The effect of socio-demographic factors on mental health and addiction high-cost use: a retrospective, population-based study in Saskatchewan

Cost structure in specialist mental healthcare: what are the main drivers of the most expensive episodes?

BACKGROUND

Mental disorders are one of the costliest conditions to treat in Norway, and research into the costs of specialist mental healthcare are needed. The purpose of this article is to present a cost structure and to investigate the variables that have the greatest impact on high-cost episodes.

METHODS

Patient-level cost data and clinic information during 2018-2021 were analyzed (N = 180,220). Cost structure was examined using two accounting approaches. A generalized linear model was used to explain major cost drivers of the 1%, 5%, and 10% most expensive episodes, adjusting for patients' demographic characteristics [gender, age], clinical factors [length of stay (LOS), admission type, care type, diagnosis], and administrative information [number of planned consultations, first hospital visits, interval between two hospital episode].

RESULTS

One percent of episodes utilized 57% of total resources. Labor costs accounted for 87% of total costs. The more expensive an episode was, the greater the ratio of the inpatient (ward) cost was. Among the top-10%, 5%, and 1% most expensive groups, ward costs accounted for, respectively, 89%, 93%, and 99% of the total cost, whereas the overall average was 67%. Longer LOS, ambulatory services, surgical interventions, organic disorders, and schizophrenia were identified as the major cost drivers of the total cost, in general. In particular, LOS, ambulatory services, and schizophrenia were the factors that increased costs in expensive subgroups. The "first hospital visit" and "a very short hospital re-visit" were associated with a cost increase, whereas "the number of planned consultations" was associated with a cost decrease.

CONCLUSIONS

The specialist mental healthcare division has a unique cost structure. Given that resources are utilized intensively at the early stage of care, improving the initial flow of hospital care can contribute to efficient resource utilization. Our study found empirical evidence that planned outpatient consultations may be associated with a reduced health care burden in the long-term.

Socioeconomic burden of schizophrenia: a targeted literature review of types of costs and associated drivers across 10 countries

AIMS

Schizophrenia has the highest median societal cost per patient of all mental disorders. This review summarizes the different costs/cost drivers (cost components) associated with schizophrenia in 10 countries, including all cost types and stakeholder perspectives, and highlights aspects of disease associated with greatest costs.

MATERIALS AND METHODS

Targeted literature review based on a search of published research from 2006 to 2021 in the United States (US), United Kingdom (UK), France, Germany, Italy, Spain, Canada, Japan, Brazil, and China.

RESULTS

Sixty-four published articles (primary studies and literature reviews) were included. Comprehensive data were available on costs in schizophrenia overall, with very limited data for individual countries except the US. Most data is related to direct and not indirect costs, with extremely scarce data for several key cost components (adverse events, suicide, long-term care). Total schizophrenia-related per person per year (PPPY) costs were $2,004-94,229, with considerable variability among countries. Indirect costs were the main cost driver (50-90% of all costs), ranging from $1,852 to $62,431 PPPY. However, indirect costs are not collected systematically or incorporated in health technology assessments. Total schizophrenia-related PPPY direct costs were $4,394-31,798, with inpatient cost as the main cost driver (∼20-99% of direct costs). Intangible costs were not reported. Despite limited evidence, total schizophrenia-related costs were higher in patients with than without negative symptoms, largely due to increased costs of medication and medical visits.

LIMITATIONS

As this was not a systematic review, prioritization of studies may have resulted in exclusion of potentially relevant data. All costs were converted to USD but not corrected for inflation or subjected to a gross domestic product deflator.

CONCLUSIONS

Direct costs are most commonly reported in schizophrenia. The substantial underreporting of indirect and intangible costs undervalues the true economic burden of schizophrenia from a payer, patient, and societal perspective.

The association of mitochondrial DNA copy number with incident mental disorders in women: A population-based follow-up study

BACKGROUND

Available evidence suggests that mitochondrial DNA copy number (mtDNA-CN) may differ among patients with mental disorders compared to the general population. However, whether mtDNA-CN is independently associated with the subsequent incidence of mental disorders remains unclear.

MATERIAL AND METHODS

We used droplet digital PCR to measure the absolute mtDNA-CN in DNA samples obtained from a population-based follow-up study, which included a total of 2354 middle-aged women (52-63 years) who were free of mental disorders at baseline. After 17 years (median) of follow-up, 727 participants were diagnosed with mental disorders.

RESULTS

In the univariate Cox regression, lower baseline mtDNA-CN (mtDNA-CN < 117) was associated with a higher risk of mental disorders (HR = 1.16, p = 0.047). In addition, smoking, marital status and sleeping quality were associated with both mtDNA-CN and mental disorders. After adjusting for these variables, the association between mtDNA-CN and mental disorders decreased and became non-significant (HR = 1.07, p = 0.36). Stratification of data according to the subtype of mental disorders, showed that low mtDNA-CN was associated with a higher risk of alcohol or drug use disorders (HR = 1.82, p = 0.045 after adjusting).

CONCLUSION

In the present study, we could not find any independent association between mtDNA-CN blood and the most common mental disorders in a population-based follow-up study of Swedish women, except for alcohol and drug use disorders. The use of blood mtDNA-CN as a biomarker of mental disorders, in addition to other risk factors, needs to be further examined in future studies.

OUP accepted manuscript

Background

Rural dwellers with inflammatory bowel disease (IBD) face barriers to accessing specialized health services. We aimed to contrast health care utilization between rural and urban residents diagnosed with IBD in Saskatchewan, Canada.

Methods

We completed a population-based retrospective study from 1998/1999 to 2017/2018 using administrative health databases. A validated algorithm was used to identify incident IBD cases aged 18+. Rural/urban residence was assigned at IBD diagnosis. Outpatient (gastroenterology visits, lower endoscopies, and IBD medications claims) and inpatient (IBD-specific and IBD-related hospitalizations, and surgeries for IBD) outcomes were measured after IBD diagnosis. Cox proportional hazard, negative binomial, and logistic models were used to evaluate associations adjusting by sex, age, neighbourhood income quintile, and disease type. Hazard ratios (HR), incidence rate ratios (IRR), odds ratios (OR), and 95% confidence intervals (95% CI) were reported.

Results

From 5,173 incident IBD cases, 1,544 (29.8%) were living in rural Saskatchewan at IBD diagnosis. Compared to urban dwellers, rural residents had fewer gastroenterology visits (HR = 0.82, 95% CI: 0.77-0.88), were less likely to have a gastroenterologist as primary IBD care provider (OR = 0.60, 95% CI: 0.51-0.70), and had lower endoscopies rates (IRR = 0.92, 95% CI: 0.87-0.98) and more 5-aminosalicylic acid claims (HR = 1.10, 95% CI: 1.02-1.18). Rural residents had a higher risk and rates of IBD-specific (HR = 1.23, 95% CI: 1.13-1.34; IRR = 1.22, 95% CI: 1.09-1.37) and IBD-related (HR = 1.20, 95% CI: 1.11-1.31; IRR = 1.23, 95% CI: 1.10-1.37) hospitalizations than their urban counterparts.

Conclusion

We identified rural-urban disparities in IBD health care utilization that reflect rural-urban inequities in the access to IBD care. These inequities require attention to promote health care innovation and equitable management of patients with IBD living in rural areas.

Use of the Population Grouping Methodology of the Canadian Institute for Health Information to predict high-cost health system users in Ontario

BACKGROUND

Prior research has consistently shown that the heaviest users account for a disproportionate share of health care costs. As such, predicting high-cost users may be a precondition for cost containment. We evaluated the ability of a new health risk predictive modelling tool, which was developed by the Canadian Institute for Health Information (CIHI), to identify future high-cost cases.

METHODS

We ran the CIHI model using administrative health care data for Ontario (fiscal years 2014/15 and 2015/16) to predict the risk, for each individual in the study population, of being a high-cost user 1 year in the future. We also estimated actual costs for the prediction period. We evaluated model performance for selected percentiles of cost based on the discrimination and calibration of the model.

RESULTS

A total of 11 684 427 individuals were included in the analysis. Overall, 10% of this population had annual costs exceeding $3050 per person in fiscal year 2016/17, accounting for 71.6% of total expenditures; 5% had costs above $6374 (58.2% of total expenditures); and 1% exceeded $22 995 (30.5% of total expenditures). Model performance increased with higher cost thresholds. The c-statistic was 0.78 (reasonable), 0.81 (strong) and 0.86 (very strong) at the 10%, 5% and 1% cost thresholds, respectively.

INTERPRETATION

The CIHI Population Grouping Methodology was designed to predict the average user of health care services, yet performed adequately for predicting high-cost users. Although we recommend the development of a purpose-designed tool to improve model performance, the existing CIHI Population Grouping Methodology may be used - as is or in concert with additional information - for many applications requiring prediction of future high-cost users.

Increasing Prevalence and Direct Health Care Cost of Inflammatory Bowel Disease Among Adults: A Population-Based Study From a Western Canadian Province

Objectives

Our study aimed to calculate the prevalence and estimate the direct health care costs of inflammatory bowel disease (IBD), and test if trends in the prevalence and direct health care costs of IBD increased over two decades in the province of Saskatchewan, Canada.

Methods

We conducted a retrospective population-based cohort study using administrative health data of Saskatchewan between 1999/2000 and 2016/2017 fiscal years. A validated case definition was used to identify prevalent IBD cases. Direct health care costs were estimated in 2013/2014 Canadian dollars. Generalized linear models with generalized estimating equations tested the trend. Annual prevalence rates and direct health care costs were estimated along with their 95% confidence intervals (95%CI).

Results

In 2016/2017, 6468 IBD cases were observed in our cohort; Crohn’s disease: 3663 (56.6%), ulcerative colitis: 2805 (43.4%). The prevalence of IBD increased from 341/100,000 (95%CI 340 to 341) in 1999/2000 to 664/100,000 (95%CI 663 to 665) population in 2016/2017, resulting in a 3.3% (95%CI 2.4 to 4.3) average annual increase. The estimated average health care cost for each IBD patient increased from $1879 (95%CI 1686 to 2093) in 1999/2000 to $7185 (95%CI 6733 to 7668) in 2016/2017, corresponding to an average annual increase of 9.5% (95%CI 8.9 to 10.1).

Conclusions

Our results provide relevant information and analysis on the burden of IBD in Saskatchewan. The evidence of the constant increasing prevalence and health care cost trends of IBD needs to be recognized by health care decision-makers to promote cost-effective health care policies at provincial and national levels and respond to the needs of patients living with IBD.

"People just don't understand their role in it." Collaboration and coordination of care for service users with complex and severe mental health problems

PURPOSE

To explore professionals' and service users' experiences and perceptions of interprofessional collaboration and coordination for service users with complex and severe mental health issues.

DESIGN AND METHODS

A qualitative study involving semi-structured interviews of professionals and individual interviews of service users. Data were analyzed by thematic analysis.

FINDINGS

Participants described challenges and suggested improvements concerning Distribution of roles, responsibilities, and tasks; Communication; and Knowledge and attitudes.

PRACTICE IMPLICATIONS

Mental health nurses and other professional helpers should have a particular focus on common aims, clear division of roles, planning and timing of interventions, and communication with other professionals and service users.

Modeling socio-demographic and clinical factors influencing psychiatric inpatient service use: a comparison of models for zero-Inflated and overdispersed count data

BACKGROUND

Psychiatric disorders may occur as a single episode or be persistent and relapsing, sometimes leading to suicidal behaviours. The exact causes of psychiatric disorders are hard to determine but easy access to health care services can help to reduce their severity. The aim of this study was to investigate the factors associated with repeated hospitalizations among the patients with psychiatric illness, which may help the policy makers to target the high-risk groups in a more focused manner.

METHODS

A large linked administrative database consisting of 200,537 patients with psychiatric diagnosis in the years of 2008-2012 was used in this analysis. Various counts regression models including zero-inflated and hurdle models were considered for analyzing the hospitalization rate among patients with psychiatric disorders within three months follow-up since their index visit dates. The covariates for this study consisted of socio-demographic and clinical characteristics of the patients.

RESULTS

The results show that the odds of hospitalization are significantly higher among registered Indians, male patients and younger patients. Hospitalization rate depends on the patients' disease types. Having previously visited a general physician served a protective role for psychiatric hospitalization during the study period. Patients who had seen an outpatient psychiatrist were more likely to have a higher number of psychiatric hospitalizations. This may indicate that psychiatrists tend to see patients with more severe illnesses, who require hospital-based care for managing their illness.

CONCLUSIONS

Providing easier access to registered Indian people and youth may reduce the need for hospital-based care. Patients with mental health conditions may benefit from greater and more timely access to primary care.

Population-Based Evidence From a Western Canadian Province of the Decreasing Incidence Rates and Trends of Inflammatory Bowel Disease Among Adults

Background and Aims

Canada has one of the highest inflammatory bowel disease (IBD) incidence rates worldwide. Higher IBD incidence rates have been identified among urban regions compared to rural regions. The study objectives were to (i) estimate IBD incidence rates in Saskatchewan from 1999 to 2016 and (ii) test for differences in IBD incidence rates for rural and urban regions of Saskatchewan.

Methods

A population-based study was conducted using provincial administrative health databases. Individuals aged 18+ years with newly diagnosed Crohn's disease or ulcerative colitis were identified using a validated case definition. Generalized linear models with a negative binomial distribution were used to estimate incidence rates and incidence rate ratios (IRRs) adjusted for age group, sex and rurality with 95% confidence intervals (CIs).

Results

The average annual incidence rate of IBD among adults in Saskatchewan decreased from 75/100,000 (95% CI 67 to 84) in 1999 to 15/100,000 (95% CI 12 to 18) population in 2016. The average annual incidence of IBD declined significantly by 6.9% (95% CI -7.6 to -6.2) per year. Urban residents had a greater overall risk of IBD (IRR = 1.19, 95% CI 1.11 to 1.27) than rural residents. This risk difference was statistically significant for Crohn's disease (IRR = 1.25, 95% CI 1.14 to 1.36), but not for ulcerative colitis (IRR = 1.08, 95% CI 0.97 to 1.19).

Conclusions

The incidence of IBD in Saskatchewan dropped significantly from 1999 to 2016 with urban dwellers having a 19% higher risk of IBD onset compared to their rural counterparts. Health care providers and decision-makers should plan IBD-specific health care programs considering these specific IBD rates.

Defining 'actionable' high- costhealth care use: results using the Canadian Institute for Health Information population grouping methodology

Background

A small proportion of the population consumes the majority of health care resources. High-cost health care users are a heterogeneous group. We aim to segment a provincial population into relevant homogenous sub-groups to provide actionable information on risk factors associated with high-cost health care use within sub-populations.

Methods

The Canadian Institute for Health Information (CIHI) Population Grouping methodology was used to define mutually exclusive and clinically relevant health profile sub-groups. High-cost users (> = 90th percentile of health care spending) were defined within each sub-group. Univariate analyses explored demographic, socio-economic status, health status and health care utilization variables associated with high-cost use. Multivariable logistic regression models were constructed for the costliest health profile groups.

Results

From 2015 to 2017, 1,175,147 individuals were identified for study. High-cost users consumed 41% of total health care resources. Average annual health care spending for individuals not high-cost were $642; high-cost users were $16,316. The costliest health profile groups were ‘long-term care’, ‘palliative’, ‘major acute’, ‘major chronic’, ‘major cancer’, ‘major newborn’, ‘major mental health’ and ‘moderate chronic’. Both ‘major acute’ and ‘major cancer’ health profile groups were largely explained by measures of health care utilization and multi-morbidity. In the remaining costliest health profile groups modelled, ‘major chronic’, ‘moderate chronic’, ‘major newborn’ and ‘other mental health’, a measure of socio-economic status, low neighbourhood income, was statistically significantly associated with high-cost use.

Interpretation

Model results point to specific, actionable information within clinically meaningful subgroups to reduce high-cost health care use. Health equity, specifically low socio-economic status, was statistically significantly associated with high-cost use in the majority of health profile sub-groups. Population segmentation methods, and more specifically, the CIHI Population Grouping Methodology, provide specificity to high-cost health care use; informing interventions aimed at reducing health care costs and improving population health.

Longitudinal Cost of Services in a Homeless Sample with Cocaine Use Disorder

Homeless people with cocaine use disorder have multiple comorbidities and costly service needs. This study examined service costs associated with cocaine use and substance service use in substance, psychiatric, and medical service sectors. 127 homeless participants with cocaine use disorder were interviewed annually. Self-report and agency-report service use and cost data were combined. Pairwise comparisons were made with cocaine abstinence and substance service use in relation to mean and yearly proportional service costs in 3 service sectors. Among substance service users, achievement of abstinence was not associated with decreased substance service costs. Cocaine abstinence was associated with proportional reduction of substance service costs over time. Substance service use was associated with proportional reduction of psychiatric service costs over time among the abstinent subgroup. Conversely, substance service use was associated with continuing higher medical service expenditures in the abstinent subgroup and higher psychiatric service expenditures in those not abstinent. Homeless individuals who achieved cocaine abstinence after using substance services had decreased substance service expenditures. Individuals with continued substance service use had greater medical and psychiatric service costs. Policy based on maximizing benefits while minimizing costs appears insufficiently complex to incorporate the multiple needs and associated with costs of treating homeless populations.