Printer Friendly

Space and time clustering of adolescents' emergency department use and post-visit physician care for mood disorders in Alberta, Canada: a population-based 9-year retrospective study.

In their lifetimes, 7.8% of Canadian adolescents aged 15 to 18 will meet criteria for depression with differing prevalence between boys and girls (4.3% versus H.1%). (1) Global burden of depressive disorders is significant. In 2010, these disorders accounted for the most disability-adjusted life years (DALYs) caused by mental and substance use disorders with the highest proportion of total DALYs occurring in young people aged 10 to 29 years. (2) As compared to depression onset in adulthood, depression in adolescence is associated with more impaired social and occupational function, poorer quality of life, and greater medical and psychiatric co-morbidities. (3-5) Greater symptom severity, more lifetime depressive episodes, and more suicide attempts (3, 6) have also been associated with earlier disorder onset, making treatment during adolescence vital.

Most depressed Canadian adolescents do not receive mental health services. In an examination of 12-month service use rates, Cheung and Dewa reported that 40% of 15 to 18 year olds suffering from major depression had not used any health services for mental health reasons. (7) More recent Alberta-based research has suggested that mood-based crises are among the most frequent reasons for pediatric mental health emergency department (ED) visits. (8) A related study reported adolescents aged 13 to 17 were 1.5 times more likely to return for subsequent ED care compared to 6 to 12 year olds, (9) and that within 72 hours of ED discharge, 6% of children and adolescents diagnosed with a mood disorder will return for further acute care. (9) Combined, this body of Canadian literature suggests that Canadian adolescents are engaging a pattern of acute mental health services use with little to no receipt of community-based or primary care health care.

Large, national efforts to improve access to and receipt of mental health services in childhood and adolescence are ongoing (e.g., Mental Health Commission of Canada (10)). Complementary to these efforts is the use of statistical surveillance techniques in Canada's health databases as a practical and cost-effective strategy to reveal patterns of mental health resource use and inform health resource planning. We conducted a population-based study to examine emergency mental health care and follow-up care by adolescents in Alberta, Canada using a statistical surveillance technique. In this study, we identified geographic areas with higher numbers of adolescents 1) presenting to the ED than expected by chance alone, and 2) who presented to the ED but did not have a mental health-related physician follow-up visit within 30 days after an ED visit.

METHODS

Data sources and variable description

Alberta Health provided the population-based data from two databases: 1) the Ambulatory Care Classification System (ACCS (11)) database, which records ambulatory care visits to all Alberta government-funded facilities (including 104 EDs), and 2) the Alberta Health Care Insurance Plan cumulative population registry, which contains demographic and population data.

The ACCS database has a main diagnosis field and nine additional fields to capture diagnosis data (Canadian Enhancement of International Classification of Diseases, 10th Revision; ICD-10-CA (12)). All ED visits made by Alberta adolescents aged 10 to 17 years during April 1, 2002 and March 31, 2011, where the first diagnosis field had diagnostic codes for a mood disorder (F30.x-F34.x, F38.x-F39.x (13)), were extracted.

Geographic data were geo-coded to 70 subregional health authorities (sRHAs) which constitute five provincial health Zones (North, Edmonton, Central, Calgary, South) by Alberta Health along with latitudes and longitudes for population-based geographic centres (centroids). Population data included counts by sex and age (in years) and sRHA of residence at fiscal year end. Two age groups were formed (10-14, 15-17).

Adolescents with ED visits were linked with the Physician Claims File to obtain all physician claims (hereafter physician follow-up visits) within 30 days of the ED visit. This linkage provided the date of the physician claim and up to three diagnosis fields (International Classification of Diseases, 9th Revision--Clinical Modification; ICD-9-CM (14)). We identified mental health physician follow-up visits (those claims with either the first diagnosis field code as 291.x, 292.x, 303.x, 304.x, 305.x, 295.x, 297.x, 298.x, 296.x, 300.4, 311, 300.x, 308.x, 306.x, 307. x, 301.x, 302.x, 300.16, 309.x, 312.x, 313.x, 314.x, 300.9, 980.x, 981, 986, 982.x, 987.x, E95.x, 994.7, or any additional diagnostic fields matching the intentional self-harm category code E95.x, 994.7). We identified adolescents who had at least one ED visit for a mood disorder but did not have any mental health-related physician follow-up visits within 30 days of the ED visit. The University of Alberta Ethics Board provided ethics approval for the study.

Data analysis

Numerical summaries (e.g., counts, percentages) describe the demographic characteristics of adolescents with an ED visit for a mood disorder and the Alberta adolescent population. Crude and sex and age-group directly standardized rates (DSRs) were calculated (with corresponding 95% confidence intervals [CIs]). The Mann-Kendall trend test was used to assess trends in the crude rates. The adolescent population aged 10 to 17 years in Alberta as of March 31, 2003 was used as the reference population for DSRs. ED visits were excluded from analyses if sRHA of residence was missing.

The Kulldorff-Nagarwalla (KN) spatial scan test (15) is a popular statistical cluster detection technique. Circles of varying radii are created around an area (i.e., sRHAs in our data) to form zones. A likelihood ratio test compares the risk of being a case inside and outside each zone, and the maximum likelihood ratio across all zones is identified as the most likely cluster. A Monte Carlo method is used to determine the p-value. To identify spatiotemporal clusters, the zones are cylinders (i.e., the height characterizes the time). We used the KN test to identify geographic areas over time with excess numbers (clusters) of adolescents with mood disorder ED visits and adolescents without 30-day physician follow-up (spatio-temporal clustering). We used a space window of up to 50% of Alberta's population and a time window of 1 year. All tests used the sRHAs as the geographic boundaries and were adjusted by age group and sex. Further, we used the KN test to identify sRHAs that were purely spatial clusters for each of the last two fiscal years. These two years are the most recent years of data and may be more indicative of current data than earlier years. We reported the significant clusters identified as well as DSRs (with 95% CIs (16)). A p-value less than 0.05 was considered to be statistically significant. Data were analyzed using S-Plus software (17) and SaTScan (18) was used for the cluster detection analyses. The Manifold System (19) was used to produce maps of results.

RESULTS

Study cohort description

A total of 6,839 ED visits for mood disorders were made by 5,877 adolescents during the study period. Ten ED visits (0.15%) were excluded from the analysis because of missing geographic data, resulting in 6,829 ED visits available for analysis. The majority of adolescents who had mood disorder ED visits were females (64.6%), 15-17 years of age (72.0%), and were distributed across the province (Table 1). Females and adolescents aged 15-17 years had disproportionately more ED visits than would be suggested by the population distribution (Figure 1a). Increasing trends over time were seen for males aged 10-14 (p = 0.048) and aged 15-17 (p = 0.016), and for females aged 10-14 (p = 0.029). When adjusted by sex and age group, the DSRs per 100,000 for adolescents with mood disorder ED visits remained relatively steady during the first 5 years and showed increases from 2008 to 2011. Across the five geographic Zones in Alberta, there was variability among years and the North, Central, and South Zones (the latter to a lesser extent) of Alberta had disproportionately more adolescents with ED visits than would be suggested by the population distribution (Supplementary Table 1).

Approximately 32% of adolescents with an ED visit for a mood disorder did not have a mental health follow-up with a physician within 30 days. During the study period, females and adolescents aged 15-17 years had fewer follow-up visits (Figure 1b) and there was no evidence of a statistically significant trend over time for each sex and age group. When adjusted by sex and age group, the DSRs for adolescents without a 30-day physician follow-up visit after an ED visit increased over the study period from 49.9 in 2002/2003 to 57.7 in 2010/2011 (Supplementary Table 2). Across the five geographic Zones in Alberta, the North Zone of Alberta had disproportionately more adolescents without physician follow-up than would be suggested by the population distribution.

Geographical and temporal clustering

Adolescents With ED Visits for Mood Disorders

Across the study period, three potential spatio-temporal clusters of adolescents with ED visits for mood disorders (cases) were identified. The annual number of adolescents with ED visits per 100,000 was 175.9 for the province. The first potential cluster contained the vast majority of the North Zone during April 1, 2007 to March 31, 2011 (282.7 annual cases per 100,000, p < 0.001). A single sRHA in the southwest part of the Central Zone was identified as a second potential cluster during April 1, 2005 to March 31, 2009 (486.7 annual cases per 100,000, p < 0.001). A third potential cluster was identified in the Central Zone during April 1, 2008 to March 31, 2011 (245.9 annual cases per 100,000, p < 0.001). These three clusters had relative risks of 1.67, 2.78 and 1.42 respectively (Table 2a, Figure 2a). The relative risk estimate quantifies the risk of being a case inside the cluster compared to the risk outside the cluster.

The KN test was also applied to identify purely geographical clusters for each year and we focus our results on the last two fiscal years. In 2009/2010, three potential clusters were identified. These were concentrated in parts of the North Zone (DSR 305.46 per 100,000, p < 0.001), the eastern part of the Central Zone (DSR 290.24 per 100,000, p = 0.011) and the western part of the Central Zone when combined with a sRHA from the North Zone (DSR 364.35 per 100,000, p = 0.036). The DSR for sRHAs not involved in clusters was 160.83 (95% CI 146.89-175.76). The relative risks for the three clusters were 1.72, 1.61 and 1.98 respectively. One sRHA (Aspen East) from the first cluster in 2009/2010 was a potential cluster in 2010/2011 and sRHAs within the Calgary Zone formed the other potential cluster. The DSR for the sRHAs that were not part of clusters was 177.78 per 100,000 (95% CI 163.72-192.74) whereas the first cluster had a DSR of 498.15 per 100,000 (p < 0.001) and the second cluster had a DSR of 280.87 per 100,000 (p = 0.011). The relative risks in the first and second clusters were 2.61 and 1.52 respectively.

Adolescents With ED Visits for Mood Disorders Without 30-day Physician Follow-up

Three clusters of adolescents with an ED visit for a mood disorder and without 30-day physician follow-up (cases) were identified (Table 2b, Figure 2b). The first two potential clusters have the same sRHAs as identified previously and slightly different time periods. The third potential cluster contains several sRHAs in the Central Zone, some of which were identified as part of the third cluster when examining adolescents with an ED visit for a mood disorder.

When examining purely geographic clusters for the 2009/2010 and 2010/2011 years, the KN test identifies only one cluster for each year. In 2009/2010, the cluster contains most of the sRHAs in the North Zone (DSR 129.16 per 100,000, p < 0.001). This geographic area was slightly larger than the potential cluster of ED cases identified. In 2010/2011, the potential cluster (DSR 122.81 per 100,000, p < 0.001) is a subset of the cluster identified for 2009/2010. Some of these sRHAs were also part of a potential cluster of ED cases. All the sRHAs not involved in the potential cluster had DSRs of about 51 per 100,000 for each of the years.

DISCUSSION

Our population-based study spanned nine fiscal years and showed trends over time and geography for adolescents who presented to the ED for mood disorders in Alberta. The rates of adolescents presenting to an ED for a mood disorder increased during the study period, with females aged 15 to 17 having the highest rates. Sex- and age-adjusted directly standardized rates were relatively stable over time but showed variation among the health Zones in Alberta.

[FIGURE 1 OMITTED]

We identified three potential geographic and temporal clusters and identified some potential purely geographic clusters during the 2009/2010 and 2010/2011 fiscal years. These potential clusters were mainly in the north and central regions of the study region and the different analyses produced some different results. The potential clusters identified may represent real cluster areas that have a higher severity of mood disorders in adolescents requiring emergency care or may represent areas with less availability of other health services. These findings are consistent with previous population health summaries of Alberta data that have shown that the least socio-economically advantaged Alberta youth are more likely to live in rural areas of the province (e.g., North, Central, or South). (20) These less advantaged youth were more likely to be male, visit EDs more frequently (most frequent reasons for visit are psychiatric or behavioural in nature), and visit primary care physicians 5 or more times per year compared to more advantaged youth living in larger urban centres (e.g., Calgary or Edmonton). In terms of ED visits, Alberta summary data have indicated that females over 16 years were more likely than males to have multiple visits, but this trend starts to decrease after the age of 19 years. (20) In terms of primary care physician visits, Alberta summary data have shown that the number of visits to a primary physician for females and males on income supports (i.e., welfare) starts to increase at ages 10 and 15 years respectively. (21) For females on welfare, the number of primary care physician visits decreases between the ages of 20-65 years, while for males the numbers remain consistent between 20-65 years. Similarly, Alberta summary data shows that mental health and other health resources are less available in rural areas of the province. This lack of availability has contributed to the higher rates of ED visits in North, Central, and South Zones of the province and their lower rates of primary care visits per weighted population. (22)

The KN spatial scan is a popular cluster detection method and cluster detection methods have been used to identify "hot spots" of a variety of diseases. A few studies have focused on mental health conditions such as depression (23) and self-inflicted injury. (24-28) To our knowledge, we are the first to examine geographic clustering of adolescents aged 10 to 17 years who presented to EDs for mood disorders.

While the KN spatial scan can identify potential clusters, a limitation of all cluster detection methods is that they cannot determine if an identified cluster is a real cluster. Further, the KN spatial scan is most appropriate for identifying circular clusters that are close in proximity and for finding the most likely cluster. Secondary clusters and clusters with irregular shapes may be missed. In a province like Alberta with diverse population sizes in its subregions, combining multiple subregions may lead to large geographic portions identified as a potential cluster when the actual population sizes may be relatively small. Other study limitations include our definition of a case as an adolescent with at least one ED visit for mood disorders during the study period and this definition does not include all adolescents who have a mood disorder or all adolescents who seek non-ED health services. We have also assumed that the sRHA of residence has not changed over time and that the data do follow a Poisson distribution. Furthermore, the potential clusters may be spurious because of differential distributions of key variables that are unaccounted for in the analysis (i.e., some key confounder that varies with geography), variations in coding practices, or chance occurrences. Notwithstanding these limitations, our study is based on a long study period with large, population-based databases and identification of these potential clusters can lead to further targeted studies and provide areas that may benefit from the implementation of programs (e.g., education, intervention) to reduce ED use for mood disorders in adolescents.

[FIGURE 2 OMITTED]

In summary, our population-based study spanned 9 fiscal years and showed variations in the number of adolescents presenting to EDs for mood disorders and the number of adolescents presenting to EDs without 30-day physician follow-up over geography. The potential clusters identified may represent geographic areas with higher disease severity or a lower availability of non-ED health services. The clusters are not all likely to have occurred by chance and further investigation and intervention could occur to reduce ED use by adolescents with mood disorders.

REFERENCES

(1.) Cheung AH, Dewa CS. Canadian community health survey: Major depressive disorder and suicidality in adolescents. Healthcare Policy 2006;2:76-78.

(2.) Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al. Global burden of disease attributable to mental and substance use disorders: Findings from the Global Burden of Disease Study 2010. Lancet 2013;382: 1575-86. doi: 10.1016/S0140-6736(13)61611-6.

(3.) Zisook S, Lesser I, Stewart JW, Wisniewski SR, Balasubramani GK, Fava M, et al. Effect of age at onset on the course of major depressive disorder. Am J Psychiatry 2007;164:1539-46. doi: 10.1176/appi.ajp.2007.06101757. PMID: 17898345.

(4.) Wood JJ, Lynne-Landsman SD, Langer DA, Wood PA, Clark SL, Eddy JM, et al. School attendance problems and adolescents psychopathology: Structural cross-lagged regression models in three longitudinal data sets. Child Dev 2012;83:351-66. doi: 10.1111/j.1467-8624.2011.01677.x. PMID: 22188462.

(5.) McShane G, Walter G, Rey JM. Characteristics of adolescents with school refusal. Aust N Z J Psychiatry 2001;35:822-26. doi: 10.1046/j.1440-1614.2001. 00955.x.

(6.) Birmaher B, Ryan ND, Williamson DE, Brent DA, Kaufman J, Dahl RE, et al. Childhood and adolescent depression: A review of the past 10 years. Part I. J Am Acad Child Adolesc Psychiatry 1996;35:1427-39.

(7.) Cheung AH, Dewa CS. Mental health service use among adolescents and young adults with major depressive disorder and suicidality. Can J Psychiatry 2007;52:228-32.

(8.) Newton AS, Ali S, Johnson DW, Haines C, Rosychuk RJ, Keaschuk RA, et al. A four-year review of pediatric mental health emergencies in Alberta. Can J Emerg Med 2009;11:447-54.

(9.) Newton AS, Ali S, Johnson DW, Haines C, Rosychuk RJ, Keaschuk RA, et al. Who comes back? Characteristics and predictors of return to emergency department services for pediatric mental health care. Acad Emerg Med 2010; 17:177-86.

(10.) Mental Health Commission of Canada. Child and Youth. Available at: http:// www.mentalhealthcommission.ca/English/issues/child-and-youth?routetoken=cfd393bd52ed4aa54a29367f6f0c87e4&terminitial=20 (Accessed July 2, 2014).

(11.) Alberta Health and Wellness. Ambulatory Care in Alberta Using Ambulatory Care Classification System Data. Edmonton, AB: Alberta Health and Wellness, 2004.

(12.) Canadian Institute for Health Information. The Canadian Enhancement of ICD-10 (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision). Ottawa, ON: Canadian Institute for Health Information, 2001.

(13.) World Health Organization. International Statistical Classification of Diseases and Related Health Problems. Geneva, Switzerland: World Health Organization, 2010.

(14.) Practice Management Information Corporation. International Classification of Diseases and Related Health Problems (9th revision, 3rd ed., Clinical Modification). Los Angeles, CA: Practice Management Information Corporation, 1989.

(15.) Kulldorff M, Nagarwalla N. Spatial disease clusters: Detection and inference. Stat Med 1995;14:799-810. doi: 10.1002/sim.4780140809. PMID: 7644860.

(16.) Fay M, Feuer E. Confidence intervals for directly standardized rates: A method based on the Gamma distribution. Stat Med 1997;16:791-801. doi: 10.1002/(SICI)1097-0258(19970415)16:7<791::AID-SIM500>3.0.CO;2-#. PMID: 9131766.

(17.) Spotfire S+ 8.1 Workbench [computer program]. Version 3.4. Palo Alto, CA: TIBCO Software Inc., 2008.

(18.) SaTScan[TM] v9.2: Software for the spatial and space-time scan statistics [computer program]. Available at: www.satscan.org (Accessed December 8, 2013).

(19.) Manifold System 8.0 Professional Edition. Build 8.0.7.0 [computer program]. Available at: http://www.manifold.net (Accessed September 15, 2008).

(20.) Child and Youth Data Laboratory. CYDL Project Summary Report. Edmonton, AB, 2012.

(21.) Alberta Health Services. Needs Weighted Population to Actual Population by Health Sector. Internal Strategic Planning Report. Edmonton, AB: Alberta Health Services, 2012.

(22.) Predy GN, Lightfoot P, Edwards J, Sevcik M, Fraser-Lee N, Zhang J, et al. How healthy are we? 2010 Report of the Senior Medical Officer of Health, Population and Public Health, Alberta Health Services. Edmonton, AB: Alberta Health Services, 2011.

(23.) Salinas-Perez JA, Garcia-Alonso CR, Molina-Parrilla C, Jorda-Sampietro E, Salvador-Carulla L. GEOSCAT Group Identification and location of hot and cold spots of treated prevalence of depression in Catalonia (Spain). Int J Health Geogr 2012;11:36.

(24.) Exeter DJ, Boyle PJ. Does young adult suicide cluster geographically in Scotland? J Epidemiol Community Health 2007;61:731-36.

(25.) Jones P, Gunnell D, Platt S, Scourfield J, Lloyd K, Huxley P, et al. Identifying probable suicide clusters in Wales using national mortality data. PLoS One 2013;8(8):e71713.

(26.) Mesoudi A. The cultural dynamics of copycat suicide. PLoS One 2009;4(9): e7252.

(27.) Rosychuk RJ, Colman I, Rowe BH. Comparison of cluster detection using patients and events of medically treated self-inflicted injuries in Alberta, Canada. Health Serv Outcomes Res Method 2009; 9:100-16.

(28.) Rosychuk RJ, Yau C, Colman I, Schopflocher D, Rowe BH. Statistical disease cluster surveillance of medically treated self-inflicted injuries in Alberta, Canada. Chron Dis Can 2006;27:68-76.

Received: July 14, 2014

Accepted: October 13, 2014

Rhonda J. Rosychuk, PhD, PStat, PStat[R](ASA), [1, 2] Amanda S. Newton, PhD, [1, 2] Xiaoqing Niu, PhD, [1] Liana Urichuk, PhD [3]

Author Affiliations

[1.] Department of Pediatrics, University of Alberta, Edmonton, AB

[2.] Women & Children's Health Research Institute, Edmonton, AB

[3.] Alberta Health Services, Edmonton, AB

Correspondence: Rhonda J. Rosychuk, Department of Pediatrics, University of

Alberta, Rm 3-524, Edmonton Clinic Health Academy (ECHA), 11405 87 Avenue NW, Edmonton, AB T6G 1C9, Tel: [??] 780-492-0318, E-mail: rhonda.rosychuk@ ualberta.ca

Funding sources: The study was funded by an operating grant from the Canadian Institutes of Health Research (CIHR; Ottawa, Canada). Dr. Rosychuk is salary supported by Alberta Innovates-Health Solutions (AI-HS; Edmonton, Canada) as a Health Scholar. Dr. Newton holds a CIHR New Investigator Award.

Acknowledgements: The authors thank Alberta Health for providing the data.

Disclosures: This study is based in part on data provided by Alberta Health. The interpretation and conclusions contained herein are those of the researchers and do not necessarily represent the views of the Government of Alberta. Neither the Government nor Alberta Health expresses any opinion in relation to this study.

Conflict of Interest: None to declare.
Table 1. Socio-demographic and geographic characteristics of 1)
adolescents with an ED visit for a mood disorder and 2)
adolescents without a 30-day physician follow-up visit after the
ED visit as compared to total ED visits by adolescents for mood
disorders, and the Alberta adolescent population aged 10-17 years
(as of March 31, 2011)

                     Adolescents with an ED visit

                       Total      Per fiscal year
                       n (%)      Median (range)

All                    5877       640 (591-741)
Sex
  Female            3798 (64.6)   409 (388-487)
  Male              2079 (35.4)   230 (199-272)
Age group (years)
  10-14             1647 (28.0)   179 (167-221)
  15-17             4230 (72.0)   463 (422-535)
Provincial zone
  North             1138 (19.4)   137 (92-148)
  Edmonton          1368 (23.3)   151 (138-168)
  Central            961 (16.4)   106 (72-133)
  Calgary           1893 (32.2)   200 (174-293)
  South              517 (8.8)     55 (54-63)

                     Adolescents without a 30-day
                      physician follow-up visit

                       Total      Per fiscal year
                       n (%)      Median (range)

All                    1870       205 (167-259)
Sex
  Female            1206 (64.5)   130 (111-165)
  Male               664 (35.5)    72 (56-98)
Age group (years)
  10-14              530 (28.3)    58 (49-71)
  15-17             1340 (71.7)   149 (116-188)
Provincial zone
  North              472 (25.2)    51 (33-83)
  Edmonton           422 (22.6)    45 (41-57)
  Central            312 (16.7)    34 (21-57)
  Calgary            537 (28.7)    61 (51-66)
  South              127 (6.8)     14 (7-26)

                             ED visits               Alberta
                                                    population
                                                      n (%)
                       Total       Per fiscal
                       n (%)       year Median
                                     (Range)

All                    6829       744 (680-861)      373,201
Sex
  Female            4450 (65.2)   480 (446-572)   181,352 (48.6)
  Male              2379 (34.8)   266 (228-309)   191,849 (51.4)
Age group (years)
  10-14             1866 (27.3)   198 (182-257)   227,812 (61.0)
  15-17             4963 (72.7)   546 (498-629)   145,389 (39.0)
Provincial zone
  North             1344 (19.7)   150 (100-177)    50,144 (13.4)
  Edmonton          1576 (23.1)   175 (154-189)   111,479 (29.9)
  Central           1159 (17.0)   129 (90-160)     47,834 (12.8)
  Calgary           2171 (31.8)   233 (198-342)   132,963 (35.6)
  South              579 (8.5)     63 (60-72)      30,781 (8.2)

Table 2. Clusters of a) adolescents with ED visits for mood
disorders and b) adolescents without a 30-day physician
follow-up after an ED visit for a mood disorder (cases)
identified over space and time

Cluster   Time frame       Location (sRHAs)     Population   Cases

a) Adolescents with ED visits for mood disorders

1         April 2007 to    Aspen Central        45,696       513
          March 2011       Aspen North
                           Aspen East
                           Peace NW
                           Peace NE
                           Peace SE
                           Peace SW
                           High Level
                           La Crete
                           Northern Lights
                           Northwest
                           Fort McMurray
2         April 2005 to    Clearwater             2522        49
          March 2009

3         April 2008 to    Didsbury-            44,854       337
          March 2011         Strathmore
                           Wetaskiwin-
                             Hobbema
                           Ponoka
                           Lacombe
                           Red Deer
                           Olds
                           Drumheller-Hanna
                           Region 5 Southwest

b) Adolescents without a 30-day physician follow-up after an ED
visit for mood disorders

1         April 2006 to    Aspen Central        45,696       239
          March 2010       Aspen North
                           Aspen East
                           Peace NW
                           Peace NE
                           Peace SE
                           Peace SW
                           High Level
                           La Crete
                           Northern Lights
                           Northwest
                           Fort McMurray
2         April 2007 to    Clearwater             2522        22
          March 2010

3         April 2008 to    Lacombe              32,258        70
          March 2010       Red Deer
                           Drumheller-Hanna
                           Stettler-Consort
                           Region 5 Northwest
                           Region 5 Southeast
                           Region 5 South
                             Central
                           Region 5
                             Southwest

Cluster   Time frame       Location (sRHAs)     Expected   Observed/
                                                cases      expected

a) Adolescents with ED visits for mood disorders

1         April 2007 to    Aspen Central        319.19     1.61
          March 2011       Aspen North
                           Aspen East
                           Peace NW
                           Peace NE
                           Peace SE
                           Peace SW
                           High Level
                           La Crete
                           Northern Lights
                           Northwest
                           Fort McMurray
2         April 2005 to    Clearwater            17.71     2.77
          March 2009

3         April 2008 to    Didsbury-            241.07     1.40
          March 2011         Strathmore
                           Wetaskiwin-
                             Hobbema
                           Ponoka
                           Lacombe
                           Red Deer
                           Olds
                           Drumheller-Hanna
                           Region 5 Southwest

b) Adolescents without a 30-day physician follow-up after an ED
visit for mood disorders

1         April 2006 to    Aspen Central        101.92     2.35
          March 2010       Aspen North
                           Aspen East
                           Peace NW
                           Peace NE
                           Peace SE
                           Peace SW
                           High Level
                           La Crete
                           Northern Lights
                           Northwest
                           Fort McMurray
2         April 2007 to    Clearwater             4.28     5.15
          March 2010

3         April 2008 to    Lacombe               36.17     1.94
          March 2010       Red Deer
                           Drumheller-Hanna
                           Stettler-Consort
                           Region 5 Northwest
                           Region 5 Southeast
                           Region 5 South
                             Central
                           Region 5
                             Southwest

Cluster   Time frame       Location (sRHAs)     Relative   p-value
                                                risk

a) Adolescents with ED visits for mood disorders

1         April 2007 to    Aspen Central        1.67       < 0.001
          March 2011       Aspen North
                           Aspen East
                           Peace NW
                           Peace NE
                           Peace SE
                           Peace SW
                           High Level
                           La Crete
                           Northern Lights
                           Northwest
                           Fort McMurray
2         April 2005 to    Clearwater           2.78       < 0.001
          March 2009

3         April 2008 to    Didsbury-            1.42       < 0.001
          March 2011         Strathmore
                           Wetaskiwin-
                             Hobbema
                           Ponoka
                           Lacombe
                           Red Deer
                           Olds
                           Drumheller-Hanna
                           Region 5 Southwest

b) Adolescents without a 30-day physician follow-up after an ED
visit for mood disorders

1         April 2006 to    Aspen Central        2.54       < 0.001
          March 2010       Aspen North
                           Aspen East
                           Peace NW
                           Peace NE
                           Peace SE
                           Peace SW
                           High Level
                           La Crete
                           Northern Lights
                           Northwest
                           Fort McMurray
2         April 2007 to    Clearwater           5.19       < 0.001
          March 2010

3         April 2008 to    Lacombe              1.97       0.002
          March 2010       Red Deer
                           Drumheller-Hanna
                           Stettler-Consort
                           Region 5 Northwest
                           Region 5 Southeast
                           Region 5 South
                             Central
                           Region 5
                             Southwest
COPYRIGHT 2015 Canadian Public Health Association
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2015 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:QUANTITATIVE RESEARCH
Author:Rosychuk, Rhonda J.; Newton, Amanda S.; Niu, Xiaoqing; Urichuk, Liana
Publication:Canadian Journal of Public Health
Article Type:Report
Geographic Code:1CANA
Date:Jan 1, 2015
Words:4745
Previous Article:Changes to the Canadian Journal of Public Health/ Des changements a la Revue canadienne de sante publique.
Next Article:Demographic and behavioural characteristics predict bacterial STI reinfection and coinfection among a cross-sectional sample of laboratory-confirmed...
Topics:

Terms of use | Copyright © 2017 Farlex, Inc. | Feedback | For webmasters