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Psychiatry in Ontario: Current Evidence and Future State AGHPS Leadership Summit 2018

Psychiatry in Ontario: Current Evidence and Future State AGHPS Leadership Summit 2018. Paul Kurdyak MD PhD Scientist, Institute for Mental Health Policy Research, CAMH Core Senior Scientist and Program Lead, Mental Health and Addictions Program Institute for Clinical Evaluative Sciences

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Psychiatry in Ontario: Current Evidence and Future State AGHPS Leadership Summit 2018

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  1. Psychiatry in Ontario:Current Evidence and Future StateAGHPS Leadership Summit 2018 Paul Kurdyak MD PhD Scientist, Institute for Mental Health Policy Research, CAMH Core Senior Scientist and Program Lead, Mental Health and Addictions Program Institute for Clinical Evaluative Sciences Associate Professor, IHPME

  2. Disclosures • No conflicts of interest • Funding from: • CIHR • MOHTLC

  3. Objectives • To understand the importance of performance measurement to address issues related to health service quality. • To learn about recent research describing access to mental health care amongst certain patient populations. • To learn about emerging evidence describing different mental health service delivery models.

  4. What do we know about access?

  5. Access: ED vs. Outpatient by income

  6. ED as Point of Access

  7. ED as First Contact by Diagnosis

  8. First Episode Psychosis – Access to Care • 20,096 with FEP between 1999 and 2008 • Approximately 40 per cent did not receive any physician follow-up within 30 days • Nearly 60 per cent did not receive follow-up by a psychiatrist • Males had lower odds of receiving any physician follow-up. • The odds of psychiatrist follow-up decreased with increasing age and were lower for those living in rural areas.

  9. Early Intervention and MortalityAnderson et al., Am J Psychiatry. 2018 May 1;175(5):443-452

  10. Substance Use and ED use • 1 out of 15 frequent ED users is for Mental Health/Addictions • 64% of frequenty MHA ED users have substance-related issues

  11. Types of Substances at Index ED Visit

  12. Transitions from ED to Outpatient

  13. Hospitalization Transitions

  14. How does this compare to non-psychiatric Dx?

  15. 30-day readmission by diagnosis

  16. 7-Day Post-Discharge Physician Follow-Up

  17. How do we compare – CHF and COPD?

  18. Post-Discharge Follow-up by Diagnosis

  19. SCZ – Highest Readmission Rate; Lowest F/U Rate

  20. Shifting Gears • Overview of previous slides: • Indirect evidence that access to outpatient services is inadequate and transitions of care from the ED and hospitalizations to outpatients is poor • What do we know about psychiatrist supply and practice patterns?

  21. Ontario Regional Psychiatrist Supply

  22. Avg total and new patients/year

  23. <100 and <40 Patients/Yr by Years Since Graduation

  24. Supply, Psychiatrist Age and Region

  25. What about incentives? • In September, 2011, MOHLTC introduced bonus payments for: • Rapid access to patients within 30 days of psychiatric hospitalization discharge • Ongoing care for 6 months following a suicide attempt • Stated objective – to increase access at a critical period of time that would reduce deterioration, early readmission and possibly suicide attempts • We can identify individuals post-discharge AND post-suicide attempt (ED only)

  26. Reminder – Post-discharge follow-up

  27. Access to Psychiatrists Post-Discharge

  28. Psychiatrist Visit 180 Days Post-Suicide Attempt

  29. A long list of issues Access to care is problematic There is evidence that the people with the greatest need are least likely to get the care they need There are concerning trends in regional psychiatrist supply that will make access worse

  30. What evidence exists to move forward? Measurement-based care Integrated Care VERY little evidence on how to achieve good outcomes (medical and psychiatric) for individuals with serious mental illnesses

  31. Psychiatric Services, Feb. 2017; 68(2):179-188 • 18% of US psychiatrists and 11% of US psychologists routinely incorporate symptom rating scales into their practice • BUT MH providers MISS clinical deterioration in 80% of their patients • Systematic review conclusions – ALL RCTs showed frequent and timely feedback of patient-reported symptoms during pharmaco- or psychotherapy improved patient outcomes

  32. JAMA. 2016;316(8):826-834

  33. Conclusions Emerging evidence that access and transitions in care are problematic Existing psychiatrist supply and practice patterns will not address access and transition evidence without change Evidence exists, but is not being implemented in Ontario

  34. Thank you! Questions?

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