Impacts of Alternative Billing Claims on Hypertension Prevalence and Mortality Estimates in Alberta, Canada IJPDS (2017) Issue 1, Vol 1:357 Proceedings of the IPDLN Conference (August 2016)

Main Article Content

Ceara Tess Cunningham
Hude Quan
Nathalie Jette
Guanmin Chen
Published online: Apr 19, 2017


In Canada, secondary sources of health information such as physician billing claims are used for surveillance of chronic conditions such as hypertension. The value of this data may be affected by different types of physician payment models. Fee-for-service (FFS) physicians submit billing claims in order to be remunerated whereas physicians on salary or capitation also called alternative payment plans (APP) are remunerated regardless of whether claims are submitted. Thus there are concerns nationally that APPs may be associated with decreased frequency of billing submission, thereby eroding data quality and leading to underestimates of disease burdens and outcomes. We assessed the impact of APPs on hypertension prevalence, mortality and cardiovascular (CVD) hospitalization in Alberta.

The following health administrative databases from Alberta, Canada were used in this study: 1) Alberta Health Care Insurance Plan registry; 2) Hospital Discharge Abstract database (DAD); 3) Physician claims data and; 4) Vital Statistics database. We defined patients with hypertension aged 20 years and older between April 1, 2004 and March 31, 2009 (fiscal years 2004 to 2009) based on previously validated algorithm. Cases were then sorted into FFS and non-FFS billing status. Descriptive statistics for age group, sex, income quintile, rural/urban geographical location, death status and comorbidities were reported between the shadow billing and non-shadow billing groups in regards to prevalence, all-cause mortality and CVD hospitalizations.

A total of 613, 844 adult hypertensive cases were captured during the 5 year study period. The majority of hypertension cases (99.6%, n=610,167) were identified through FFS claims. The effect of non-FFS billing estimates represented a small proportion of hypertension cases (0.40%, n=3677) identified during the study period. Among the FFS claims, overall hypertension prevalence was 22.2% (n=610167) and the effect of non-FFS billing estimates (0.13%, n=3677) on prevalence estimates was relatively minor. All-cause mortality 33.8 (95% CI 33.6-34) and CVD 40.6 (40.4-40.9) were higher for FFS cases than non-FFS cases 19.0 (16.6-21.8) and CVD: 8.0 (6.4-9.8).

During the study time period, the impact of non-FFS (i.e. shadow billings) on physician claims may not have impacted hypertension prevalence estimates greatly. Since Alberta uses shadow billing incentive programs, future research is needed to determine whether incentive programs should be considered in other provinces or nationally in order to preserve the overall quality of physician claims data.


This talk unpacks the culture of caution surrounding the use and sharing of administrative data in the UK and suggests the adoption of the authors' novel decision-making tool and organisational strategy based on the public interest, to achieve good governance. Administrative data, which implicate all public sector data, are in constant demand -to be shared for `joined-up' services, used as evidence in Government inquiries and for research purposes. These demands are often made on the basis that they serve `the public interest' but public authorities are without the decision-making tools to make proportionate decisions outwith narrow and risk-averse interpretations of legal requirements. Public authorities are operating within a `culture of caution', fuelled by misperceptions of what the law does or does not require for data to be used/shared `in the public interest'; uncertainties regarding incentives for data sharing; perceived controversies if something `goes wrong'; and imbalanced assessment of risks without robust assessment of potential public interests to be served or the potential `harm' from not sharing data.


This discussion is substantiated by reference to major contributions to this field (e.g. Law Commission Report on data sharing in 2014; Thomas and Walport's data sharing review in 2008 etc.) and to the authors' engagement with the administrative data community as part of the legal work package to the Administrative Data Research Centre Scotland.


The research reveals that public authorities exhibit extreme hesitance to undertake data sharing initiatives for reasons including:

  • misperceptions of the law (due to legal complexity, lack of legal precedent and authoritative guidance on data sharing)

  • lack of resources and expertise to manage increasing demands to use/share data

  • individuals fear reprisal if something `goes wrong' with data handling

  • senior-management fear public backlash for new uses of data and organisational reputational damage

  • no understanding of the incentives to share data if there is no `direct' benefit to the public authority in question.


We conclude by focussing on how to overcome the culture of caution, to one of confidence. We suggest the adoption of our decision-making matrix to help data custodians distinguish between real versus perceived barriers to data sharing (i.e. dispelling legal myths and identifying areas where changes can be made). We also introduce strategic solutions in our public interest mandate which entails overt commitment to use public sector data when it is in the public interest to do so.

Article Details

Most read articles by the same author(s)

1 2 3 4 > >>