Managing mental health: why we need to redress the balance between healthcare spending and social spending.

BACKGROUND: Mental health outcomes vary widely among high-income countries, although mental health problems represent an increasing proportion of the burden of disease for all countries. This has led to increased demand for healthcare services, but mental health outcomes may also be particularly sensitive to the availability of social services. This paper examines the variation in the absolute and relative amounts that high-income countries spend on healthcare and social services to determine whether increased expenditure on social services relative to healthcare expenditure might be associated with better mental health outcomes. METHODS: This paper estimates the association between patterns of government spending and population mental health, as measured by the death rate resulting from mental and behavioural disorders, across member countries of the Organisation for Economic Cooperation and Development (OECD). We use country-level repeated measures multivariable modelling for the period from 1995 to 2016 with region and time effects, adjusted for total spending and demographic and economic characteristics. Healthcare spending includes all curative services, long-term care, ancillary services, medical goods, preventative care and administration whilst social spending consists of all transfer payments made to individuals and families as part of the welfare state. RESULTS: We find that a higher ratio of social to healthcare expenditure is associated with significantly better mental health outcomes for OECD populations, as measured by the death rate resulting from mental and behavioural disorders. We also find that there is no statistically significant association between healthcare spending and population mental health when we do not control for social spending. CONCLUSION: This study suggests that OECD countries can have a significant impact on population mental health by investing a greater proportion of total expenditure in social services.

Geographical variation analysis of all-cause hospital readmission cases in Winnipeg, Canada.

BACKGROUND: Hospital readmission is costly and potentially avoidable. The concept of virtual wards as a new model of care is intended to reduce hospital readmissions by providing short-term transitional care to high-risk and complex patients in the community. In order to provide information regarding the development of virtual wards in the Winnipeg Health Region, Canada, this study used spatial statistics to identify geographic variations of hospital readmissions in 25 neighborhood clusters. METHODS: The data were obtained from the Population Health Research Data Repository housed at the Manitoba Centre for Health Policy. We used a Bayesian Disease Mapping approach which applied Markov chain Monte Carlo (MCMC) for cluster detection. RESULTS: Between 2005/06 and 2008/09, 123,842 patients were hospitalized in all Winnipeg hospitals. Of these, 41,551 (33%) were readmitted to hospital in the year following discharge. Most of these readmitted patients (89.4%) had 1-2 readmissions, while 11.6% of readmitted patients had more than 2 readmissions after initial discharge. The smoothed age- and sex- adjusted relative risk rates of hospital readmission in 25 Winnipeg neighborhood clusters ranged between 0.73 and 1.27. We found that there were spatial cluster variations of hospital readmission across the Winnipeg Health Region. Seven neighborhood clusters are more likely to be significant potential clusters for hospital readmissions (p < .05), while six neighborhood clusters are less likely to be significant potential clusters. CONCLUSIONS: This study provides the foundation and implementation guide for the Winnipeg Regional Health Authority virtual ward program. The findings will also help to improve long-term condition management in community settings and will help program planners to assure the efficient use of healthcare resources.

New questions, new data, old interventions: the health effects of a guaranteed annual income.

OBJECTIVES: This study investigates whether administration data from universal health insurance can yield new insight from an old intervention. Specifically, did a guaranteed annual income experiment from the 1970s, designed to investigate labor market outcomes, reduce hospitalization rates? METHOD: The study re-examined the saturation site of a guaranteed annual income experiment in Dauphin, Manitoba (CANADA) conducted between 1974 and 1979 (MINCOME). We used health administration data generated by the universal government health insurance plan to identify subjects (approximately 12,500 residents of Dauphin and its rural municipality). We used propensity-score matching to select 3 controls for each subject from this database, matched on geography of residence, age, sex, family size and type. Outcome measures were hospital separations and physician claims. RESULTS: Hospital separations declined 8.5% among subjects relative to controls during the experimental period. Accident and injury codes and mental health codes were most responsible for the decline. CONCLUSIONS: Even though MINCOME was designed to measure the impact of a GAI on the number of hours worked, one can re-visit old experiments with new data to determine the health impact of population interventions designed for other purposes. We determined that hospitalization rates declined significantly after the introduction of a guaranteed income.

Exploring dental hygiene decision making: A quantitative study of potential organizational explanations.

BACKGROUND: To improve public access to oral health care, dental hygienists have been identified for practice expansion, and, therefore, they must demonstrate decision-making capacity. This study aimed to identify and test potentially influential factors in dental hygiene decision making. Organizational and gender factors were hypothesized to be most influential and focused the study. METHODS: A 2-phase mixed methods approach was used. In Phase I, a qualitative decision-making model was developed and subsequently published in 2012. Phase II tested aspects of the model through an electronic survey instrument and key informant interviews. This article reports on the statistical results of the quantitative survey. A third article will report on the qualitative thematic analyses and merged interpretation. RESULTS: The Phase I qualitative model guided the development of the survey instrument. The survey had a 38% response rate; moderate to weak correlations between predictor variables (structural and individual) and clinical decision making were shown. The final statistical model demonstrated that individual characteristics and graduating from a 3-year dental hygiene program were together significantly associated with decision-making capacity. DISCUSSION AND CONCLUSIONS: Individual characteristics and longer education were together shown to be associated with increased decision-making capacity. These findings did not show the organization or gender to be important in influencing decision-making capacity. However, the merging of the quantitative survey and qualitative key informant data will potentially inform how the organization influences the individual dental hygienist.

CONTEXTE: Afin d'améliorer l'accès de la population aux soins de santé buccodentaire, les hygiénistes dentaires ont été désignés pour une expansion de la pratique et doivent par conséquent démontrer une capacité décisionnelle. La présente étude visait à cerner et à vérifier les facteurs influents potentiels dans la prise de décision en hygiène dentaire. L'étude était axée sur l'hypothèse que les facteurs organisationnels et de sexe étaient les plus influents. MÉTHODOLOGIE: Une approche méthodologique mixte en 2 phases a été utilisée. Dans la phase I, un modèle décisionnel qualitatif a été conçu et publié par la suite en 2012. La phase II a évalué des aspects du modèle au moyen d'un outil de sondage électronique et des entrevues d'intervenants clés. Cet article présente les résultats statistiques de ce sondage quantitatif. Un troisième article fera part des analyses thématiques qualitatives et des interprétations fusionnées. RÉSULTATS: La phase I du modèle qualitatif a guidé la conception de l'outil de sondage. Le sondage avait un taux de réponse de 38 %, et des corrélations modérées à faibles entre les variables indépendantes (structurelles et individuelles) et la prise de décision clinique étaient démontrées. Le modèle statistique final a démontré que les caractéristiques individuelles, ainsi que l'obtention d'un diplôme d'un programme d'hygiène dentaire de 3 ans étaient fortement associées à la capacité décisionnelle. DISCUSSION ET CONCLUSIONS: Les caractéristiques individuelles et des études plus longues étaient ensemble associées à une meilleure capacité décisionnelle. Ces résultats n'ont pas montré que l'organisation ou le sexe étaient des facteurs d'influence importants dans la capacité décisionnelle. Cependant, la fusion du sondage quantitatif et des données qualitatives des intervenants clés pourrait éclaircir la façon dont l'organisation influence chaque hygiéniste dentaire.

Health-related quality of life and economic burden to smoking behaviour among Canadians.

OBJECTIVES: The objectives of this study were to: (1) examine whether the smoking status of the Canadian population is associated with a reduction in health-related quality of life (HRQoL); (2) calculate the overall economic burden of loss in HRQoL using a commonly accepted $100,000 willingness-to-pay (WTP) threshold to gain one quality-adjusted life year (QALY); and (3) calculate the loss of HRQoL over a lifetime. METHODS: We used the 2015 Canadian Community Health Survey. The variations in HRQoL were estimated using a multivariable generalized linear model. Total expected lifetime QALYs lost due to smoking were calculated by compounding the annual adjusted health utility loss associated with smoking across a respondent's remaining years of life expectancy stratified by age. A discount rate of 1.5% was applied to the analysis based on recent analysis of the costs of borrowing in Canada. RESULTS: Smoking is significantly associated with HRQoL loss. This study demonstrated that smoking is associated with a 0.05 and 0.01 reduction in Health Utilities Index Mark 3 (HUI3) score for current and former smokers, which also corresponds to a loss of 0.66 quality-adjusted life years in average, and also is associated with substantial individual and societal economic cost. The total lifetime economic burden of HUI3 loss per smoker was $65,935, yielding in the aggregate a societal burden of $1068.88 billion in the study population. CONCLUSION: Tobacco control, prevention and intervention not only will improve HRQoL but also will generate social returns on investment.

The effects of cigarette price and the amount of pocket money on youth smoking initiation and intensity in Canada.

OBJECTIVES: To investigate the price and income elasticities of adolescent smoking initiation and intensity to determine the extent to which increased pocket money leads to greater smoking among youth, and whether higher taxes can mitigate this effect. METHODS: We used the 2012/2013 Canadian Youth Smoking Survey including students in grades 7-12. The multivariable logistic regression was used to examine the probability of smoking initiation, and a linear regression to examine the smoking intensity determined by province-level prices of cigarettes, pocket money, and a vector of individual characteristics, including age, sex, race, and school-related and psychosocial factors. RESULTS: Of respondents, 28.8% have tried cigarette smoking. More than 90% of these initiated smoking between age 9 and 17. Male smokers consumed a higher average number of whole cigarettes daily than did females. The price elasticity of smoking initiation and intensity for youth in the full sample were - 1.13 and - 1.02, respectively, which means that a 10% increase in price leads to an 11.3% reduction in initiation and a 10.2% reduction in intensity. The income elasticity of smoking initiation and intensity for youth in the full sample were 0.07 and 0.06, respectively, which means that a 10% increase in income leads to a 0.7% increase in initiation and a 0.6% increase in intensity. CONCLUSION: Economic measures such as taxation that raise the price of cigarettes may be a useful policy tool to limit smoking initiation and intensity.

Enzyme replacement therapy in orphan and ultra-orphan diseases: the limitations of standard economic metrics as exemplified by Fabry-Anderson disease.

BACKGROUND: Fabry-Anderson disease is an x-linked deficiency of lysosomal alpha-galactosidase A (GALA), resulting in chronic renal failure, cardiac arrhythmia, hypertrophy, valvular disease, pain (acro-paraesthesiae) and stroke, together with premature mortality. The disease has a significant impact on quality of life (QOL), as illustrated by studies using the EQ-5D. A specific treatment is available for Fabry-Anderson disease consisting of intravenous enzyme replacement therapy (ERT) of the deficient enzyme. The variable clinical efficacy and cost of ERT has resulted in reluctance by some health providers to approve it. METHODS: We use the limited QOL data available in the Fabry-Anderson disease literature on ERT to derive standard economic metrics. These were derived by bootstrap estimates of the incremental net benefit (INB) statistics together with a cost-effectiveness acceptability curve relating the willingness to pay to the probability that the INB was >0. The estimates were further developed by adoption of a supplementary Bayesian approach utilising a sceptical and enthusiastic prior of the INB of ERT in Fabry-Anderson disease. RESULTS: ERT for Fabry-Anderson disease is not economically viable by standard health programme evaluation metrics. Based on current ERT costs (year 2005 values), derivation of the INB distribution, and a Bayesian analysis using an enthusiastic and sceptical prior of the INB, an upper (350,000 dollars over 1 year) and lower (175,000 dollars over 1 year) economic cost, respectively, of ERT was derived. CONCLUSION: The cost of ERT will always result in a net deficit to society under current costing and ERT efficacy as determined by the QALY metric. The rules of fair cooperation should govern decision making both for ERT in Fabry-Anderson disease and for funding therapeutic advances in other rare diseases belonging to the orphan and ultra-orphan categories.

Development and validation of a predictive model for all-cause hospital readmissions in Winnipeg, Canada.

OBJECTIVE: A number of predictive models have been developed to identify patients at risk of hospital readmission. Most of these have focused on readmission within 30 days of discharge. We used population-based health administrative data to develop a predictive model for hospital readmission within 12 months of discharge in Winnipeg, Canada. METHODS: This was a retrospective cohort study with derivation and validation data sets. Multivariable logistic regression analyses were performed and factors significantly associated with readmission were selected to construct a risk scoring tool. RESULTS: Several variables were identified that predicted readmission (i.e. older age, male, at least one hospital admission in the previous two years, an emergent (index) hospital admission, Charlson comorbidity score >0 and length of stay). Discrimination power was acceptable (C statistic =0.701). At a median risk score threshold, the sensitivity, specificity, positive and negative predictive values were 45.5%, 79%, 68.8% and 58.6%. CONCLUSIONS: This predictive model demonstrated that hospital readmission within 12 months of discharge can be reasonably well predicted based on administrative data. It will help health care providers target interventions to prevent unnecessary hospital readmissions.

Medical savings accounts in a universal system: wishful thinking meets evidence.

Medical savings accounts (MSAs) and similar approaches based on flowing reimbursements through individuals/consumers rather than providers are unsuited for systems with universal coverage. Data from Manitoba, Canada reveal that, because expenditures for physician and hospital services are highly skewed in all age groups, MSAs would substantially increase both public expenditures and out-of-pocket costs for the most ill. The empirical distribution of health expenditures limits the potential impact of many current 'demand-based' approaches to cost control. Because most of the population is relatively healthy and uses few hospital and physician services, inducing the general population to spend less will not yield substantial savings.

Is herpes zoster vaccination likely to be cost-effective in Canada?

OBJECTIVES: To synthesize the current literature detailing the cost-effectiveness of the herpes zoster (HZ) vaccine, and to provide Canadian policy-makers with cost-effectiveness measurements in a Canadian context. METHODS: This article builds on an existing systematic review of the HZ vaccine that offers a quality assessment of 11 recent articles. We first replicated this study, and then two assessors reviewed the articles and extracted information on vaccine effectiveness, cost of HZ, other modelling assumptions and QALY estimates. Then we transformed the results into a format useful for Canadian policy decisions. Results expressed in different currencies from different years were converted into 2012 Canadian dollars using Bank of Canada exchange rates and a Consumer Price Index deflator. Modelling assumptions that varied between studies were synthesized. We tabled the results for comparability. SYNTHESIS: The Szucs systematic review presented a thorough methodological assessment of the relevant literature. However, the various studies presented results in a variety of currencies, and based their analyses on disparate methodological assumptions. Most of the current literature uses Markov chain models to estimate HZ prevalence. Cost assumptions, discount rate assumptions, assumptions about vaccine efficacy and waning and epidemiological assumptions drove variation in the outcomes. This article transforms the results into a table easily understood by policy-makers. CONCLUSION: The majority of the current literature shows that HZ vaccination is cost-effective at the price of $100,000 per QALY. Few studies showed that vaccination cost-effectiveness was higher than this threshold, and only under conservative assumptions. Cost-effectiveness was sensitive to vaccine price and discount rate.

Smoking during pregnancy: findings from the 2009-2010 Canadian Community Health Survey.

OBJECTIVES: Smoking during pregnancy may cause many health problems for pregnant women and their newborns. However, there is a paucity of research that has examined the predictors of smoking during pregnancy in Canada. This study used data from the 2009-2010 Canadian Community Health Survey (CCHS) to estimate the prevalence of smoking during pregnancy and examine the demographic, socioeconomic, health-related and behavioral determinants of this behavior. METHODS AND FINDINGS: The data were obtained from the 2009-2010 CCHS master data file. Weighted estimates of the prevalence were calculated. Multivariable logistic regression was used to determine demographic, socioeconomic, health related and behavioral characteristics associated with smoking behavior during pregnancy. Women living in the Northern Territories had a high rate of smoking during pregnancy (59.3%). The prevalence of smoking during pregnancy was also high among women under 25 years old, of low socioeconomic status, who reported not having a regular medical doctor, being fair to poor in self-perceived health, having at least one chronic disease, having at least one mental illness, being heavy smokers, and being regular alcohol drinkers. Results from multivariable logistic regression revealed that the odds of smoking during pregnancy were decreased with increasing age (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.91-0.99), having a regular family doctor [OR, 0.24; 95% CI, 0.11-0.52], having highest level of family income [OR, 0.09; 95% CI, 0.03-0.29]. Mothers who reported poor or fair self-perceived health [OR, 2.13; 95% CI, 0.96-4.71] and those who had at least one mental illness [OR, 1.81; 95% CI, 1.00-3.28] had greater odds of smoking during pregnancy. CONCLUSIONS: There are a number of demographic, socio-economic, health-related and behavioral characteristics that should be considered in developing and implementing effective population health promotional strategies to prevent smoking during pregnancy, promoting health and well-being of pregnant women and their newborns.

Paying people to be healthy.

User Financial Incentives (UFIs) have emerged as a powerful tool for health promotion. Strong evidence suggests that large enough incentives paid to individuals conditional on behaviour they can control encourages more of the desired behaviour. However, such interventions can have unintended consequences for non-targeted behaviours. Implementation difficulties that result in individuals not understanding the nature of the incentive, unintended opportunities to "game" the system and inefficient roll-outs, can dampen results. Moreover, the legitimacy of paternalistic interventions by health planners requires careful consideration if we accept that the families involved will almost certainly be better judges of their own best interests than outsiders.

Economic evaluation of Manitoba Health Lines in the management of congestive heart failure.

OBJECTIVE: This one-year study investigated whether the Manitoba Provincial Health Contact program for congestive heart failure (CHF) is a cost-effective intervention relative to the standard treatment. DESIGN: Individual patient-level, randomized clinical trial of cost-effective model using data from the Health Research Data Repository at the Manitoba Centre for Health Policy, University of Manitoba. METHODS: A total of 179 patients aged 40 and over with a diagnosis of CHF levels II to IV were recruited from Winnipeg and Central Manitoba and randomized into three treatment groups: one receiving standard care, a second receiving Health Lines (HL) intervention and a third receiving Health Lines intervention plus in-house monitoring (HLM). A cost-effectiveness study was conducted in which outcomes were measured in terms of QALYs derived from the SF-36 and costs using 2005 Canadian dollars. Costs included intervention and healthcare utilization. Bootstrap-resampled incremental cost-effectiveness ratios were computed to take into account the uncertainty related to small sample size. RESULTS: The total per-patient mean costs (including intervention cost) were not significantly different between study groups. Both interventions (HL and HLM) cost less and are more effective than standard care, with HL able to produce an additional QALY relative to HLM for $2,975. The sensitivity analysis revealed that there is an 85.8% probability that HL is cost-effective if decision-makers are willing to pay $50,000. CONCLUSION: Findings demonstrate that the HL intervention from the Manitoba Provincial Health Contact program for CHF is an optimal intervention strategy for CHF management compared to standard care and HLM.

Is it worthwhile to invest in home care?

The objective of this study was to estimate the impact of the First Nations and Inuit Home and Community Care Program (FNIHCCP) on the rates of hospitalization for ambulatory care sensitive conditions (ACSCs) in the province of Manitoba. A population-based time trend analysis was conducted using the de-identified administrative data housed at the Manitoba Centre for Health Policy, including data from 1984/85 to 2004/05. Findings show a significant decline in the rates of hospitalization (all conditions) following the introduction of the FNIHCCP in communities served by health offices (p<0.0001), health centres (p<0.0001) and nursing stations (p=0.0022). Communities served by health offices or health centres also experienced a significant reduction in rates of hospitalization for chronic conditions (p<0.0001).The results of this study suggest that investment in home care resulted in a significant decline in rates of avoidable hospitalization, especially in communities that otherwise had limited access to primary healthcare.

Have investments in on-reserve health services and initiatives promoting community control improved First Nations' health in Manitoba?

The objective of this study was to document the relationship between First Nation's community characteristics and the rates of hospitalization for Ambulatory Care Sensitive Conditions (ACSC) in the province of Manitoba, Canada. A population-based time trend analysis of selected ACSC was conducted using the de-identified administrative data housed at the Manitoba Centre for Health Policy, including vital statistics and health information. The study population included all Manitoba residents eligible under the universal Manitoba Health Services Insurance Plan and living on First Nation reserves between 1984/85 and 2004/05. Twenty-nine ACSC defined using 3, 4 and 5 digit ICD-9-CM and ICD-10-CM codes permitted cross-sectional and longitudinal comparison of hospitalization rates. The analysis used Generalized Estimated Equation (GEE) modeling. Two variables were significant in our model: level of access to primary health care on-reserve; and level of local autonomy. Communities with local access to a broader complement of primary health care services showed a lower rate of hospitalization for ACSC. We also examined whether there was a significant trend in the rates of hospitalization for ACSC over time following the signature of an agreement increasing local autonomy over resource allocation. We found the rates of hospitalization for ACSC decreased with each year following the signature of such an agreement. This article demonstrates that communities with better local access to primary health care consistently show lower rates of ACSC. Secondly, the longer community health services have been under community control, the lower its ACSC rate.

Variations in Lifetime Healthcare Costs across a Population.

The mean costs of providing healthcare increase with age, but within every age/sex cohort there is substantial variation. Moreover, this variation does not disappear over the users' lifetime. This study applies Markov modelling to administrative data to examine the variability of healthcare costs currently covered under the Canada Health Act across a population and over the lifespan. Policy initiatives that ignore individual variability across the lifespan yield inequitable results. For example, age-specific policies that exempt seniors from costs charged to the rest of the population will transfer healthcare resources to healthy low-cost seniors from younger individuals with higher needs.

Medical Savings Accounts: will they reduce costs?

BACKGROUND: Medical Savings Accounts are an attempt to reduce health care costs by transferring responsibility for expenditures to patients, while providing them with state-supported base amounts to cover some of the costs. We wondered whether such a system would actually be effective, given the fact that medical care expenditures (and illness) are unequally distributed across the population. METHODS: We used the Manitoba Population Health Research Data Respository to assess costs incurred by individual residents of Manitoba for all physician visits and admissions to hospital between 1997 and 1999, and we calculated an average expenditure per person per year over the 3 years. RESULTS: During fiscal years 1997-1999, physician and hospital costs that could be attributed to individual Manitoba residents averaged $730 each year. Most users accounted for very little expenditure. About 40% of the entire population of Manitoba used less than $100 each, and 80% used less than $600. The highest-using 1% of the Manitoba population accounted for 26% of all spending on hospital and physician care, whereas the lowest-using 50% accounted for 4%. When examined by age category, the results were similar. Even in the highest age category, most of the population falls into the low-usage category. If the entitlement under a Medical Savings Account scheme was set at the current average cost of $730 per year, then total spending by government on health care for this healthy group would increase (by $505 million) rather than decrease. If the "catastrophic threshold," above which the insurer would pay costs, was set at $1,000 per year, then the sickest 20% of Manitoba residents would become personally responsible for just over $60 million of current health care costs. The net result is a 54% increase in spending on hospital and physician costs that can be allocated to individuals. INTERPRETATION: Medical Savings Accounts will not save money but will instead, under most formulations, lead to an increase in spending on the healthiest members of the population.