New and continuing physician-based outpatient mental health care among children and adolescents during the COVID-19 pandemic in Ontario, Canada: a population-based study.

Objective: To assess physician-based mental health care utilization during the COVID-19 pandemic among children and adolescents new to care and those already engaged with mental health services, and to evaluate differences by sociodemographic factors. Study design: We performed a population-based repeated cross-sectional study using linked health and administrative databases in Ontario, Canada among all children and adolescents 3-17 years. We examined outpatient visit rates per 1,000 population for mental health concerns for those new to care (no physician-based mental healthcare for ≥1 year) and those with continuing care needs (any physician-based mental healthcare <1 year) following onset of the pandemic. Results: Among ~2.5 million children and adolescents (48.7% female, mean age 10.1 ± 4.3 years), expected monthly mental health outpatient visits were 1.5/1,000 for those new to mental health care and 5.4/1,000 for those already engaged in care. Following onset of the pandemic, visit rates for both groups were above expected [adjusted rate ratio (aRR) 1.22, 95% CI 1.17, 1.27; aRR 1.10, 95% CI 1.07, 1.12] for new and continuing care, respectively. The greatest increase above expected was among females (new: aRR 1.33, 95% CI 1.25, 1.42; continuing: aRR 1.22 95% CI 1.17, 1.26) and adolescents ages 13-17 years (new: aRR 1.31, 95% CI 1.27, 1.34; continuing: aRR 1.15 95% CI 1.13, 1.17). Mood and anxiety concerns were prominent among those new to care. Conclusion: In the 18 months following onset of the pandemic, outpatient mental health care utilization increased for those with new and continuing care needs, especially among females and adolescents.

Population-Based Repeated Cross-Sectional Study of Hospitalizations for Comorbid Physical and Psychiatric Disorders in Young Adults in Ontario, Canada.

PURPOSE: To measure trends in the rates and costs of hospitalizations over a 15-year period among young adults with physical and/or psychiatric disorders. METHODS: This population-based, repeated cross-sectional study identified all 18- to 26- year-olds hospitalized in Ontario, Canada from April 1, 2003 and March 31, 2018 (fiscal years 2003-2017). Using discharge diagnoses, we assigned hospitalizations to one of four categories: 1) psychiatric disorder only; 2) primary psychiatric disorder with comorbid physical illness; 3) primary physical with comorbid psychiatric disorder; and 4) physical illness only. We compared health service utilization and changes in rates of hospitalizations over time using restricted cubic spline regression. Secondary outcome measures included change in hospital costs for each hospitalization category over the study period. RESULTS: Of 1,076,951 hospitalizations in young adults (73.7% female), 195,726 (18.2%) had a psychiatric disorder (either primary or comorbid). There were 129,676 hospitalizations (12.0%) with psychiatric disorders only, 36,287 (3.4%) with primary psychiatric and comorbid physical disorders, 29,763 (2.8%) with primary physical and comorbid psychiatric disorders, and 881,225 (81.8%) with physical disorders only. Rates of hospitalization for psychiatric disorders only increased 81% from 4.32 to 7.84/1,000 population, and those with physical health disorders with comorbid psychiatric disorders increased 172% from 0.47 to 1.28/1,000 population. Substance-related disorders were the most common comorbid psychiatric disorders among youth hospitalized for physical illness and increased 260% from 0.9 to 3.3/1,000 population. DISCUSSION: Hospitalizations among young adults with primary and comorbid psychiatric disorders have increased significantly over the past 15 years. Health system resources should be adequately directed to meet the shifting and complex needs of hospitalized young adults.

Sociodemographic Differences in Physician-Based Mental Health and Virtual Care Utilization and Uptake of Virtual Care Among Children and Adolescents During the COVID-19 Pandemic in Ontario, Canada: A Population-Based Study.

OBJECTIVE: We sought to evaluate the relationship between social determinants of health and physician-based mental healthcare utilization and virtual care use among children and adolescents in Ontario, Canada, during the COVID-19 pandemic. METHODS: This population-based repeated cross-sectional study of children and adolescents (3-17 years; N = 2.5 million) used linked health and demographic administrative data in Ontario, Canada (2017-2021). Multivariable Poisson regressions with generalized estimating equations compared rates of outpatient physician-based mental healthcare use during the first year of the COVID-19 pandemic with expected rates based on pre-COVID patterns. Analyses were conducted by socioeconomic status (material deprivation quintiles of the Ontario Marginalization index), urban/rural region of residence, and immigration status. RESULTS: Overall, pediatric physician-based mental healthcare visits were 5% lower than expected (rate ratio [RR] = 0.95, 95% confidence interval [CI], 0.92 to 0.98) among those living in the most deprived areas in the first year of the pandemic, compared with the least deprived with 4% higher than expected rates (RR = 1.04, 95% CI, 1.02 to 1.06). There were no differences in overall observed and expected visit rates by region of residence. Immigrants had 14% to 26% higher visit rates compared with expected from July 2020 to February 2021, whereas refugees had similarly observed and expected rates. Virtual care use was approximately 65% among refugees, compared with 70% for all strata. CONCLUSION: During the first year of the pandemic, pediatric physician-based mental healthcare utilization was higher among immigrants and lower than expected among those with lower socioeconomic status. Refugees had the lowest use of virtual care. Further work is needed to understand whether these differences reflect issues in access to care or the need to help inform ongoing pandemic recovery planning.

Utilization of Physician-Based Mental Health Care Services Among Children and Adolescents Before and During the COVID-19 Pandemic in Ontario, Canada.

IMPORTANCE: Public health measures to reduce the spread of COVID-19 have heightened distress among children and adolescents and contributed to a shift in delivery of mental health care services. OBJECTIVES: To measure and compare physician-based outpatient mental health care utilization before and during the COVID-19 pandemic and quantify the extent of uptake of virtual care delivery. DESIGN, SETTING, AND PARTICIPANTS: Population-based repeated cross-sectional study using linked health and administrative databases in Ontario, Canada. All individuals aged 3 to 17 years residing in Ontario from January 1, 2017, to February 28, 2021. EXPOSURES: Pre-COVID-19 period from January 1, 2017, to February 29, 2020, and post-COVID-19 onset from March 1, 2020, to February 28, 2021. MAIN OUTCOMES AND MEASURES: Physician-based outpatient weekly visit rates per 1000 population for mental health diagnoses overall and stratified by age group, sex, and mental health diagnostic grouping and proportion of virtual visits. Poisson generalized estimating equations were used to model 3-year pre-COVID-19 trends and forecast expected trends post-COVID-19 onset and estimate the change in visit rates before and after the onset of COVID-19. The weekly proportions of virtual visits were calculated. RESULTS: In a population of almost 2.5 million children and adolescents (48.7% female; mean [SD] age, 10.1 [4.3] years), the weekly rate of mental health outpatient visits was 6.9 per 1000 population. Following the pandemic onset, visit rates declined rapidly to below expected (adjusted relative rate [aRR], 0.81; 95% CI, 0.79-0.82) in April 2020 followed by a growth to above expected (aRR, 1.07; 95% CI, 1.04-1.09) by July 2020 and sustained at 10% to 15% above expected as of February 2021. Adolescent female individuals had the greatest increase in visit rates relative to expected by the end of the study (aRR, 1.26; 95% CI, 1.25-1.28). Virtual care accounted for 5.0 visits per 1000 population (72.5%) of mental health visits over the study period, with a peak of 5.3 visits per 1000 population (90.1%) (April 2020) and leveling off to approximately 70% in the latter months. CONCLUSIONS AND RELEVANCE: Physician-based outpatient mental health care in Ontario increased during the pandemic, accompanied by a large, rapid shift to virtual care. There was a disproportionate increase in use of mental health care services among adolescent female individuals. System-level planning to address the increasing capacity needs and to monitor quality of care with such large shifts is warranted.

Health System-Level Evaluation of Tele-Mental Health Services Among Children and Adolescents in Ontario, Canada.

OBJECTIVE: To describe the characteristics of children and adolescents receiving tele-mental health services in Ontario, Canada and examine access to a psychiatrist, in-person or via tele-mental health services, following a mental health and addictions (MHA)-related emergency department (ED) visit or hospitalization. METHOD: Using linked health and administrative data, we described two cohorts: (1) children and adolescents (1-18 years) who used a provincial tele-mental health programme from January 1, 2013 to March 31, 2017, comparing their MHA-related service use (outpatient, ED, hospitalization) in the 1 year prior to and the 1 year following initial consultation; (2) children and adolescents with high mental health service needs, defined as those with an incident MHA-related ED visit or hospitalization between January 1, 2013 and December 31, 2016, examining their 1-year follow-up with telemedicine and other health care utilization. RESULTS: In the first cohort, 7,216 children and adolescents (mean age 11.8 [±3.8] years) received tele-mental health services. The proportion of MHA-related ED visits [15.1% pre vs. 12.6% post (test statistic 23.57, P < 0.001)] or hospitalizations [10.2% pre vs. 8.7% post (test statistic 11.96, P < 0.001)] declined in the year following tele-mental health consultation, while local psychiatry visits increased [8.4% pre vs. 17.0% post (test statistic 298.69, P < 0.001)]. In the second cohort (n = 84,033), only 1.5% received tele-mental health services, 40.7% saw a psychiatrist in-person, and 32.5% received no MHA-related outpatient care in follow-up. CONCLUSIONS: Tele-mental health services were rarely used in Ontario, even among high-needs children and adolescents, despite their association with increased access to care and less need for acute mental health care.

Ovarian cancer incidence and death in average-risk women undergoing bilateral salpingo-oophorectomy at benign hysterectomy.

BACKGROUND: Opportunistic bilateral salpingo-oophorectomy is often offered to patients undergoing benign hysterectomy to prevent ovarian cancer, but the magnitude of risk reduction obtained with bilateral salpingo-oophorectomy in this population remains unclear and must be weighed against potential risks of ovarian hormone deficiency. OBJECTIVE: This study aimed to quantify the relative and absolute risk reduction in ovarian cancer incidence and death associated with bilateral salpingo-oophorectomy at the time of benign hysterectomy. STUDY DESIGN: We performed a population-based cohort study of all adult women (≥20 years) undergoing benign hysterectomy from 1996 to 2010 in Ontario, Canada. Patients with ovarian pathology, previous breast or gynecologic cancer, or evidence of genetic susceptibility to malignancy were excluded. Inverse probability of treatment-weighted Fine-Gray subdistribution hazard models were used to quantify the effect of bilateral salpingo-oophorectomy on ovarian cancer incidence and death while accounting for competing risks and adjusting for demographic characteristics, gynecologic conditions, and comorbidities. Analyses were performed in all women and specifically in women of postmenopausal age (≥50 years) at the time of hysterectomy. RESULTS: We identified 195,282 patients (bilateral salpingo-oophorectomy, 24%; ovarian conservation, 76%) with a median age of 45 years (interquartile range, 40-51 years). Over a median follow-up of 16 years (interquartile range, 12-20 years), 548 patients developed ovarian cancer (0.3%), and 16,170 patients (8.3%) died from any cause. Bilateral salpingo-oophorectomy was associated with decreased ovarian cancer incidence (hazard ratio, 0.23; 95% confidence interval, 0.14-0.38; P<.001) and decreased ovarian cancer death (hazard ratio, 0.30; 95% confidence interval, 0.16-0.57; P<.001). At 20 years follow-up, the weighted cumulative incidences of ovarian cancer were 0.08% and 0.46% with bilateral salpingo-oophorectomy and ovarian conservation, respectively, yielding an absolute risk reduction of 0.38% (95% confidence interval, 0.32-0.45; number needed to treat, 260). After restricting to women aged ≥50 years at hysterectomy, the absolute risk reduction was 0.62% (95% confidence interval, 0.47-0.77; number needed to treat, 161). CONCLUSION: Bilateral salpingo-oophorectomy resulted in a significant absolute reduction in ovarian cancer among women undergoing benign hysterectomy. Population-average risk estimates derived in this study should be balanced against other potential implications of bilateral salpingo-oophorectomy to inform practice guidelines, patient decision-making, and surgical management.

Examining Variations in the Prevalence of Diagnosed Mood or Anxiety Disorders Among Migrant Groups in Ontario, 1995-2015: A Population-Based, Repeated Cross-Sectional Study.

BACKGROUND: International evidence on the frequency of mood or anxiety disorders among migrant groups is highly variable, as it is dependent on the time since migration and the socio-political context of the host country. Our objective was to estimate trends in the prevalence of diagnosed mood or anxiety disorders among recent (<5 years in Canada) and settled (5-10 years in Canada) migrant groups, relative to the general population of Ontario, Canada. METHODS: We used a repeated cross-sectional design consisting of four cross-sections spanning 5 years each, constructed using health administrative databases from 1995 to 2015. We included all Ontario residents between the ages of 16 and 64 years. We assessed differences in the prevalence of mood or anxiety disorders adjusting for age, sex, and neighbourhood-level income. We further evaluated the impact of migrant class and region of birth. RESULTS: The prevalence of mood or anxiety disorders was lower among recent (weighted mean = 4.10%; 95% confidence interval [CI], 3.59% to 4.60%) and settled (weighted mean = 4.77%; 95% CI, 3.94% to 5.61%) migrant groups, relative to the general population (weighted mean = 7.39%; 95% CI, 6.83% to 7.94%). Prevalence estimates varied greatly by region of birth and migrant class. We found variation in prevalence estimates over time, with refugee groups having the largest increases between 1995 and 2015. CONCLUSIONS: Our findings highlight the complexity of mood and anxiety disorders among migrant groups, and that not all groups share the same risk profile. These results can be used to help inform health service allocation and the development of supportive programs for specific migrant groups.

Association of bilateral salpingo-oophorectomy with all cause and cause specific mortality: population based cohort study.

OBJECTIVES: To determine if bilateral salpingo-oophorectomy, compared with ovarian conservation, is associated with all cause or cause specific death in women undergoing hysterectomy for non-malignant disease, and to determine how this association varies with age at surgery. DESIGN: Population based cohort study. SETTING: Ontario, Canada from 1 January 1996 to 31 December 2015, and follow-up to 31 December 2017. PARTICIPANTS: 200 549 women (aged 30-70 years) undergoing non-malignant hysterectomy, stratified into premenopausal (<45 years), menopausal transition (45-49 years), early menopausal (50-54 years), and late menopausal (≥55 years) groups according to age at surgery; median follow-up was 12 years (interquartile range 7-17). EXPOSURES: Bilateral salpingo-oophorectomy versus ovarian conservation. MAIN OUTCOMES MEASURES: The primary outcome was all cause death. Secondary outcomes were non-cancer and cancer death. Within each age group, overlap propensity score weighted survival models were used to examine the association between bilateral salpingo-oophorectomy and mortality outcomes, while adjusting for demographic characteristics, gynaecological conditions, and comorbidities. To account for comparisons in four age groups, P<0.0125 was considered statistically significant. RESULTS: Bilateral salpingo-oophorectomy was performed in 19%, 41%, 69%, and 81% of women aged <45, 45-49, 50-54, and ≥55 years, respectively. The procedure was associated with increased rates of all cause death in women aged <45 years (hazard ratio 1.31, 95% confidence interval 1.18 to 1.45, P<0.001; number needed to harm 71 at 20 years) and 45-49 years (1.16, 1.04 to 1.30, P=0.007; 152 at 20 years), but not in women aged 50-54 years (0.83, 0.72 to 0.97, P=0.018) or ≥55 years (0.92, 0.82 to 1.03, P=0.16). Findings in women aged <50 years were driven largely by increased non-cancer death. In secondary analyses identifying a possible change in the association between bilateral salpingo-oophorectomy and all cause death with advancing age at surgery, the hazard ratio gradually decreased during the menopausal transition and remained around 1 at all ages thereafter. CONCLUSION: In this observational study, bilateral salpingo-oophorectomy at non-malignant hysterectomy appeared to be associated with increased all cause mortality in women aged <50 years, but not in those aged ≥50 years. While caution is warranted when considering bilateral salpingo-oophorectomy in premenopausal women without indication, this strategy for ovarian cancer risk reduction does not appear to be detrimental to survival in postmenopausal women.

Acute mental health service use following onset of the COVID-19 pandemic in Ontario, Canada: a trend analysis.

BACKGROUND: The extent to which heightened distress during the COVID-19 pandemic translated to increases in severe mental health outcomes is unknown. We examined trends in psychiatric presentations to acute care settings in the first 12 months after onset of the pandemic. METHODS: This was a trends analysis of administrative population data in Ontario, Canada. We examined rates of hospitalizations and emergency department visits for mental health diagnoses overall and stratified by sex, age and diagnostic grouping (e.g., mood disorders, anxiety disorders, psychotic disorders), as well as visits for intentional self-injury for people aged 10 to 105 years, from January 2019 to March 2021. We used Joinpoint regression to identify significant inflection points after the onset of the pandemic in March 2020. RESULTS: Among the 12 968 100 people included in our analysis, rates of mental health-related hospitalizations and emergency department visits declined immediately after the onset of the pandemic (peak overall decline of 30% [hospitalizations] and 37% [emergency department visits] compared to April 2019) and returned to near prepandemic levels by March 2021. Compared to April 2019, visits for intentional self-injury declined by 33% and remained below prepandemic levels until March 2021. We observed the largest declines in service use among adolescents aged 14 to 17 years (55% decline in hospitalizations, 58% decline in emergency department visits) and 10 to 13 years (56% decline in self-injury), and for those with substance-related disorders (33% decline in emergency department visits) and anxiety disorders (61% decline in hospitalizations). INTERPRETATION: Contrary to expectations, the abrupt decline in acute mental health service use immediately after the onset of the pandemic and the return to near prepandemic levels that we observed suggest that changes and stressors in the first 12 months of the pandemic did not translate to increased service use. Continued surveillance of acute mental health service use is warranted.

Factors affecting management of children's low-risk distal radius fractures in the emergency department: a population-based retrospective cohort study.

BACKGROUND: Ten randomized controlled trials over the last 2 decades support treating low-risk pediatric distal radius fractures with removable immobilization and without physician follow-up. We aimed to determine the proportion of these fractures being treated without physician follow-up and to determine whether different hospital and physician types are treating these injuries differently. METHODS: We conducted a retrospective population-based cohort study using ICES data. We included children aged 2-14 years (2-12 yr for girls and 2-14 yr for boys) with distal radius fractures having had no reduction or operation within a 6-week period, and who received treatment in Ontario emergency departments from 2003 to 2015. Proportions of patients receiving orthopedic, primary care and no follow-up were determined. Multivariable log-binomial regression was used to quantify associations between hospital and physician type and management. RESULTS: We analyzed 70 801 fractures. A total of 20.8% (n = 14 742) fractures were treated without physician follow-up, with the proportion of physician follow-up consistent across all years of the study. Treatment in a small hospital emergency department (risk ratio [RR] 1.86, 95% confidence interval [CI] 1.72-2.01), treatment by a pediatrician (RR 1.22, 95% CI 1.11-1.34) or treatment by a subspecialty pediatric emergency medicine-trained physician (RR 1.73, 95% CI 1.56-1.92) were most likely to result in no follow-up. INTERPRETATION: While small hospital emergency departments, pediatricians and pediatric emergency medicine specialists were most likely to manage low-risk distal radius fractures without follow-up, the majority of these fractures in Ontario were not managed according to the latest research evidence. Canadian guidelines are required to improve care of these fractures and to reduce the substantial overutilization of physician resources we observed.

Incidence of Access to Ambulatory Mental Health Care Prior to a Psychiatric Emergency Department Visit Among Adults in Ontario, 2010-2018.

Importance: Psychiatric emergency department (ED) visits may be avoidable if individuals have access to adequate outpatient care, but the extent to which individuals use the ED itself as a key point of access is largely unknown. Objective: To describe the extent to which the ED is a first point of contact for mental health care among adults, and identify key factors associated with this outcome. Design, Setting, and Participants: This cohort study was conducted from 2010 to 2018 in Ontario, Canada. Using health care administrative data, all individuals aged 16 years and older with an incident psychiatric ED visit were included. Statistical analysis was performed from September 2019 to February 2021. Main Outcomes and Measures: The primary outcome was no outpatient mental health or addictions contact in the 2 years preceding the incident ED visit. The study also measured predisposing (age, sex, immigrant status, comorbidity), enabling (neighborhood income, rurality, continuity of primary care), and need factors (diagnosis from incident ED visit) associated with the so-called first-contact ED visits, generating adjusted odds ratios (aORs) and 95% CIs. Results: The cohort included 659 084 patients who visited the ED. Among these patients, 340 354 were female individuals (51.6%), and the mean (SD) age was 39.1 (18.5) years. The incident ED visit was a first contact for 298 924 individuals (45.4%). Patients who had increased odds of first-contact ED visits included older individuals (aged 65-84 years vs 16-24 years; aOR, 1.13; 95% CI, 1.12-1.14), male individuals (aOR, 1.14; 95% CI, 1.13-1.15), immigrants (eg, economic class immigrant vs nonimmigrant status: aOR, 1.20; 95% CI, 1.18-1.21), rural residents (aOR, 1.21; 95% CI, 1.20-1.21), and in those with minimal primary care (aOR, 1.68; 95% CI, 1.67-1.69). All diagnoses had a higher likelihood of first-contact ED visits than mood disorders, particularly substance and alcohol use disorders (aOR, 1.66; 95% CI, 1.65-1.68). Conclusions and Relevance: This study's results suggest that nearly half of incident psychiatric ED visits were first-contact visits, which may be avoidable. Targeted efforts to improve outpatient access should focus on populations with risk factors for first-contact ED presentations, including men, older adults, rural residents, those with poor primary care connectivity, and those with substance-related diagnoses.

A Bayesian approach to estimating the population prevalence of mood and anxiety disorders using multiple measures.

AIMS: There is currently no universally accepted measure for population-based surveillance of mood and anxiety disorders. As such, the use of multiple linked measures could provide a more accurate estimate of population prevalence. Our primary objective was to apply Bayesian methods to two commonly employed population measures of mood and anxiety disorders to make inferences regarding the population prevalence and measurement properties of a combined measure. METHODS: We used data from the 2012 Canadian Community Health Survey - Mental Health linked to health administrative databases in Ontario, Canada. Structured interview diagnoses were obtained from the survey, and health administrative diagnoses were identified using a standardised algorithm. These two prevalence estimates, in addition to data on the concordance between these measures and prior estimates of their psychometric properties, were used to inform our combined estimate. The marginal posterior densities of all parameters were estimated using Hamiltonian Monte Carlo (HMC), a Markov Chain Monte Carlo technique. Summaries of posterior distributions, including the means and 95% equally tailed posterior credible intervals, were used for interpretation of the results. RESULTS: The combined prevalence mean was 8.6%, with a credible interval of 6.8-10.6%. This combined estimate sits between Bayesian-derived prevalence estimates from administrative data-derived diagnoses (mean = 7.4%) and the survey-derived diagnoses (mean = 13.9%). The results of our sensitivity analysis suggest that varying the specificity of the survey-derived measure has an appreciable impact on the combined posterior prevalence estimate. Our combined posterior prevalence estimate remained stable when varying other prior information. We detected no problematic HMC behaviour, and our posterior predictive checks suggest that our model can reliably recreate our data. CONCLUSIONS: Accurate population-based estimates of disease are the cornerstone of health service planning and resource allocation. As a greater number of linked population data sources become available, so too does the opportunity for researchers to fully capitalise on the data. The true population prevalence of mood and anxiety disorders may reside between estimates obtained from survey data and health administrative data. We have demonstrated how the use of Bayesian approaches may provide a more informed and accurate estimate of mood and anxiety disorders in the population. This work provides a blueprint for future population-based estimates of disease using linked health data.

Practice variation in bilateral salpingo-oophorectomy at benign abdominal hysterectomy: a population-based study.

BACKGROUND: Bilateral salpingo-oophorectomy at benign hysterectomy is not recommended in premenopausal women who are in the premenopausal stage because of its potential associations with increased all-cause mortality and cardiovascular disease; however, contemporary practice patterns are unknown. OBJECTIVE: This study aimed to quantify between-surgeon variation in bilateral salpingo-oophorectomy and identify surgeon and patient characteristics associated with bilateral salpingo-oophorectomy to evaluate current quality of care and identify targets for knowledge translation and future research. STUDY DESIGN: We conducted a population-based retrospective cross-sectional study of adult women (≥20 years) undergoing benign abdominal hysterectomy from 2014 to 2018 in Ontario, Canada. Hierarchical multivariable logistic regression models, stratified by age group (<45, 45-54, ≥55 years), were used to model between-surgeon variation after multivariable adjustment for patient and surgeon characteristics. Cases of bilateral salpingo-oophorectomy were classified as potentially appropriate or potentially avoidable based on the presence or absence of diagnostic indications. RESULTS: Of 44,549 eligible women, 17,797 (39.9%) underwent concurrent bilateral salpingo-oophorectomy, and 26,752 (60.1%) did not. In all three age strata, the individual surgeon providing care was one of the strongest factors influencing whether patients received bilateral salpingo-oophorectomy (median odds ratio, 2.00-2.53). Surgeons accounted for more than 22% of the residual observed variation in bilateral salpingo-oophorectomy in women aged 45-54 years compared with 16% and 14% of the residual observed variation in bilateral salpingo-oophorectomy in women aged <45 and ≥55 years, respectively. Non-gynecologic patient factors, such as obesity (odds ratio, 1.33; 95% confidence interval, 1.17-1.52; P<.001) and residing in low-income regions (odds ratio, 1.34; 95% confidence interval, 1.16-1.55; P<.001), were also associated with bilateral salpingo-oophorectomy. Approximately 40% of patients who underwent bilateral salpingo-oophorectomy had no indication for the procedure in their discharge records. CONCLUSION: Marked between-surgeon variation in bilateral salpingo-oophorectomy rates, even after adjusting for patient case mix, suggests ongoing uncertainty in practice. Stronger evidence-based guidelines on the risks and benefits of salpingo-oophorectomy as women age are needed, particularly focusing on perimenopausal women.

Does physician compensation for declaration of involuntary status increase the likelihood of involuntary admission? A population-level cross-sectional linked administrative database study.

BACKGROUND: There is substantial variability in involuntary psychiatric admission rates across countries and sub-regions within countries that are not fully explained by patient-level factors. We sought to examine whether in a government-funded health care system, physician payments for filling forms related to an involuntary psychiatric hospitalization were associated with the likelihood of an involuntary admission. METHODS: This is a population-based, cross-sectional study in Ontario, Canada of all adult psychiatric inpatients in Ontario (2009-2015, n = 122 851). We examined the association between the proportion of standardized forms for involuntary admissions that were financially compensated and the odds of a patient being involuntarily admitted. We controlled for socio-demographic characteristics, clinical severity, past-health care system utilization and system resource factors. RESULTS: Involuntary admission rates increased from the lowest (Q1, 70.8%) to the highest (Q5, 81.4%) emergency department (ED) quintiles of payment, with the odds of involuntary admission in Q5 being nearly significantly higher than the odds of involuntary admission in Q1 after adjustment (aOR 1.73, 95% CI 0.99-3.01). With payment proportion measured as a continuous variable, the odds of involuntary admission increased by 1.14 (95% CI 1.03-1.27) for each 10% absolute increase in the proportion of financially compensated forms at that ED. CONCLUSIONS: We found that involuntary admission was more likely to occur at EDs with increasing likelihood of financial compensation for invoking involuntary status. This highlights the need to better understand how physician compensation relates to the ethical balance between the right to safety and autonomy for some of the world's most vulnerable patients.

Mental Health and Addictions System Performance in Ontario: An Updated Scorecard, 2009-2017.

Scorecards, particularly those that report on health system performance over time, can shed light on issues related to access and quality. In this updated 2020 Mental Health and Addictions Scorecard, we report on a number of indicators between 2009 and 2017. In general, we found that the performance of the mental health and addictions health system did not improve substantially over time. Among the many findings, over the past decade, suicide rates have not declined and rates of emergency department visits for deliberate self-harm have continued to rise. The highest rates of deliberate self-harm and the greatest rise over time in overall mental health and addictions-related outpatient visits, emergency department visits and hospitalizations were experienced by individuals aged 14-24 years. There continues to be a growing use of mental health services in outpatient settings, with the majority of care provided by primary care physicians. We also observed a slight decrease over time in the proportion of individuals who had no physician-delivered mental health care prior to presenting to the emergency department, which suggests an improvement in access over time.

Deconstructing The Rise In Mental Health-Related ED Visits Among Children And Youth In Ontario, Canada.

Mental illness is a leading cause of disability among youth. In Ontario, Canada, rates of mental health or addiction-related emergency department (ED) visits continue to rise in children and youth; however, it is unclear what is driving this change. We deconstructed this trend by sociodemographic and clinical characteristics, using linked health administrative data sets. Mental health or addiction-related ED visit rates increased by 89.1 percent between 2006 and 2017, with the greatest rise observed for those ages 14-21, high-acuity cases, and anxiety and mood disorders. We observed a significantly sharp increase after 2009, when several socioenvironmental changes occurred, including the emergence of social media and the Great Recession. Our findings of greater numbers of teenagers and young adults experiencing mental health problems and a shift in acuity and diagnoses have important implications for both ED staffing and outpatient mental illness prevention efforts. Further research is needed to examine whether better case management, care coordination, and after-hours services will help reverse these trends.

Discharge and post-discharge outcomes of psychiatric inpatients with a lifetime history of exposure to interpersonal trauma: A population-based study.

OBJECTIVE: To examine discharge and post-discharge outcomes for psychiatric inpatients with a history of exposure to physical, sexual, or emotional trauma. METHODS: In this population-based cohort study using health-administrative data, adult psychiatric inpatients in Ontario, Canada (2009-2016) with and without self-reported lifetime exposure to interpersonal trauma were compared on their likelihood of: discharge against medical advice; post-discharge outpatient follow-up; and post-discharge emergency department (ED) visits, rehospitalization, deliberate self-harm and suicide. Modified Poisson regressions generated relative risks (aRR) and 95% confidence intervals (CI), adjusted for age, sex, income, medical comorbidities, and psychiatric diagnosis. RESULTS: Psychiatric inpatients with a history of interpersonal trauma (n = 50,832/160,436, 31.7%) were at elevated risk for discharge against medical advice (5.6% vs. 4.6%; aRR = 1.27, 1.21-1.33), and for 1-year post-discharge psychiatric ED visits (31.0% vs. 28.3%, aRR = 1.04, 1.02-1.06), and deliberate self-harm (5.5% vs. 3.7%, aRR = 1.30, 1.23-1.36). Post-discharge 30-day follow-up with primary care was slightly more common among those with a trauma history (37.6% vs. 34.5%, aRR = 1.06, 1.04-1.08); psychiatrist follow-up was less common (35.1% vs. 37.1%, aRR = 0.87, 0.86-0.89). Elevations in risk were observed for those with primary diagnoses of psychotic, mood and anxiety disorders, but not for those with a primary diagnosis of substance-related disorders. Risk elevations were specifically observed in those without a diagnosis of post-traumatic stress disorder. CONCLUSION: Implementing supports and services during and after inpatient hospitalization that take into account a history of interpersonal trauma may help reduce certain undesirable discharge and post-discharge outcomes in this slightly higher-risk group.

Trends in objectively measured and perceived mental health and use of mental health services: a population-based study in Ontario, 2002-2014.

BACKGROUND: Mental illness is widely perceived to be more of a public health concern now than in the past; however, it is unclear whether this perception is due to an increase in the prevalence of mental illness, an increase in help-seeking behaviours or both. We examined temporal trends in use of mental health services as well as objectively measured and perceived mental health. METHODS: We conducted a repeat cross-sectional study of Ontario residents who participated in Statistics Canada's Canadian Community Health Survey (2002-2014). We assessed temporal trends in objectively measured past-year major depressive episode (based on criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, and International Classification of Diseases, 10th Revision) and past-month psychological distress (Kessler Psychological Distress Scale-6 score ≥ 8) and perceived, self-rated mental health. We also examined use of mental health services, including service use among those with a need for mental health care. RESULTS: A total of 260 090 survey participants were included. The age- and sex-standardized prevalence of a major depressive episode (4.8%, 95% confidence interval [CI] 4.2%-5.3% in 2002 v. 4.9%, 95% CI 4.2%-5.7% in 2012; p = 0.9) and psychological distress (7.0%, 95% CI 6.3%-7.6% in 2002 v. 6.5%, 95% CI 5.7%-7.5% in 2012; p = 0.4) did not change significantly over time. However, self-rated fair or poor mental health status increased from 4.9% in 2003-2005 to 6.5% in 2011-2014 (p trend < 0.001), as did the use of mental health services (7.2% to 12.8%, p trend < 0.001). The percentage of individuals who had subjective or objectively measured mental health problems and did not access mental health services decreased significantly over time. INTERPRETATION: Given the stable prevalence of objectively measured psychiatric symptoms, the increase in use of mental health services appears to be, at least partly, explained by an increase in perceived poor mental health and help-seeking behaviours.

Health Service Use among Individuals with Depression and Psychological Distress: A Population-Based Cohort Study in Ontario, Canada: Utilisation des services de santé par les personnes souffrant de dépression et de détresse psychologique : une étude de cohorte dans la population de l'Ontario, Canada.

OBJECTIVES: Relatively little is known about how health-care utilization differs among individuals with psychological distress compared to those with major depressive disorder (MDD). METHODS: Ontario participants of the Canadian Community Health Survey Cycle 1.2 (2002) were linked to health administrative data to follow their health-care utilization patterns for up to 15 years. Based on their survey responses, we classified individuals hierarchically into Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria MDD, psychological distress (Kessler-6: 8 to 24), or an unexposed group with neither condition. We compared the rates of outpatient and acute care mental and nonmental health-related visits across the 3 groups over time using Poisson regression. RESULTS: Among the 430 individuals with MDD, 668 with psychological distress, and 9,089 in the unexposed group, individuals with MDD and psychological distress had higher rates of health-care utilization than the unexposed overall and across time. The rates of psychiatrist visits for the MDD group were significantly higher than the other groups initially but declined over the follow-up. Conversely, the rates of psychiatrist visits among the psychological distress group increased over time and converged with that of the MDD group by the end of follow-up (rate ratioMDD vs. psychological distress at 1 year: 4.20 [1.97 to 11.40]; at 15 years: 1.53 [0.54 to 4.08]). Acute care visits were similar between the MDD and psychological distress groups at all time points. CONCLUSIONS: Individuals with psychological distress required mental health care rivalling that of individuals with MDD over time, suggesting that even a cross-sectional assessment of significant psychological distress is a serious clinical concern.

Epidemiology of Interpersonal Trauma among Women and Men Psychiatric Inpatients: A Population-Based Study.

OBJECTIVE: Small clinical samples suggest that psychiatric inpatients report a lifetime history of interpersonal trauma. Since past experiences of trauma may complicate prognosis and treatment trajectories, population-level knowledge is needed about its prevalence and correlates among inpatients. METHODS: Using health-administrative databases comprising all adult psychiatric inpatients in Ontario, Canada (2009 to 2016, n = 160,436, 49% women), we identified those who reported experiencing physical, sexual, and/or emotional trauma in their lifetime, 1 year, and 30 days preceding admission. We described the prevalence of each type of trauma, comparing women and men using modified Poisson regression, and identified individual-level characteristics associated with lifetime trauma history using multivariable logistic regression. RESULTS: 31.7% of inpatients reported experiencing trauma prior to admission. Lifetime prevalence was higher in women (39.6% vs. 24.1%; age-adjusted prevalence ratio [aPR] = 1.68; 95% CI, 1.65 to 1.71), including sexual (22.7% vs. 8.4%; aPR = 2.81; 95% CI, 2.73 to 2.89), emotional (33.3% vs. 19.4%; aPR = 1.76; 95% CI, 1.72 to 1.79), and physical trauma (24.2% vs. 14.8%; aPR = 1.68; 95% CI, 1.65 to 1.72). Factors most prominently associated with lifetime trauma were witnessing parental substance use (adjusted odds ratio [aOR] = 8.68; 95% CI, 8.39 to 8.99), female sex (aOR = 2.29; 95% CI, 2.23 to 2.35), and number of recent stressful life events (aOR = 1.62; 95% CI, 1.59 to 1.65). CONCLUSIONS: These results suggest that trauma-informed approaches are essential to consider in the design and delivery of inpatient psychiatric services for both women and men.