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Validating abortion procedure coding in Canadian administrative databases Samiedaluie, Saied; Peterson, Sandra; Brant, Rollin; Kaczorowski, Janusz; Norman, Wendy V Jul 12, 2016

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RESEARCH ARTICLE Open AccessValidating abortion procedure coding inCanadian administrative databasesSaied Samiedaluie1*, Sandra Peterson2, Rollin Brant3, Janusz Kaczorowski4 and Wendy V. Norman1AbstractBackground: The British Columbia (BC) Ministry of Health collects abortion procedure data in the Medical ServicesPlan (MSP) physician billings database and in the hospital information Discharge Abstracts Database (DAD). Ourstudy seeks to validate abortion procedure coding in these databases.Methods: Two randomized controlled trials enrolled a cohort of 1031 women undergoing abortion. The researchercollected database includes both enrollment and follow up chart review data. The study cohort was linked to MSPand DAD data to identify all abortions events captured in the administrative databases. We compared clinical chartdata on abortion procedures with health administrative data. We considered a match to occur if an abortion relatedcode was found in administrative data within 30 days of the date of the same event documented in a clinical chart.Results: Among 1158 abortion events performed during enrollment and follow-up period, 99.1 % were found in atleast one of the administrative data sources. The sensitivities for the two databases, evaluated using a gold standard,were 97.7 % (95 % confidence interval (CI): 96.6–98.5) for the MSP database and 91.9 % (95 % CI: 90.0–93.4) for the DAD.Conclusions: Abortion events coded in the BC health administrative databases are highly accurate. Single-payer healthadministrative databases at the provincial level in Canada have the potential to offer valid data reflecting abortionevents.Trial registration: ClinicalTrials.gov Identifier NCT01174225, Current Controlled Trials ISRCTN19506752.Keywords: Induced abortion, Clinical coding, Database, Data collection, Reproducibility of results, British ColumbiaBackgroundAccurate capture of abortion events within administrativedata is important for both population health surveillanceand for policy and program planning and evaluation. Abor-tion is a common procedure in Canada, with 92,524 re-ported in 2011 including 14,341 in the province of BritishColumbia (BC), and 37 % of women seeking a hospital-provided abortion in 2011 reporting having had at least oneprior abortion [1]. Interventions that assist women present-ing for an abortion to avoid subsequent unintended preg-nancies have the potential to address this problem, yetclinical follow up post-abortion has a very high attritionrate. Health administrative data could potentially be used totest the effectiveness of health policies and programs withpotential to impact the number of abortions performed.However, we were unable to find any evidence that thevalidity of the data capture of these events within a single-payer health administrative data system in Canada has everbeen documented.Observation of outcomes after an index abortion pre-sents unique challenges, due to very low rates of returnfor clinical follow up post abortion [2, 3]. Failure to re-turn for follow up is frequently associated with lower so-cioeconomic status, of particular concern as women oflow socioeconomic status are over-represented amongthe population presenting for abortion, and particularlyfor repeat abortion [2, 4, 5]. Comprehensive chart reviewamong all clinical services offering abortion within a jur-isdiction, while theoretically possible, is time-consuming,costly and impeded by the wide range of medical recordsystems used. Further, chart audit methodology is likelyto decline in accuracy due to the recent approval inCanada of mifepristone (RU-486) for use to induce med-ical abortion, which may be performed in a wide range* Correspondence: samiedal@mail.ubc.ca1Department of Family Practice, University of British Columbia, Vancouver,CanadaFull list of author information is available at the end of the article© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Samiedaluie et al. BMC Health Services Research  (2016) 16:255 DOI 10.1186/s12913-016-1485-4of primary care settings otherwise unrelated to settingsself-identifying as abortion clinics [6].Capture of abortion events using health administrativedata has the potential to provide comprehensive data onboth numbers and rates of abortion in relation to a widerange of determinants, as well as in relation to subse-quent health system events. Administrative data capturecould be associated with lower costs than chart reviewand with greater accuracy for subsequent events than clin-ical follow up. Administrative databases have the addedadvantage of allowing for extraction of additional informa-tion, such as delivery outcomes and hospitalization re-cords, which could be of value to inform health policy andsystem decision making.The accuracy of using health administrative data to cap-ture abortion events is currently unknown as no validationof abortion procedure capture and coding in administra-tive data compared to verified clinical records has beenundertaken. Previous Canadian studies on administrativedata capture have shown the validity of administrativecoding for cardiac and perinatal procedures [7–9]. Basedon these results, we anticipate a high degree of accuracyin administrative coding for abortions.We conducted two randomized controlled trials (RCTs)enrolling over a thousand women presenting for abortionin BC [5, 10–12]. We followed up each participantthrough the review of clinical chart records from all sixabortion clinic facilities in BC for both index and subse-quent abortions. We examined the analogous data foreach participant as captured through the provincial healthadministrative linked databases of Population Data BC,and the BC Ministry of Health [13–16]. By comparingthese different data sources, we evaluated the validity ofusing health administrative data to capture abortionevents among residents of BC registered in the provincialhealth system.MethodsStudy dataFrom 2009 to 2012, two RCTs studying the effectivenessof intrauterine contraceptive devices enrolled a cohort of1031 women presenting for surgical abortion at BCclinics [5, 10–12]. Women were screened using the eligi-bility criteria of the studies. Two main conditions forbeing eligible to participate were the intention not toconceive within the subsequent year and current registra-tion with the BC provincial health plan (Medical ServicesPlan). Over three years, the two studies recruited 530women undergoing a first trimester abortion and 501women undergoing a second trimester abortion. Studieswere carried out in five BC surgical abortion clinics, ofwhich two are hospital-based and three are in the commu-nity setting. Chart review was conducted at these fiveclinics, as well as at an additional community based clinicwhich offers only medical abortion, to capture subsequentevents among enrolled participants.Women enrolling in the study gave consent for follow upclinically and through linkages using health administrativedata, as well as through the completion of annual question-naires. The participants were followed subsequently for fiveyears including by an annual chart review at all six abortionclinics in BC. The chart review data set, including initial en-rollment data as well as direct confirmation of individual ini-tial and subsequent clinical events whenever it was required,constitutes the researcher-collected database for this study.The trials were conducted under the supervision of anindependent Data and Safety Monitoring Board. Ethicsapproval for the trials, including the current secondaryanalysis, was obtained from the University of BritishColumbia- Children’s and Women’s Hospital ResearchEthics Board (REB) (H10-00306, H10-00798) and fromthe analogous REBs for all health authorities with studysites. Both study protocols, and the intake cohort char-acteristics for one RCT, have been published [5, 10–12].Administrative dataIn BC, administrative data relevant to abortion care arecaptured through diagnostic and procedural coding forfees billed by physicians in the Medical Services Plan(MSP) Payment Information database, and diagnostic andprocedural coding at hospital discharge in the DischargeAbstracts Database (DAD). There are several researchconducted based on the data captures in these databases[17–22]. Different characteristics of MSP and DAD data-bases are described in Table 1. Abortions are identified inthe MSP data with ICD-9 codes 635.x-638.x, and fee itemcodes 4110-4114, 14545, and, if performed in known abor-tion facilities by physicians consistently coded as providingabortion services, the induction of abortion is indicated bythe code 0787 [23]. In the hospital DAD data abortions areidentified with ICD-10-CA code O04 and CCI procedureTable 1 Characteristics of administrative database capturingabortions data in BCCharacteristic Medical Services Plan (MSP)Payment InformationDischarge AbstractDatabaseCoverage Individuals covered by theMedical Services Plan(MSP), BC’s universalinsurance programIn-patients and day surgerypatients in acute carehospitals in BCData Billing information for allmedically required services(both procedure anddiagnostic codes)Data on discharges,transfers and deathsProvided by Fee-for-service practitioners Acute care hospitalsAbortioncodesICD-9 codes 635.x-638.x ICD-10-CA code O04fee item codes4110-4114, 14545CCI procedure codesbeginning with 5CA.code 0787Samiedaluie et al. BMC Health Services Research  (2016) 16:255 Page 2 of 6codes beginning with 5CA. We analyzed MSP coding forfee items related to abortion procedures (i.e., 17B: consultfor abortion) to investigate procedures that were missingcodes or were in unexpected date ranges.The study cohort was linked to the administrative datain 2014 using personal health numbers (PHN) and date ofbirth as unique patient identifiers. Administrative data forall index and subsequent abortion procedures occurringfor the study cohort between June 1, 2009 and September30, 2013 were captured. We required the women’s consentduring enrollment to perform this data linkage as theabortion data in these two health databases is not publiclyavailable. Using hospital and anonymous physician codes,we excluded, for the purposes of this comparison, any pro-cedures that did not occur at the six clinics for which wehad access to clinical charts.AnalysisThere are two sets of abortions events in our studythat we can use to validate the procedure coding ofabortions; the index abortions, occurring at the time ofenrollment in either of the two RCTs; and the subsequentabortions, which occurred within the 5-year follow uptimeline. All discrepancies between data sources were in-vestigated through chart review at the relevant facility.When comparing the administrative data with theresearcher-collected medical chart data, we consideredan abortion event to be matched if an abortion proced-ure code exists in the relevant administrative data sourcewith a date that is accurate within ±30 days compared tothe researcher-collected data. In cases with multiple abor-tion related procedural codes within a window of 30 days,we assumed it to be a single abortion event, an assump-tion that was universally supported by review of chartdata. A common observation in the MSP data was thepresence of abortion-related diagnostic codes (such as atthe time of provision of consultation, follow up, or com-plications) in the absence of an abortion procedure code.We examined these cases but once all inconsistencieswere resolved through specific clinical chart confirmation,we were able to restrict our consideration to cases with anabortion procedural code for the purpose of matching be-tween databases.We report discrepancies and the source, if known, oferrors or omissions in the administrative data. In the ana-lysis of index abortions, sensitivity is defined as the ratioof correct matches of the administrative data with theresearcher-collected medical chart data. Since the abor-tions are recorded in two administrative databases in BC,we provide the sensitivity statistics for each data sourceseparately as well as for the two databases combined.In the analysis of subsequent abortions, we found abor-tions performed at study related facilities identified in ad-ministrative data that were not present in researcher-collected data. Therefore, for this cohort of abortions weconduct a two-direction analysis to measure the numberof matched events in the administrative and researcher-collected databases. When reporting the results of ourcomparisons, we also include the exact binomial confi-dence intervals calculated using the Clopper-Pearsonmethod. All the statistical analysis in this paper was con-ducted using the statistical software R.ResultsWe present the results of our analysis for index abortionevents separately from our consideration of subsequentabortion events.Index abortionsThere were 1031 women enrolled in our studies. Out ofthe 1031 index abortions that were registered in ourresearcher-collected database, 1022 events (99.1 %, 95 %confidence interval (CI): 98.3–99.6) were matched in atleast one of the two administrative data sources, and 932(90.4 %, 95 % CI: 88.4–92.1) were found in both. Therewere nine cases that did not match to any MSP or DADdata (all cases conducted at a non-hospital setting). Over-all, the MSP data correctly captured 1007 of 1031 events(97.7 %) and the DAD captured 947 (91.9 %). Among the24 abortion events that were not found in the MSP,abortion-related codes (such as consultation or follow up)were present for 13 of them. Moreover, we found twocases where MSP procedure codes had been submittedtwice for the same procedure. Figure 1 shows the numberFig. 1 Number of the index abortions found in different datasources. Legend: RCD = Research Collected Database, MSP = MedicalService Plan Payment Database, DAD = Discharge Abstract DatabaseSamiedaluie et al. BMC Health Services Research  (2016) 16:255 Page 3 of 6of index abortions in the researcher-collected databasematched in the administrative datasets.Table 2 shows the sensitivity of the two administrativedata sources and the combination of the two (eventsthat were correctly matched in at least one of the twodatabases) for the index abortions. The comparative sen-sitivities are 97.7 % (95 % CI: 96.6–98.5) for the MSPdata and 91.9 % (95 % CI: 90.0–93.4) for the DAD. Thedifference in sensitivity between MSP and DAD data isstatistically significant for the index abortions. When thetwo administrative data sources are used together foridentifying the index abortion procedures, the relativesensitivity to the gold standard (researcher-collecteddata) is 99.1 % (95 % CI: 98.3–99.6).Subsequent abortionsThere were 125 subsequent abortions found in theresearcher-collected data within the time-frame of thisanalysis, out of which 124 events were matched in at leastone of the administrative data sources. However, over thesame time period, there were two abortions that wereidentified in the administrative databases but were notcaptured by the researcher collected medical chart reviewdatabase. Therefore, a total of 127 abortion events haveoccurred which are confirmed by at least one of the avail-able data sources. There were also two abortion proce-dures found in the DAD that did not reflect actualabortion procedures, as confirmed through review of theclinical charts. Table 3 shows the number of subsequentabortions found in each of the administrative data andresearch-collected data sources and the number of eventsthat were matched by the other database.Event date differenceOf all index and subsequent abortions matched within our30 day window (1146 events), 99.1 % (95 % CI: 98.4–99.6)had the same date in researcher-collected and administra-tive data sources and 99.6 % (95 % CI: 99.0–99.9) werediscrepant by one day or less. Table 4 provides additionaldetail of this date comparison. The majority of the datediscrepancies occurred in cases where the abortion pro-cedure was conducted over multiple days.DiscussionThis is the first study to examine the validity of adminis-trative data capture of abortion procedure events inCanada. We found a high degree of accuracy, with over99 % of procedures being correctly identified by at leastone of the two administrative databases.While the two administrative data sources combinedhad a high sensitivity (99.1 %), there was a significantdifference in the concordance rates between the MSPand DAD for the index and subsequent abortion events.The accuracy of the hospital discharge data was lowercompared to fee for service data (MSP), 91.9 % versus97.7 % sensitivity among the index cases. The match ratefor DAD was even less in the set of subsequent abor-tions, where only 61.4 % of cases were matched. Thelarge difference in capturing the index and subsequentabortion events was expected. The majority of study par-ticipants had their index abortion in a hospital settingbut only for these was the procedure captured in thehospital discharge data. Community setting clinics,where some of the index abortions and a large portionof the subsequent abortions occurred do not contributeto the hospital discharge data. Across Canada more thanhalf of all abortions reporting location of service deliveryare performed in clinic settings [1]. Thus, the hospitalTable 2 Sensitivity of administrative databases for the indexabortions when compared to the researcher-collected databaseSource Sensitivity (95 % CI)MSP or DAD 99.1 (98.3–99.6)MSP 97.7 (96.6–98.5)DAD 91.9 (90.0–93.4)MSP Medical Service Plan Payment Database, DAD DischargeAbstracts DatabaseTable 3 Number of subsequent abortions events found indifferent data sourcesSource N Proportion (95 % CI)Total subsequent abortionsfound in all databases127 ReferenceMatched in RCD 125 98.4 (94.4–99.8)Matched in MSP or DAD 126 99.2 (95.7–100)MSP 126 99.2 (95.7–100)DAD 78 61.4 (52.4–69.9)Matched in both admin and RCD 124 97.6 (93.3–99.5)RCD Research Collected Database, MSP Medical Service Plan PaymentDatabase, DAD Discharge Abstracts DatabaseTable 4 Event date difference among all data sources for indexand subsequent abortionsDaysdifferenceFrequency Percent CumulativeFrequencyCumulativePercent−30 1 0.09 1 0.09−7 1 0.09 2 0.17−3 1 0.09 3 0.26−1 2 0.17 5 0.440 1136 99.13 1141 99.561 3 0.26 1144 99.832 1 0.09 1145 99.916 1 0.09 1146 100Samiedaluie et al. BMC Health Services Research  (2016) 16:255 Page 4 of 6discharge abstract database (DAD) is not reliable as anindependent source for capturing abortions in Canada.The high capture rate of abortions events by the com-bined BC administrative databases suggests that this tech-nique can be used as a reliable source in abortion relatedstudies in BC. Based on the access, cost and time neededto collect data from available sources, researcher-collectedcompared to administrative databases, the prospectivedata user can decide the most appropriate technique.Researcher-collected clinical chart data is likely to requireindividual consent as well as, or at least with, ethics reviewboard approval. The variety of clinical data storage sys-tems (paper and a number of different electronic medicalrecords) may make collection of clinic-based data cumber-some and expensive. However, the clinical chart data isavailable immediately after the event, while data capturein administrative data sources may require 18–24 monthsprior to availability. Further, permission to access the datamay require additional time [24]. Thus the potential datauser must weigh the various practical considerations tochoose an appropriate data source, as our results do notpresent a significant variation in the accuracy of the dataavailable from either source.We were limited in this study by our inability to capturechart data from all abortion settings in BC. In 2010, lessthan 10 % of abortions in BC occurred in clinics not in-volved in this study [25]. Among the study cohort, admin-istrative data found only 1.7 % of women presented for asubsequent abortion at a location for which we did nothave corresponding clinical chart data. Thus this limitationdid not significantly affect our ability to validate the cap-ture of subsequent abortion outcomes using these admin-istrative data. Similarly, another limitation is the exclusionof non-BC residents among the index abortion sample.This exclusion (which was necessary as MSP informationdoes not exist for non-residents) accounted for only 3.5 %of patients assessed for eligibility. We feel that these limita-tions impact neither the validity of administrative data usein the context of clinical trials, nor the capture and report-ing of abortion data at the provincial level.This analysis has focused on the validation of the cap-ture of clinical abortion events in the BC governmenthealth administrative databases. The results may have lim-ited application to the capture of abortion events in theadministrative data of other jurisdictions. The CanadianInstitute for Health Information (CIHI) has found that theuse of fee for service data, analogous to MSP data in BC,to record abortions varies significantly between Canadianprovinces [1]. This accords with our findings where thecombination of MSP and hospital discharge data pro-vided a better capture of events. The ability to combinelinked administrative data from both of these sources,and to compare to clinical chart recorded events, is amajor strength of this study.ConclusionsAbortion procedures are common and of interest to healthresearchers, health policy makers and health program plan-ners. The capture of abortion procedure events in healthadministrative data in Canada has not been previously vali-dated. The high degree of accurate capture (over 99 %) thatwe found validates the use of linked BC health administra-tive data to capture abortion procedure events.AbbreviationsBC, British Columbia; CI, confidence interval; CIHI, Canadian Institute for HealthInformation; DAD, Discharge Abstracts Database (representing hospital servicesand diagnostic data in BC); MSP, Medical Services Plan (representing physicianservices and diagnostic billing data in BC); PHN, personal health number; RCD,Research Collected Database; RCT, randomized controlled trial; REB, ResearchEthics Board; WHRI, Women’s Health Research InstituteFundingOne RCT was supported by a Large Grant from the Society of Family Planning(SFP4-6). The other RCT was supported by an Operating Grant (MOP-106653)and a Primary Health Care Bridge Funding Grant (PCB-102963), both from theCanadian Institutes of Health Research (CIHR). Additionally, pilot study work wassupported by a Sue Harris Family Practice Research Grant from the Women’sHealth Research Instituted (WHRI) of the Provincial Health Services Authority ofBC. Infrastructure support for this study is provided by the WHRI, the Women’sServices Clinic of Kelowna General Hospital, Kelowna, BC, and the Departmentof Family Practice, Faculty of Medicine, UBC. The levonorgestrel releasing IUCused in one of the RCTs were donated by Bayer Inc., Canada as their solecontribution to the study. None of the above organizations was involved in anymanner with the study design, or with the collection, analysis, andinterpretation of data; or in the writing of the manuscript; or in the decision tosubmit the manuscript for publication. Dr. Norman is supported as a Scholar ofthe Michael Smith Foundation for Health Research, and by the CanadianInstitutes of Health Research and the Public Health Agency of Canada as aChair in Applied Public Health Research (CPP-137903).Availability of data and materialsAll data used for this analysis are protected under the privacy policies of theData Stewards of the BC health administrative data and Population Data BC,and within the terms of the institutional review board approval for thisstudy, and are not publicly available.Authors’ contributionsAll authors made substantial contributions to conception and design of thisstudy. WVN contributed to acquisition of data. SP and RB helped withpreparation of the analytic dataset. SS an SP carried out the analysis of dataand produced the results. SS contributed to the design of methodology anddrafted the manuscript. WVN, RB, and JK participated in the analysis ofresults and contributed to critical revision for important intellectual content.All authors have read and approved the final manuscript.Competing interestsThe author(s) declare that they have no competing interests.Consent for publicationNot applicable.Ethics approval and consent to participateBoth studies received institutional review board approval from the University ofBritish Columbia - Children’s and Women’s Research Ethics Board (H10-00798and H10-00306), the Interior Health Authority Research Ethics Board (2010-28and 2010-034), and Vancouver Island Health Authority Clinical Research EthicsBoard (C2010-47). This analysis was additionally approved by the Data Stewardsof the provincial health administrative data held within Population Data BClinked data holdings. All inferences, opinions, and conclusions drawn in thisanalysis and program recommendations are those of the authors, and do notreflect the opinions or policies of the Data Steward(s).Samiedaluie et al. BMC Health Services Research  (2016) 16:255 Page 5 of 6Author details1Department of Family Practice, University of British Columbia, Vancouver,Canada. 2Centre for Health Services and Policy Research, School ofPopulation and Public Health, University of British Columbia, Vancouver,Canada. 3Department of Statistics, University of British Columbia, Vancouver,Canada. 4Département de médecine de famille et de médecine d’urgence,l’Université de Montréal, Montréal, Canada.Received: 21 December 2015 Accepted: 17 June 2016References1. Canadian Institute for Health Information. Induced abortions performedin Canada in 2011. 2014. https://www.cihi.ca/en/ta_11_alldatatables20130221_en.pdf. Accessed 2 Jun 2015.2. Stanek AM, Bednarek PH, Nichols MD, Jensen JT, Edelman AB. Barriersassociated with the failure to return for intrauterine device insertionfollowing first-trimester abortion. Contraception. 2009;79(3):216–20.3. Norman WV. Induced abortion in Canada 1974–2005: trends over the firstgeneration with legal access. Contraception. 2012;85(2):185–91.4. Bednarek PH, Creinin MD, Reeves MF, Cwiak C, Espey E, Jensen JT.Immediate versus delayed IUD insertion after uterine aspiration. N Engl JMed. 2011;364(23):2208–17.5. Norman WV, Chiles J, Turner C. The contraceptive experience amongwomen seeking abortion. Contraception. 2011;84(3):314.6. Health Canada. Regulatory decision summary (SBD): MIFEGYMISO - 2015 -Health Canada. 2015. http://www.hc-sc.gc.ca/dhp-mps/prodpharma/rds-sdr/drug-med/rds_sdr_mifegymiso_160063-eng.php. Accessed 10 Jul 2016.7. Lee DS, Stitt A, Wang X, Yu JS, Gurevich Y, Kingsbury KJ, Austin PC, Tu JV.Administrative hospitalization database validation of cardiac procedurecodes. Med Care. 2013;51(4):e22–26.8. Joseph KS, Fahey J. Validation of perinatal data in the discharge abstractdatabase of the Canadian Institute for Health Information. Chronic Dis Can.2009;29(3):96–100.9. Frosst G, Hutcheon J, Joseph KS, Kinniburgh B, Johnson C, Lee L. Validatingthe British Columbia perinatal data registry: a chart re-abstraction study.BMC Pregnancy Childbirth. 2015;15(1):123.10. Norman WV, Kaczorowski J, Soon JA, Brant R, Bryan S, Trouton KJ, Dicus L.Immediate vs. delayed insertion of intrauterine contraception after secondtrimester abortion: study protocol for a randomized controlled trial. Trials.2011;12(1):149. doi:10.1186/1745-6215-12-149.11. Norman WV, Chiles JL, Turner CA, Brant R, Aslan A, Kaczorowski J.Comparing the effectiveness of copper intrauterine devices available inCanada. Is FlexiT non-inferior to NovaT when inserted immediately afterfirst-trimester abortion? study protocol for a randomized controlled trial.Trials. 2012;13(1):147. doi:10.1186/1745-6215-13-147.12. Norman WV, Brooks M, Brant R, Soon JA, Majdzadeh A, Kaczorowski J. Whatproportion of Canadian women will accept an intrauterine contraceptive atthe time of second trimester abortion? baseline data from a randomizedcontrolled trial. J Obstet Gynaecol Can. 2014;36(1):51–9.13. British Columbia Ministry of Health. Medical Services Plan (MSP)Payment Information File. Population Data BC. Data Extract. MOH(2014). 2014. http://www.popdata.bc.ca/data.14. British Columbia Ministry of Health. Consolidation File (MSP Registration &Premium Billing). Population Data BC. Data Extract. MOH (2014). 2015.http://www.popdata.bc.ca/data15. British Columbia Vital Statistics Agency. Vital Statistics Deaths.Population Data BC. Data Extract. BC Vital Statistics Agency (2014). 2014.http://www.popdata.bc.ca/data.16. Canadian Institute for Health Information. Discharge Abstract Database(Hospital Separations). Population Data BC. Data Extract. MOH (2014). 2014.http://www.popdata.bc.ca/data.17. Lisonkova S, Liu S, Bartholomew S, Liston RM, Joseph KS. Temporal trends inmaternal mortality in Canada II: estimates based on hospitalization data.J Obstet Gynaecol Can. 2011;33(10):1020–30.18. Smolina K, Hanley GE, Mintzes B, Oberlander TF, Morgan S. Trends anddeterminants of prescription drug use during pregnancy and postpartum inBritish Columbia, 2002–2011: a population-based cohort study. PLoS One.2015;10(5):e0128312.19. Leung VW, Soon JA, Lynd LD, Marra CA, Levine M. Population-basedevaluation of the effectiveness of two regimens for emergencycontraception. Int J Gynecol Obstet. 2016;133(3):342–6.20. Bedouch P, Marra CA, FitzGerald JM, Lynd LD, Sadatsafavi M. Trends inasthma-related direct medical costs from 2002 to 2007 in British Columbia,Canada: a population based-cohort study. PLoS One. 2012;7(12):e50949.21. Chamberlayne R, Green B, Barer ML, Hertzman C. Creating a population-based linked health database: a new resource for health services research.Can J Public Health. 1998;89(4):270.22. Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS, MaternalHealth Study Group of the Canadian Perinatal Surveillance System. Maternalmortality and severe morbidity associated with low-risk planned cesareandelivery versus planned vaginal delivery at term. Can Med Assoc J. 2007;176(4):455–60.23. Doctors of BC. Doctors of BC Guide to Fees. 2015. https://www.doctorsofbc.ca/resource-centre/physicians/handbooks-guides. Accessed 1 Jun 2015.24. Population Data BC. The data access request (DAR) process. 2014.https://www.popdata.bc.ca/dataaccess/process. Accessed 10 Jul 2016.25. Norman WV, Soon JA, Maughn N, Dressler J. Barriers to rural induced abortionservices in Canada: findings of the British Columbia abortion providers survey(BCAPS). PLoS One. 2013;8(6):e67023. doi:10.1371/journal.pone.0067023.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Samiedaluie et al. BMC Health Services Research  (2016) 16:255 Page 6 of 6

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