Canadian Chronic Disease Surveillance System:
Summary of methods

On this page

• Background
• Diseases and conditions
• Definitions of terms
• Data procedures
• Formulae used for calculation of prevalence, incidence and all-cause mortality
• Provincial and territorial notes

Background

The Canadian Chronic Disease Surveillance System (CCDSS) is a collaborative network of provincial and territorial surveillance systems supported by the Public Health Agency of Canada (PHAC).

In each province and territory, the health insurance registry database is linked to the physician billing and hospitalization databases using the health card number as a unique personal identifier. Where available and specified by the case definition, data from the prescription drug databases are also linked.

Case definitions are applied to these linked databases to identify individuals with chronic diseases/conditions, and aggregate data are sent to PHAC. The aggregate data are used by PHAC to estimate chronic disease/condition incidence, prevalence, all-cause mortality and use of health services.

The start year for reporting CCDSS data varies by disease/condition. The determination of the first reported year aims to allow enough time to capture all prevalent cases, given the parameters of the disease/condition specific case definition, and to ensure previously prevalent cases are excluded from incident cases.

Diseases and conditions

In the current edition of the CCDSS Data Tool, data up to 2020–2021 are reported for the following diseases/conditions:

Cardiovascular diseases

• acute myocardial infarction
• heart failure
• hypertension, excluding gestational hypertension
• ischemic heart disease
• stroke
• hospitalized stroke

Chronic respiratory diseases

• asthma
• chronic obstructive pulmonary disease

Diabetes

• diabetes mellitus (types combined), excluding gestational diabetes

Mental illnesses

• use of health services for mental illness and alcohol/drug induced disorders
• use of health services for mood and anxiety disorders
• use of health services for schizophrenia
• schizophrenia

Musculoskeletal disorders

• use of health services for arthritis
• gout and other crystal arthropathies
• juvenile idiopathic arthritis
• osteoarthritis
• rheumatoid arthritis
• osteoporosis
• osteoporosis-related fractures (any fracture, forearm, hip, humerus, pelvic, spine)
• osteoporosis-related fracture care gap (diagnosis, bone mineral density test, prescribed medication)

Neurological conditions

• dementia, including Alzheimer disease
• epilepsy
• multiple sclerosis
• parkinsonism, including Parkinson disease

Multimorbidity

• two or more of the selected CCDSS chronic conditions (see multimorbidity)
• three or more of the selected CCDSS chronic conditions (see multimorbidity)

Definitions of terms

Age-specific estimate/rate: The incidence, prevalence and all-cause mortality estimates/rates are calculated for a five-year age group or a life-course age group (i.e., 1-19, 20-34, 35-49, 50-64, 65-79, 80+), using counts randomly rounded either up or down to an adjacent multiple of 5 (see random rounding). Data by five-year age groups are reported at the national level only.

Age-standardized estimate/rate: The incidence, prevalence and all-cause mortality estimates/rates age-standardized to the 2011 Canadian population to adjust for differences in population age structure, are calculated using unrounded counts and five-year age groups.

Case definition: CCDSS disease/condition-specific case definitions are applied to identify individuals with the disease/condition (cases). The specific criteria used to identify the disease/condition, including the codes from the 9th or 10th edition of the International Classification of Disease (ICD), the Canadian Classification of Health Interventions (CCI), the Canadian Classification of Diagnostic, Therapeutic and Surgical Procedures (CCP), and the Drug Identification Numbers (DINs), are listed in the CCDSS case definitions documentation.

Coefficient of variation (CV): A measure used to describe the precision of an estimate/rate. More specifically, the CV of an estimate/rate is the ratio of the standard error of the estimate/rate to the estimate/rate itself. Estimates/rates with a CV between 16.6% and 33.3% should be interpreted with caution and those with a CV greater than 33.3% are not reported (see data quality).

Confidence interval (CI): A statistical measurement of the reliability of an estimate/rate. The size of the CI relates to the precision of the estimate/rate, with narrow CIs indicating greater precision than those that are wide. The 95% CI shows an estimated range of values that is likely to include the true value 19 times out of 20.

Crude estimate/rate: The incidence, prevalence and all-cause-mortality estimates/rates are calculated using counts randomly rounded either up or down to an adjacent multiple of 5 (see random rounding).

Fiscal year: The CCDSS data are reported by fiscal year, April 1 to March 31.

Incidence rate: The number of new cases of a disease/condition occurring in a given time period in a population at risk, expressed as a rate.

Life-course age groups: The sequence of age categories individuals pass through as they age from childhood to older adult. The categories used in the CCDSS data tool are: 1-19, 20-34, 35-49, 50-64, 65-79, 80+.

Mortality (all-cause) rate: The number of deaths from any cause occurring in a given time period in a population, expressed as a rate.

Mortality (all-cause) rate ratio: The all-cause mortality rate among individuals with the disease/condition (cases) divided by the all-cause mortality rate among individuals without the disease/condition (non-cases). In the CCDSS data tool, these rates are age-standardized to account for the different age distribution between cases and non-cases. A rate ratio greater than one indicates that cases experience a higher mortality burden compared to non-cases, regardless of the cause of death. Assuming the baseline age-standardized mortality rates between cases and non-cases are similar, the difference in all-cause mortality can be attributed directly or indirectly to the disease/condition.

Multimorbidity: Multimorbidity refers to the concurrent presence of two or more independent chronic medical conditions within an individual. As a chronic condition surveillance indicator, it involves tracking the prevalence and patterns of multiple chronic conditions within a population over time. The list of selected CCDSS chronic conditions in the multimorbidity estimates includes asthma, chronic obstructive pulmonary disease, dementia (including Alzheimer disease), diabetes (types combined, excluding gestational diabetes), epilepsy, gout and other crystal arthropathies, heart failure, hypertension (excluding gestational hypertension), ischemic heart disease, multiple sclerosis, osteoarthritis, osteoporosis, parkinsonism (including Parkinson disease), rheumatoid arthritis, schizophrenia, and stroke.

Prevalence estimate: The number of cases of a disease/condition present in a given time period in a population, expressed as a proportion. In the CCDSS data tool, prevalence may be reported over three different periods: annual (cases identified during one year), cumulative (cases identified during the capture period) and active (a subset of cumulative prevalence cases that meet the active prevalence criteria).

Standard error (SE): A statistical measure of the degree of variation of an estimate/rate. The size of the SE relates to the precision of the estimate/rate, with a smaller SE suggesting better precision. The SE is used to calculate the confidence intervals associated with an estimate/rate.

Data procedures

Before estimates/rates are calculated, the following data procedures are applied.

Age group aggregation for age-specific estimates/rates

The data submitted by provinces and territories by five-year age groups are aggregated using the following life-course age groups: 1-19, 20-34, 35-49, 50-64, 65-79 and 80+ with a few exceptions:

• For parkinsonism including Parkinson disease, osteoporosis, osteoporosis-related fractures and heart failure, the first age group is 40-49;
• For schizophrenia, the first age group is 10-19;
• For rheumatoid arthritis, the first age group is 16-34; and
• For juvenile idiopathic arthritis, only one age group is used, i.e. 0-15;
• For multimorbidity, a hybrid age group approach is used, with lifetime age groups used between 35 and 64, and five-year age groups used for 65+.

Confidentiality

Two different procedures are used to ensure data confidentiality and avoid residual disclosure:

• Data suppression
Estimates, rates and rate ratios are not reported if the corresponding unrounded counts are less than 10. Note that all provincial/territorial unrounded counts, whether suppressed or not, are part of the total counts used to produce Canadian estimates, rates and rate ratios.
• Random rounding
All provincial/territorial and Canadian counts of 10 or greater are randomly rounded up or down to an adjacent multiple of 5. The Canadian counts are obtained by summing unrounded provincial/territorial counts prior to random rounding. Random rounding is used only to calculate crude estimates/rates. Age-standardized estimates/rates are based on unrounded counts.

Data quality

The estimates, rates and rate ratios with a coefficient of variation exceeding 33.3% are suppressed to ensure that the provincial/territorial data are of acceptable quality.

Formulae used for calculation of prevalence, incidence and all-cause mortality

Prevalence estimate

Annual prevalence	$$\begin{gathered} {\displaystyle \frac{{\mathrm{Total\; number\; of\; individuals\; meeting\; annual} \\ \mathrm{case\; definition\; during\; the\; fiscal\; year}& }_{}^{}}{{\mathrm{Total\; number\; of\; individuals\; with\; valid} \\ \mathrm{health\; insurance\; during\; the\; fiscal\; year}& }_{}^{}}\times \mathrm{100\; or\; 100,000\; for\; osteoporosis-related} \\ \mathrm{fractures\; and\; hospitalized\; stroke\; events}} \end{gathered}$$
Cumulative prevalence	$$\begin{gathered} {\displaystyle \frac{{\mathrm{Total\; number\; of\; individuals\; who\; met\; the\; case\; definition\; during} \\ \mathrm{the\; capture\; period\; and\; who\; are\; alive\; during\; the\; fiscal\; year}& }_{}^{}}{{\mathrm{Total\; number\; of\; individuals\; with\; valid} \\ \mathrm{health\; insurance\; during\; the\; fiscal\; year}& }_{}^{}}\times \mathrm{100}} \end{gathered}$$
Active prevalence	Specific to epilepsy and, gout and other crystal arthropathies: $$\begin{gathered} {\displaystyle \frac{{\mathrm{Total\; number\; of\; individuals\; who\; met\; the\; active\; case\; definition\; during} \\ \mathrm{the\; capture\; period\; and\; who\; are\; alive\; during\; the\; fiscal\; year}& }_{}^{}}{{\mathrm{Total\; number\; of\; individuals\; with\; valid} \\ \mathrm{health\; insurance\; during\; the\; fiscal\; year}& }_{}^{}}\times \mathrm{100}} \end{gathered}$$
	Specific to asthma: $$\begin{gathered} {\displaystyle \frac{{\mathrm{Total\; number\; of\; individuals\; who\; met\; the\; active\; case\; definition\; during} \\ \mathrm{the\; capture\; period\; and\; who\; are\; alive\; during\; the\; fiscal\; year}& }_{}^{}}{{\mathrm{Total\; number\; of\; cumulative\; prevalence} \\ \mathrm{cases\; meeting\; condition\; case\; definition}& }_{}^{}}\times \mathrm{100}} \end{gathered}$$

Incidence rate

Incidence rate	$$\begin{gathered} {\displaystyle \frac{{\mathrm{Total\; number\; of\; incident\; cases\; during\; the\; fiscal\; year}& }_{}^{}}{{\mathrm{Total\; number\; of\; individuals\; with\; valid\; health\; insurance} \\ \mathrm{during\; the\; fiscal\; year\; –\; prevalent\; cases\; +\; incident\; cases}& }_{}^{}}\times \mathrm{100,000}} \end{gathered}$$

Mortality (all-cause) rates and rate ratio

Mortality (all-cause) rate with the disease/condition	$$\begin{gathered} {\displaystyle \frac{{\mathrm{Total\; number\; of\; deaths\; from\; all\; causes\; during\; the\; fiscal} \\ \mathrm{year\; among\; individuals }\mathrm{with}\mathrm{ the\; disease/condition}& }_{}^{}}{{\mathrm{Total\; number\; of\; individuals }\mathrm{with}\mathrm{ the} \\ \mathrm{disease/condition\; during\; the\; fiscal\; year}& }_{}^{}}\times \mathrm{100,000\; or\; 1,000} \\ \mathrm{for\; hip\; fracture}} \end{gathered}$$
Mortality (all-cause) rate without the disease/condition	$$\begin{gathered} {\displaystyle \frac{{\mathrm{Total\; number\; of\; deaths\; from\; all\; causes\; during\; the\; fiscal} \\ \mathrm{year\; among\; individuals }\mathrm{without}\mathrm{ the\; disease/condition}& }_{}^{}}{{\mathrm{Total\; number\; of\; individuals }\mathrm{without}\mathrm{ the} \\ \mathrm{disease/condition\; during\; the\; fiscal\; year}& }_{}^{}}\times \mathrm{100,000\; or\; 1,000} \\ \mathrm{for\; hip\; fracture}} \end{gathered}$$
Rate ratio of mortality (all-cause) rates	$$\begin{gathered} {\displaystyle \frac{{\mathrm{All-cause\; mortality\; rate\; among} \\ \mathrm{individuals }\mathrm{with}\mathrm{ the\; disease/condition}& }_{}^{}}{{\mathrm{All-cause\; mortality\; rate\; among} \\ \mathrm{individuals }\mathrm{without}\mathrm{ the\; disease/condition}& }_{}^{}}} \end{gathered}$$

Provincial and territorial notes

• Manitoba: Mortality data for 2021-2022 are excluded.
• New Brunswick: Data for 2021-2022 are not available.
• Newfoundland and Labrador: Data before 2008–2009 are excluded.
• Northwest Territories: Only hospital data are included. Data are only available for acute myocardial infarction, hospitalized stroke and hip fracture.
• Nunavut: Data before 2005–2006 are excluded.
• Quebec: Data cells with counts smaller than 5 were suppressed by Quebec and substituted with random numbers (1-4) by PHAC. As a result, age-specific incidence and mortality rates may be randomly over or under estimated.
  The modernization of the billing system for fee-for-service medical services by the Régie de l'assurance maladie du Québec (RAMQ) in 2016 has resulted in a decrease in the entry of diagnostic codes in the fee-for-service medical services file. Data for 2016–2017 and subsequent years should therefore be interpreted with caution, as a slight underestimation is suspected.
• Saskatchewan: Data for 2021-2022 are not available.
• Yukon: Data before 2010–2011 are excluded.

Note: For more information on the interpretation of the data for specific diseases/conditions please see the CCDSS case definitions documentation and the data tool notes.