Healthcare Utilization and Costs for Musculoskeletal Disorders in Ontario, Canada.

OBJECTIVE: To examine the magnitude and costs of ambulatory primary care, specialist physician care, and hospital service use for musculoskeletal disorders (MSDs) in Canada's largest province, Ontario. METHODS: Administrative health databases were analyzed for fiscal year 2013-2014 for adults aged ≥ 18 years, including data on physician services, emergency department (ED) visits, and hospitalizations. International Classification of Diseases diagnostic codes were used to identify MSD services. A validated algorithm was used to estimate direct medical costs. Person-visit rates and numbers of persons and visits were tabulated by care setting, age, sex, and physician specialty. Data were examined for all MSDs combined, as well as for specific diagnostic groupings. RESULTS: Overall, 3.1 million adult Ontarians (28.5%) made over 8 million outpatient physician visits associated with MSDs. These included 5.6 million primary care visits. MSDs accounted for 560,000 (12.3%) of all adult ED visits. Total costs for MSD-related care were $1.6 billion, with 12.6% of costs attributed to primary care, 9.2% to specialist care, 8.6% to ED care, 8.5% to day surgery, and 61.2% associated with inpatient hospitalizations. Costs due to arthritis accounted for 40% of total MSD care costs ($639 million). MSD-related imaging costs were $169 million, yielding a total cost estimate of $1.8 billion for MSDs overall. CONCLUSION: MSDs place a significant and costly burden on the healthcare system. Health system planning needs to consider the large and escalating demand for care to reduce both the individual and population burden.

The potential for diversion of prescribed opioids among orthopaedic patients: Results of an anonymous patient survey.

INTRODUCTION: Diversion of prescription opioid medication is a contributor to the opioid epidemic. Safe handling practices can reduce the risk of diversion. We aimed to understand: 1) if orthopaedic patients received instructions on how to safely handle opioids, 2) their typical storage/disposal practices, and 3) their willingness to participate in an opioid disposal program (ODP). METHODS: Cross-sectional study of adult orthopaedic patients who completed an anonymous survey on current or past prescription opioid use, instruction on handling, storage and disposal practices, presence of children in the household, and willingness to participate in an ODP. Frequencies and percentages of responses were computed, both overall and stratified by possession of unused opioids. RESULTS: 569 respondents who reported either current or past prescription opioid use were analyzed. 44% reported receiving storage instructions and 56% reported receiving disposal instructions from a health care provider. Many respondents indicated unsafe handling practices: possessing unused opioids (34%), using unsafe storage methods (90%), and using unsafe disposal methods (34%). Respondents with unused opioids were less likely to report receiving handling instructions or using safe handling methods, and 47% of this group reported having minors or young adults in the household. Respondents who received storage and disposal instructions were more likely to report safe storage and disposal methods. Seventy-four percent of respondents reported that they would participate in an ODP. CONCLUSION: While many orthopaedic patients report inadequate education on safe opioid handling and using unsafe handling practices, findings suggest targeted education is associated with better behaviours. However, patients are willing to safely dispose of unused medication if provided a convenient option. These findings suggest a need to address patient knowledge and behavior regarding opioid handling to reduce the risk of opioid diversion.

Understanding the Association Between Osteoarthritis and Social Participation: The Canadian Longitudinal Study on Aging.

OBJECTIVE: The focus on disability in osteoarthritis (OA) has largely been on the ability to perform specific activities, which neglects the greater implications for social participation. We investigated the association between OA and social participation, considering activity limitations and instrumental supports as intervening variables in the association. METHODS: Data were from 21,214 respondents, ages 45-85 years, from cycle 1 of the Canadian Longitudinal Study on Aging. The questionnaire elicited information regarding self-reported doctor-diagnosed OA, difficulty with 14 activities, perceived availability and receipt of instrumental supports, and 17 social participation activities. Structural equation modeling was used. The primary outcome was social participation, and the primary predictor was OA. The intervening variables included activity limitations, received instrumental supports, and perceived instrumental supports. Latent variables were developed for intervening and social participation variables. The covariates included age, sex, body mass index, income, education, smoking, and comorbidity count. RESULTS: The mean age of the respondents was 63 years, 51% were female, and 26.5% reported having OA. Two distinct social participation indicators were identified, including social participation-diversity and social participation-intensity. When intervening variables were not considered, minimal/no association was found between OA and social participation. When intervening variables were considered, unique pathways linking OA and social participation were found. The overall negative association between activity limitations and social participation was partially direct and partially buffered by both receipt of and perceived availability of instrumental supports. In the absence of activity limitations, OA was associated with greater social participation. CONCLUSION: Enhanced social participation in people with OA who do not have activity limitations may reflect proactive steps taken by those with mild OA to maintain activity and social engagement. For those with activity limitations, findings highlight the need for interventions to mitigate limitations and draw particular attention to the importance of both provision and awareness of available instrumental supports in maintaining social participation.

Healthcare utilization and costs for spinal conditions in Ontario, Canada - opportunities for funding high-value care: a retrospective cohort study.

BACKGROUND CONTEXT: An important step in improving spinal care is understanding how current health-care resources and associated cost are being utilized and distributed across a health-care system. PURPOSE: Our objective was to examine the magnitude and distribution of direct health care costs for spinal conditions across physician type and hospital setting. DESIGN/SETTING: Cross-sectional analysis of administrative health data for the fiscal year 2013-2014 from the province of Ontario, Canada. PATIENT SAMPLE: Adult population aged 18+ years (N=10,841,302). OUTCOME MEASURES: Person visit rates and total number of people and visits by specific care settings were calculated for all spinal conditions as well as stratified by nontrauma and trauma-related conditions. Variation in rates by age and sex was examined. The proportion of patients seeing physicians of different specialties was calculated for each condition grouping. Direct medical costs were estimated and their percentage distribution by care setting calculated for nontrauma and trauma-related conditions. Additionally, costs for spinal imaging overall and stratified by type of scan were determined. METHODS: Administrative health databases were analyzed, including data on physician services, emergency department visits, and hospitalizations. ICD-9 and -10 diagnostic codes were used to identify nontraumatic (degenerative or inflammatory) and traumatic spinal disorders. A validated algorithm was used to estimate direct medical costs. RESULTS: Overall, 822,000 adult Ontarians (7.6%) made 1.6 million outpatient physician visits for spinal conditions; the majority (1.1 million) of these visits were for nontrauma conditions. Approximately, 86% of outpatient visits were in primary care. Emergency Department (ED) visits for nontrauma spinal conditions (130,000 out of 156,000 ED visits) accounted for 2.8% of all ED visits in the province. Total costs for spine-related care were $264 million (CDN) with 64% of costs due to nontrauma conditions. For these nontrauma conditions, ED visits cost $28 million for 130,000 visits ($215 per visit). For $32 million spent in primary care, 890,000 visits were made ($36 per visit). Spine imaging costs were $66.5 million, yielding a combined total of $330 million in health care spending for spinal conditions. CONCLUSIONS: Spinal conditions place a large and costly burden on the health-care system. The disproportionate annual cost associated with ED visits represents a potential opportunity to redirect costs to fund more clinically and cost-effective models of care for nontraumatic spinal conditions.

Association of regional racial/cultural context and socioeconomic status with arthritis in the population: a multilevel analysis.

OBJECTIVE: To examine the extent to which differences in individual- and regional-level socioeconomic status and racial/cultural origin account for geographic variations in the prevalence of self-reported arthritis, and to determine whether regional characteristics modify the effect of individual characteristics associated with reporting arthritis. METHODS: Analyses were based on the 2000-2001 Canadian Community Health Survey (>15 years, n = 127,513). Arthritis was self-reported as a long-term condition diagnosed by a health professional. A 2-level logistic regression model was used to identify predictors of reporting arthritis. Individual-level variables included age, sex, income, education, immigration status, racial/cultural origin, smoking, physical activity, and body mass index. Regional-level variables included the proportion of low-income families, low education, unemployment, recent immigrants, Aboriginals, and Asians. RESULTS: At the individual level, age, sex, low income, low education, Aboriginal origin, current smoking, and overweight/obesity were positively associated with reporting arthritis; recent immigration and Asian origin were negatively associated with reporting arthritis. At the regional level, percentages of low-income families and the Aboriginal population were independently associated with reporting arthritis. Regional income and racial/cultural origin moderated the effects of individual income and racial/cultural origin; low-income individuals residing in regions with a higher proportion of low-income families reported arthritis more than low-income individuals living in better-income regions. CONCLUSION: Both individual and regional factors were found to contribute to variations in the prevalence of arthritis, although significant unexplained variation remained. Further research is required to better understand the mechanisms that underlie these regional effects and to identify other contributing factors to the remaining variation.

The relative impact of 13 chronic conditions across three different outcomes.

STUDY OBJECTIVE: Previous estimates of individual and population attributable risks for adverse outcomes due to chronic conditions have considered only a limited number of conditions and outcomes, with some studies using inappropriate formulae or methods of estimation. This study re-examines the magnitude of individual and population attributable risks for a wide range of conditions and various health outcomes. DESIGN: Log-Poisson regression was used to calculate prevalence ratios as an indicator of individual risk and population-associated fractions of 13 chronic conditions, examining activity limitations, self-rated health and physician visits. The effect of multimorbidity on prevalence ratios was examined. SETTING: Canada, 2000-01. PARTICIPANTS: Nationally representative sample of Canadians aged 12+ years (n _ 130 880). MAIN RESULTS: At the individual level, fibromyalgia/chronic fatigue syndrome and cancer, and to a lesser extent stroke and heart disease, were associated with an increased risk of both activity limitations and a self-rated health status of fair or poor; high blood pressure was associated with four or more physician visits in the previous 12 months. In contrast, population attributable fractions were substantial for arthritis/rheumatism, heart disease, back problems and high blood pressure across all outcomes. Adjustment for multimorbidity resulted in a marked decreases in prevalence ratios. CONCLUSIONS: Differences in the ranking of individual risks and population attributable fractions for different diseases and outcomes are substantial. This needs to be taken into account when setting priorities, as interventions may need to be targeted to different conditions depending on which aspects of health are being considered, and whether the focus is on individuals, such as in clinical care, or improving the health of the population.

Physical therapy services for older adults with at least moderately severe hip or knee arthritis in 2 Ontario counties.

OBJECTIVE: Physical therapy (PT) is a recommended treatment for the management of arthritis. We investigated factors related to referral to PT services in people with hip or knee arthritis and describe characteristics of treatment received. METHODS: As part of a longitudinal study of the population aged > or = 55 years with at least moderately severe hip or knee arthritis in 2 Ontario counties (n = 1350), participants were surveyed in the third year of followup about use of PT. Participants were categorized as to whether they had total joint replacement surgery in the past year (TJR group, n = 52) or did not (non-TJR group, n = 1298). Multivariate logistic regression was used to identify determinants of referral to PT considering sociodemographic characteristics, comorbidity, use of prescribed arthritis medication, and arthritis severity (WOMAC summary score). RESULTS: Overall, 18.7% of the cohort was referred to PT in the past year: 65.4% of the TJR group and 16.8% of the non-TJR group. The only significant predictor of PT in the TJR group was current use of prescribed arthritis medication. Greater arthritis severity, current use of prescribed arthritis medication, and greater comorbidity were significant independent predictors of referral to PT for the non-TJR group in multivariate logistic regression. The Ontario Health Insurance Plan paid for the majority of PT received. CONCLUSION: Low rates of referral to PT in the previous year suggest possible underutilization. Further research is needed to examine patterns of use of PT throughout the course of the arthritis disease process and to examine barriers to PT access.