Neuropathic Pain in a Primary Care Electronic Medical Record Database

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1 Centre for Studies in Family Medicine Neuropathic Pain in a Primary Care Electronic Medical Record Database Looking for a Condition not Coded in ICD or ICPC Joshua Shadd, MD CCFP Heather Maddocks, PhD Candidate Scott McKay, MD CCFP Bridget L. Ryan, PhD Post-doctoral fellowship through the Dr. Brian W. Gilbert Canada Research Chair.

2 The DELPHI Database Deliver Primary Healthcare Information* Electronic Medical Records (EMRs) 10 Practice Sites 25 Family Physicians 30,000 + patients Inception October 2005 * DELPHI is funded by the Canada Foundation for Innovation and the Primary Health Care Transition Fund.

3 Neuropathic Pain Pain resulting from damage to or dysfunction of the nervous system Many causes (e.g. diabetic polyneuropathy, postherpetic neuralgia, sciatica) Estimated population prevalence: 2-3%

4 Neuropathic Pain Diagnostic Coding -- Neuropathic Pain is not directly coded International Classification of Diseases (ICD) all patients International Classification for Primary Care (ICPC) 10% subsample of patients Medications Distinct pharmacotherapeutic treatments

5 Finding Patients with Neuropathic Pain Possible Inclusion Diagnosis (e.g. diabetes) Medication (e.g. amitriptyline) Exclusion Diagnosis - Other indication For medication (e.g. depression)

6 Determining Prevalence in an EMR Prevalence = # patients with NeP population at risk within a defined timeframe Can we determine the period prevalence of neuropathic pain in the DELPHI database? What kinds of judgments are involved in making this calculation?

7 Defining Population at Risk Pt 6 Pt 5 Pt 4 Pt 3 Pt 2 Pt 1 October 2005 December 2010 Prevalence = # patients with NeP population at risk within a defined timeframe

8 Defining Population at Risk Pt 6 Pt 5 Pt 4 Pt 3 Pt 2 Pt 1 October 2005 December 2010 How long is our defined timeframe? 24 m.

9 Defining Population at Risk Pt 6 Pt 5 Pt 4 Pt 3 Pt 2 Pt 1 October 2005 December 2010 How do we ensure equal exposure?

10 Defining Population at Risk Pt 6 Pt 5 Pt 4 Pt 3 Pt 2 Pt 1 October 2005 December 2007 December 2008 December 2010 Do we want a recent cohort? Yes

11 Defining Population at Risk Pt 6 Pt 5 Pt 4 Pt 3 Pt 2 Pt 1 October 2005 December 2007 December 2008 December 2010 How many visits are needed to enter the relevant information in the EMR? 2

12 Defining Population at Risk Pt 6 Pt 5 Pt 4 Pt 3 Pt 2 Pt 1 October 2005 December 2007 December 2008 December 2010 Adults with >1 office visit between Dec 2007 and Dec 2008 AND >2 visits before end of 24 month exposure window

13 Narrow Window Pt 6 Pt 5 Pt 4 Pt 3 Pt 2 Pt 1 October 2005 December 2007 December 2008 December 2010 Pt 1: Medications & Inclusion Diagnoses All Patients: Exclusion Diagnoses Conservative Assumptions: - inclusion diagnoses time-limited - exclusion diagnoses chronic

14 Broad Window Pt 6 Pt 5 Pt 4 Pt 3 Pt 2 Pt 1 October 2005 December 2010 Medications, Inclusion Diagnoses, Exclusion Diagnoses Liberal assumuption: - all inclusion & exclusion diagnoses are chronic

15 Population at Risk Cohorts All Patients ICD coding 10% Subset Both ICPC and ICD coding Broad Window 27,059 3,152 Narrow Window 19,196 2,801

16 Conclusions The appropriate denominator in PHC EMR studies depends on the question. Numerous judgments on the part of the researchers are necessary in constructing the research cohort. As in all research, interpreting findings from PHC EMR studies requires understanding the population for that particular study.

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