Institutionalizing Community-engaged Translational Science in an Academic Institution: A Community Stakeholder-Driven Process.

BACKGROUND: Although studies have described the power imbalance in academic-community partnerships, little has been published describing how community-based participatory research-informed practitioners can change academic institutions to promote more effective community-engaged research. OBJECTIVES: This paper describes a university-funded community-based participatory project in which academic researchers and their community partners worked together to articulate, develop and advocate for institutionalizing best practices for equitable partnerships throughout the university. METHODS: Findings derive from a collaborative ethnographic process evaluation. RESULTS: The study describes the integral steps proposed to promote equitable community-university research collaboration, the process by which these principles and best practice recommendations were developed, and the institutional change outcomes of this process. CONCLUSIONS: When universities make even small investments toward promoting and nurturing community-engaged research, the quality of the science can be enhanced to advance health equity and community-university relationships can improve, particularly if based on trust, mutual respect, and openness to accomplish a shared vision.

"At the End I Have a Say": Engaging the Chinese Community in Advance Care Planning.

CONTEXT: Despite the association of advance care planning (ACP) with improved patient and caregiver outcomes, Chinese American elders have low rates of ACP. OBJECTIVES: Assess ACP facilitators/barriers in the San Francisco (SF) Chinese community and codesign, implement, and test community-based ACP-promoting pilot events. METHODS: A Chinese Community Committee (N = 19 community-based organization leaders, health system representatives, community members) conducted focus groups in Cantonese and English with Chinese older adults (age ≥55), caregivers, and community leaders. The Committee designed and implemented pilot events in-person and online. We analyzed focus group data using thematic analysis; assessed pre-to-post-event readiness to engage in ACP (validated survey; 14 scale, 4 = most ready); and assessed event acceptability. RESULTS: A total of 34 people participated in six focus groups. Themes described Chinese community-specific importance of ACP (e.g., reduces family burden), barriers (e.g., younger generations lack tools to discuss ACP with elders and vice versa), and facilitators (e.g., intergenerational events, culturally/linguistically appropriate materials). Based on focus groups findings, the Committee developed a novel ACP tool and designed intergenerational events. A total of 195 participants attended 10 events; 95% were Chinese, 90% spoke Chinese languages, 80% were women. ACP readiness increased significantly (1.66 [SD 0.84] vs. 2.03 [SD 0.85]; P < 0.001); 94% of participants were comfortable attending and 96% would recommend events. CONCLUSION: Community-developed intergenerational events that highlight the value of ACP and address barriers are acceptable and increase ACP engagement in the Chinese community.

The development and validation of a patient-reported outcome measure to assess financial hardship among older cancer survivors in China: hardship and recovery with distress survey.

Background: Financial hardship has been described as a patient's economic experiencefollowing cancer-related treatment. Standardized patient-reported outcome measures(PROM) to assess this distress has not been well-studied, especially among older cancer survivors. Objective: The aim of this study was to develop and validate PROM for assessing the financial hardship of older cancer survivors in China. Methods: Items were generated using qualitative interviews and literature review. Items were screened based on Delphi expert consultation and patients' opinions. Item response theory (IRT) and classical test theory (CTT) were used to help reduce items. Retained items formed a pilot instrument that was subjected to psychometric testing. A cut-off score for the new instrument for predicting poor quality of life was identified by receiver operating characteristic (ROC) analysis. Results: Qualitative interviews and literature review generated 135 items, which were reduced to 60 items because of redundancy. Following Delphi expert consultation and patients' evaluation, 24 items with high importance were extracted. Sixteen items were selected due to satisfactory statistical analysis based on CTT and IRT. Ten items were retained and comprised 2 domains after loadings in exploratory factor analysis (EFA). Internal consistency was satisfactory (α = 0.838). Test-retest reliability was good (intraclass correlation, 0.909). The ROC analysis suggested that the cut-off of 18.5 yielded an acceptable sensitivity and specificity. Conclusions: The PROM for Hardship and Recovery with Distress Survey (HARDS) consists of 10 items that specifically reflect the experiences of financial hardship among older Chinese cancer survivors, and it also showed good reliability and validity in clinical settings.

Older cancer survivors living with financial hardship in China: A qualitative study of family perspectives.

OBJECTIVE: Financial hardship among older cancer survivors has not been well-studied, despite its debilitating effects on their health and well-being. The purpose of this study was to describe the lived experiences of Chinese older cancer survivors who have experienced financial hardship following a cancer diagnosis. METHODS: A qualitative study was conducted. Data was collected using in-depth interviews with 21 older cancer survivors (aged ≥ 60) with financial hardship and 20 family caregivers in Shandong Province, China between August 2020 and January 2021. Data were analyzed using Colaizzi's phenomenological method. RESULTS: Four main themes emerged: (1) older survivors have insufficient ability to address cancer-related costs; (2) financial transfers from adult children to older parents became prevalent after a cancer diagnosis; (3) cancer-related financial worries and stress extended into children's families; (4) coping and adjustment strategies were used by the extended family. Traditional Confucian culture and the Chinese health care system considerably impacted the interpretation of financial hardship. CONCLUSION: Both older cancer survivors and their adult children experienced financial distress impacted by filial piety in China. Strategies adapted to Confucian family values and the health care system are needed to address cancer-related financial hardships.

High-Cost Patients and Preventable Spending: A Population-Based Study.

BACKGROUND: Although high-cost (HC) patients make up a small proportion of patients, they account for most health system costs. However, little is known about HC patients with cancer or whether some of their care could potentially be prevented. This analysis sought to characterize HC patients with cancer and quantify the costs of preventable acute care (emergency department visits and inpatient hospitalizations). METHODS: This analysis examined a population-based sample of all HC patients in Ontario in 2013. HC patients were defined as those above the 90th percentile of the cost distribution; all other patients were defined as non-high-cost (NHC). Patients with cancer were identified through the Ontario Cancer Registry. Sociodemographic and clinical characteristics were examined and the costs of preventable acute care for both groups by category of visit/condition were estimated using validated algorithms. RESULTS: Compared with NHC patients with cancer (n=369,422), HC patients with cancer (n=187,770) were older (mean age 70 vs 65 years), more likely to live in low-income neighborhoods (19% vs 16%), sicker, and more likely to live in long-term care homes (8% vs 0%). Although most patients from both cohorts tended to be diagnosed with breast, prostate, or colorectal cancer, those with multiple myeloma or pancreatic or liver cancers were overrepresented among the HC group. Moreover, HC patients were more likely to have advanced cancer at diagnosis and be in the initial or terminal phase of treatment compared with NHC patients. Among HC patients with cancer, 9% of spending stemmed from potentially preventable/avoidable acute care, whereas for NHC patients, this spending was approximately 30%. CONCLUSIONS: HC patients with cancer are a unique subpopulation. Given the type of care they receive, there seems to be limited scope to prevent acute care spending among this patient group. To reduce costs, other strategies, such as making hospital care more efficient and generating less costly encounters involving chemotherapy, should be explored.

Evaluating the Cost Effectiveness of a Suicide Prevention Campaign Implemented in Ontario, Canada.

BACKGROUND: Although suicide-prevention campaigns have been implemented in numerous countries, Canada has yet to implement a strategy nationally. This is the first study to examine the cost utility of the implementation of a multidimensional suicide-prevention program that combines several interventions over a 50-year time horizon. METHODS: We used Markov modeling to capture the dynamic changes to health status and estimate the incremental cost per quality-adjusted life-year gained over a 50-year period for Ontario residents for a suicide-prevention strategy compared to no intervention. The strategy consisted of a package of interventions geared towards preventing suicide including a public health awareness campaign, increased identification of individuals at risk, increased training of primary-care physicians, and increased treatment post-suicide attempt. Four health states were captured by the Markov model: (1) alive and no recent suicide attempt; (2) suicide attempt; (3) death by suicide; (4) death (other than suicide). Analyses were from a societal perspective where all costs, irrespective of payer, were included. We used a probabilistic analysis to test the robustness of the model results to both variation and uncertainty in model parameters. RESULTS: Over the 50-year period, the suicide-prevention campaign had an incremental cost-effectiveness ratio (ICER) of $18,853 (values are in Canadian dollars) per QALY gained. In all one-way sensitivity analyses, the ICER remained under $50,000/QALY. In the probabilistic analysis, there was a probability of 94.8% that the campaign was cost effective at a willingness-to-pay of $50,000/QALY (95% confidence interval of ICER probabilistic distribution: 2650-62,375). Among the current population, the intervention was predicted to result in the prevention of 4454 suicides after 50 years (1033 by year 10; 2803 by year 25). A healthcare payer perspective sensitivity analysis showed an ICER of $21,096.14/QALY. INTERPRETATION: These findings demonstrate that a suicide-prevention campaign in Ontario is very likely a cost-effective intervention to reduce the incidence of suicide and suggest suicide-prevention campaigns are likely to be cost effective for some other Canadian provinces and potentially other countries.

Serious quit attempts and cessation implications for Asian American male smokers.

INTRODUCTION: Smoking prevalence remains high among Asian American immigrant men, particularly those with limited English proficiency. Understanding ways to promote serious quit attempts (defined as a quit attempt lasting at least 24 h) could be crucial for reducing tobacco-related health disparities in this population. This study examines correlates of serious past year quit attempts among Chinese and Vietnamese American male daily smokers. METHODS: Baseline survey data were collected between 2015 and 2017 from a lifestyle intervention trial (N = 340 Chinese and Vietnamese male daily smokers). Data analysis was conducted in 2019. Multivariable logistic regression analysis was used to identify factors associated with serious past year quit attempts. RESULTS: Less than half (43.2%) of the study participants had at least one serious past year quit attempt. Significant correlates of serious quit attempts included utilizing evidence-based methods (OR = 12.83, 95% CI 5.17-31.84) or other methods (OR = 3.92, 95% CI 3.92-13.73) to facilitate quitting compared to those who did not attempt to quit. Also, participants who had a physician encounter in the past year were more likely to have had a serious quit attempt (OR = 2.25, 95% CI 1.12-4.53). Discussing smoking during a past year doctor's visit, however, was not a significant correlate of serious quit attempts. CONCLUSIONS: Our findings underscore the importance of promoting the use of smoking cessation resources, and potentially utilizing healthcare encounters to facilitate cessation. Investigations are warranted to understand better how patient-physician interactions can enhance smoking cessation.

Defining and quantifying preventable and non-preventable hospital-acquired malnutrition-A cohort study.

AIM: To define and quantify hospital-acquired malnutrition, including the concept of preventable and non-preventable malnutrition; and identify the main causes of preventable malnutrition. Furthermore, demonstrate potential cost-savings for a quaternary hospital in Sydney (Australia) if a theoretical model of preventable malnutrition was applied to the penalties associated with hospital-acquired malnutrition, compared to the current government framework. METHODS: A retrospective audit was conducted on electronic medical records reassessing cases of hospital-acquired malnutrition previously identified by dietitians or medical coders. Costs were calculated using the Independent Hospital Pricing Authority's (IHPA) pricing principles for hospital-acquired complications (version 3, 2018). RESULTS: Twenty-three patients of 15 419 admissions were identified with hospital-acquired malnutrition in the 3-month study period. Sixteen cases (70%) were classified as preventable, two cases (9%) were classified as non-preventable, and five cases were non-hospital-acquired cases of malnutrition. Under the IHPA proposed costing model, total cost of all hospital-acquired malnutrition to the hospital is estimated to be $162 600 over 3 months. The theoretical model of preventable malnutrition resulted in a cost penalty of only $98 600, which is a hospital cost-saving of $64 000 (or 40% of the overall penalty) when compared to the current government framework. CONCLUSIONS: The majority of hospital-acquired malnutrition cases were found to have a preventable component. It is proposed that a costing model that penalises hospitals for only preventable hospital-acquired malnutrition be considered, which would permit hospitals to focus on addressing preventable (and thus actionable) causes of hospital-acquired malnutrition with not only potential health benefits to patients but cost-savings to hospitals.

Determining preventable acute care spending among high-cost patients in a single-payer public health care system.

BACKGROUND: Research has shown that a small proportion of patients account for the majority of health care spending. The objective of this analysis was to determine the amount and proportion of preventable acute care spending among high-cost patients. METHODS: We examined a population-based sample of all adult high-cost patients using linked administrative health care data housed at ICES in Toronto, Ontario. High-cost patients were defined as those in and above the 90th percentile of the cost distribution. Preventable acute care (emergency department visits and hospitalisations) was defined using validated algorithms. We estimated costs of preventable and non-preventable acute care for high- and non-high-cost patients by category of visit/condition. We replicated our analysis for persistent high-cost patients and high-cost patients under 65 years and those 65 years and older. RESULTS: We found that 10% of all acute care spending among high-cost patients was considered preventable; this figure was higher for non-high-cost patients (25%). The proportion of preventable acute care spending was higher for persistent high-cost patients (14%) and those 65 years and older (12%). Among ED visits, the largest portion of preventable care spending was for primary care treatable conditions; for hospitalisations, the highest proportions of preventable care spending were for COPD, bacterial pneumonia and urinary tract infections. CONCLUSIONS: Although high-cost patients account for a substantial proportion of health care costs, there seems to be limited scope to prevent acute care spending among this patient population. Nonetheless, care coordination and improved access to primary care, and disease prevention may prevent some acute care.

Food insecurity status and mortality among adults in Ontario, Canada.

BACKGROUND: Food insecurity is associated with a wide array of negative health outcomes and higher health care costs but there has been no population-based study of the association of food insecurity and mortality in high-income countries. METHODS: We use cross-sectional population surveys linked to encoded health administrative data. The sample is 90,368 adults, living in Ontario and respondents in the Canadian Community Health Survey (CCHS). The outcome of interest is all-cause mortality at any time after the interview and within four years of the interview. The primary variable of interest is food insecurity status, with individuals classed as "food secure", "marginally food insecure", "moderately food insecure", or "severely food insecure". We use logistic regression models to determine the association of mortality with food insecurity status, adjusting for other social determinants of health. RESULTS: Using a full set of covariates, in comparison to food secure individuals, the odds of death at any point after the interview are 1.28 (CI = 1.08, 1.52) for marginally food insecure individuals, 1.49 (CI = 1.29, 1.73) for moderately food insecure individuals, and 2.60 (CI = 2.17, 3.12) for severely food insecure individuals. When mortality within four years of the interview is considered, the odds are, respectively, 1.19 (CI = 0.95, 1.50), 1.65 (CI = 1.37, 1.98), and 2.31 (CI = 1.81, 2.93). INTERPRETATION: These findings demonstrate that food insecurity is associated with higher mortality rates and these higher rates are especially large for the most severe food insecurity category. Efforts to reduce food insecurity should be incorporated into broader public health initiatives to reduce mortality.

The role of mental health and addiction among high-cost patients: a population-based study.

AIMS: Previous work found that, among high-cost patients, those with a majority of mental health and addiction (MHA)-related costs (>50%) incur over 30% more costs than other high-cost patients. However, this work did not examine other high-cost patients in depth or whether they had any MHA-related costs. The objective of this analysis was to examine the role of MHA-related care among other high-cost patients. METHODS: Using administrative healthcare data from Ontario, Canada, this study selected all patients in the 90th percentile of the cost distribution in 2012. It focused primarily on two groups based on the percentage of MHA-related costs relative to total costs: (1) high-cost patients with some MHA-related costs (0% > and <50%) and (2) high-cost patients with no MHA-related costs (0%). We examined socio-demographic and clinical characteristics, utilization and costs for both groups, and modeled patient-level costs using appropriate regression techniques. We also compared these groups with high-cost patients with a majority of MHA-related costs (>50%). RESULTS: High-cost patients with some MHA-related costs incurred over 40% more costs than those without ($27,883 vs $19,702). Patients with some MHA-related costs were older, lived in poorer neighborhoods, and had higher levels of comorbidity compared to those without. After controlling for relevant variables, having any type of MHA-related utilization increased costs by $2,698. Having a diagnosis of psychosis had a large impact on costs. LIMITATIONS: This study did not examine children and adolescents. We were only able to account for 91% of all costs incurred by the public third-party payer; addiction-related costs from community-based agencies were not available. CONCLUSIONS: High-cost patients with MHA incur higher costs compared to those without. When considering interventions aimed at high-cost patients, policy-makers should consider their complex nature, specifically both their physical and MHA-related comorbidities.

Payment incentives for community-based psychiatric care in Ontario, Canada.

BACKGROUND: In September 2011, the government of Ontario implemented payment incentives to encourage the delivery of community-based psychiatric care to patients after discharge from a psychiatric hospital admission and to those with a recent suicide attempt. We evaluated whether these incentives affected supply of psychiatric services and access to care. METHODS: We used administrative data to capture monthly observations for all psychiatrists who practised in Ontario between September 2009 and August 2014. We conducted interrupted time-series analyses of psychiatrist-level and patient-level data to evaluate whether the incentives affected the quantity of eligible outpatient services delivered and the likelihood of receiving follow-up care. RESULTS: Among 1921 psychiatrists evaluated, implementation of the incentive payments was not associated with increased provision of follow-up visits after discharge from a psychiatric hospital admission (mean change in visits per month per psychiatrist 0.0099, 95% confidence interval [CI] -0.0989 to 0.1206; change in trend 0.0032, 95% CI -0.0035 to 0.0095) or after a suicide attempt (mean change -0.0910, 95% CI -0.1885 to 0.0026; change in trend 0.0102, 95% CI 0.0045 to 0.0159). There was also no change in the probability that patients received follow-up care after discharge (change in level -0.0079, 95% CI -0.0223 to 0.0061; change in trend 0.0007, 95% CI -0.0003 to 0.0016) or after a suicide attempt (change in level 0.0074, 95% CI -0.0094 to 0.0366; change in trend 0.0006, 95% CI -0.0007 to 0.0022). INTERPRETATION: Our results suggest that implementation of the incentives did not increase access to follow-up care for patients after discharge from a psychiatric hospital admission or after a suicide attempt, and the incentives had no effect on supply of psychiatric services. Further research to guide design and implementation of more effective incentives is warranted.

The direct health care costs of eating disorders among hospitalized patients: A population-based study.

OBJECTIVE: To estimate the direct health care costs of eating disorders in Ontario, Canada, in 2012, using a prevalence-based cost-of-illness approach. METHOD: We selected a population-based sample of all patients eligible for public health care insurance over the age of 4 with a hospitalization for an eating disorder at any point since 1988. We estimated total and mean direct net costs per patient in 2012, from the third public payer perspective, by sex, age group, and health service type. RESULTS: In 2012, there were 6,326 patients ever hospitalized for an eating disorder. They had a mean age of 31 at hospitalization, were mostly female (93%), and generally from high-income, urban neighborhoods. Direct total costs were just under $63 million CAD; direct net costs were roughly $48 million CAD. Mean net costs per patient were higher for females than males ($7,743.40 and $6,340.50, respectively), and higher for patients under 20 and patients 65+ ($17,961.50 and $14,953.90, respectively). The main cost drivers were psychiatric hospitalizations and physician visits, although this varied by age group. For younger patients, net costs were mainly because of psychiatric hospitalizations, while for older patients net costs were mainly because of psychiatric and nonpsychiatric hospitalizations, and other care. DISCUSSION: The cost of eating disorders is substantial and varies by sex and age group. Our findings suggest that, from a health care utilization/cost perspective, the effect of eating disorders is likely to persist over the lifespan.

The direct healthcare costs associated with psychological distress and major depression: A population-based cohort study in Ontario, Canada.

The objective of our study was to estimate direct healthcare costs incurred by a population-based sample of people with psychological distress or depression. We used the 2002 Canadian Community Health Survey on Mental Health and Well Being and categorized individuals as having psychological distress using the Kessler-6, major depressive disorder (MDD) using DSM-IV criteria and a comparison group of participants without MDD or psychological distress. Costs in 2013 USD were estimated by linking individuals to health administrative databases and following them until March 31, 2013. Our sample consisted of 9,965 individuals, of whom 651 and 409 had psychological distress and MDD, respectively. Although the age-and-sex adjusted per-capita costs were similarly high among the psychologically distressed ($3,364, 95% CI: $2,791, $3,937) and those with MDD ($3,210, 95% CI: $2,413, $4,008) compared to the comparison group ($2,629, 95% CI: $2,312, $2,945), the population-wide excess costs for psychological distress ($441 million) were more than twice that for MDD ($210 million) as there was a greater number of people with psychological distress than depression. We found substantial healthcare costs associated with psychological distress and depression, suggesting that psychological distress and MDD have a high cost burden and there may be public health intervention opportunities to relieve distress. Further research examining how individuals with these conditions use the healthcare system may provide insight into the allocation of limited healthcare resources while maintaining high quality care.

How Much Do Mental Health and Substance Use/Addiction Affect Use of General Medical Services? Extent of Use, Reason for Use, and Associated Costs.

OBJECTIVE: To measure service use and costs associated with health care for patients with mental health (MH) and substance use/addiction (SA) problems. METHODS: A 5-year cross-sectional study (2007-2012) of administrative health care data was conducted (average annual sample size = 123,235 adults aged >18 years who had a valid Ontario health care number and used at least 1 service during the year; 55% female). We assessed average annual use of primary care, emergency departments and hospitals, and overall health care costs for patients identified as having MH only, SA only, co-occurring MH and SA problems (MH+SA), and no MH and/or SA (MH/SA) problems. Total visits/admissions and total non-MH/SA visits (i.e., excluding MH/SA visits) were regressed separately on MH, SA, and MH+SA cases compared to non-MH/SA cases using the 2011-2012 sample ( N = 123,331), controlling for age and sex. RESULTS: Compared to non-MH/SA patients, MH/SA patients were significantly ( P < 0.001) more likely to visit primary care physicians (1.82 times as many visits for MH-only patients, 4.24 for SA, and 5.59 for MH+SA), use emergency departments (odds, 1.53 [MH], 3.79 [SA], 5.94 [MH+SA]), and be hospitalized (odds, 1.59 [MH], 4.10 [SA], 7.82 [MH+SA]). MH/SA patients were also significantly more likely than non-MH/SA patients to have non-MH/SA-related visits and accounted for 20% of the sample but over 30% of health care costs. CONCLUSIONS: MH and SA are core issues for all health care settings. MH/SA patients use more services overall and for non-MH/SA issues, with especially high use and costs for MH+SA patients.

Efficacy of a Church-Based, Culturally Tailored Program to Promote Completion of Advance Directives Among Asian Americans.

Having an Advance Directive (AD) can help to guide medical decision-making. Asian Americans (AA) are less likely than White Americans to complete an AD. This pilot study investigated the feasibility and efficacy of a church-based intervention to increase knowledge and behavior change related to AD among Chinese and Vietnamese Americans. This study utilized a single group pre- and post-intervention design with 174 participants from 4 churches. Domain assessed: demographics; AD-related knowledge, beliefs, attitudes, and intentions; AD completion; and conversations with a healthcare proxy. Data were analyzed using Chi square and multiple logistic regression techniques. We observed significant increases in participants' AD-related knowledge, intentions, and a gain in supportive beliefs and attitudes about AD, resulting in 71.8 % AD completion, and 25.0 % having had a proxy conversation. Providing culturally-tailored intervention and step-by-step guidance can help to achieve significant changes in AD related knowledge and behavior in AA church goers.

The Economic Burden of Chronic Psychotic Disorders in Ontario.

BACKGROUND: Chronic psychotic disorders are severe and disabling mental disorders associated with poor psychiatric and medical outcomes. These disorders are considered one of the most costly mental disorders due young age at onset and the need for intensive health care over the life course. AIMS OF THE STUDY: The purpose of this study was to estimate the direct health care costs of chronic psychotic disorders in Ontario in 2012 from the perspective of the third-party payer (i.e., the ministry of health), using a prevalence-based cost-of-illness approach. METHODS: We selected all patients eligible for public health insurance over the age of 15 with a diagnosis of chronic psychotic disorder, using a validated algorithm. Using linked administrative health care databases, we estimated net costs associated with chronic psychotic disorders (i.e., the difference in cost for patients with psychosis and control subjects), using a case-control design. Mean net prevalence costs were estimated for the full sample and disaggregated by sex, age group (16-24; 25-44; 45-64; 65 and over) and health service. RESULTS: In 2012, there were 142,821 patients with a chronic psychotic disorder in Ontario. They had a mean age of 49, were made up of slightly more males (53%) and were mostly from low-income, urban neighbourhoods. Roughly 17% of patients had a psychiatric hospitalization, with an average of 2 hospitalizations and average length of stay of 49 days. The total direct cost of patients with chronic psychotic disorders to the ministry of health was just under 2.1 billion CAD. Total net costs were around 1.5 billion CAD. The main cost drivers were psychiatric hospitalizations (48%), followed by long-term care (14%). Mean net costs were slightly higher for females than males (CAD 10,653 vs. CAD 10,647, respectively). Mean net costs were highest for patients 65 and over, and lowest for patients 25-44 (CAD 15,230 vs. CAD 8,585, respectively). The main cost drivers also varied with age. For younger patients, three-quarters of the net cost were due to psychiatric hospitalizations (74%), while for older patients net costs were mainly due long-term care (38%), followed by psychiatric (24%) and non-psychiatric (14%) hospitalizations. DISCUSSION AND LIMITATIONS: The direct net costs of treating patients with chronic psychotic disorders are substantial and represent a sizeable portion of the Ontario health care budget (3%). Previous research has found similar findings in other jurisdictions. These estimates do not account for costs of addiction services. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Our results suggest there are important utilization/cost differences between age groups. As patients with chronic psychotic disorders become older chronic disease and disability become more prominent, as reflected in higher costs with long-term care and non-psychiatric hospitalizations. IMPLICATIONS FOR HEALTH POLICIES: These findings highlight the need for health care systems to address both physical and mental illness simultaneously, especially for older patients with chronic psychotic disorders. IMPLICATIONS FOR FURTHER RESEARCH: Future research should focus on the predictors of care over the life course of patients with chronic psychotic disorders. In addition, further work should examine how the interplay between mental and physical health contribute to increased costs among patients with psychosis.

Patients With High Mental Health Costs Incur Over 30 Percent More Costs Than Other High-Cost Patients.

A small proportion of health care users, called high-cost patients, account for a disproportionately large share of health care costs. Most literature on these patients has focused on the entire population. However, high-cost patients whose use of mental health care services is substantial are likely to differ from other members of the population. We defined a mental health high-cost patient as someone for whom mental health-related services accounted for at least 50 percent of total health care costs. We examined these patients' health care utilization and costs in Ontario, Canada. We found that their average cost for health care, in 2012 Canadian dollars, was $31,611. In contrast, the cost was $23,681 for other high-cost patients. Mental health high-cost patients were younger, lived in poorer neighborhoods, and had different health care utilization patterns, compared to other high-cost patients. These findings should be considered when implementing policies or interventions to address quality of care for mental health patients so as to ensure that mental health high-cost patients receive appropriate care in a cost-effective manner. Furthermore, efforts to manage mental health patients' health care use should address their complex profile through integrated multidisciplinary health care delivery.

The burden of disease attributable to cannabis use in Canada in 2012.

BACKGROUND AND AIMS: Cannabis use is associated with several adverse health effects. However, little is known about the cannabis-attributable burden of disease. This study quantified the age-, sex- and adverse health effect-specific cannabis-attributable (1) mortality, (2) years of life lost due to premature mortality (YLLs), (3) years of life lost due to disability (YLDs) and (4) disability-adjusted life years (DALYs) in Canada in 2012. DESIGN: Epidemiological modeling. SETTING: Canada. PARTICIPANTS: Canadians aged ≥ 15 years in 2012. MEASUREMENTS: Using comparative risk assessment methodology, cannabis-attributable fractions were computed using Canadian exposure data and risk relations from large studies or meta-analyses. Outcome data were obtained from Canadian databases and the World Health Organization. The 95% confidence intervals (CIs) were computed using Monte Carlo methodology. FINDINGS: Cannabis use was estimated to have caused 287 deaths (95% CI = 108, 609), 10,533 YLLs (95% CI = 4760, 20,833), 55,813 YLDs (95% CI = 38,175, 74,094) and 66,346 DALYs (95% CI = 47,785, 87,207), based on causal impacts on cannabis use disorders, schizophrenia, lung cancer and road traffic injuries. Cannabis-attributable burden of disease was highest among young people, and males accounted for twice the burden than females. Cannabis use disorders were the most important single cause of the cannabis-attributable burden of disease. CONCLUSIONS: The cannabis-attributable burden of disease in Canada in 2012 included 55,813 years of life lost due to disability, caused mainly by cannabis use disorders. Although the cannabis-attributable burden of disease was substantial, it was much lower compared with other commonly used legal and illegal substances. Moreover, the evidence base for cannabis-attributable harms was smaller.

Association between household food insecurity and annual health care costs.

BACKGROUND: Household food insecurity, a measure of income-related problems of food access, is growing in Canada and is tightly linked to poorer health status. We examined the association between household food insecurity status and annual health care costs. METHODS: We obtained data for 67 033 people aged 18-64 years in Ontario who participated in the Canadian Community Health Survey in 2005, 2007/08 or 2009/10 to assess their household food insecurity status in the 12 months before the survey interview. We linked these data with administrative health care data to determine individuals' direct health care costs during the same 12-month period. RESULTS: Total health care costs and mean costs for inpatient hospital care, emergency department visits, physician services, same-day surgeries, home care services and prescription drugs covered by the Ontario Drug Benefit Program rose systematically with increasing severity of household food insecurity. Compared with total annual health care costs in food-secure households, adjusted annual costs were 16% ($235) higher in households with marginal food insecurity (95% confidence interval [CI] 10%-23% [$141-$334]), 32% ($455) higher in households with moderate food insecurity (95% CI 25%-39% [$361-$553]) and 76% ($1092) higher in households with severe food insecurity (95% CI 65%-88% [$934-$1260]). When costs of prescription drugs covered by the Ontario Drug Benefit Program were included, the adjusted annual costs were 23% higher in households with marginal food insecurity (95% CI 16%-31%), 49% higher in those with moderate food insecurity (95% CI 41%-57%) and 121% higher in those with severe food insecurity (95% CI 107%-136%). INTERPRETATION: Household food insecurity was a robust predictor of health care utilization and costs incurred by working-age adults, independent of other social determinants of health. Policy interventions at the provincial or federal level designed to reduce household food insecurity could offset considerable public expenditures in health care.