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Volume 20, Issue 2, Fall/Winter 2020

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Jeff

Report from the Chair

Hello All! Here is a quick update on what has been happening in the ACHORD Group since our last newsletter.

All faculty, staff and students in ACHORD continue to work from home due to the COVID-19 situation and will continue to do so throughout the Winter 2021 term.

Two new PhD students started in September under Dean Eurich’s supervision, Heidi Fernandes and Daniel O’Brien. Their bios as elsewhere in the newsletter; welcome to both!

Congratulations to Nathan McClure and Candace Necyk on successfully completing their PhD’s and to Jiabi Wen for successfully completing her MSc. Nathan started a degree in Medicine at the U of A in September; although Candace relocated to BC, she continues in her faculty position in Pharmacy and Jiabi started a PhD under Arto Ohinmaa’s supervision in September so will be around for awhile. Great work everyone!

Like the rest of the academic world, we have been attending virtual conferences as all face-to-face conferences have gone virtual. These include the EuroQol Plenary, 26th Annual International Society for Quality of Life Research (ISOQOL), Alberta Diabetes Institute Virtual Research Day, and The 2020 North American Primary Care Research Group (NAPCRG) virtual conference.

The Alberta’s PROMs and EQ-5D Research and Support Unit (APERSU) also continues to work remotely. We held both the APERSU Board of Directors Meeting and Scientific Advisory Committee Meeting via Zoom in October. In lieu of the face-to-face annual meetings normally hosted by APERSU, it was decided that two online forums be held. One forum on PROMs in Hip and Knee was held in November with the Canadian Institute of Health Information (CIHI) and Alberta Bone and Joint Health Institute (ABJHI) participating. Another online forum on Primary Care PROMs will be held in the New Year.

Our partnership funding in The Diabetes Infrastructure for Surveillance Evaluation and Research (DISER) project comes to an end this fall. The aim of our involvement in the project was to support the DON SCN in the establishment of DISER, extending our previous ADSS and ABCD Cohort projects as initial infrastructure for diabetes surveillance in the province. The aim of DISER is to enhance surveillance of diabetes self-care activities to help AHS and the DON SCN improve its delivery of care. Unfortunately, with the end of the funding comes a farewell; we would like to thank Nonsikelelo Mathe for her leadership on this project and look forward to working together again in the future. While the partnership funding has ended, ACHORD will continue to participate in DISER, with Jeff Johnson serving on the Partnership Committee and the Clinical Data Advisory & Management (CDAM) committee.

Evaluation of routinely Measured PATient reported outcomes in HemodialYsis care (EMPATHY) project is a cluster randomized controlled trial (RCT) that was implemented in three renal programs: Alberta Kidney Care – North (AKC-N), Alberta Kidney Care – South (AKC-S), and Ontario Renal Network (ORN). While AKC-N completed the 1-year trial period in October 2019, the COVID-19 pandemic put the trial on hold in AKC-S and ORN. Trial activities resumed over the summer and both renal programs will complete data collection by the end of November 2020. The EMPATHY research team looks forward to meta-analyzing all the data together in the coming months. To learn more about the EMPATHY trial, click here to read the protocol paper which was recently published in BMC Health Services Research.

In addition to the RCT, all renal programs collected qualitative data from patients and clinicians to evaluate the routine use of patient-reported outcome measures (PROMs) for clinical care in the hemodialysis setting. The AKC-N team produced a mixed-methods secondary analysis of the burden of mental health symptoms and perceptions of their management in hemodialysis care. Outputs from this work included a poster presentation at the 26th Annual International Society for Quality of Life Research (ISOQOL) conference and a pending publication. Click here to view the virtual ISOQOL poster. The AKC-N team is also in the midst of another mixed-methods analysis on how routine PROMs for hemodialysis care influence patient-clinician communication. The ORN team published an article on patient and provider perspectives on implementing PROMs for hemodialysis care in Clinical Journal of the American Society of Nephrology. Click here to read the article. The COVID-19 pandemic disrupted qualitative data collection in AKC-S so the team is working on plans to resume data collection or work with the data they have. All renal programs are now working toward sustainability plans for PROMs in hemodialysis care, with EMPATHY results to guide official decision-making.

I hope the information in our newsletter is informative, and if you have any questions about our activities, please do not hesitate to contact us. I look forward to updating you in late spring/early summer on ACHORD’s activities. Best wishes for a wonderful holiday season, here’s hoping 2021 will be a fabulous year!

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Project Update

Deeper Insights into Health – Data Linkage with Alberta’s Tomorrow Project

Your daily activities, such as eating, sleeping and physical exercise, can have great impact on your health. By filling out health and lifestyle questionnaires, participants of Alberta’s Tomorrow Project (ATP), the largest population-based cohort study of cancer and chronic diseases in Alberta, provided unique information on individual lifestyle behaviours and disease risk factors. This information about personal behaviours cannot be easily obtained from other data sources, and is an important contribution to help people understand the underlying causes leading to chronic conditions like cardiovascular disease, diabetes and cancer.

The ATP cohort began in 2000 and is led by a team based in Alberta Health Services. Over 50,000 Albertans participate in this project. In 2008, ATP joined forces with other regional cohorts to create a nation-wide research platform known as the Canadian Partnership for Tomorrow’s Health (CanPATH; https://canpath.ca/). More details of ATP can be found at www.myATP.ca.

How can we make the ATP cohort data even more valuable for the study of chronic diseases? Almost all – more than 99% - of ATP participants have given consent to link their personal behavioral and risk factor survey data to other health-related records. With the support of Alberta Health (AH), the Ministry of Health in Alberta, ACHORD has partnered with ATP to build an Alberta-based research platform for cancer and chronic disease study by linking multiple health data sources to the ATP cohort. These health datasets include AH clinical and healthcare data, Alberta Precision Laboratories (APL) diagnostic laboratory data, Alberta Cancer Registry (ACR) cancer diagnosis and treatment data and the Canadian Urban Environmental Health Research Consortium (CANUE) socio-geographic data.

By linking all these health data together with the ATP cohort, researchers in Alberta can easily access anonymous, de-identified individual level healthcare data, such as doctors’ visits, medication, diagnosis and health outcomes, along with patients’ individual lifestyles, biomarker data, socio-economic status, socio-geographic and environmental factors. ATP research using multiple data sources linked by the ACHORD can provide clinicians and policy makers with a holistic view of how personal lifestyle behaviors, social and environmental factors and healthcare systems interact with each other to influence the health and wellness of Albertans. Linking and co-analyzing the ATP lifestyle and risk factor data with other health-related data has greatly enhanced the research capacity of ATP to study cancer and chronic diseases. The following is a list of publications arising from this ACHORD-ATP partnership, using the ATP cohort data linked with multiple health datasets.

1. Diet Quality and Health Service Utilization for Depression: A Prospective Investigation of Adults in Alberta's Tomorrow Project. Marozoff S, Veugelers PJ, Dabravolskaj J, Eurich DT, Ye M, Maximova K. Nutrients. 2020 Aug 13;12(8):2437. doi: 10.3390/nu12082437. PMID: 32823652
2. Validation of drug prescription records for senior patients in Alberta's Tomorrow Project: Assessing agreement between two population-level administrative pharmaceutical databases in Alberta, Canada. Ye M, Vena JE, Johnson JA, Xu JY, Eurich DT. Pharmacoepidemiol Drug Saf. 2019 Oct;28(10):1417-1421. doi: 10.1002/pds.4861. Epub 2019 Jul 26. PMID: 31348593
3. Systemic use of antibiotics and risk of diabetes in adults: A nested case-control study of Alberta's Tomorrow Project. Ye M, Robson PJ, Eurich DT, Vena JE, Xu JY, Johnson JA. Diabetes Obes Metab. 2018 Apr;20(4):849-857. doi: 10.1111/dom.13163. Epub 2017 Dec 27. PMID: 29152889
4. Anthropometric changes and risk of diabetes: are there sex differences? A longitudinal study of Alberta's Tomorrow Project. Ye M, Robson PJ, Eurich DT, Vena JE, Xu JY, Johnson JA. BMJ Open. 2019 Jul 19;9(7):e023829. doi: 10.1136/bmjopen-2018-023829. PMID: 31326923
5. Changes in body mass index and incidence of diabetes: A longitudinal study of Alberta's Tomorrow Project Cohort. Ye M, Robson PJ, Eurich DT, Vena JE, Xu JY, Johnson JA. Prev Med. 2018 Jan;106:157-163. doi: 10.1016/j.ypmed.2017.10.036. Epub 2017 Nov 5. PMID: 29117506
1. Diet Quality and Health Service Utilization for Depression: A Prospective Investigation of Adults in Alberta's Tomorrow Project. Marozoff S, Veugelers PJ, Dabravolskaj J, Eurich DT, Ye M, Maximova K. Nutrients. 2020 Aug 13;12(8):2437. doi: 10.3390/nu12082437. PMID: 32823652
2. Validation of drug prescription records for senior patients in Alberta's Tomorrow Project: Assessing agreement between two population-level administrative pharmaceutical databases in Alberta, Canada. Ye M, Vena JE, Johnson JA, Xu JY, Eurich DT. Pharmacoepidemiol Drug Saf. 2019 Oct;28(10):1417-1421. doi: 10.1002/pds.4861. Epub 2019 Jul 26. PMID: 31348593
3. Systemic use of antibiotics and risk of diabetes in adults: A nested case-control study of Alberta's Tomorrow Project. Ye M, Robson PJ, Eurich DT, Vena JE, Xu JY, Johnson JA. Diabetes Obes Metab. 2018 Apr;20(4):849-857. doi: 10.1111/dom.13163. Epub 2017 Dec 27. PMID: 29152889
4. Anthropometric changes and risk of diabetes: are there sex differences? A longitudinal study of Alberta's Tomorrow Project. Ye M, Robson PJ, Eurich DT, Vena JE, Xu JY, Johnson JA. BMJ Open. 2019 Jul 19;9(7):e023829. doi: 10.1136/bmjopen-2018-023829. PMID: 31326923
5. Changes in body mass index and incidence of diabetes: A longitudinal study of Alberta's Tomorrow Project Cohort. Ye M, Robson PJ, Eurich DT, Vena JE, Xu JY, Johnson JA. Prev Med. 2018 Jan;106:157-163. doi: 10.1016/j.ypmed.2017.10.036. Epub 2017 Nov 5. PMID: 29117506
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Meet The Students

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Heidi head

Heidi Fernandes, PharmD, RPh, MSc

Training Program: PhD in Epidemiology, University of Alberta, School of Public Health

Heidi received her PharmD from the University of Waterloo School of Pharmacy in 2017 and became a practicing pharmacist. She then went on to complete her MSc, also at Waterloo, focussing on pharmacy practice research specifically on Ontario pharmacists expanded scope of practice with travel medicine.

She will be completing her PhD in Epidemiology under the supervision of Dr. Dean Eurich. Her thesis will focus on the impact of cannabis for medicinal purposes using one the largest known databases to investigate its effectiveness and safety. As a healthcare professional herself, Heidi’s research interests include topics challenging front-line clinicians such as new clinical areas and authorities.

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Daniel

Daniel O'Brien, MD, MAS

Training Program: PhD in Public Health,
University of Alberta, School of Public Health
Rhinology and Endoscopic Skull Base Fellow, Division of Otolaryngology

I am a clinical fellow in the Division of Otolaryngology-Head and Neck Surgery, at the University of Alberta. I completed my BS in Chemistry at Creighton University in 2010, before returning to my hometown of Sacramento, California to attend the University of California Davis. While at Davis, I completed both my master’s degree and my MD. I next joined the Department of Otolaryngology at West Virginia University, where I completed my surgical training in June of 2020. In July, I joined the Division of Otolaryngology at the University of Alberta as a clinical fellow in Rhinology and Endoscopic Skull Base Surgery.

My supervisor in the School of Public Health is Dr. Dean Eurich and the planned focus of my research will be in one of two directions. The first possible avenue is the evaluation, development, and validation of patient reported outcomes measures used for patients undergoing endoscopic sinus and skull base surgery. The other potential path is assessing the personal exposure risk of those who work in the operating theater to caustic chemicals and surgical byproducts (smoke, viruses, etc.) and means of mitigating these risks.

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Recent Literature from the ACHORD Journal Club

(Paper discussed Tuesday, November 3, 2020; Commentary by Sabrina Saba)

Sesso HD, Christen WG, Bubes V, et al. Multivitamins in the Prevention of Cardiovascular Disease in Men: The Physicians' Health Study II Randomized Controlled Trial. JAMA. 2012;308(17):1751–1760. PMID: 23117775

Article Summary:
The popularity of multivitamins has increased rapidly in the past few decades, and currently, multivitamins are one of the most commonly used supplements in the world. While there is still uncertainty regarding the long-term health benefits of vitamins, adults continue to take vitamin supplements with the belief that they may prevent chronic diseases or improve general health and wellbeing. The authors describe the possible financial implications of chronic supplement consumption, as well as the concern that individuals who believe they are deriving benefits from supplements may be less likely to engage in other preventive health behaviors. This study specifically explored heart disease, the leading cause of death worldwide, for which evidence of the preventative role of multivitamins is mixed.

For more than a decade, the Physicians’ Health Study II (PHS ll), a randomized controlled trial, investigated the effects of daily multivitamin use in over 14,000 male doctors over the age of 50. In this paper, the authors wanted to find out the effect of multivitamin use on major cardiovascular events. The paper considered all clinically important outcomes. The primary endpoint was major cardiovascular disease (CVD) (fatal and non-fatal stroke, myocardial infarction or CVD death)) and secondary endpoints were total MI, total stroke (fatal and non-fatal), CV death alone, ischemic and hemorrhagic stroke, and total mortality. Other major endpoints, such as cancer, were assessed and reported in a different paper. The authors did not use any surrogates as they only looked at the hard clinical endpoints. Morbidity and mortality follow-up in PHS II were high—98.2% and 99.9%, respectively. In addition, morbidity and mortality follow-up as a percentage of person-time each exceeded 99.9%. Adherence with the multivitamin component was defined from participant self-report, which has been shown to be highly reliable in physicians, as taking at least two-thirds of the pills.

For the primary endpoint, the hazard ratio (HR) for multivitamin vs placebo was 1.01. This effect is extremely small, non-significant and clinically inconsequential. The risk ratio (RR) is 1.02, that is clinical and statistically non-significant (11.98% of major CVD in multivitamin group and 11.69% in placebo group). In terms of absolute risk reduction (ARR), there was none. The AR was higher in the multivitamin arm compared to placebo. The confidence interval (CI) was 0.91 to 1.10. The 95% CI were reasonably precise but given the sample size, we would have expected a smaller CI. So the true effect could range from a 9% reduction in major CVD to a 10% increase; both of these are well below the 20% rule and so the results are likely not important. The authors conclude that among the population of US male physicians followed for more than a decade, consumption of a daily multivitamin did not reduce major cardiovascular events, MI, stroke, and CVD mortality. With no clinical benefits observed, it may not be worth the costs to the province, and there may also be unintended harms to consider.

Discussion Within Journal Club:
We first discussed internal and external validity of research, and the trade-off that emerges between the value of a study with a high level of internal validity (such as this RCT, with carefully controlled variables) and the value of a study that may be more externally valid (generalizable to the somewhat less controlled environment of the “real world”). For example, as this study’s population consisted of male physicians over the age of 50, the information gained from this study is clearly a good fit for males from a higher socioeconomic class. As such, the selective generalizability of this study made this a perfect example of a well-preserved internally valid but externally invalid study. We then asked which was better – a study that is internally valid, or a study that is externally valid – and the importance of internal validity as a first step. Without trustworthy, internally valid results, external validity becomes irrelevant.

We also considered the difference between confounding (a “nuisance” variable associated with both the outcome and the exposure, accounting for some of the perceived effect) and effect modification (a variable that affects the outcome, but not the exposure; stratification is helpful). In terms of follow-up, we talked about the 5/20% rule of thumb. The study indicated <5% events not record that would suggest that follow-up was very good for a 10-15 year trial and it is below our 5/20% rule. We also discussed that there was no differential losses to follow-up. On the other hand, even if there is some differential losses for the non-fatal events, the impact is likely minimal on the study results. We had a brief discussion about intention-to-treat (ITT) analysis and how loss to follow-up can affect the analysis, and how ITT is different from per-protocol analysis. We agreed that there is no arguing that multivitamins are important when nutritional requirements are not met through diet alone (for example, if there is a nutritional deficit), but, if in the absence of clinically important deficits, then multivitamins might very well pose an unnecessary financial burden and health expenditure.

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ACHORD Seen and Heard

Recent Publications

Boisvenue JJ, Oliva CU, Manca DP, Johnson JA, Yeung RO. Feasibility of identifying and describing the burden of early-onset metabolic syndrome in primary care electronic medical record data: a cross-sectional analysis. CMAJ Open 2020;8(4):e779-e787. PMID: 33234585

Campbell SA, Light PE, Simpson SH. Costarting sitagliptin with metformin is associated with a lower likelihood of disease progression in newly treated people with type 2 diabetes: a cohort study. Diabet Med 2020;37(10):1715-1722. PMID: 31618475

Diabetes Canada Clinical Practice Guidelines Expert Committee, Lipscombe L, Butalia S, Dasgupta K, Eurich DT, MacCallum L, Shah BR, Simpson S, Senior PA. Pharmacologic Glycemic Management of Type 2 Diabetes in Adults: 2020 Update. Can J Diabetes 2020;44(7):575-591. PMID: 32972640

Dubois TB, Simpson SH, Eurich DT. Time to Treatment Intensification in Newly Treated Adult Type 2 Diabetes Patients: Comparison of Canada and the United States. Can J Diabetes 2020;44(4):312-316. PMID: 31831258

Hall JJ, Eurich DT, Nagy D, Tjosvold L, Gamble JM. Thiazide Diuretic-Induced Change in Fasting Plasma Glucose: a Meta-analysis of Randomized Clinical Trials. J Gen Intern Med 2020;35(6):1849-1860. PMID: 32157653

Mazaroff S, Veugelers PJ, Dabravolskaj J, Eurich DT, Ye M, Maximova K. Diet Quality and Health Service Utilization for Depression: A Prospective Investigation of Adults in Alberta’s Tomorrow Project. Nutrients 2020;12(8):2437. PMID: 32823652

Necyk C, Johnson JA, Minhas-Sandhu J, Tsuyuki RT, Eurich DT. Evaluation of comprehensive annual care plans by pharmacists in Alberta for patients with complex conditions. J Am Pharm Assoc (2003) 2020;60(6):1029-1036. PMID: 32962900

Soprovich AL, Seaton CL, Bottorff JL, Duncan MJ, Caperchione CM, Oliffe JL, James C, Rice S, Tjosvold L, Eurich DT, Johnson ST. A systematic review of workplace behavioral interventions to promote sleep in men. Sleep Health 2020;6(3):418-430. PMID: 32461158

Thomas S, Johnson JA, Xie F. 3125 steps to perfect health: a nonparametric approach to developing the EQ-5D-5L value set. Qual Life Res 2020;29(11):3109-3118. PMID: 32705459

Meeting Presentations and Invited Talks

Eurich DT. Edmonton zone makes up almost 66% of new COVID-19 cases in Alberta, experts plead for public health measures to be followed. Global News. August 19, 2020.

Eurich DT. Hockey Edmonton prepares for return to play under COVID-19 pandemic. CBC News August 22, 2020.

Eurich DT. Second wave hasn't arrived in Alberta yet, epidemiologists say, but surge likely coming. Calgary Herald, September 24, 2020.

Eurich DT. Edmonton docs describe hospital horrors — and Calgary counterpart says city is next. Calgary Herald, November 21, 2020.

Eurich DT. Alberta logs record-high 1,336 COVID-19 cases; One per cent of Albertans have now tested positive. Calgary Herald, November 22, 2020.

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ACHORD Accolades

Congratulations to:

▪ Nathan McClure on successful completion of his PhD.
▪ Jiabi Wen on successful completion of her MSc.
▪ Candace Necyk on successful completion of her PhD.
Nathan McClure on successful completion of his PhD.
Jiabi Wen on successful completion of her MSc.
Candace Necyk on successful completion of her PhD.

Other ACHORD News

Congratulations to Nathan McClure on his marriage to Lindsay McInnes in August.

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ACHORD
University of Alberta
2-040 Li Ka Shing CHRI
Edmonton, AB T6G 2E1
email: achord@ualberta.ca
Phone: 780-248-1010

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