The experiences of familial mental illness stigma among individuals living with mental illnesses.

Persons with mental illnesses may experience stigma from their immediate family members in addition to other forms of stigma. Using semi-structured interviews, we investigated experiences of familial mental illness stigma among 15 people diagnosed with mental illnesses in a mid-sized city in Canada. We identified five themes that speak to participants' experiences of familial mental illness stigma and ways to reduce it. The themes include the following: diagnosis as a 'double-edged sword,' potential familial isolation, familial stigma as societal stigma localized, stories of acceptance, and confronting potential familial mental illness stigma. Participants' narratives indicate that familial mental illness stigma is rooted in the broader social or public stigma, which sees its way into familial relations as well. This stigma takes various forms, including relationship bias or unfair treatment, breakdown in romantic relationships, loss of status, verbal and emotional abuse, exclusion from decision-making, and alienation within their immediate and extended families. Familial mental illness stigma experiences negatively impact participant's psychological well-being and personal empowerment. However, participants also shared ways that family members create supportive environments or actively confront or prevent stigma. Overall, this study has contributed to knowledge on mental illness stigma, particularly familial mental illness stigma from the perspective of participants living with a mental illness in a high-income country. Suggestions for future research include a focus on strategies to prevent ongoing familial mental illness stigma and large-scale studies to explore familial mental illness stigma to understand why families might perpetrate stigma.

Disparities in Access to a Regular Primary Care Physician Among First-Generation Migrants with Early Psychosis in Ontario, Canada.

Disparities in primary care utilization among migrants with early psychosis may be related to lack of access to a regular primary care physician. This study aimed to investigate access to a regular primary care physician among first-generation migrants with early psychosis. People aged 14-35 years with first onset non-affective psychotic disorder in Ontario, Canada were identified in health administrative data (N = 39,440). Access to a regular primary care physician through enrollment in the year prior to diagnosis was compared between first-generation migrants (categorized by country of birth) and the general population using modified Poisson regression. Most migrant groups had a lower prevalence of regular primary care physician access relative to the general population, particularly migrants from Africa (African migrants: 81% vs. non-migrants: 89%). Adjustment for sociodemographic and clinical factors attenuated these differences, although the disparities for migrants from Africa remained (PR = 0.96, 95%CI = 0.94-0.99). Interventions aimed at improving primary care physician access in migrant groups may facilitate help-seeking and improve pathways to care in early psychosis.

Early Psychosis Intervention and Primary Care: A Mixed Methods Study of Family Physician Knowledge, Attitudes, Preferences, and Needs.

Family physicians (FPs) play an important but underappreciated role in the pathways to care for people with early psychosis. We conducted a mixed-methods study to describe the knowledge, attitudes, preferences, and needs of FPs towards the recognition and management of early psychosis. We sent a cross-sectional postal survey to a random sample of FPs in Ontario, Canada, and conducted in-depth qualitative interviews with twenty. FPs were generally aware of important early psychosis symptoms, however, there were some knowledge gaps. Among surveyed FPs, 25% were unsure of the availability of early psychosis intervention services in their region, and most (80%) would prefer to co-manage with specialists. In the qualitative interviews, FPs expressed varied comfort levels in recognizing psychosis, and that timely access to psychiatry was a main concern. Our findings suggest that FPs require better support in recognizing and managing early psychosis and facilitating connections with specialized care.

Treatment and Mortality Following Cancer Diagnosis Among People With Non-affective Psychotic Disorders in Ontario, Canada: A Retrospective Cohort Study.

BACKGROUND AND HYPOTHESIS: People with psychotic disorders have a higher risk of mortality following cancer diagnosis, compared to people without psychosis. The extent to which this disparity is influenced by differences in cancer-related treatment is currently unknown. We hypothesized that, following a cancer diagnosis, people with psychotic disorders were less likely to receive treatment and were at higher risk of death than those without psychosis. STUDY DESIGN: We constructed a retrospective cohort of cases of non-affective psychotic disorder (NAPD) and a general population comparison group, using Ontario Health (OH) administrative data. We identified cases of all cancers diagnosed between 1995 and 2019 and obtained information on cancer-related treatment and mortality. Cox proportional hazards models were used to compare the probability of having a consultation with an oncologist and receiving cancer-related treatment, adjusting for tumor site and stage. We also compared the rate of all-cause and cancer-related mortality between the two groups, adjusting for tumor site. STUDY RESULTS: Our analytic sample included 24 944 people diagnosed with any cancer. People with NAPD were less likely to receive treatment than people without psychosis (HR = 0.87, 95% CI = 0.82, 0.91). In addition, people with NAPD had a greater risk of death from any cause (HR = 1.68, 95% CI = 1.60, 1.76), compared to people without NAPD. CONCLUSIONS: The lower likelihood of receiving cancer treatment reflects disparities in accessing cancer care for people with psychotic disorders, which may partially explain the higher mortality risk following cancer diagnosis. Future research should explore mediating factors in this relationship to identify targets for reducing health disparities.

Effectiveness of a mindfulness-based intervention for persons with early psychosis: A multi-site randomized controlled trial.

BACKGROUND: The Mindfulness Ambassador Program (MAP) is a group-based, facilitated mindfulness-based intervention (MBI). We sought to determine the effectiveness of MAP on reducing negative psychotic symptoms and enhancing mindfulness skills among persons experiencing early psychosis. METHODS: We conducted a pragmatic randomized controlled trial (RCT) at three early psychosis intervention (EPI) programs in Ontario, Canada. Participants (N = 59) were randomly assigned to receive MAP (n = 29) for 1-hour weekly sessions over 3 months, or to treatment as usual (TAU, n = 30). Assessments were conducted at baseline, 3 months, and 6 months using the Self-Evaluation of Negative Symptoms (SNS) and Kentucky Inventory of Mindfulness Skills (KIMS). Linear mixed methods were used to assess the joint effects of group and time. RESULTS: At 3 months, participants who received MAP (n = 17) demonstrated greater reductions on the SNS relative to TAU (n = 15), which were clinically and statistically significant (-4.1; 95%CI -7.5, -0.7; p = 0.019). At 6 months, the difference between MAP (n = 10) and TAU (n = 13) was no longer statistically significant (-1.2; 95%CI -5.2,2.7; p = 0.54). On the KIMS, no significant effects were found at 3 months (+0.3; 95%CI -2.0,2.5; p = 0.82) or 6 months (+0.4; 95%CI -2.2,2.9; p = 0.79). CONCLUSIONS: We conducted one of the first multi-site RCTs of a MBI for early psychosis. Our findings indicated that MAP was more effective in reducing negative symptoms compared to TAU in the short term. Earlier reductions in negative psychotic symptoms may help facilitate recovery in the long term.

The effect of non-medical cannabis retailer proximity on use of mental health services for psychotic disorders in Ontario, Canada.

BACKGROUND: Cannabis is associated with the onset and persistence of psychotic disorders. Evidence suggests that accessibility of substances is associated with an increased risk of use-related harms. We sought to examine the effect of residing in proximity to non-medical cannabis retailers on the prevalence of health service use for psychosis. METHODS: We conducted a cross-sectional study using linked health administrative data, and used geospatial analyses to determine whether people in Ontario, Canada (aged 14-60 years) resided within walking (1.6 km) or driving (5.0 km) distance of non-medical cannabis retailers (open as of February-2020). We identified outpatient visits, emergency department (ED) visits, and hospitalizations for psychotic disorders between 01-April-2019 and 17-March-2020. We used zero-inflated Poisson regression models and gamma generalized linear models to estimate the association between cannabis retailer proximity and indicators of health service use. RESULTS: Non-medical cannabis retailers were differentially located in areas with high levels of marginalization and pre-existing health service use for psychosis. People residing within walking or driving distance of a cannabis retailer had a higher rate of psychosis-related outpatient visits, ED visits, and hospitalizations, compared to people living outside these areas. This effect was stronger among those with no prior service use for psychosis. CONCLUSIONS: Proximity to a non-medical cannabis retailer was associated with higher health service use for psychosis, even after adjustment for prior health service use. These findings suggest that opening of non-medical cannabis retailers could worsen the burden of psychosis on mental health services in areas with high-risk populations.

Is there an advantage? Considerations for researchers studying the effects of the type of Medicare coverage.

OBJECTIVE: To describe common methodological problems that arise in comparisons of Medicare Advantage (MA) and Traditional Medicare (TM) and within-MA studies and provide suggestions of how researchers can address these issues. STUDY SETTING: Published research evaluating Medicare coverage options in the United States. STUDY DESIGN: We considered key conceptual challenges and promising solutions that have been used thus far and suggest additional directions. DATA COLLECTION: Not available. PRINCIPAL FINDINGS: Many existing studies of MA versus TM include significant limitations, such as failing to account for unobserved confounders driving both beneficiary coverage choice and health outcomes once enrolled, not accounting for variation in benefit generosity, provider networks, or plan design across MA plans, and/or having been conducted at a time when MA enrollment was less than a third of all Medicare beneficiaries. We provide a review of methods that can help researchers to overcome these weaknesses and suggest additional methods and data sources that may aid future research. CONCLUSIONS: The MA program is becoming an essential part of the US healthcare system. By accounting for non-random movement into and out of MA and studying the heterogeneity of beneficiary experience across plan and market characteristics, researchers can provide the high-quality evidence necessary for policymakers to design the program and reform TM in ways that maximize beneficiary outcomes.

Medicare Advantage Is Associated with Lower Utilization of Total Joint Arthroplasty.

BACKGROUND: Medicare Advantage (MA) insurers use managed care techniques to review the utilization of medical services and control costs. It is unclear if MA enrollees have a lower utilization of elective surgical procedures such as inpatient hip and knee total joint arthroplasty (TJA), which have traditionally been covered by traditional Medicare (TM) without restrictions. METHODS: We conducted a cross-sectional study using a 20% sample of 2018 TM claims and MA encounter records for 5,300,188 TM enrollees and 1,970,032 MA enrollees who were 65 to 85 years of age. We calculated unadjusted and adjusted differences (controlling for beneficiary and market characteristics) in the incidence of TJA for MA compared with TM, and by MA plan type. Finally, we calculated differences in the time to contact with an orthopaedic surgeon and time to the surgical procedure among enrollees with an osteoarthritis diagnosis. RESULTS: After controlling for observable characteristics, there was a 15.6% lower incidence of TJA in MA enrollees compared with TM enrollees (p < 0.001). Compared with TM enrollees, health maintenance organization (HMO) enrollees were 28.1% less likely to undergo TJA, controlling for observable characteristics (p < 0.001). From the initial diagnosis, the time to contact with an orthopaedic surgeon and the time to the surgical procedure were also lower among TM enrollees compared with MA enrollees. At 2 years after an osteoarthritis diagnosis, 10.4% of TM enrollees, 7.9% of preferred provider organization (PPO) enrollees, and 5.7% of HMO enrollees had undergone inpatient TJA. CONCLUSIONS: MA coverage was associated with a lower utilization of elective, inpatient hip and knee TJA. MA was also associated with a longer time to orthopaedic surgeon evaluation and surgical procedure. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Alternative approaches to measuring value: an update on innovative methods in the context of the United States Medicare drug price negotiation program.

INTRODUCTION: The United States has begun assessing the value of pharmaceuticals to inform negotiated prices in the Medicare program. Given strong political objections in the United States to the use of QALYs, Medicare will need to adopt an alternative approach to measuring value. AREAS COVERED: In this narrative review, we identified six alternative approaches to measuring value (equal value life-years, health years in total, generalized risk-adjusted cost-effectiveness, severity weighting based on absolute or proportional shortfall, comparative effectiveness based on conventional clinical endpoints, and comparative effectiveness based on both conventional endpoints and patient-centric value elements) and five criteria for assessing these approaches (responsiveness to concerns about discrimination, feasibility, transparency, flexibility, and the ability to incorporate factors beyond traditional value elements). EXPERT OPINION: Four of the alternatives are broadly aligned with the cost-effectiveness framework, but none fully addresses all aspects of the stated concerns that QALYs may be used to unintentionally implement discrimination. We note, however, that the extent to which these concerns lead to discrimination in practice is unknown. Finally, we recommend an approach for measuring value in terms of comparative effectiveness that combines quantitative ranking and weighting of distinct criteria (including patient-centric value elements) with deliberation.

Using Real-World Data to Inform Value-Based Contracts for Cell and Gene Therapies in Medicaid.

OBJECTIVE: High upfront costs and long-term benefit uncertainties of gene therapies challenge Medicaid budgets, making value-based contracts a potential solution. However, value-based contract design is hindered by cost-offset uncertainty. The aim of this study is to determine actual cost-offsets for valoctocogene roxaparvovec (hemophilia A) and etranacogene dezaparvovec (hemophilia B) from Colorado Medicaid's perspective, defining payback periods and its uncertainty from the perspective of Colorado Medicaid. METHODS: This cost analysis used 2018-2022 data from the Colorado Department of Health Care Policy & Financing to determine standard-of-care costs and employed cost simulation models to estimate the cost of Medicaid if patients switched to gene therapy versus if they did not. Data encompassed medical and pharmacy expenses of Colorado Medicaid enrollees. Identified cohorts were patients aged 18+ with ICD-10-CM codes D66 (hemophilia A) and D67 (hemophilia B). Severe hemophilia A required ≥ 6 claims per year for factor therapies or emicizumab, while moderate/severe hemophilia B necessitated ≥ 4 claims per year for factor therapies. Patients were included in the cohort in the year they first met the criteria and were subsequently retained in the cohort for the duration of the observation period. Standard-of-care included factor VIII replacement therapy/emicizumab for hemophilia A and factor IX replacement therapies for hemophilia B. Simulated patients received valoctocogene roxaparvovec or etranacogene dezaparvovec. Main measures were annual standard-of-care costs, cost offset, and breakeven time when using gene therapies. RESULTS: Colorado Medicaid's standard-of-care costs for hemophilia A and B were $426,000 [standard deviation (SD) $353,000] and $546,000 (SD $542,000) annually, respectively. Substituting standard-of-care with gene therapy for eligible patients yielded 8-year and 6-year average breakeven times, using real-world costs, compared with 5 years with published economic evaluation costs. Substantial variability in real-world standard-of-care costs resulted in a 48% and 59% probability of breakeven within 10 years for hemophilia A and B, respectively. Altering eligibility criteria significantly influenced breakeven time. CONCLUSIONS: Real-world data indicates substantial uncertainty and extended payback periods for gene therapy costs. Utilizing real-world data, Medicaid can negotiate value-based contracts to manage budget fluctuations, share risk with manufacturers, and enhance patient access to innovative treatments.

Who sleeps well in Canada? The social determinants of sleep health among middle-aged and older adults in the Canadian Longitudinal Study on Aging.

OBJECTIVES: Sleep health inequities likely contribute to disparities in health outcomes. Our objective was to identify social determinants of sleep health among middle-aged/older adults in Canada, where prior evidence is limited. METHODS: We analyzed cross-sectional data from the Canadian Longitudinal Study on Aging, a survey of over 30,000 community-dwelling adults aged 45-85years. Self-reported measures included sleep duration, sleep satisfaction, and sleep efficiency. We explored associations between sleep measures and social determinants of health. We used modified Poisson regression to estimate prevalence ratios for sleep satisfaction and sleep efficiency, and linear regression for sleep duration. Estimates were adjusted for all social, lifestyle, and clinical covariates. We explored effect modification by sex. RESULTS: Of the 11 social determinants explored, all were significantly associated with at least one domain of sleep health. These associations were reduced to 9 variables with adjustment for all social variables, and 7 with further adjustment for lifestyle and clinical covariates, including differences by sex, age, education, marital status, employment, race/ethnicity, and sexual orientation. Better sleep health in >1 domain was observed among males, older age groups (65 and older), higher income groups, the retired group, and homeowners with adjustment for social variables, and only in males and older age groups with additional adjustment for lifestyle and clinical variables. Only sleep duration associations were modified by sex. CONCLUSIONS: Sleep health disparities among Canadian adults exist across socioeconomic gradients and racial/ethnic minority groups. Poor sleep health among disadvantaged groups warrants increased attention as a public health problem in Canada.

Sociodemographic Factors and the Risk of Pediatric Out-of-Hospital Cardiac Arrest in Ontario, Canada: A Province-Wide Case-Control Study.

BACKGROUND: Pediatric out-of-hospital cardiac arrest (POHCA) is associated with significant mortality and poor neurological outcomes. We aimed to describe the association between sociodemographic factors and POHCA risk in Ontario, Canada. METHODS AND RESULTS: We conducted a province-wide case-control study at ICES, where patient records are linked across administrative databases. The case group included children (aged 1 day to 17 years) who experienced an out-of-hospital cardiac arrest between 2004 and 2020. Controls were matched up to 1:4 on age, sex, index date, and key comorbidities. We used conditional logistic regression to measure the association between sociodemographic indicators and POHCA risk. The case and control groups included 1826 and 7254 children, respectively. Children living in areas with the highest levels of material deprivation (adjusted odds ratio [aOR], 2.35 [95% CI, 1.94-2.85]) and dependency (aOR, 1.22 [95% CI, 1.01-1.48]) had a higher odds of POHCA, relative to children living in regions with the lowest levels of material deprivation and dependency, respectively. Children living in neighborhoods with the lowest levels of ethnic diversity had a higher odds of POHCA (aOR, 1.62 [95% CI, 1.30-2.01]), relative to children living in neighborhoods with the highest levels of ethnic diversity. The odds of POHCA were lower in immigrants (aOR, 0.67 [95% CI, 0.47-0.95]), relative to the general population. Northern urban residence was associated with a higher odds of POHCA (aOR, 1.45 [95% CI, 1.13-1.87]), relative to southern urban residence. CONCLUSIONS: Children living in neighborhoods with high levels of marginalization may have an elevated risk of experiencing POHCA. These findings highlight the importance of addressing disparities through targeted prevention and intervention efforts.

The association between household food insecurity and healthcare costs among Canadian children.

OBJECTIVE: To examine the relationship between household food insecurity and healthcare costs in children living in Ontario, Canada. METHODS: We conducted a cross-sectional, population-based study using four cycles of the Canadian Community Health Survey (2007-2008, 2009-2010, 2011-2012, 2013-2014) linked with administrative health databases (ICES). We included Ontario children aged 1-17 years with a measure of household food insecurity (Household Food Security Survey Module) over the previous 12 months. Our primary outcome was the direct public-payer healthcare costs per child over the same time period (in Canadian dollars, standardized to year 2020). We used gamma-log-transformed generalized estimating equations accounting for the clustering of children to examine this relationship, and adjusted models for important sociodemographic covariates. As a secondary outcome, we examined healthcare usage of specific services and associated costs (e.g. visits to hospitals, surgeries). RESULTS: We found that adjusted healthcare costs were higher in children from food-insecure than from food-secure households ($676.79 [95% CI: $535.26, $855.74] vs. $563.98 [$457.00, $695.99], p = 0.047). Compared with children living in food-secure households, those in insecure households more often accessed hospitals, emergency departments, day surgeries, and home care, and used prescription medications. Children from food-secure households had higher usage of non-physician healthcare (e.g. optometry) and family physician rostering services. CONCLUSION: Even after adjusting for measurable social determinants of health, household food insecurity was associated with higher public-payer health services costs and utilization among children and youth. Efforts to mitigate food insecurity could lessen child healthcare needs, as well as associated costs to our healthcare systems.

RéSUMé: OBJECTIF: Examiner la relation entre l'insécurité alimentaire des ménages et les coûts des soins de santé chez les enfants vivant en Ontario, au Canada. MéTHODE: Nous avons mené une étude populationnelle transversale en utilisant les quatre cycles de l'Enquête sur la santé dans les collectivités canadiennes (2007­2008, 2009­2010, 2011­2012, 2013­2014) liés à des bases de données administratives sur la santé (ICES). Nous avons inclus les enfants ontariens de 1 à 17 ans et un indicateur d'insécurité alimentaire des ménages (le Module d'enquête sur la sécurité alimentaire des ménages) au cours des 12 mois antérieurs. Les coûts directs des soins de santé publics par enfant au cours de cette période (en dollars canadiens de 2020) ont constitué notre résultat principal. Nous avons utilisé des équations d'estimation généralisées transformées par la fonction logarithme gamma tenant compte du regroupement des enfants pour analyser cette relation, et des modèles ajustés pour les covariables sociodémographiques importantes. Comme résultat secondaire, nous avons analysé l'utilisation de certains services de soins de santé (p. ex. les visites dans les hôpitaux, les chirurgies) et les coûts associés. RéSULTATS: Nous avons constaté que les coûts ajustés des soins de santé étaient plus élevés chez les enfants des ménages aux prises avec l'insécurité alimentaire que chez ceux des ménages à l'abri de l'insécurité alimentaire (676,79 $ [IC de 95%: 535,26 $, 855,74 $] contre 563,98 $ [457,00 $, 695,99 $], p = 0,047). Comparativement aux enfants des ménages à l'abri de l'insécurité alimentaire, ceux qui vivaient dans des ménages aux prises avec l'insécurité avaient plus souvent recours aux hôpitaux, aux services des urgences, aux chirurgies d'un jour et aux soins à domicile, et ils prenaient des médicaments sur ordonnance. Les enfants des ménages à l'abri de l'insécurité alimentaire avaient plus souvent recours aux soins de santé non médicaux (p. ex. l'optométrie) et aux services de leur médecin de famille attitré. CONCLUSION: Même après l'apport d'ajustements pour tenir compte des déterminants sociaux de la santé mesurables, l'insécurité alimentaire des ménages était associée à des coûts de soins de santé publics plus élevés et à une plus grande utilisation de ces soins chez les enfants et les jeunes. Des efforts pour atténuer l'insécurité alimentaire pourraient réduire les besoins de soins de santé des enfants, ainsi que les coûts associés pour nos systèmes de soins de santé.

Impact of non-medical cannabis legalization with market restrictions on health service use and incident cases of psychotic disorder in Ontario, Canada.

BACKGROUND: Cannabis is a risk factor in the onset and persistence of psychotic disorders. There is concern that non-medical cannabis legalization in Canada may have population-level impacts on psychotic disorders. We sought to examine changes in health service use and incident cases of psychotic disorder following cannabis legalization, during a period of tight restrictions on retail stores and product types. METHODS: We conducted a cross-sectional interrupted time-series analysis using linked population-based health administrative data from Ontario (Canada) from January 2014 to March 2020. We identified psychosis-related outpatient visits, emergency department visits, hospitalizations, and inpatient length of stay, as well as incident cases of psychotic disorders, among people aged 14 to 60 years. RESULTS: We did not find evidence of increases in health service use or incident cases of psychotic disorders over the short-term (17 month) period following cannabis legalization. However, we found clear increasing trends in health service use and incident cases of substance-induced psychotic disorders over the entire observation window (2014-2020). CONCLUSION: Our findings suggest that the initial period of tight market restriction following legalization of non-medical cannabis was not associated with an increase in health service use or frequency of psychotic disorders. A longer post-legalization observation period, which includes expansion of the commercial cannabis market, is needed to fully understand the population-level impacts of non-medical cannabis legalization; thus, it would be premature to conclude that the legalization of non-medical cannabis did not lead to increases in health service use and incident cases of psychotic disorder.

Filgrastim and infliximab biosimilar uptake in Medicare Advantage compared with Traditional Medicare, 2016-2019.

BACKGROUND: Medicare Advantage (MA) and Traditional Medicare face different financing structures and incentives and may implement different strategies to encourage biosimilar uptake. Strategies used by health insurers can influence biosimilar uptake, which can in turn promote savings to insurers and patients. OBJECTIVE: To compare filgrastim and infliximab biosimilar uptake between MA and Traditional Medicare from 2016 to 2019 and examine biosimilar uptake by different MA carriers and plan types (Health Maintenance Organization [HMO] or Preferred Provider Organization). METHODS: We use a 2016-2019 nationally representative random 20% sample of the carrier (physician) and outpatient paid claims for Traditional Medicare data and final-action carrier and outpatient records for MA data. We compare quarterly biosimilar uptake from 2016 to 2019 for the first 2 drugs with biosimilar competition: (1) filgrastim, (Neupogen, originator), and biosimilars tbo-filgrastim (GRANIX) and filgrastim-sndz (ZARXIO), and (2) infliximab (Remicade, originator), and biosimilars infliximab-dyyb (Inflectra) and infliximab-abda (Renflexis). RESULTS: From their introduction, there was consistently greater uptake of filgrastim and infliximab biosimilars in MA compared with Traditional Medicare. By Q4 2019, filgrastim biosimilar uptake was 7.6 percentage points higher in MA (80.3%) than Traditional Medicare (72.7%). By Q4 2019, infliximab biosimilar uptake was 28.7% and 15.4% in MA and Traditional Medicare, respectively. Kaiser HMO plans were primarily responsible for the higher uptake of biosimilars in MA; in Q4 2019, filgrastim and infliximab biosimilar uptake was 98.8% and 78.8%, respectively. CONCLUSIONS: Our findings suggest that filgrastim and infliximab biosimilar uptake is greater in MA compared with Traditional Medicare, which is driven in part by particularly high uptake of biosimilars in MA Kaiser HMO plans. This highlights the need for future work to examine specific strategies and levers employed by MA Kaiser HMO plans and other insurers to increase biosimilar uptake, which can lead to cost savings for physician-administered drugs.

Models of shared care for the management of psychotic disorder after first diagnosis in Ontario.

OBJECTIVE: To describe the provision of care for young people following first diagnosis of psychotic disorder. DESIGN: Retrospective cohort study using health administrative data. SETTING: Ontario. PARTICIPANTS: People aged 14 to 35 years with a first diagnosis of nonaffective psychotic disorder in Ontario between 2005 and 2015 (N=39,449). MAIN OUTCOME MEASURES: Models of care, defined by psychosis-related service contacts with primary care physicians and psychiatrists during the 2 years after first diagnosis of psychotic disorder. RESULTS: During the 2-year follow-up period, 29% of the cohort received only primary care, 30% received only psychiatric care, and 32% received both primary and psychiatric care (shared care). Among the shared care group, 72% received care predominantly from psychiatrists, 20% received care predominantly from primary care physicians, and 9% received approximately equal care from psychiatry and primary care. Variation in patient and physician characteristics was observed across the different models of care. CONCLUSION: One in 3 young people with psychotic disorder received shared care during the 2-year period after first diagnosis. The findings highlight opportunities for increasing collaboration between primary care physicians and psychiatrists to enhance the quality of care for those with early psychosis.

Role of Patient Sorting in Avoidable Hospital Stays in Medicare Advantage vs Traditional Medicare.

Importance: Unlike traditional Medicare (TM), Medicare Advantage (MA) plans limit in-network care to a specific network of Medicare clinicians. MA plans thus play a role in sorting patients to a subset of clinicians. It is unknown whether the performance of physicians who treat MA and TM beneficiaries is different. Objective: To examine whether avoidable hospital stay differences between MA and TM can be explained by the primary care clinicians who treat MA and TM beneficiaries. Design, Setting, and Participants: This was a cross-sectional study of a nationally representative sample of MA and TM beneficiaries in 2019 with any of 5 chronic ambulatory care-sensitive conditions (ACSCs). The relative risk (RR) of avoidable hospital stays in MA compared with TM was estimated with inverse probability of treatment-weighted Poisson regression, both without and with clinician fixed effects. The degree to which the estimated MA vs TM difference could be explained by patient sorting was calculated by comparing the 2 RR estimates. Data were analyzed between February 2022 and April 2023. Exposure: Enrollment in MA. Main Outcome and Measures: Whether a beneficiary had avoidable hospital stays in 2019 due to any of the ACSCs. Avoidable hospital stays included both hospitalizations and observation stays. Results: The study sample comprised 1 323 481 MA beneficiaries (mean [SD] age, 75.4 [7.0] years; 56.9% women; 69.3% White) and 1 965 863 TM beneficiaries (mean [SD] age, 75.9 [7.4] years; 57.1% women; 82.5% White). When controlling for the primary care clinician, the RR of avoidable hospital stays in MA vs TM changed by 2.6 percentage points (95% CI, 1.72-3.50; P < .001), suggesting that compared with TM beneficiaries, MA beneficiaries saw clinicians with lower rates of avoidable hospital stays. This effect size was statistically significant to explain the 2% lower rate of avoidable hospital stays in MA than in TM. Conclusions and Relevance: In this cross-sectional study of MA and TM beneficiaries, the lower rate of avoidable hospital stays among MA beneficiaries than TM beneficiaries was attributable to MA beneficiaries visiting clinicians with lower rates of avoidable hospital stays. The patient sorting that occurs in MA plays a critical role in the lower rates of avoidable hospital stays compared with TM.

Composite Sterno-Omohyoid Functional Muscle Transfer for Dual-Vector Smile Reanimation: A Case Series.

Background: Facial reanimation flaps often add bulk and produce single-vector smiles, and multivector flaps frequently require challenging intramuscular dissection. Objective: To evaluate the effectiveness of sterno-omohyoid flap (SOHF) transfer for dual-vector smile reanimation by measuring upper dental show and oral commissure movement. Methods: SOHF transfers from 2017 to 2020 were retrospectively evaluated using eFACE and Emotrics software. Results: Four patients with flaccid and one with nonflaccid facial paralysis were identified (four females and one male, median age: 39 years (range: 38-65); two acoustic neuromas, two congenital, one temporal bone fracture). Median follow-up was 20 months (range: 14-26). All flaps received masseteric nerves and two had additional cross-face grafts. Four developed contraction [median time to contraction: 5.5 months (range: 3-10)]. Mean oral commissure excursion and dental exposure improvements were 7.6 ± 4.0 mm (p = 0.03) and 2.9 ± 1.8 mm (p = 0.05), respectively. Dynamic, smile, and midface-smile eFACE improvements were 20.3 ± 6.8 (p = 0.007), 25.5 ± 14.5 (p = 0.03), and 50.5 ± 12.0 mm (p = 0.004) points, respectively. Mean SOHF mass was 14 ± 1.7 g. Conclusion: The SOHF is a small flap that provides dual-vector smile reanimation in flaccid and nonflaccid facial paralysis.

Access to a regular primary care physician among young people with early psychosis in Ontario, Canada.

AIM: Access to a primary care physician in early psychosis facilitates help-seeking and engagement with psychiatric treatment. We examined access to a regular primary care physician in people with early psychosis, compared to the general population, and explored factors associated with access. METHODS: Using linked health administrative data from Ontario (Canada), we identified people aged 14-35 years with a first diagnosis of nonaffective psychotic disorder (n = 39 449; 2005-2015). We matched cases to four randomly selected general population controls based on age, sex, neighbourhood, and index date (n = 157 796). We used modified Poisson regression to estimate prevalence ratios (PR) for access to a regular primary care physician in the year prior to first diagnosis of psychotic disorder, and the sociodemographic and clinical factors associated with access. RESULTS: A larger proportion of people with early psychosis had a regular primary care physician, relative to the general population (89% vs. 68%; PR = 1.30, 95%CI = 1.30-1.31). However, this was accounted for by a higher prevalence of comorbidities among people with psychosis, and this association was no longer present after adjustment (PR = 0.97, 95%CI = 0.97, 0.98). People with early psychosis who were older, male, refugees and those residing in lower income or high residential instability neighbourhoods were less likely to have a regular primary care physician. CONCLUSION: Approximately one in ten young people with early psychosis in Ontario lack access to a regular primary care physician. Strategies to improve primary care physician access are needed for management of physical comorbidities and to ensure continuity of care.

Risk stratification for treating people at ultra-high risk for psychosis: A cost-effectiveness analysis.

People who are at ultra-high risk (UHR) for psychosis receive clinical care with the aim to prevent first-episode psychosis (FEP), regardless of the risk of conversion to psychosis. An economic model from the Canadian health system perspective was developed to evaluate the cost-effectiveness of treating all with UHR compared to risk stratification over a 15-year time horizon, based on conversion probability, expected quality-of-life and costs. The analysis used a decision tree followed by a Markov model. Health states included: Not UHR, UHR with <20 % risk of conversion to FEP (based on the North American Prodrome Longitudinal Study risk calculator), UHR with ≥20 % risk, FEP, Remission, Post-FEP, and Death. The analysis found that: risk stratification (i.e., only treating those with ≥20 % risk) had lower costs ($1398) and quality-adjusted life-years (0.055 QALYs) per person compared to treating all. The incremental cost-effectiveness ratio for 'treat all' was $25,448/QALY, and suggests treating all may be cost-effective. The model was sensitive to changes to the probability of conversion.