may be the only source of data.
  • If necessary, PHIWG may recommend additional questions be added to RRFSS. PHIWG will work through PHIWG members who are part of RRFSS and will follow the process outlined by the RRFSS Working Group.
    List of Data Gaps and Requests to Public Health Branch
  • Repeat low income data request for children 0-6 from Statistics Canada for 2001 Census.
  • Include nutritious food basket protocol on web with permission for PHIWG to link to it.
  • Consider adding Student Drug Use Survey to HELPS.
  • Resolve discrepancy in reporting counts < 5 for infectious diseases versus all other data.
  • Data gap: osteoporosis.
    Common Edits throughout Indicators
  • Replace k with the most appropriate multiplier.
  • Clarify that rates, ratios and counts < 5 should be suppressed (not just counts).
  • Comments on the Canadian Census: the last bullet is incorrect. It applies to Vital Statistics, not the Census.
    Standardization
  • Stress need to standardize when making comparisons. Add generic comment that the crude rate is important (it’s the only real number) but need to do standardization.
  • Statistics Canada does age and sex standardization because it standardizes both male and female rates to the total population, not to the male and female populations. If this is what we recommend, we need to make this more explicit in the appendices.
  • PHIWG debated the use of five-year age groupings for standardization when counts are so small at the local level. You can collapse neighbouring rates if the crude rates are similar and the groups are homogeneous, but this is a judgment call.
  • Because the repercussions of different approaches are not fully understood, a Standardization Sub-Group was formed with the intention of taking real numbers and standardizing different ways. The Sub-Group consists of Mary-Anne Pietrusiak, Sue Bondy, Julie Stratton, Jennifer Pennock, and Brenda Coleman. They will communicate their results to the whole group.
    Chartbook Pages
  • Sherri discussed the history of the electronic chartbook pages and that the HIUs are now preparing to pick up the project from SRHIP. The project had developed into a more interactive, query-driven model which was not what was originally envisioned.
  • PHIWG indicated that they would like a basic model which consists of updated chartbook pages with no interactive options.
  • Brenda Guarda and Elizabeth Rael volunteered to work on the project with Sherri and the HIUs.
    Use of ISCIS Data
  • Brenda Ross, evaluation analyst for the Healthy Babies Health Children program spoke briefly to PHIWG.
  • She mentioned that she is also on an intergovernmental group that is developing indicators of reproductive and child health
  • Currently ISCIS has an 87% consent rate for the Parkin tool for HBHC program but there is a lot of variation among the health units – from 60% to 95%+.
  • PHIWG could make a request for a report, we would just have to follow the process.
  • The new database, scheduled for release in summer 2002, will have more flexibility in providing reports.
  • ISCIS could potentially provide a variety of indicators.
  • Ruth Diaz, an epidemiology student, outlined some potential indicators in a discussion paper as part of her practicum.
    Action: Mary-Anne will distribute the discussion paper to all members.
  • Brenda’s discussion with PHIWG provided a lot of ideas. Brenda Coleman will follow-up with Brenda Ross after PHIWG members have had the chance to review the various documents.
    New Appendices
  • References
  • Methodology for life expectancy
  • National and Provincial Case Definitions for Infectious Diseases

4.1 Introduction (Mary-Anne Pietrusiak)
  • The introduction needs to be totally updated once Round 2 has been completed.
  • The points under Guidelines will be discussed within the other sections as we come to the relevant issue.
  • Need a section on “How to use this document”
  • Describe history of PHIWG and include PHERO article.
    Action: Elizabeth will verify that PHERO article can be used on web site.
  • Describe the National initiative with link to their web site.
  • PHIWG Guidelines will be in separate section.
  • Consider putting general references in this section.

4.2 Population (Sherri Ennis (lead), Brenda Guarda, Carol Paul)

    Population by Age and Sex
  • Use population estimates rather than Census counts. PHIWG thought that estimates are more accurate because they are adjusted, whereas the Census is not.
    Dependency Ratios
  • Use population estimates rather than Census counts.
  • Note that the child dependency ratio uses the same definition (ages 0-14) as Statistics Canada and that Manitoba uses 0-24.
    Population Growth
  • Use population estimates rather than Census counts.
    Proportion of Immigrants and Recent Immigrants
  • The National Indicator uses 15 years.
  • Add 5, 10, 15 year breakdowns.
    Ethnic Origin
  • After a lot of debate, it was decided to keep this indicator but to expand on comments describing limitations.
  • Statistics Canada proposes not to use it because of differences in questions over time. We comment that it should not be used for comparisons over time.
  • Add comment that this reflects self-reported ethnic origin.
  • Rename to Ethnic or Cultural Group
  • List RRFSS as alternative data source (used as optional module in Toronto with different wording from Census question).
    Action: Heather will forward question to Sherri.
    Mother Tongue
  • Keep
    Home Language
  • Keep
    Percent who cannot speak English nor French
  • Correct wording in description and method of calculation from “home language” to “cannot speak”.
    New Indicators:
  • Projected population growth – use projections (past growth uses estimates)
  • Proportion urban/rural
  • Proportion of Population Aboriginal

4.3 Infectious Diseases (Julie Stratton (lead), Carla Troy)

Add another appendix for national and provincial case definitions. Specify that the national definitions come from CCDR and the provincial ones from RDIS. Add the dates of the definition where possible, and the year that the disease became reportable.

    Mortality from Infectious Diseases
  • Add codes for meningococcal meningitis and hemophilus influenza B.
    Incidence of Selected Vaccine-Preventable Diseases
  • Keep
    Vaccination Coverage for Selected Diseases
  • Change description to correspond with Mandatory.
  • Check with the benchmarking project to see if definitions are consistent.
  • Add note that vaccination coverage should be run at a consistent time each year, preferably June.
    Influenza and Pneumococcal Vaccination Rates Among Long-Term Care Facility Residents
  • Change description to specify diseases.
    Influenza and Pneumococcal Vaccination Rates Among Long-Term Care Facility Workers
  • Change “long-term” to “health”
    Influenza Vaccination
  • Add CCHS as data source
  • List RRFSS as alternative data source.
    Action: Brenda Guarda will check for similarity between the questions.
    Adverse Vaccine Reactions
  • Add definition of AVR
    Action: Heather will send out a definition of AVRs to Julie.
    Incidence of Selected STDs
  • Keep
    Hospitalization for Pelvic Inflammatory Disease
  • Keep
    Incidence of Tuberculosis and Drug-Resistant Tuberculosis
  • Need to narrow down definition.
    Action: Brenda Coleman to forward definition ideas to Julie.
    Incidence of Animal Rabies
  • Rename to Proportion of Positive Animal Rabies
    Incidence of Selected Enteric Diseases
  • Keep
    Hospitalization for Selected Enteric Diseases
  • Add more diseases.
  • Include the ICD-9 codes

4.4 Social Environment and Health (Sherri Ennis (lead), Brenda Guarda, Carol Paul)
    Unemployment Rate
  • Add long-term unemployment.
  • Add labour force survey as alternative data source for more recent data.
    Incidence of Low Income
  • Rename to “Low Income Rate” to be consistent with National Indicators
  • The data for children 0-6 was from a special request by Public Health Branch to Statistics Canada. PHIWG thought the data were important to have updated.
    Action: Mary-Anne will indicate to the PHB to request data from 2001 Census when available.
  • It was unclear whether the denominator was number of children or households.
    Action: Sherri will check the denominator information.
  • May have separate indicator for children and youth.
    Proportion of Single Parent Families with Children
  • Add category for male vs. female head of family.
    Education Level of Population 15 and Older
  • Add note that national indicator has a different breakdown.
    Percent of Households Paying 30% or More Household Income on Housing
  • Rename to Housing Affordability to be consistent with national indicators.
    Cost of a Nutritious Food Basket
  • Add note that discriminating costs between health units are small, that data are available for 1999+, and that the provincial average is weighted by the number of stores that the health unit used in data collection, not by population.
  • If possible, provide web link to protocol.
    New Indicators
  • Commuting
  • Labour Force Participation Rate
  • Income indicator – need to determine whether personal or household, and average or median
  • Income inequality
  • Crime
  • Food security – from CCHS

4.5 Mortality (Sherri Ennis)
    Crude Death Rate and All-Cause Mortality; Mortality by ICD-9 Chapter
  • rename to “All-Cause Mortality”
  • combine the two indicators into one
  • note problem with 1997 mortality data about increased number of undefined causes of death.
  • cross-reference other selected causes of death throughout document.
    Potential Years of Life Lost (PYLL) by ICD-9 Chapter
  • rename to “Potential Years of Life Lost (PYLL)”.
  • Use terminology PYLL [75] to make it clear that the calculation goes to age 75.
  • cross-reference to other selected causes of PYLL throughout document.
    Life Expectancy
  • need feedback from Doug Manuel
  • add an appendix to describe methodology
    Avoidable Mortality from Specific Diseases
  • After a lot of discussion, PHIWG decided to keep this indicator
  • Add more updated references.
  • Check the National Indicators.

4.6 Hospitalization (Sherri Ennis)
    All-Cause Hospital Separation Rates; Hospital Separations by ICD-9 Chapter
  • rename to “All-Cause Hospital Separations”
  • combine the two indicators into one

4.7 Chronic Disease and Injuries
Injury Prevention and Substance Abuse Prevention (Julie Stratton, Jo-Anne Peterson)
    Death from Selected Causes of Injury
  • Add e-code for poisonings
  • For total death from injury, use same method as National Indicators, excluding certain e-codes.
    Hospital Morbidity from Selected Causes of Injury
  • Add e-codes for poisonings, falls from playground equipment (E884.0), and sports injuries.
  • For total hospitalization from injury, use same method as National Indicators, excluding certain e-codes.
  • Add Trauma Registry as alternative data source.
    Action: Julie will contact the Trauma Registry to find out how their data differ from hospitalization data available to us on Data Warehouse. Brenda Coleman will help out if necessary because of her contacts with Registry.
    Alcohol-Related Injuries and Deaths from Motor Vehicle Traffic Collisions
  • Add comment that data are available from HIUs upon request.
    New Indicators
  • Heather to investigate poison control database.
  • Seatbelt use among drivers
  • Adolescent drug use from Student Drug Use Survey – need to investigate process for obtaining local level data.
  • PYLL
  • Collision rate (Sherri will develop since she is presently working on a report using the MTO data).

4.8 Child Health (Ruth Sanderson)
    Selected Causes of Death in Children and Adolescents
  • Add some more specific causes including SIDS (798.0), asthma
    Selected Causes of Hospital Morbidity in Children
  • Add some more specific causes, including asthma.
    Breast-feeding Initiation
  • Change to one word: breastfeeding
  • Add CCHS as source of data.
  • Check whether age of mother included is same in CCHS as OHS (15-49 or 15-55?). May have to exclude some women when doing comparisons.
    DMF/def Index; Proportion of Caries-Resistant Children
  • Did not have enough time to discuss.
    New Indicators
  • Breastfeeding duration from CCHS – extensive notes needed since it is tricky to derive taking into account the baby’s age.
  • Did not have enough time to discuss other indicators.

4.9 Chronic Diseases (Jane Hohenadel (lead), Jennifer Pennock)
    Mortality from Selected Chronic Diseases
  • Drop hypertensive disease.
  • To be consistent with the National Indicators, add all circulatory disease, bronchitis/emphysema/ asthma, diabetes.
    PYLL from Selected Chronic Diseases
  • Drop hypertensive disease.
  • Add asthma, diabetes.
    Hospital Separations for Selected Chronic Diseases
  • Drop hypertensive disease
  • Add all circulatory disease, bronchitis/emphysema/asthma, asthma on its own.
    Prevalence of Selected Chronic Health Problems
  • Add heart disease, effects of stroke.
    New Indicators
  • Discussion around adding measurement of blood pressure from OHS. May be considered in another section.