HEALTHCARE UTILIZATION IN QUEBEC IMMIGRANTS AND NONIMMIGRANTS WITH

HEALTHCARE UTILIZATION IN QUEBEC IMMIGRANTS AND NON-IMMIGRANTS WITH CHRONIC HEPATITIS C INFECTION Supervisor: Dr. Christina Greenaway Thesis committee: Dr. Laurent Azoulay Dr. Marina Klein Dr. Russell Steele Rhiannon Kamstra M. Sc. Student Mc. Gill EBOH 50 th Anniversary May 1 st, 2015

Chronic Hepatitis C Up to 85% of people infected by Hepatitis C Virus become chronically infected Cirrhosis 30% HCC Liver failure WHO Guidelines (April 2014) develop liver disease in 20 -30 years Transplant 2

Transmission MEDICAL PROCEDURES 300 k cases/year from unsafe injections BLOOD PRODUCTS Pre-screening era INJECTION DRUG USE 60% of new cases in 3 Canada

Burden 350 k global deaths per year 185 million 250, 000 infections worldwide Canadians infected At least 35% of cases are undetected Mohd Hanafiah et al. Hepatology (2013) Lavanchy D. Liver Int. (2009) Hepatitis C In Canada: 2005 -2010 Surveillance Report (PHAC) 4

Rising healthcare use Projected 60% increase in annual costs due to HCV in Canada over the next 20 years(Myers 2014) Myers et al. Can J Gastroenterol Hepatol (2014) Hepatitis C In Canada: 10 2005 -2010 Surveillance Report (PHAC) 5

Immigrants Often migrate from regions with high prevalence Different risk factors and health status Very limited data – modelling estimates suggest 20% of cases in Canada occur in immigrants Hepatitis C In Canada: 2005 -2010 Surveillance Report (PHAC) Evolving epidemiology of hepatitis C virus. Lavanchy (2011) 6

Rationale WHY? Inform policy and planning with data about healthcare utilization in the Quebec HCVinfected population Immigrants are a unique subgroup – understanding differences will help prevention and treatment efforts 7

Objective Estimate and compare all-cause and liver-related healthcare utilization for immigrants and non-immigrants with HCV, identifying predictors of utilization 8

Study Design Retrospective longitudinal cohort study Cases ascertained from mandatory reportable disease database (MADO) from 1998 -2007 Loss of RAMQ coverage (>6 months) Death 1 year prior to diagnosis End of study Dec. 31, 2007 Date of diagnosis Censoring Assess prevalent comorbidities Measure incident healthcare utilization 9

Deterministic linkage RAMQ ID • AGE • SEX • LOCATION • COVERAGE MED-ECHO PHYSICIAN BILLING OUTPATIENT VISITS BILLING CODES HOSPITALIZATIONS DIAGNOSTIC CODES Deterministic linkage VISA # • ARRIVAL DATE • COUNTRY OF ORIGIN PROCEDURES HEALTH SERVICES DATA 10

Cohort Selection 11

Definitions Focused on hospitalizations as measure of healthcare utilization • Liver-related complications are serious Primary measures of healthcare utilization Hospital stays (N) Days in hospital (N) Liver-related hospitalizations required at least one diagnostic code (ICD 9, ICD 10, or procedure code) to match a specified list (including cirrhosis, liver transplant, liver cancer) Prevalent comorbidities were identified using hospitalizations and physician billing using ICD 9 and 10 codes 12

Analysis 1 2 Summarize and compare characteristics of hospitalizations in immigrants and nonimmigrants (e. g. , mean N per subject, rate per 100 PY, length of stay, reason for stay) Examined influence of demographic differences on rate of hospitalizations in immigrants/non-immigrants using negative binomial modelling 13

Demographics N = 20, 139 cases (1998 -2007) Median follow-up: 3. 9 years (immigrants) 4. 8 years (non-immigrants) Immigrants accounted for 9% of cases 26% originated from East Asia/Pacific (most common region of origin) Time from arrival to diagnosis was 9. 8 ± 6. 9 years 14

Immigrants Demographics Older at diagnosis (47. 6 years vs. 43. 2 years) Only 53% male (vs. 68%) 78% located in Montreal (vs. 38%) 30 Prevalence (%) 25 Immigrants Non-immigrants Drug/alcohol related 4 -10 x more common in non-immigrants 20 15 10 5 0 More frequent in immigrants at baseline Cirrhosis Decompensated HCC Diabetes Alcohol abuse Drug abuse HIV 15

All-cause hospitalizations Most subjects were never hospitalized during follow-up. Non-immigrants had a higher burden of all-cause hospitalizations 49. 3% of non-immigrants ever hospitalized Stays per subject and person-time higher in non-immigrants Characteristic Immigrants N = 1821 Non-immigrants N = 18318 p N (%) ever hospitalized 652 (35. 80) 9032 (49. 31) <. 0001 Total hospitalizations (N) 1525 29239 Mean stays person (95% CI) 0. 84 (0. 76 -0. 92) 1. 60 (1. 56 -1. 64) Crude rate of stays / 100 PY 22. 1 (20. 2 -24. 2) 37. 1 (36. 2 -38. 1) Mean days person (95% CI) 7. 34 (6. 31 -8. 37) 15. 77 (15. 01 -16. 53) <. 0001 Crude rate of hospital days / 100 PY 167. 3 325. 7 Mean length of stay ± SD (days) 11. 37 ± 16. 61 11. 51 ± 25. 25 <. 0001 16

All-cause hospitalizations Category of primary diagnosis % of all hospitalizations Immigrants Non-immigrants 1 Liver/viral hepatitis 11. 6% Mental disorders 20. 5% 2 Nervous system/ sense organs 10. 2% Injury & poisoning 10. 3% 3 Pregnancy/childbirth 8. 7% Digestive system (excl. liver) 8. 7% 17

Liver-related hospitalizations 7. 2% of subjects contributed all liver-related stays Characteristic Immigrants N = 1821 Non-immigrants N = 18318 p N (%) ever hospitalized 142 (7. 80) 1299 (7. 09) 0. 27 Total hospitalizations (N) 286 3164 Mean stays person (95% CI) 0. 16 (0. 13 -0. 19) 0. 17 (0. 16 -0. 18) Crude rate of stays / 100 PY 6. 4 (4. 7 -8. 6) 5. 8 (5. 3 -6. 4) Mean days person (95% CI) 2. 32 (1. 72 -2. 92) 2. 37 (2. 16 -2. 58) Rate of hospital days / 100 PY 52. 9 48. 8 Mean length of stay ± SD (days) 15. 17 ± 21. 02 14. 04 ± 21. 11 0. 63 0. 89 Liver-related hospitalization was similar for immigrants and non-immigrants despite comorbidities Most in-hospital deaths in immigrants were liver-related (57. 9% vs. 41. 8%) 18

Modelling What is driving similar rates of liver-related hospitalization vs. different all-cause All-cause hospitalizations Covariate Univariate Rate ratio, 95%CI p Multivariate (Rate ratio, 95%CI p Immigrant status Non-immigrant REFERENCE Immigrant Age (cont. ) 0. 60 (0. 54 -0. 65) 1. 02 (1. 02 -1. 02) REFERENCE <. 0001 0. 52 (0. 47 -0. 57) 1. 02 (1. 02 -1. 02) <. 0001 Sex M REFERENCE F 1. 26 (1. 16 -1. 29) REFERENCE <. 0001 1. 28 (1. 21 -1. 34) <. 0001 19

Modelling What is driving similar rates of liver-related hospitalization vs. different all-cause Liver-related hospitalizations Covariate Univariate Rate ratio, 95%CI Multivariate (Rate ratio, 95%CI p p Immigrant status Non-immigrant REFERENCE Immigrant Age (cont. ) 1. 10 (0. 80 -1. 49) 1. 09 (1. 08 -1. 09) REFERENCE <. 5652 <. 0001 0. 69 (0. 52 -0. 92) 1. 09 (1. 08 -1. 09) 0. 0102 <. 0001 Sex M REFERENCE F 0. 89 (0. 74 -1. 06) REFERENCE 0. 1935 0. 69 (0. 59 -0. 82) <. 0001 Relative rate of liver-related affected by different age and sex distribution 20

Discussio n • Immigrants are different – implications for prevention and treatment • Non-immigrants have more all-cause hospitalization but similar liver-related – Despite more prevalent risk factors for progression (alcohol, HIV) • Suggests other drivers of liver-related in immigrants – Older age (late detection) 21

Main limitations • Passive detection and reporting – Symptom-based screening – Determined by care-seeking • Non-linkage – 20% non-linkage to RAMQ • Limited accuracy of diagnostic coding – Defining liver-related stays, comorbidities – Detection depends on care seeking • Reference group 22

Acknowledgements Supervisor: Dr. Chris Greenaway Thesis committee members: Dr. Laurent Azoulay Dr. Marina Klein Dr. Russ Steele Members of the Greenaway team: Alain, Viet, Nour & Catherine Mc. Gill and LDI staff 23

References & Resources Lavanchy, D. "The global burden of hepatitis C. " Liver International 29. s 1 (2009): 74 -81. Lavanchy, D. "Evolving epidemiology of hepatitis C virus. " Clinical Microbiology and Infection 17. 2 (2011): 107 -115. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet. 2012; 380(9859): 2095 -128. Mohd Hanafiah K, Groeger J, Flaxman AD, Wiersma ST. Global epidemiology of hepatitis C virus infection: New estimates of age-specific antibody to HCV seroprevalence. Hepatology. 2013; 57(4): 1333 -42. Myers, Robert P. , et al. "Burden of disease and cost of chronic hepatitis C virus infection in Canada. " Canadian journal of gastroenterology & hepatology 28. 5 (2014): 243. Public Health Agency of Canada. Hepatitis C in Canada: 2005 -2010 Surveillance Report; 2012. (Online) Remis RS. Modelling the incidence and prevalence of hepatitis C infection and its sequelae in Canada, 2007. Health Canada, Ottawa: Final report. 2007. World Health Organization (WHO). Guidelines for the screening, care and treatment of persons with hepatitis C infection. April 2014. (Online) 24

Questions 25