Cohort study of team-based care among marginalized people who use drugs in Ottawa.

OBJECTIVE: To describe team-based care use among a cohort of people who use drugs (PWUD) and to determine factors associated with receipt of team-based care. DESIGN: A cohort study using survey data collected between March and December 2013. These data were then linked to provincial-level health administrative databases to assess patterns of primary care among PWUD in the 2 years before survey completion. SETTING: Ottawa, Ont. PARTICIPANTS: Marginalized PWUD 16 years of age or older. MAIN OUTCOME MEASURES: Patients were assigned to primary care models based on survey responses and then were categorized as attached to team-based medical homes, attached to non-team-based medical homes, not attached to a medical home, and no primary care. Descriptive statistics and multinomial logistic regression were used to determine associations between PWUD and medical home models. RESULTS: Of 663 total participants, only 162 (24.4%) received team-based care, which was associated with high school level of education (adjusted odds ratio [AOR] = 2.18; 95% CI 1.13 to 4.20), receipt of disability benefits (AOR = 2.47; 95% CI 1.22 to 5.02), and HIV infection (AOR = 2.88; 95% CI 1.28 to 6.52), and was inversely associated with recent overdose (AOR = 0.49; 95% CI 0.25 to 0.94). In comparison, 125 (18.8%) received non-team-based medical care, which was associated with university or college education (AOR = 2.31; 95% CI 1.04 to 5.15) and mental health comorbidity (AOR = 4.18; 95% CI 2.33 to 7.50), and was inversely associated with being detained in jail in the previous 12 months (AOR = 0.51; 95% CI 0.28 to 0.90). CONCLUSION: Although team-based, integrated models of care will benefit disadvantaged groups the most, few PWUD receive such care. Policy makers should mitigate barriers to physician care and improve integration across health and social services.

Engagement in primary health care among marginalized people who use drugs in Ottawa, Canada.

BACKGROUND: There may be less primary health care engagement among people who use drugs (PWUD) than among the general population, even though the former have greater comorbidity and more frequent use of emergency department care. We investigated factors associated with primary care engagement among PWUD. METHODS: The Participatory Research in Ottawa: Understanding Drugs (PROUD) cohort study meaningfully engaged and trained people with lived experience to recruit and survey marginalized PWUD between March-December 2013. We linked this survey data to provincial-level administrative databases held at ICES. We categorized engagement in primary care over the 2 years prior to survey completion as: not engaged (< 3 outpatient visits to the same family physician) versus engaged in care (3+ visits to the same family physician). We used multivariable logistic regression to determine factors associated with engagement in primary care. RESULTS: Characteristics of 663 participants included a median age of 43 years, 76% men, and 67% living in the two lowest income quintile neighborhoods. Despite high comorbidity and a median of 4 (interquartile range 0-10) primary care visits in the year prior to survey completion, only 372 (56.1%) were engaged in primary care. Engagement was most strongly associated with the following factors: receiving provincial benefits, including disability payments (adjusted odds ratio [AOR] 4.14 (95% confidence interval [CI] 2.30 to 7.43)) or income assistance (AOR 3.69 (95% CI 2.00 to 6.81)), having ever taken methadone (AOR 3.82 (95% CI 2.28 to 6.41)), mental health comorbidity (AOR 3.43 (95% CI 2.19 to 5.38)), and having stable housing (AOR 2.09 (95% CI 1.29 to 3.38)). CONCLUSIONS: Despite high comorbidity, engagement in primary care among PWUD was low. Our findings suggest that social care (housing, disability, and income support) and mental health care are associated with improved primary care continuity; integration of these care systems with primary care and opioid substitution therapy may lessen the significant morbidity and acute care use among PWUD.

Hepatitis C Testing, Status and Treatment among Marginalized People Who Use Drugs in an Inner City Setting: An Observational Cohort Study.

BACKGROUND: Chronic hepatitis C virus (HCV) infection is common among people who inject drugs (PWID) and is associated with morbidity and premature death. Although HCV can be cured, treatment may be inaccessible. We studied HCV testing, status and treatment among marginalized people who use drugs in Ottawa, Canada, a setting with universal insurance coverage for physician services. METHODS: We analyzed data from the Participatory Research in Ottawa: Understanding Drugs study, a cross-sectional, peer-administered survey of people who use drugs from 2012 to 2013. We linked responses to population-based health administrative databases and used multivariable Poisson regression to identify factors independently associated with self-reported HCV testing, self-reported positive HCV status, and database-determined engagement in HCV treatment. RESULTS: Among 663 participants, 562 (84.8%) reported testing for HCV and 258 (45.9%) reported HCV-positive status. In multivariable analysis, HCV-positive status was associated with female gender (RR 1.27; 95%CI 1.04 to 1.55), advancing age (RR 1.03/year; 95%CI 1.02 to 1.04), receiving disability payments (RR 1.42; 95%CI 1.06 to 1.91), injecting drugs (RR 5.11; 95%CI 2.64 to 9.91), ever injecting with a used needle (RR 1.30; 95%CI 1.12 to 1.52), and ever having taken methadone (RR 1.26; 95%CI 1.05 to 1.52). Of HCV positive participants, 196 (76%) were engaged in primary care but only 23 (8.9%) had received HCV therapy. Conclusions/Importance: Although HCV testing and positive status rates are high among PWID in our study, few have received HCV treatment. Innovative initiatives to increase access to HCV treatment for PWID are urgently needed.

A cohort study examining emergency department visits and hospital admissions among people who use drugs in Ottawa, Canada.

BACKGROUND: The health of people who use drugs (PWUD) is characterized by multimorbidity and chronicity of health conditions, necessitating an understanding of their health care utilization. The objective of this study was to evaluate emergency department (ED) visits and hospital admissions among a cohort of PWUD. METHODS: We used a retrospective observational design between 2012 and 2013. The population was a marginalized cohort of PWUD (the PROUD study) for whom survey data was linked (n = 663) to provincial health administrative data housed at the Institute for Clinical Evaluative Sciences. We constructed a 5:1 comparison group matched by age, sex, income quintile, and region. The main outcomes were defined as having two or more ED visits, or one or more hospital admissions, in the year prior to survey completion. We used multivariable logistic regression analyses to identify factors associated with these outcomes. RESULTS: Compared to the matched cohort, PWUD had higher rates of ED visits (rate ratio [RR] 7.0; 95% confidence interval [95% CI] 6.5-7.6) and hospitalization (RR 7.7; 95% CI 5.9-10.0). After adjustment, factors predicting more ED visits were receiving disability (adjusted odds ratio [AOR] 3.0; 95% CI 1.7-5.5) or income assistance (AOR 2.7; 95% CI 1.5-5.0), injection drug use (AOR 2.1; 95% CI 1.3-3.4), incarceration within 12 months (AOR 1.6; 95% CI 1.1-2.4), mental health comorbidity (AOR 2.1; 95% CI 1.4-3.1), and a suicide attempt within 12 months (AOR 2.1; 95% CI 1.1-3.4). Receiving methadone (AOR 0.5; 95% CI 0.3-0.9) and having a regular family physician (AOR 0.5; 95% CI 0.2-0.9) were associated with lower odds of having more ED visits. Factors associated with more hospital admissions included Aboriginal identity (AOR 2.4; 95% CI 1.4-4.1), receiving disability (AOR 2.4; 95% CI 1.1-5.4), non-injection drug use (opioids and non-opioids) (AOR 2.2; 95% CI 1.1-4.4), comorbid HIV (AOR 2.4; 95% CI 1.2-5.6), mental health comorbidity (AOR 2.4; 95% CI 1.3-4.2), and unstable housing (AOR 1.9; 95% CI 1.0-3.4); there were no protective factors for hospitalization. CONCLUSIONS: Improved post-incarceration support, housing services, and access to integrated primary care services including opioid replacement therapy may be effective interventions to decrease acute care use among PWUD, including targeted approaches for people receiving social assistance or with mental health concerns.