Information Management. A System We Can Count On. Chronic Conditions. in the Central East LHIN

Information Management A System We Can Count On Chronic Conditions in the Central East LHIN Health System Intelligence Project October 2007

Table of Contents About HSIP..................................ii Introduction.................................1 Overview of Chronic Conditions...............2 Prevalence of Selected Chronic Conditions.....4 Multiple Chronic Conditions..................5 Commonly Occurring Co-morbidities..............5 Physician Use................................6 A Closer Look at Selected Chronic Conditions...............................7 Cancer......................................8 Diabetes....................................10 Comparative Burden of Chronic Conditions...26 Risk Factors................................27 Population Attributable Fraction................29 Interpretation of Population Attributable Fractions.30 Conclusion..................................34 References..................................36 Appendix A Examples of Chronic Disease Definitions.........41 Appendix B Technical Notes..............................43 Appendix C Prevalence of Chronic Conditions...............46 Depression..................................12 Heart Disease...............................14 Hypertension...............................16 Stroke......................................18 Asthma.....................................20 Chronic Obstructive Pulmonary Disease.......22 Arthritis and Related Conditions.............24 Chronic Conditions in the Central East LHIN Page i

About HSIP The Health System Intelligence Project This report is produced by the Health System Intelligence Project (HSIP). HSIP consists of a team of health system experts retained by the Ministry of Health and Long-Term Care s Health Results Team for Information Management (HRT-IM) to provide the Local Health Integration Networks (LHINs) with: Sophisticated data analysis; Interpretation of results; Orientation of new staff to health system data analysis issues; Training on new techniques and technologies pertaining to health system analysis and planning. The Health Results Team for Information Management created the Health System Intelligence Project to complement and augment the existing analytical and planning capacity within the Ministry of Health and Long-Term Care. The project team is working in concert with Ministry analysts to ensure that the LHINs are provided with the analytic supports they need for their local health system planning activities. Report Authors: Namrata Bains, HSIP (Project Lead) Kristin Dall, HSIP Jane Hohenadel, HSIP For further information, please contact: hrtim@ontario.ca. Acknowledgements We would like to thank the Population Health Policy and Planning & Women s Health Branch of the Ontario Ministry of Health and Long-Term Care for advice and support in development of this project. We gratefully acknowledge Ngoc-Thy Dinh, Dr. Doug Manuel (Institute for Clinical Evaluative Sciences) and Lee Sieswerda (Thunder Bay District Health Unit) for their guidance on the calculation of Population Attributable Fractions. Page ii Chronic Conditions in the Central East LHIN

Introduction Chronic conditions are the leading causes of avoidable illness, death and disability worldwide, and account for a substantial proportion of health care system utilization. 1 Many chronic conditions can be prevented or have their onset delayed, and the factors that put populations at risk for chronic diseases such as diabetes, heart disease and respiratory conditions are modifiable and widespread. Approximately 89% of Ontario residents have at least one behavioural risk factor for chronic disease (e.g., smoking, alcohol misuse, physical inactivity, poor diet or excess weight), and because many chronic conditions have common underlying risk factors, this increases the risk of having several chronic diseases. 1 The purpose of this report describes the prevalence and burden of nine selected chronic conditions: cancer, diabetes, depression, heart disease, hypertension, stroke, chronic obstructive pulmonary disease (COPD), asthma and arthritis for residents of the Central East Local Health Integration Network (LHIN) with provincial rates provided as comparators. The impact of co-morbidities is examined by looking at the prevalence of multiple chronic conditions and describing which chronic conditions tend to co-exist. A section on risk factors describes the prevalence of modifiable risk factors associated with chronic disease. As well, population attributable fractions are calculated to quantify the proportion of chronic disease that would be prevented if the risk factor were removed from the entire population. The Central East LHIN In 2006 the Central East LHIN was home to 1,484,300 people which accounted for 11.7% of the population of Ontario. Approximately 195,400 Central East LHIN residents (13.2% of the population) are seniors, similar to the proportion of seniors in Ontario overall (12.9%). Close to 93,400 residents of the Central East LHIN are aged 75 or older (6.3% of the population). 2 Highlights Among residents of the Central East LHIN, the chronic conditions presented in this report (cancer, diabetes, depression, heart disease, hypertension, stroke, asthma, COPD and arthritis) accounted for: 1 out of 4 inpatient hospital separations; 1 in 10 emergency department visits; and 1 in 5 visits to general practitioners or family physicians. In the Central East LHIN: 36% of residents had at least one of the selected chronic conditions (cancer, diabetes, heart disease, hypertension, stroke, asthma, COPD or arthritis) which are the focus of this report; arthritis and hypertension were two of the most common chronic conditions, affecting 16.9% and 15.3% of the population aged 12+ respectively; the prevalence rate for cancer was significantly lower than the provincial rate; almost half of residents aged 65+ had two or more of the selected chronic conditions; conditions such as cancer and heart disease had high inpatient hospital separation rates whereas high rates of visits to family physicians were found for conditions such as hypertension and arthritis; approximately 50% of the population (aged 12+) were physically inactive and over 40% of those aged 18+ were either overweight or obese. Chronic Conditions in the Central East LHIN Page 1

Overview of Chronic Conditions Unlike acute conditions which have a sudden, sharp onset and relatively short duration, chronic conditions develop slowly over time, are long lasting and often progress in severity. While chronic conditions can often be controlled or managed, they usually cannot be cured. Although there is no single standard definition of chronic disease, definitions typically make reference to factors such as the duration, prognosis, pattern and sequelae of the disease and may specify the existence of functional limitations or need for care as part of the criteria. 3 Both Health Canada and the Centers for Disease Control and Prevention have described chronic diseases as those that have a prolonged course, do not resolve spontaneously and for which a complete cure is rarely achieved. 4 This definition is fairly broad and inclusive. Conditions that cause relatively few problems, such as acne or seasonal allergies would, under this definition, be considered chronic diseases. i The Public Health Agency of Canada also suggests this alternative definition: chronic (or non-communicable) diseases are typically characterized as having an uncertain etiology, multiple risk factors, long latency, prolonged affliction, a noninfectious origin, and can be associated with impairments or functional disability. 6 Another more restrictive definition describes chronic diseases as diseases which have one or more of the following characteristics: they are permanent, leave residual disability, are caused by nonreversible pathological alteration, require special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation, or care. 7 Most researchers agree that chronic conditions have prolonged duration (i.e., of several months), but different studies may use different time intervals such as three, six or twelve months as the criterion. Some additional examples of definitions of chronic disease/conditions are provided in Appendix A. Not all chronic conditions have the same burden of illness and many of those who have a chronic condition have at least one other condition. 5,8 People with multiple chronic conditions (i.e., co-morbidities) are more likely to have activity limitations, and require substantially more health care compared to people with a single chronic condition. 5,9 A detailed analysis of chronic conditions in British Columbia concluded that chronic conditions tend to cluster in individuals and that there was a consistent trend of increased health care utilization with increasing co-morbidity. The researchers recommend that, in addition to understanding the prevalence and impact of individual chronic diseases, health care providers must take into account the broader, complex needs of those who have co-morbidities. 9 A wide range of factors influence the onset and prognosis of chronic conditions. These factors may be biological, social, environmental, or related to personal health practices. Age is a major risk factor for most chronic conditions 10 and one of the main reasons for the increasing prevalence of chronic conditions is the ageing population. With age, people are not only more likely to acquire a chronic condition but to have multiple chronic conditions. 5 Socio-economic factors are thought to contribute to the development of chronic disease on multiple levels (i.e., acting at both the individual and population level). Those who are socio-economically disadvantaged are often found to be at higher risk for many chronic conditions. 11-13 Although this may be partly explained by the higher prevalence of modifiable risk factors among those with low income or low educational attainment, socioeconomic status itself has also been established as an independent risk factor for chronic disease. 13 Behavioural risk factors those related to health practices are particularly important because they are modifiable. These risk factors also give rise to intermediate risk factors such as obesity, high blood pressure and high serum cholesterol. 14 Changes in the prevalence of risk factors such as smoking, alcohol misuse, obesity, physical inactivity and poor diet can lead to substantial reductions in the burden of chronic disease. Many behavioural risk factors are linked to more than one chronic condition, and moreover, many risk factors co-exist and interact with one another. 15 i The terms chronic disease and chronic conditions are often used interchangeably and this may account for some of the variations in definitions. One report suggests that chronic conditions is a general term that includes both chronic illnesses (disease) and impairments. 5 Page 2 Chronic Conditions in the Central East LHIN

This report focuses on selected chronic conditions for which prevalence data were available namely cancer, diabetes, depression, heart disease, hypertension, stroke, COPD, asthma and arthritis. These have been identified by others as having high prevalence and/or being high impact conditions that are not only leading causes of illness, death, and disability but also place a significant burden on individuals, families and the health care system. 5,16,17 Furthermore, many of these conditions have common underlying modifiable risk factors which, if mitigated, might prevent or delay the onset of disease. Some conditions such as renal disease and osteoporosis are important chronic conditions but could not be examined because prevalence data were not available. On the other hand, conditions such as migraine headaches or allergies are highly prevalent but were not considered for detailed analysis because of their lack of correspondence to specific diagnosis codes in hospitalization and mortality datasets. We also examine the prevalence of modifiable risk factors and their contribution to the selected chronic conditions presented in this report, including smoking, alcohol misuse, physical inactivity, poor diet and overweight/obesity. With the exception of depression, data from the 2005 Canadian Community Health Survey (CCHS) cycle 3.1 18 were used to describe the prevalence of chronic conditions and their risk factors. These are based on self-reports. Depression related questions were not collected across all Ontario regions in either cycles 2.1 or 3.1 of the CCHS but were available from the CCHS 1.2 (Mental Health and Well-being; 2002). 19 By using data from the CCHS 1.2 we were able to examine the overall prevalence of depression for the Central East LHIN, but only able to provide age and sex specific prevalence estimates at the provincial level. Also, we were unable to examine the co-morbidity of depression along with the other selected conditions. Confidence intervals (95%) were calculated for all survey based prevalence estimates and are shown as error bars in figures. Age-specific mortality, acute inpatient hospital separation, emergency department (ED) and general practitioner/family physician (GP/FP) utilization rates were calculated using the most recent data available from the Ontario Ministry of Health and Long-Term Care s Provincial Health Planning Database (PHPDB). 2 These provide an indication of the impact of the disease on the health care system as well as a sense of the burden of disease. Rates are provided for Central East LHIN residents with provincial numbers provided as comparators. Detailed technical notes on methods can be found in Appendix B. Chronic Conditions in the Central East LHIN Page 3

Prevalence of Selected Chronic Conditions Prevalence is the proportion of the population with a particular disease at a given moment in time, and provides a broad measure of disease burden. 2 The CCHS asked respondents to report on whether they have specific chronic conditions which are expected to last or have already lasted six months or more and that have been diagnosed by a health professional. According to the CCHS (cycle 3.1), in 2005, 70% of Central East LHIN residents aged 12 or older reported having at least one chronic condition and 36% had at least one of the chronic conditions (cancer, diabetes, heart disease, hypertension, stroke, asthma, COPD or arthritis) which are the focus of this report. Among the selected chronic conditions examined, arthritis, which includes both rheumatoid and osteoarthritis, was the most frequently reported chronic condition among residents of the Central East LHIN (16.9%) and Ontario overall (17.2%). Hypertension, another common chronic condition, affected 15.3% of Central East LHIN residents and 15.4% of the Ontario population aged 12 or older. With the exception of cancer, crude prevalence rates for these selected chronic conditions were similar among Central East LHIN residents and Ontarians overall. Cancer prevalence rates among Central East LHIN residents were significantly lower than provincial rates but these must be viewed with caution because they are based on a relatively small sample (see Figure 1). Prevalence rates for all chronic conditions captured by the CCHS are provided in Appendix C. Figure 1: Prevalence of selected chronic conditions, Central East LHIN and Ontario, 2005 25.0 22.5 20.0 17.5 Percentage 15.0 12.5 10.0 7.5 5.0 2.5 0.0 Central East Ontario Arthritis Hypertension Asthma Heart disease Diabetes Depressioni COPD ii Cancer Stroke (2002) 16.9 15.3 8.0 4.7 4.6 4.2 5.2 0.9 * 1.2 17.2 15.4 8.0 4.8 4.8 4.8 4.1 1.5 1.1 Error bars represent 95% confidence intervals. Source: 2005 Canadian Community Health Survey and 2002 Canadian Community Health Survey (Mental Health and Well-being), Statistics Canada, Ontario Share File. i Prevalence of depression is calculated for those age 15 years and over. ii COPD includes chronic pulmonary disease, emphysema and bronchitis and is reported for the population aged 30 or older. Coefficient of variation 16.6% to 33.3% - interpret with caution. * Significantly different from provincial average based on assessment of 95% confidence intervals. Page 4 Chronic Conditions in the Central East LHIN

Multiple Chronic Conditions Of the 36% of Ontarians (aged 12+) with a selected i chronic condition, 37% had multiple chronic conditions. The presence of multiple or co-morbid conditions not only increases an individual s total burden of illness, but also the burden on the health care system. 9, 20 Persons with multiple chronic conditions tend to have longer hospital stays, higher health care costs, increased hospital mortality, and higher rates of readmission. 20, 21 The prevalence of multiple chronic conditions increases with age (see Figure 2). In Ontario, 18% of the population aged 12-44 had a chronic condition, and most of those had only one condition. Among those aged 65-74 and 75+ not only did most people have a chronic condition, but over half those with a chronic condition had at least one other condition. Provincially, while less than one percent of people aged 12-44 reported having three or more chronic conditions, 5.8% of those aged 45-64, 15.9% of those aged 65-74 and 22.2% of those aged 75+ had three or more chronic conditions in 2005. Among Central East LHIN residents aged 45+, 27% had two or more chronic conditions, the same as the proportion for Ontario overall. Among those aged 65+, the proportion of people with two or more chronic conditions was 46% for the Central East LHIN and Ontario. Commonly Occurring Co-morbidities In Ontario, among those aged 45+, 13% of the population reported having both arthritis/rheumatism and hypertension. Six percent of the population aged 45+ had a combination of heart disease and hypertension or heart disease and arthritis/rheumatism. Five percent of the population reported having both diabetes and hypertension, while four percent had both diabetes and arthritis/rheumatism. Among those aged 65+, almost 24% reported having both arthritis/rheumatism and hypertension and 11% had both arthritis/rheumatism and heart disease. Approximately 10% of seniors aged 65+ reported having both heart disease and hypertension and nine percent had both diabetes and hypertension. A further eight percent of seniors had both diabetes and arthritis/rheumatism. Figure 2: Population aged 12+ reporting one, two or three or more of selected chronic conditions, by age groups and sex, Ontario, 2005 90 80 Percentage 70 60 50 40 30 20 10 Three or more Two One 0 12-44 45-64 65-74 75 + Male Female Total Three + 0.5 5.8 15.9 22.2 3.9 5.3 4.6 Two 2.6 11.8 25.9 29.1 8.1 9.6 8.9 One 15.0 32.2 35.0 32.6 21.9 23.7 22.8 Age group Sex Source: 2005 Canadian Community Health Survey, Statistics Canada, Ontario Share File. i Selected chronic conditions include arthritis, asthma, heart disease, diabetes, stroke, hypertension, COPD and cancer. Chronic Conditions in the Central East LHIN Page 5

Physician Use The 2005 CCHS captures information on how many times respondents consulted with GP/FPs and specialists in the past year. Figure 3 shows the average number of GP/FP and specialist consultations in the past 12 months, for Ontario residents, by presence of selected chronic conditions. Among those with only one of the selected chronic conditions, the average number of consultations with GP/FPs was highest for those with cancer (6.7) and those suffering from the effects of a stroke (6.5) whereas the fewest consultations were made by those with asthma (3.4) or hypertension only (4.0). The average number of consultations with GP/FPs was consistently higher among those who had co-morbidities. For example, persons whose only chronic condition was COPD had an average of 4.7 consultations with a GP/FP in the past 12 months, but those who had COPD plus at least one other condition had 6.7 consultations. Ontarians without any of the selected chronic conditions had an average of 2.4 consultations with a GP/FP, and 0.7 consultations with a specialist in the past 12 months. These rates were slightly higher than those for Ontarians who did not report any chronic conditions at all (1.8 and 0.4 consultations respectively). Overall, Central East LHIN residents, aged 12+, reported an average of 3.2 consultations with GP/FPs and 0.9 consultations with specialists in the past 12 months, similar to the Ontario averages (3.3 and 1.0 consultations respectively). Figure 3: Average number of consultations with GP/FPs and specialists in past 12 months, population aged 12+, Ontario, 2005 Cancer - alone Cancer + other condition(s) 6.7 6.9 5.8 5.2 Diabetes - alone 4.7 1.4 Diabetes + other condition(s) 6.4 1.6 GP/FP Heart disease - alone 4.1 1.2 Specialist Heart disease + other condition(s) 6.5 2.4 Hypertension - alone 4.0 0.8 Hypertension + other condition(s) 5.8 1.6 Stroke - alone 6.5 2.7 Stroke + other condition(s) 7.9 2.2 Asthma - alone 3.4 1.1 Asthma + other condition(s) 6.5 2.4 COPD - alone 4.7 2.1 COPD + other condition(s) 6.7 2.0 Arthritis - alone 4.1 1.1 Arthritis + other condition(s) 6.2 1.9 No chronic condition No selected chronic condition Total population aged 12+ 1.8 0.4 2.4 0.7 3.3 1.0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 Average number of consultations Source: 2005 Canadian Community Health Survey, Statistics Canada, Ontario Share File. Page 6 Chronic Conditions in the Central East LHIN

A Closer Look at Selected Chronic Conditions This section examines the burden of illness associated with each selected chronic condition in greater detail. Prevalence rates, based on 2005 CCHS data (cycle 3.1), are shown in figures with 95% confidence intervals (indicated by error bars in the figures). The estimated prevalence of cancer, diabetes, depression, heart disease, hypertension, stroke, asthma, COPD and arthritis is based on self-reports to CCHS questions that asked respondents about long-term conditions, diagnosed by a health professional, which are expected to last or have already lasted six or more months. Mortality i, inpatient hospital separation, ED visit, and GP/FP visit data were obtained from the PHPDB. 2 Mortality and health service utilization crude rates, stratified by age and sex, were calculated per 100,000 population for residents of the Central East LHIN and are provided in tables. Ontario values are provided as comparators. The presence of co-morbid conditions was examined for each chronic condition. Note that this analysis only includes the selected conditions considered in this report. Therefore the percentage of people with cancer and another chronic condition refers specifically to those that have hypertension, heart disease, stroke, diabetes, asthma, COPD or arthritis/rheumatism in addition to cancer. Depression was not included in the examination of co-morbidity, as it was not asked in the 3.1 cycle of the CCHS. i Mortality rates for the Central East LHIN area are not provided because the data are incomplete (see Appendix B). Chronic Conditions in the Central East LHIN Page 7

Cancer Cancer (i.e., malignant neoplasms excluding skin cancers and benign tumors) is a leading cause of death in Ontario: it accounted for 29% of deaths in 2003. 2 Among Ontario males, prostate, colorectal and lung cancers accounted for 54% of new cases and 48% of cancer deaths in 2003. Among females, breast, lung and colorectal cancers accounted for 51% of new cases and 48% of cancer deaths. 2,22 The burden of cancer can be substantially decreased through reducing behavioural risk factors, early detection of some cancers through screening, and through treatment. According to the World Health Organization, 40% of cancers can be prevented by a healthy diet, physical activity and not using tobacco. In fact, tobacco use is the single largest preventable cause of cancer in the world. An additional third of the cancer burden could be reduced through early detection and treatment. 23 According to the 2005 CCHS, 0.9% of Central East LHIN residents aged 12+ reported they have cancer, significantly lower than the provincial rate of 1.5%. Figure 4 provides age and sex-specific cancer prevalence rates for Central East LHIN and Ontario residents. As with most chronic conditions, cancer prevalence increased with age. Provincially, cancer prevalence rates among those aged 75+ were almost twenty times greater than those for the 12-44 age group. The prevalence rate for Central East females was lower than that for Ontario females. Although cancer prevalence provides some information about the burden of disease, the incidence of cancer (i.e., the number or rate of newly diagnosed cases) is a more useful measure when planning health services. Furthermore, because different cancers have different risk factors, prognoses and treatment options each cancer site should, ideally, be examined separately. Age-standardized incidence rates for lung, colorectal, breast, and prostate cancer are provided in Table 1. According to the Ontario Cancer Registry, there were over 6,000 incident (new) cancer cases for Central East LHIN residents in 2003. 22 Approximately 13% of these cases were lung cancers and 12% were colorectal Figure 4: Prevalence of cancer by age group and sex, population aged 12+, Central East LHIN and Ontario, 2005 20 Central East Ontario 15 Percentage 10 5 0 1.4 * 1.2 1.3 0.7 0.3 1.9 3.0 5.3 3.3 5.9 1.7 12 to 44 45 to 64 65 to 74 75+ Male Female Age group Sex Source: 2005 Canadian Community Health Survey, Statistics Canada, Ontario Share File. Coefficient of variation 16.6% to 33.3% - interpret with caution. Data not reportable because of high sampling variability. * Significantly different from provincial average based on assessment of 95% confidence intervals. Page 8 Chronic Conditions in the Central East LHIN

cancers. Prostate cancer accounted for 15% of total cases (30% of cases in men) and breast cancer accounted for 13% of all Central East LHIN cancer cases (25% of cases among women). Table 1 shows age-standardized incidence rates for these four main sites, and for all malignant neoplasms. Overall cancer incidence rates were significantly lower among Central East LHIN residents compared to Ontario, whereas lung, colorectal, prostate and female breast cancer rates were similar to provincial rates. Cancer mortality rates increased dramatically with age (Table 2) as did hospital separation rates. Note that treatment modalities such as chemotherapy and radiotherapy are provided as ambulatory care and not captured as inpatient hospital separations, therefore these numbers do not reflect all cancer-related treatments. 24 Although cancer is not a common reason for ED visits, ED visit rates among those aged 45+ were higher for Central East LHIN residents compared to Ontario. GP/FPs are involved in the care of cancer patients in the diagnostic, active treatment, posttreatment and palliative care stages. 25 There were approximately 2,600 GP/FP visits per 100,000 population related to cancer by Central East LHIN residents, and the rate was much higher among those aged 65 or older. The 2005 CCHS shows that, among Ontario residents (aged 12+) who reported having cancer: 69% had at least one other selected chronic condition in addition to cancer; 36% had two or more other chronic conditions; 41% had arthritis/rheumatism; 33% had high blood pressure. Table 1: Age-standardized cancer incidence rates, per 100,000 population, Central East LHIN and Ontario, 2003 Lung cancer Breast cancer Colorectal cancer Prostate cancer All sites Sex Central Ontario Central Ontario Central Ontario Central Ontario Central Ontario East East East East East Male 55.1 63.0 1.2 1.2 52.7 57.6 127.8 124.9 423.1 449.1 Female 41.8 41.7 89.1 98.0 37.6 41.0 n/a n/a 331.8 352.6 Total 47.5 51.0 47.4 52.2 44.7 48.6 58.4 56.9 370.3 393.0 Source: Ontario Cancer Registry, SEERStat 2003 Rates are age-standardized to the 1991 Canadian population. Table 2: Cancer mortality, hospital separation, emergency department visit and GP/FP visit rates by age group and sex, per 100,000 population, Central East LHIN and Ontario residents Age group, sex Mortality rate i Hospital ED visit rate ii GP/FP visit rate ii separation rate ii Central Ontario Central Ontario Central Ontario Central Ontario East East East East 0-11 2.4 29 27 21 10 220 159 12-44 14.5 83 88 17 18 501 509 45-64 202.9 691 687 186 160 3,449 3,865 65-74 795.3 1,847 1,852 584 464 9,785 10,932 75+ 1,558.0 2,139 2,286 677 594 12,495 15,091 Male 210.8 506 504 156 128 2,598 2,827 Female 186.6 451 463 125 107 2,576 2,956 All ages 198.5 478 483 140 118 2,587 2,893 Source: Deaths, Inpatient Discharges, Ambulatory Visits, Medical Services and Population Estimates, Ontario Ministry of Health and Long-Term Care Provincial Health Planning Database. i) Based on average over 2001-2003. ii) For 2005/06 fiscal year Not calculated due to data quality issues. Chronic Conditions in the Central East LHIN Page 9

Diabetes Diabetes (i.e., diabetes mellitus) is a metabolic disorder that interferes with the body s ability to produce or effectively use the insulin it produces. 26 Diabetes is characterized by elevated blood sugar levels. Type 1 diabetes typically arises in childhood and requires daily injections of insulin whereas type 2 diabetes more commonly develops in adulthood and can often be managed through diet, exercise, and oral drugs. Gestational diabetes occurs in approximately 4% of women during pregnancy and typically resolves itself following birth. The majority (90%) of diabetes patients have type 2 diabetes. 27 The Ontario Diabetes Database, which contains data on a population-based cohort of people who have been identified via administrative data as having diabetes has been used extensively to describe the incidence and prevalence of diabetes in Ontario. 12,28 Researchers using this database have found that, provincially, prevalence rates increased from 6.9% to 8.8% between 2000 and 2005. The increase in prevalence is attributed to both increasing incidence and falling mortality. 28 According to the CCHS, 4.6% of Central East LHIN residents (aged 12+) reported having diabetes in 2005, similar to the provincial prevalence of 4.8%. There is evidence that diabetes may be underreported in surveys and therefore the true prevalence is likely to be higher than the estimates provided here. 28, 29 The provincial prevalence rate based on CCHS data is substantially lower than the prevalence rate obtained through the Ontario Diabetes Database (8.8% in 2005). Prevalence of diabetes increases with age, as shown in Figure 5. For Central East LHIN residents aged 12-44, 1.4% reported having diabetes in 2005, compared to 16.7% of those aged 75+. Prevalence rates were higher among males than females in both the Central East LHIN and provincially. Among Ontario residents with diabetes, 21% reported taking insulin while 69% reported taking pills to control blood sugar. Figure 5: Prevalence of diabetes by age group and sex, population aged 12+, Central East LHIN and Ontario, 2005 40 Central East Ontario 30 Percentage 20 10 0 1.4 1.1 6.6 7.1 10.3 14.3 16.7 14.9 5.9 5.6 3.4 4.1 12 to 44 45 to 64 65 to 74 75+ Male Female Age group Sex Source: 2005 Canadian Community Health Survey, Statistics Canada, Ontario Share File. Coefficient of variation 16.6% to 33.3% - interpret with caution. Page 10 Chronic Conditions in the Central East LHIN

Inpatient hospital separation and ED visit rates for diabetes increased with age (provincially and within the LHIN), with rates for Central East LHIN residents being similar to provincial rates (Table 3). Diabetes diagnoses among Central East LHIN residents accounted for over 14,000 visits per 100,000 population to GP/FPs. The highest GP/FP utilization rates were noted in the 65-74 age group. GP/FP visit rates for diabetes were higher, compared to Ontario, across all age groups for Central East LHIN residents. It has been suggested that more primary care visits by diabetes patients is associated with fewer hospital admissions for acute complications from diabetes. 30 Provincially and within the Central East LHIN, hospital separation, ED visit and GP/FP visit rates were higher among males than females (consistent with higher prevalence rates). A high proportion of those with diabetes are likely to have another chronic condition. The 2005 CCHS shows that, among Ontario residents (aged 12+) who reported having diabetes: 76% had at least 1 other selected chronic condition; 42% had 2 or more additional chronic conditions; 53% also had hypertension; 40% also had arthritis/rheumatism; 21% also had heart disease. The co-existence of high blood pressure and diabetes is of particular concern because both these conditions are strongly linked to cardiovascular disease, renal disease and diabetic retinopathy. 31 Screening for diabetic retinopathy is an important part of disease management and clinical practice guidelines recommend that all newly diagnosed diabetics, aged 30+, receive an eye exam within one year. In 2004/05 fewer than half (43.6%) of newly diagnosed diabetes patients (aged 30+) in the Central East LHIN had an eye examination within one year of diagnosis. 32 In Ontario, cardiac disease and stroke occur earlier in persons with diabetes, and diabetes patients are three times more likely than non-diabetics to have a cardiac or stroke related hospital admission. 12, 33 Kidney disease is another serious complication of diabetes; diabetics are 12 times more likely to require dialysis because of chronic kidney failure than those without diabetes. 34 Table 3: Diabetes mortality, hospital separation, emergency department visit and GP/FP visit rates by age group and sex, per 100,000 population, Central East LHIN and Ontario residents Age group, sex Mortality rate i Hospital ED visit rate ii GP/FP visit rate ii separation rate ii Central Ontario Central Ontario Central Ontario Central Ontario East East East East 0-11 - 28 27 40 44 181 171 12-44 1.2 49 51 102 113 3,778 2,946 45-64 16.2 102 114 209 236 26,380 21,150 65-74 82.0 218 255 392 434 52,218 45,158 75+ 277.7 367 381 676 616 42,638 38,794 Male 26.2 105 112 198 208 16,020 13,218 Female 25.4 77 83 155 165 13,436 11,160 All ages 25.8 91 97 176 186 14,705 12,176 Source: Deaths, Inpatient Discharges, Ambulatory Visits, Medical Services and Population Estimates, Ontario Ministry of Health and Long-Term Care Provincial Health Planning Database. i) Based on average over 2001-2003. ii) For 2005/06 fiscal year Not calculated due to data quality issues. - Data suppressed due to small numbers Chronic Conditions in the Central East LHIN Page 11

Depression Depression is a complex chronic mental disorder. It can have a variety of symptoms that interfere with the ability to work, sleep, study or enjoy activities. Genetics, psychological, biological or social factors may increase susceptibility to depression. The presence of other chronic conditions may actually contribute to the onset or worsening of depression. 35 Cycle 1.2 of the CCHS (Mental Health and Well-being) contains data on the prevalence of selected mental disorders among Ontarians aged 15 or older. In 2002, 4.2% of Central East LHIN residents (aged 15+) reported they had experienced feelings or symptoms associated with a major depressive episode within the past 12 months, similar to the Ontario prevalence of 4.8%. A major depressive episode is defined as a period of two weeks or more with persistent depressed mood and loss of interest or pleasure in normal activities, accompanied by symptoms such as decreased energy, changes in sleep and appetite, impaired concentration, and feelings of guilt, hopelessness or suicidal thought. 19 Unlike many other chronic conditions, prevalence rates for depression were higher in the younger age groups (see Figure 6). Among Ontarians aged 15-44 Figure 6: Prevalence of depression by age group and sex, population aged 15+, Ontario, 2002 20 15 Percentage 10 5 1.8 1.7 0 5.7 4.6 3.5 6.1 15 to 44 45 to 64 65 to 74 75+ Male Female Age group Sex Source: 2002 Canadian Community Health Survey (Mental Health and Well-being), Statistics Canada, Ontario Share File. Coefficient of variation 16.6% to 33.3% - interpret with caution. Page 12 Chronic Conditions in the Central East LHIN

years, 5.7% had a major depressive episode in the past 12 months, compared to 1.8% of those aged 65+. The prevalence of depression was also significantly higher among Ontario females (6.1%) compared to males (3.5%). Table 4 provides mortality and health care utilization rates for depression among those aged 12+. Although there are relatively few deaths where depression is given as the underlying cause (less than 45 in Ontario in 2003), depression is a major risk factor for deaths from suicide and self-inflicted injury. Hospital separation rates and ED visit rates for depression (i.e., for either a depressive episode or a recurrent depressive disorder) were higher among those aged 12-64 compared to those aged 65+, and higher among females than males for Central East LHIN residents and Ontario overall (Table 4). GP/FP visit rates were notably higher in the 45-64 age group compared to other age groups and were also much higher among females than males. In general, hospital separation and ED visit rates for depressive disorders were lower among Central East LHIN residents compared to the province. GP/FP visit rates for depression for Central East LHIN residents were much lower than rates for Ontario residents. Table 4: Depression mortality, hospital separation, emergency department visit and GP/FP visit rates by age group and sex, per 100,000 population, Central East LHIN and Ontario Age group, sex Mortality rate i Hospital ED visit rate ii GP/FP visit rate ii separation rate ii Central Ontario Central Ontario Central Ontario Central Ontario East East East East 12-44 - 133 138 293 322 2,334 3,184 45-64 - 158 158 252 253 3,434 4,655 65-74 0.6 108 123 117 135 2,445 2,859 75+ 5.9 142 145 115 131 2,330 3,330 Males, age 12+ 0.3 105 115 220 234 1,798 2,316 Females, age 12+ 0.6 172 170 286 311 3,488 4,839 Total, age 12+ 0.5 139 143 254 273 2,663 3,600 Source: Deaths, Inpatient Discharges, Ambulatory Visits, Medical Services and Population Estimates, Ontario Ministry of Health and Long-Term Care Provincial Health Planning Database. i) Based on average over 2001-2003. ii) For 2005/06 fiscal year Not calculated due to data quality issues. - Data suppressed due to small numbers Chronic Conditions in the Central East LHIN Page 13

Heart Disease Heart disease is a general term for a group of conditions that affect the functioning of the heart. It includes conditions such as chronic rheumatic heart disease, ischemic heart disease (IHD), pulmonary heart disease, atrial fibrillations, and other forms of heart disease including congestive heart failure. Although heart disease is less prevalent than many other chronic conditions discussed in this report, it is a leading cause of death and places a substantial burden on the health care system with high rates of inpatient hospital separations and ED use relative to other chronic conditions. According to the CCHS, 4.7% of Central East LHIN residents reported having heart disease in 2005, similar to the provincial rate of 4.8%. As with most chronic conditions, the prevalence of heart disease increases with age (see Figure 7). Among Central East residents aged 75+, one in four reported having heart disease. Provincially, prevalence rates for heart disease were higher for males than females (5.4 versus 4.2%). The most common form of heart disease among Ontario residents, accounting for the majority of heart disease related deaths (approximately 80%) and hospital separations (approximately 60%) is ischemic heart disease. Ischemic heart disease (also called coronary heart disease or coronary artery disease) refers to a condition in which the heart muscle is damaged or works inefficiently often because of Figure 7: Prevalence of heart disease by age group and sex, population aged 12+, Central East LHIN and Ontario, 2005 40 Central East Ontario 30 Percentage 20 10 0 1.0 0.8 5.1 5.4 13.8 16.1 24.7 23.5 5.6 5.4 3.9 4.2 12 to 44 45 to 64 65 to 74 75+ Male Female Age group Sex Source: 2005 Canadian Community Health Survey, Statistics Canada, Ontario Share File. Coefficient of variation 16.6% to 33.3% - interpret with caution. Page 14 Chronic Conditions in the Central East LHIN

atherosclerosis resulting in reduced blood supply to the heart. IHD includes angina pectoris (chest pain), acute myocardial infarction (heart attack) and chronic ischemic heart disease. Table 5 shows that mortality and inpatient hospital separation rates for IHD increased dramatically with age. Provincially, there was a five-fold increase in IHD mortality rates between the ages of 45-64 and 65-74 and again between the ages of 65-74 and 75+. Hospital separation rates for Central East LHIN and Ontario residents show almost a three-fold increase between the ages of 45-64 and 65-74 with a smaller increase between the 65-74 and 75+ age groups. GP/FP visit rates also showed a sharp increase with age and were highest among those aged 75+. Mortality and health care utilization rates were higher among males than females both provincially and among Central East LHIN residents. According to the 2005 CCHS, among Ontarians (aged 12+) who reported having heart disease: 78% had at least one of the other selected chronic conditions presented in this report; 47% had two or more other chronic conditions in addition to heart disease; 49% had also been diagnosed with hypertension; 47% had arthritis/rheumatism in addition to heart disease; 21% also had diabetes; and 13% also had COPD. Table 5: Ischemic heart disease mortality, hospital separation, emergency department visit and GP/FP visit rates by age group and sex, per 100,000 population, Central East LHIN and Ontario Age group, sex Mortality rate i Hospital ED visit rate ii GP/FP visit rate ii separation rate ii Central Ontario Central Ontario Central Ontario Central Ontario East East East East 12-44 3.2 57 44 39 35 415 372 45-64 68.9 770 691 423 438 5,994 5,611 65-74 351.4 1,903 1,796 1,012 1,094 21,639 19,735 75+ 1,609.6 2,515 2,589 1,894 2,071 33,125 32,778 Males, age 12+ 171.9 806 734 445 458 7,782 7,215 Females, age 12+ 142.7 383 375 283 304 4,491 4,266 Total, age 12+ 157.0 589 551 362 380 6,098 5,714 Source: Deaths, Inpatient Discharges, Ambulatory Visits, Medical Services and Population Estimates, Ontario Ministry of Health and Long-Term Care Provincial Health Planning Database. i) Based on average over 2001-2003. ii) For 2005/06 fiscal year Not calculated due to data quality issues. Chronic Conditions in the Central East LHIN Page 15

Hypertension Hypertension or high blood pressure is both a chronic condition and an independent risk factor for heart disease, stroke and chronic kidney disease. According to the 2005 CCHS, approximately 15% of Central East LHIN and Ontario residents (aged 12+) reported having high blood pressure. Of those Central East LHIN residents who reported having hypertension, almost 90% reported taking medication for high blood pressure, a similar proportion to Ontario (86%). Prevalence of hypertension increases with age. Among Central East LHIN residents aged 12-44 only 3.8% reported having high blood pressure, compared to 44.1% of those aged 65-74 and 51.8% of those aged 75+. These percentages were similar to those for Ontario residents overall (see Figure 8). Males and females had similar prevalence rates. Although hypertension contributes to other conditions, hypertension in and of itself is rarely the underlying cause of death or the main diagnosis for an acute inpatient hospital separation or ED visit. Because hypertension can be diagnosed, treated and managed by primary care physicians, rates of GP/FP visits for hypertension are high among Central East LHIN and Ontario residents in general (see Table 6). Hospital Figure 8: Prevalence of hypertension by age group and sex, population aged 12+, Central East LHIN and Ontario, 2005 70 60 Central East Ontario 50 Percentage 40 30 20 10 0 3.8 3.9 21.9 22.6 44.1 43.4 51.8 47.7 15.2 14.9 15.4 15.9 12 to 44 45 to 64 65 to 74 75+ Male Female Age group Sex Source: 2005 Canadian Community Health Survey, Statistics Canada, Ontario Share File. Coefficient of variation 16.6% to 33.3% - interpret with caution. Page 16 Chronic Conditions in the Central East LHIN

separation and ED visit rates were lower among Central East LHIN residents across all age and sex groups compared to Ontario rates. Hypertension is a major risk factor for heart disease and stroke increasing the risk of both these conditions by two to three times. 10 According to the 2005 CCHS, among Ontario residents (aged 12+) who reported having hypertension: 59% had at least one of the other selected chronic conditions presented in this report; 24% had two or more other chronic conditions in addition to hypertension; 39% also had arthritis/rheumatism; 17% reported they had been diagnosed with diabetes; and 15% also had heart disease. Table 6: Hypertension mortality, hospital separation, emergency department visit and GP/FP visit rates by age group and sex, per 100,000 population, Central East LHIN and Ontario Age group, sex Mortality rate i Hospital ED visit rate ii GP/FP visit rate ii separation rate ii Central Ontario Central Ontario Central Ontario Central Ontario East East East East 12-44 0.1 4 5 38 44 6,727 5,849 45-64 1.9 15 21 210 235 52,503 46,002 65-74 10.0 21 44 382 463 109,261 99,514 75+ 71.0 53 102 544 681 113,294 110,753 Males, age 12+ 4.8 11 17 121 144 32,400 29,248 Females, age 12+ 7.5 14 23 182 210 39,356 35,465 Total, age 12+ 6.2 12 20 152 178 35,960 32,413 Source: Deaths, Inpatient Discharges, Ambulatory Visits, Medical Services and Population Estimates, Ontario Ministry of Health and Long-Term Care Provincial Health Planning Database. i) Based on average over 2001-2003. ii) For 2005/06 fiscal year Not calculated due to data quality issues. Chronic Conditions in the Central East LHIN Page 17

Stroke A stroke occurs when there is an interruption of blood supply to the brain. Strokes are captured under the broader grouping of cerebrovascular disease. A stroke may be ischemic (i.e., blood supply to brain is suddenly interrupted due to a clot), hemorrhagic (i.e., artery supplying blood to brain suddenly bleeds) or a transient cerebral ischemic attack (i.e., TIAs or ministrokes where there has been a temporary reduction in blood supply to the brain). The majority (approximately 80%) of strokes are ischemic. 36 According to the CCHS, 1.2% of Central East LHIN residents suffered from the effects of a stroke in 2005, similar to the provincial prevalence of 1.1%. The prevalence of stroke increases sharply with age (Figure 9). Approximately one percent of Central East LHIN residents aged 45-64 suffered from the effects of a stroke compared to 7.8% of those aged 75+. Figure 9: Prevalence of stroke by age group and sex, population aged 12+, Central East LHIN and Ontario, 2005 20 Central East Ontario 15 Percentage 10 5 0 1.1 1.4 1.2 1.2 0.9 1.1 0.2 3.1 3.4 7.8 6.7 12 to 44 45 to 64 65 to 74 75+ Male Female Age group Sex Source: 2005 Canadian Community Health Survey, Statistics Canada, Ontario Share File. Coefficient of variation 16.6% to 33.3% - interpret with caution. Data not reportable because of high sampling variability. Page 18 Chronic Conditions in the Central East LHIN

Table 7 provides mortality and health service utilization rates for stroke. There were approximately 4,400 deaths from stroke in Ontario in 2003 accounting for five percent of all deaths. The majority (77%) of these deaths were among persons aged 75+. Mortality rates from stroke increased almost seven-fold between the ages of 65-74 and 75+ for Ontario residents. Consistent with the age-related increase in prevalence, inpatient hospital separation, ED visit and GP/FP visit rates for stroke also increased with age, with the rates being highest in the 75+ age group. Hospital separation rates were slightly lower for Central East LHIN residents compared to Ontario residents, whereas ED and GP/FP visit rates were similar to provincial rates. Stroke survivors can have significant disability and rehabilitation services are an important part of their recovery process. This is not captured in our analysis as it only includes acute inpatient hospital separations. Stroke, along with hypertension and heart disease, is a cardiovascular condition and shares many of the same risk factors. Hypertension, a major risk factor for both heart disease and stroke, is a commonly reported comorbidity among those who suffered from a stroke as is heart disease. According to the 2005 CCHS, among Ontario residents (aged 12+) who reported having suffered from a stroke: 84% had at least one other selected chronic condition; 56% had two or more other chronic conditions in addition to suffering from the effects of a stroke; 55% also had hypertension; 32% reported they had been diagnosed with heart disease; 27% had diabetes in addition to having had a stroke. Table 7: Stroke mortality, hospital separation, emergency department visit and GP/FP visit rates by age group and sex, per 100,000 population, Central East LHIN and Ontario Age group, sex Mortality rate i Hospital ED visit rate ii GP/FP visit rate ii separation rate ii Central Ontario Central Ontario Central Ontario Central Ontario East East East East 12-44 1.2 11 12 18 15 65 64 45-64 11.8 102 114 159 159 611 653 65-74 73.3 406 444 602 594 2,425 2,489 75+ 498.1 1,130 1,287 1,506 1,502 6,105 6,134 Males, age 12+ 35.7 150 162 214 207 906 873 Females, age 12+ 50.5 150 169 212 208 792 835 Total, age 12+ 43.2 150 166 213 208 848 854 Source: Deaths, Inpatient Discharges, Ambulatory Visits, Medical Services and Population Estimates, Ontario Ministry of Health and Long-Term Care Provincial Health Planning Database. i) Based on average over 2001-2003. ii) For 2005/06 fiscal year Not calculated due to data quality issues. Chronic Conditions in the Central East LHIN Page 19