Statement of Intent

This documents intends to:

  • Primary: Describe what we gain by going beyond Acute Care services in utilization analysis
  • Secondary A: Describe how people with sever alcohol addiction use health services
  • Secondary B: Demonstrate utility of the Clinical Context Coding Scheme (CCCS)

Paraphrases

  • Primary
    • This document shows what we would miss from the clinical story of 4,067 patients with sever alcohol addiction if we DO NOT go beyong emergency and acute care (ED + Acute) data in analyses of service utilization.
    • This document shows what we would gain in the clinical story of 4,067 patients with sever alcohol addiction if we go beyong emergency and acute care (ED + Acute) data in analyses of service utilization.
    • This document presents two views of health service utilizations: one that covers the full spectrum of health services and another looking ONLY at the emergency and acute care (ED + Acute) data.
  • Secondary A
    • This document reports service utilization patterns for 4,067 residents of Vancouver Island with heavy substance use addictions, observed between 2007 and 2017.
    • This documents describes the trace that 4,067 patients with severy alcohol addiction left in the cross-continuum encounter data of Vancouver Island Health Authority between 2007 and 2017.
  • Secondary B
    • This document demonstrates the structure of the Clinical Context Coding Scheme (CCCS) with respect to the target cohort.
    • This document show how CCCS can be used to assist in describing the cross-continuum terrain of health services characteristic for a given cohort of patients.

Addiction Cohort

The EHR build of Island Health distinguishes ~1,700 distinct health program. The cohort of 4,067 persons was selected on the basis of transaction data of Island Health with these programs. Specifically, persons were included if they had at least one encounter with any of the following health programs :

  • Detox
  • Stabilization Unit
  • Holly (post-withdrawal stabilization unit)
  • Grove (post-withdrawal stabilization unit)
  • Intensive Case Management Service, Johnson Street (713 Outreach)
  • Intensive Case Management Service, PES (SAMI)
  • Sobering and Assessment Centre (maximum 23 hour stay - for persons who are under the influence of alcohol or other drugs.

Note: These VIHA programs (N ~ 1,700) are what Clinical Context Coding Scheme groups into ~150 “service classes” using (6) dimensions of service description.

These criteria are ‘biased’ in favour of ensuring inclusion of persons who have serious/chronic problems with abuse of alcohol. However, by including the Sobering and Assessment Centre in the inclusion criteria for defining the cohort, there will be some cases where the person uses drugs other than alcohol. In future analyses, we can refine the inclusion/exclusion criteria on the basis of the Substance Use Profile from the Minimum Reporting Requirements (MRR).

Encounter Data

For each individuals in our Addiction cohort (N = 4,067) we have extracted the complete record of engagement with VIHA services for the period between January 1, 2007 and September 1, 2017. We call these records encounter data, because they keep track of patients’ encounters with the healthcare system. There records were then mapped onto 6 categories of CCCS(6) classification system (see ./manipulation/1-greeter-transactions.R script), producing 124 distinct service classes, operationalized as unique combination of CCCS(6) dimensions. The resultant data for one person is exemplified in Figure 1.

Figure 1: Heavy Addiction through the lens of service engagment: longitudinal view for a fictional patient

Figure 1: Heavy Addiction through the lens of service engagment: longitudinal view for a fictional patient

To produce the aggregate which would describe service utilization of the entire cohort, we have summed the number of registered encounters over 1) all 10 years of obsevations and 2) all 4,067 individuals in the cohort. The aggregate table produced by this process is the focal point of the analysis in the report. We import the aggregated results for the Addiction cohort (N = 4,067).

In this data frame (ds):

  • Each row is a class of health services (aka service class)
  • Service class is identified by service_class_code and/or service_class_description
  • Engagement with VIHA services is quantified as number of unique persons n_people or a number of unique transactions n_encounters
  • Clinical Context Coding Scheme places each transaction 6 dimensions:
    • intensity_type (intensity level-1)
    • intensity_severity_risk (intensity level-2)
    • clinical_focus (the nature of health conditions)
    • service_type (type of services provided)
    • service_location (where service takes place)
    • population_age (age of people targeted by this health service)

You can examine the row-level content of this dataframe directly, by consulting the dynamic table of the aggregate at the end of this document or a dedicated pivot tool.

CCCS Summary

This section will provide a summary views based on the elements of the Clinical Context Coding Scheme (CCCS). Each dimension of CCCS(6) groups the same set of encounters into different number of categories.

  1. Intensity_Type - this is a set of categories that are used to classify the 1700 service locations into groups that are relatively homogeneous with respect to the manner in which service intensity would be coded. (e.g. “Ambulatory_Chronic” would refer to ambulatory services provided over an extended period of time)

  2. Intensity_Severity_Risk - this set of categories is nested within Intensity_Type and is used to characterize the intensity of services provided within an Intensity_Type class. (e.g. three levels of intensity within the “Ambulatory_Chronic” class)

  3. Clinical_Focus - this set of categories refers to the predominant clinical focus of a service associated with a location in the Cerner location build. (e.g. “Diabetes” or “Frailty/Neurocognitive, Psychiatric”)

  4. Service_Type - this set of categories refers to the type of service provided. (e.g. “Assertive Community Treatment” or “Acute Care - Tertiary”)

  5. Service_Location - this set of categories refers to the physical location where a given service is provided. (e.g. “Ambulatory Clinic” or “Hospital” or “Home”)

  6. Population_Age - this set of categories refers to the age range of the patients/clients who access a particular service. (e.g. “Infants” or “Older Adults Exclusively” or “Mixed”)

Table 1: Number of categories engaged by the cohort in each CCCS dimension

cccs_dimension n_people n_encounters n_categories
clinical_focus 4,067 160,318 43
intensity_severity_risk 4,067 160,318 36
intensity_type 4,067 160,318 14
population_age 4,067 160,318 8
service_location 4,067 160,318 14
service_type 4,067 160,318 53
Table 2: How much we miss by focusing ONLY on (ED + Acute) service data
ed_acute n_service_classes n_encounters
FALSE 100 104,370
TRUE 24 55,336
NA 1 612

Service Terrain

Appendix A - dynamic table

Appendix B - pivot tool

See Beyond Acute for a stand-alone pivot too.

Session Information

For the sake of documentation and reproducibility, the current report was rendered in the following environment. Click the line below to expand.

Environment 

- Session info -------------------------------------------------------------------------------------------------------
 setting  value                       
 version  R version 3.5.2 (2018-12-20)
 os       Windows 10 x64              
 system   x86_64, mingw32             
 ui       RTerm                       
 language (EN)                        
 collate  English_United States.1252  
 ctype    English_United States.1252  
 tz       America/Los_Angeles         
 date     2019-08-04                  

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