Differences in the use of psychiatric outpatient services between the United States and Ontario

The case for a partnership with self-help groups

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Comparison of the use of medical resources and outcomes in the treatment of aneurysmal subarachnoid hemorrhage between Canada and the United States

OBJECTIVE

Using data from a randomized trial of tirilazad mesylate, we assessed the differences between Canada and the United States in the use of medical resources and outcomes in the treatment of aneurysmal subarachnoid hemorrhage during the first 90 days after admission to the hospital.

METHODS

Of the 877 patients for whom economic data were available, 194 were enrolled in Canada and 683 were enrolled in the United States. The differences between the countries in patient characteristics, use of medical resources, and outcomes were analyzed by comparing means and the 95% confidence intervals (CIs) around the differences in means. These differences also were predicted with use of multivariable regression analysis.

RESULTS

The average hospital stay was 4.2 days longer (95% CI, 1.3 to 7.1 days) in Canada, but most of the extra stay was among patients admitted to the study in poor neurological condition. In general, however, hospital stays in Canada were substantially less intensive. Patients treated in Canada spent 3.7 fewer days (95% CI, 1.2 to 6.1 days) in nursing homes and rehabilitation centers than did patients in the United States. No statistically significant differences were seen for Glasgow Outcome Scale score, death, and occurrence of vasospasm.

CONCLUSIONS

For patients admitted to the study in good neurological condition, the apparent difference in length of stay between Canada and the United States was caused by a shift in the sites of formal care rather than to the length of this care. For those admitted in poor neurological condition, both the length and sites of care differed between the two countries. No significant difference in outcomes appeared to justify these differences in the use of medical resources.

Medication management of depression in the United States and Ontario

OBJECTIVE

To compare rates of contact for mental problems and receipt of appropriate antidepressant medication management for persons in the general population with major depression in the United States and Ontario, Canada.

DESIGN

Survey using the U.S. National Comorbidity Survey and the Mental Health Supplement of the Ontario Health Survey.

PARTICIPANTS

All persons with major depression as described in DSM-III-R in the previous 12 months, from a multistage random sample of persons aged 21 to 54 years living in households in the United States (n = 574) and Ontario (n = 250) in 1990.

MEASUREMENTS AND MAIN RESULTS

Self-reported contact with general medical or mental health specialty providers for mental problems and appropriate medication management, defined as a combination of antidepressant medication use and four or more visits to any provider within the previous 12 months, were the main outcome measures. The proportion of depressed persons receiving appropriate management was lower in the United States than in Ontario (7.3% vs 14.9% in Ontario, adjusted odds ratio [AOR] 95% CI 0.4; 95% confidence interval [CI] 0.2, 0.8). This difference was largely the result of fewer Americans than Canadians having any mental health care from general medical physicians (9.6% in the United States vs 25.8% in Ontario; AOR 0.3; 95% CI 0.1, 0.5) rather than from specialty providers (20.8% in the United States vs 28.9% in Ontario; AOR 0.7; 95% CI 0.4, 1.1). These between-country differences were much greater for the poor than for those with higher incomes. The Ontario-United States AOR of making contact with either type of clinical provider was 7.5 (95% CI 2.7, 20.7) for lowest-income persons but 2.1 (95% CI 0.3, 5.6) for highest-income persons. The proportions of depressed recipients of any mental health care who received appropriate management were similar between countries (23.9% in the United States vs 27.7% in Ontario; AOR 0.8; 95% CI 0.3, 1.7).

CONCLUSIONS

Most persons with depression in the United States and Ontario do not receive appropriate medication management. The rate of appropriate medication management in the United States relative to Ontario is lower largely because there is less contact with general medical physicians for mental problems, especially for the poor. Economic barriers, rather than knowledge and attitudinal factors, appear to explain this difference.

The use of outpatient mental health services in the United States and Ontario: the impact of mental morbidity and perceived need for care

OBJECTIVES

This study compared the associations of individual mental health disorders, self-rated mental health, disability, and perceived need for care with the use of outpatient mental health services in the United States and the Canadian province of Ontario.

METHODS

A cross-sectional study design was employed. Data came from the 1990 US National Comorbidity Survey and the 1990 Mental Health Supplement to the Ontario Health Survey.

RESULTS

The odds of receiving any medical or psychiatric specialty services were as follows: for persons with any affective disorder, 3.1 in the United States vs 11.0 in Ontario; for persons with fair or poor self-rated mental health, 2.7 in the United States vs 5.0 in Ontario; for persons with mental health-related disability. 3.0 in the United States vs 1.5 in Ontario. When perceived need was controlled for, most of the between country differences in use disappeared.

CONCLUSIONS

The higher use of mental health services in the United States than in Ontario is mostly explained by the combination of a higher prevalence of mental morbidity and a higher prevalence of perceived need for care among persons with low mental morbidity in the United States.