From the Editor

It makes sense that those with substance use problems and mental illness consume more health resources – but how much more? As Canadians opt for medical assistance in dying, what will the impact be on health spending?

Readings don’t necessarily follow a theme. But this week, we push past newspaper headlines to consider two topical issues in more detail, tapping the latest in the literature.

Pushing past the headlines

In the first paper, Graham et al. consider health costs and utilization for people with mental health and/or substance use problems. Spoiler alert: these individuals are much more likely to use health services, resulting in higher costs. That’s not exactly a surprise, but Graham et al. provide a detailed analysis in an area that has been understudied.

In the second paper, drawing from Dutch data, Trachtenberg and Manns estimate the savings from medically assisted death.

Both papers are timely. Both reach interesting conclusions.


Substance Use and Health Services

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

Kathryn Graham, Joyce Cheng, Sharon Bernards, Samantha Wells, Jürgen Rehm, Paul Kurdyak

The Canadian Journal of Psychiatry, January 2017

The critical role of mental health (MH) in overall health is well recognized, including a mental health action plan developed by the World Health Organization; however, the extent that mental health contributes to use of general health care services remains unclear. Even less is known regarding co-occurring mental health and substance use/addiction (SA) problems and how they are related to health service use.

Several studies have found that frequent emergency department users may be more likely to have MH and/or SA (MH/SA) problems compared to less frequent users. However, most of these studies used small samples from a single hospital or community, and a recent review concluded that findings depend on factors such as location of the health care setting. Evidence also indicates high rates of MH and SA problems among frequent users of other medical services (e.g., primary care). Again, these studies used small samples from a single clinic or practice. One exception was a study of all health care users in British Columbia, which found that frequent health care users were more likely than less frequent users to be diagnosed with a psychosocial condition (including both MH and SA); however, this study did not determine whether services used were for psychosocial versus other health conditions.

Kathryn Graham

So begins a new paper published in The Canadian Journal of Psychiatry. In brief: “We used a 5-year cross-sectional study design to examine 12-month health care utilization among persons categorized as having MH only, SA only, and both MH and SA (MH+SA) problems compared to individuals not identified as having MH or SA problems (non-MH/SA).”

Here’s what the authors did:

· The authors randomly selected 200,000 Ontarians with valid public health insurance for each fiscal year, starting in 2007.

· Drawing on the Institute for Clinical Evaluative Sciences administrative health databases, the authors gathered information on inpatient services, ED visits, and other aspects of health utilization (based on, for example, the CIHI inpatient service utilization).

· “For each of the 4 patient categories (MH only, SA only, MH+SA, non-MH/SA), we calculated the average number of primary care physician visits, ED visits, and hospitalizations (both MH/SA and non-MH/SA related) across the 5 years.”

· Diagnoses were drawn from the databases. So, for example, a person was described as having a mental health problem if she or he had an inpatient hospitalization that was given a mental health code. Exclusion criteria included diagnoses of delirium and dementia.

· The authors also compared the health-care utilization of these four groups, their associated health costs, and – interestingly – what types of services people with mental health and/or substance use problems sought care for (psychiatric or non-psychiatric care).

· Statistical analyses were done, including logical regression, to compare the 4 patient categories.

Here’s what they found:

· Of the 200,000 selected for each fiscal year, people who didn’t use health services were excluded, as were those under 19. The resulting average sample size across 5 years was 124,235.

· Demographically: those without either mental health or substance use problems were more female (53.38%), as were those with mental health problems (62.22%); in contrast, substance use tended to be more of a male experience (69.04%). The average age was late 40s for those without mental health or substance use problems (48.68) or with a mental health problem (48.25) but younger (43.71) for those with substance use or substance use and mental health (41.73).

· In terms of services: “MH+SA patients visited primary care physicians most often (annual mean of 24.92 visits) followed by SA (15.72), MH (11.80), and non-MH/SA (6.53)…” “MH+SA patients visited the emergency department most frequently (mean of 2.48 visits per year), followed by SA (1.33 visits), MH (0.69 visits), and non-MH/SA (0.42 visits)…” “[H]ospitalizations indicate the same pattern, with most frequent hospitalizations by MH+SA patients, followed by SA, MH, and non-MH/SA.” See graph below.

· Looking at odds ratios: people with MH+SA used health services more than those without either problem for physical health problems. For instance, the odds ratio of hospitalization for someone with MH+SA was 7.82. (!) But someone with both these types of problems had an odds ratio of 2.18 of being hospitalized for a non-mental health or substance use problem. (!!)

· Needless to say, costs were highest for those with MH+SA ($10,913 per person per year vs $6,478 for SA, $5,184 for MH, and for $3,095 non-MH/SA).

The authors conclude:

It is clear that primary care physicians and other medical/hospital workers play a major role in assisting persons who have mental health and substance use/addiction problems. As such, MH/SA is not a specialty health issue but rather a core health issue that affects all health service environments. Therefore, it is critical that health professionals in these environments have core competencies relating to MH and SA identification, prevention, and treatment, as well as an understanding of interrelationships and interactions of physical health with MH/SA to ensure that persons with MH/SA problems receive appropriate and comparable quality of care to those who do not have these problems.

A few thoughts:

1. This is a good paper.

2. More and more, we are discussing substance use problems – including opioids (as I noted a couple of weeks ago). The Graham et al. paper pushes us past the headlines, and shows us from a health-care system perspective the impact on cost and use of services.

3. The conclusion is thoughtful and worth careful consideration: mental health co-morbid with substance use “is not a specialty health issue but rather a core health issue…”

Medically Assisted Death and Health Costs

“Cost analysis of medical assistance in dying in Canada”

Aaron J. Trachtenberg and Braden Manns

CMAJ, 23 January 2017

The Criminal Code of Canada’s prohibitions on medical assistance in dying have been lifted. The logistics of offering medical assistance in dying to Canadians need to be formalized, and the consequences of this practice need to be anticipated. As with any new medical intervention, understanding the clinical and costing implications of medical assistance in dying is important.

Health care costs increase substantially among patients nearing the end of life, accounting for a disproportionate amount of health care spending. For example, in Manitoba, more than 20% of health care costs are attributable to patients within the 6 months before dying, despite their representing only 1% of the population. Furthermore, as death approaches, health care costs increase dramatically in the final months. Patients who choose medical assistance in dying may forego this resource-intensive period.

Braden Manns and Aaron J. Trachtenberg

So begins a paper just published in the CMAJ. In brief: using a methodology developed by Emanuel and Battin (first published in the New England Journal of Medicine), the authors do a cost analysis of medical assistance in dying, or MAiD.

The paper is relatively straight-forward, and doesn’t require much of a summary.

· They attempt to predict the number of deaths due to MAiD, drawing heavily on Dutch data.

· They note that: “Based on these numbers, we estimated that medical assistance in dying will eventually play a role in 1%–4% of all deaths in Canada.”

· “We predicted that about 40% of Canadians who choose medical assistance in dying will have their lives shortened by 1 week, and 60% of patients will have their lives shortened by 1 month.”

What do they find? Again, they looked at several scenarios. At 1% of deaths: “We expect that net health care costs would be reduced by $33.2 million per year if 1% of deaths are due to medical assistance in dying. When end-of-life costs were reduced by 40% and 70% with the assumption that a palliative approach would have been chosen, net cost savings are reduced to $19.3 million and $8.9 million, respectively…”

They conclude:

Our analysis suggests that the provision of medical assistance in dying in Canada will be cost neutral or result in a reduction in total health care costs, although the true effect on health care costs will not be certain until we determine who the typical Canadian patient requesting the intervention is and how its practice is implemented across the country.

A few thoughts:

1. This CMAJ paper is interesting.

2. The analysis is crude. It draws from Dutch data – but does extrapolate data from the Netherlands and apply to Canada? And how might Canadian demand change over time?

3. Accepting their numbers – crude but not meaningless – there is little in way of cost-savings with MAiD. Millions of dollars in savings must be put in perspective; we spend in Canada $228 billion a year on health care.

4. Of course, there is more to MAiD than cost savings. Indeed, some will feel that this paper adds nothing to the larger debate because MAiD isn’t about saving (or spending) money.

5. This paper has no direct tie into mental health. But the Supreme Court ruling that mandated the MAiD legislation included those with mental illness – meaning that future legislation is likely to address this population. What would be the savings if people with mental illness were allowed a MAiD option? A more pointed question: What would be the lost (economic) productivity?

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.