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Abstract Background Major depressive disorder (MDD) is one of the world’s leading causes of disability. Our purpose was to characterize the total costs of MDD and evaluate the degree to which the British Columbia provincial health system meets its objective to protect people from the financial impact of illness. Methods We performed a population-based cohort study of adults newly diagnosed with MDD between 2015 and 2020 and followed their health system costs over two years. The expenditure proportion of MDD-related, patient paid costs relative to non-subsistence income was estimated, incidences of financial hardship were identified and the slope index of inequality (SII) between the highest and lowest income groups compared across regions. Results There were 250,855 individuals diagnosed with MDD in British Columbia over the observation period. Costs to the health system totalled >$1.5 billion (2020 CDN), averaging $138/week for the first 12 weeks following a new diagnosis and $65/week to week 52 and $55/week for weeks 53–104 unless MDD was refractory to treatment ($125/week between week 12–52 and $101/week over weeks 53–104). The proportion of MDD-attributable costs not covered by the health system was 2-15x greater than costs covered by the health system, exceeding $700/week for patients with severe MDD or MDD that was refractory to treatment. Population members in lower-income groups and urban homeowners had disadvantages in the distribution of financial protection received by the health system (SII reached − 8.47 and 15.25, respectively); however, financial hardship and inequities were mitigated province-wide if MDD went into remission (SII − 0.07 to 0.6). Conclusions MDD-attributable costs to health systems and patients are highest in the first 12 weeks after a new diagnosis. During this time, lower income groups and homeowners in urban areas run the risk of financial hardship.

Abstract Background Inpatient palliative care is associated with lower inpatient costs; however, this has yet to be studied using a more nuanced, multi-tiered measure of inpatient palliative care and a national population-representative dataset. Using a population-based cohort of Canadians who died in hospital, our objectives were to: describe patients’ receipt of palliative care and active interventions in their terminal hospitalization; and examine the relationship between inpatient palliative care and hospitalization costs. Methods Retrospective cohort study using data from the Discharge Abstract Database in Canada between fiscal years 2012 and 2015. The cohort were Canadian adults (age ≥ 18 years) who died in hospital between April 1st, 2012 and March 31st, 2015 (N = 250,640). The exposure was level of palliative care involvement defined as: medium-high, low, or no palliative care. The main measure was acute care costs calculated using resource intensity weights multiplied by the cost of standard hospital stay, represented in 2014 Canadian dollars (CAD). Descriptive statistics were represented as median (IQR), and n(%). We modelled cost as a function of palliative care using a gamma generalized estimating equation (GEE) model, accounting for clustering by hospital. Results There were 250,640 adults who died in hospital. Mean age was 76 (SD 14), 47% were female. The most common comorbidities were: metastatic cancer (21%), heart failure (21%), and chronic obstructive pulmonary disease (16%). Of the decedents, 95,450 (38%) had no palliative care involvement, 98,849 (38%) received low involvement, and 60,341 (24%) received medium to high involvement. Controlling for age, sex, province and predicted hospital mortality risk at admission, the cost per day of a terminal hospitalization was: $1359 (95% CI 1323: 1397) (no involvement), $1175 (95% CI 1146: 1206) (low involvement), and $744 (95% CI 728: 760) (medium-high involvement). Conclusions Increased involvement of palliative care was associated with lower costs. Future research should explore whether this relationship holds for non-terminal hospitalizations, and whether palliative care in other settings impacts inpatient costs.

Abstract Background A minority of individuals use a large portion of health system resources, incurring considerable costs, especially in acute-care hospitals where a significant proportion of deaths occur. We sought to describe and contrast the characteristics, acute-care use and cost in the last year of life among high users and non-high users who died in hospitals across Canada. Methods We conducted a population-based retrospective-cohort study of Canadian adults aged ≥18 who died in hospitals across Canada between fiscal years 2011/12–2014/15. High users were defined as patients within the top 10% of highest cumulative acute-care costs in each fiscal year. Patients were categorized as: persistent high users (high-cost in death year and year prior), non-persistent high users (high-cost in death year only) and non-high users (never high-cost). Discharge abstracts were used to measure characteristics and acute-care use, including number of hospitalizations, admissions to intensive-care-unit (ICU), and alternate-level-of-care (ALC). Results We identified 191,310 decedents, among which 6% were persistent high users, 41% were non-persistent high users, and 46% were non-high users. A larger proportion of high users were male, younger, and had multimorbidity than non-high users. In the last year of life, persistent high users had multiple hospitalizations more often than other groups. Twenty-eight percent of persistent high users had ≥2 ICU admissions, compared to 8% of non-persistent high users and only 1% of non-high users. Eleven percent of persistent high users had ≥2 ALC admissions, compared to only 2% of non-persistent high users and

Abstract Background Primary care serves all age groups and individuals with health states ranging from those with no chronic conditions to those who are medically complex, or frail and approaching the end of life. For information to be actionable and guide planning, there must be some population disaggregation based on differences in expected needs for care. Promising approaches to segmentation in primary care reflect both the breadth and severity of health states, the types and amounts of health care utilization that are expected, and the roles of the primary care provider. The purpose of this study was to assess population segmentation as a tool to create distinct patient groups for use in primary care performance reporting. Methods This cross-sectional study used administrative data (patient characteristics, physician and hospital billings, prescription medicines data, emergency department visits) to classify the population of British Columbia (BC), Canada into one of four population segments: low need, multiple morbidities, medically complex, and frail. Each segment was further classified using socioeconomic status (SES) as a proxy for patient vulnerability. Regression analyses were used to examine predictors of health care use, costs and selected measures of primary care attributes (access, continuity, coordination) by segment. Results Average annual health care costs increased from the low need ($ 1460) to frail segment ($10,798). Differences in primary care cost by segment only emerged when attributes of primary care were included in regression models: accessing primary care outside business hours and discontinuous primary care (≥5 different GP’s in a given year) were associated with higher health care costs across all segments and higher continuity of care was associated with lower costs in the frail segment (cost ratio = 0.61). Additionally, low SES was associated with higher costs across all segments, but the difference was largest in the medically complex group (cost ratio = 1.11). Conclusions Population segments based on expected need for care can support primary care measurement and reporting by identifying nuances which may be lost when all patients are grouped together. Our findings demonstrate that variables such as SES and use of regression analyses can further enhance the usefulness of segments for performance measurement and reporting.

Abstract Background One in nine emergency department (ED) visits in Canada are caused by adverse drug events, the unintended and harmful effects of medication use. Medication reviews by clinical pharmacists are interventions designed to optimize medications and address adverse drug events to impact patient outcomes. However, the effect of medication reviews on long-term outpatient health services utilization is not well understood. This research studied the effect of medication review performed by clinical pharmacists on long-term outpatient health services utilization. Methods Data included information from 10,783 patients who were part of a prospective, multi-centre quality improvement evaluation from 2011 to 2013. Outpatient health services utilization was defined as total ED visits and physician contacts, aggregated to four physician specialty groups: general and family practitioners (GP); medical specialists; surgical specialists; and imaging and laboratory specialists. During triage, patients deemed high-risk based on their medical history, were systematically allocated to receive either a medication review (n = 6403) or the standard of care (n = 4380). Medication review involved a critical examination of a patient’s medications to identify and resolve medication-related problems and communicate these results to community care providers. Interrupted time series analysis compared the effect of the intervention on health services utilization relative to the standard of care controlling for pre-intervention differences in utilization. Results ED-based pharmacist-led medication review did not result in a significant level or trend change in the primary outcome of total outpatient health services utilization. There were also no differences in the secondary outcomes of primary care physician visits or ED visits relative to the standard of care in the 12 months following the intervention. Our findings were consistent when stratified by age, hospital site, and whether patients were discharged on their index visit. Conclusion This was the first study to measure long-term trends of physician visits following an ED-based medication review. The lack of differences in level and trend of GP and ED visits suggest that pharmacist recommendations may not have been adequately communicated to community-based providers, and/or recommendations may not have affected health care delivery. Future studies should evaluate physician acceptance of pharmacist recommendations and should encourage patient follow-up to community providers.

Abstract Background Health systems worldwide struggle to identify, adopt, and implement in a timely and system-wide manner the best—evidence-informed—policy-level practices. Yet, there is still only limited evidence about individual and institutional best practices for fostering the use of scientific evidence in policy-making processes The present project is the first national-level attempt to (1) map and structurally analyze—quantitatively—health-relevant policy-making networks that connect evidence production, synthesis, interpretation, and use; (2) qualitatively investigate the interaction patterns of a subsample of actors with high centrality metrics within these networks to develop an in-depth understanding of evidence circulation processes; and (3) combine these findings in order to assess a policy network’s “absorptive capacity” regarding scientific evidence and integrate them into a conceptually sound and empirically grounded framework. Methods The project is divided into two research components. The first component is based on quantitative analysis of ties (relationships) that link nodes (participants) in a network. Network data will be collected through a multi-step snowball sampling strategy. Data will be analyzed structurally using social network mapping and analysis methods. The second component is based on qualitative interviews with a subsample of the Web survey participants having central, bridging, or atypical positions in the network. Interviews will focus on the process through which evidence circulates and enters practice. Results from both components will then be integrated through an assessment of the network’s and subnetwork’s effectiveness in identifying, capturing, interpreting, sharing, reframing, and recodifying scientific evidence in policy-making processes. Discussion Knowledge developed from this project has the potential both to strengthen the scientific understanding of how policy-level knowledge transfer and exchange functions and to provide significantly improved advice on how to ensure evidence plays a more prominent role in public policies.