Characteristics of health care related to mental health and substance use disorders among Community Health Centre clients in Ontario: a population-based cohort study

Richard G. Booth; Lucie Richard; Lihua Li; Salimah Z. Shariff; Jennifer Rayner

doi:10.9778/cmajo.20190089

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Figure 1:
Flow diagram showing creation of the cohort subgroups. Note: CHC = Community Health Centre, PCPOP = Primary Care Population.
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Figure 2:
Selected demographic and comorbidity characteristics of the cohort subgroups at baseline. Note: CHC = Community Health Centre, COPD = chronic obstructive pulmonary disease.
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Figure 3:
Ontario Marginalization Index (24)^, (25) characteristics of the cohort subgroups at baseline. Note: CHC = Community Health Centre.

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Table 1:

Characteristics of the cohort subgroups at baseline

Characteristic	Group; no. (%) of people^*
Characteristic	Priority-population CHC n = 6575	Nonpriority-population CHC n = 15 208	Community control n = 1 673 200
Female sex	3293 (50.1)	9050 (59.5)	978 646 (58.5)
Age group, yr
21–35	1656 (25.2)	3712 (24.4)	361 560 (21.6)
35–49	2240 (34.1)	4373 (28.8)	477 381 (28.5)
50–64	2212 (33.6)	5016 (33.0)	502 974 (30.1)
≥ 65	467 (7.1)	2107 (13.9)	331 285 (19.8)
Income quintile^†
Quintile 1 (lowest)	3030 (46.1)	6049 (39.8)	346 854 (20.7)
Quintile 2	1367 (20.8)	3258 (21.4)	330 170 (19.7)
Quintile 3	961 (14.6)	2362 (15.5)	326 318 (19.5)
Quintile 4	687 (10.4)	1960 (12.9)	340 802 (20.4)
Quintile 5 (highest)	448 (6.8)	1495 (9.8)	318 302 (19.0)
Residential instability^†
Quintile 1 (lowest)	218 (3.3)	1284 (8.4)	300 967 (18.0)
Quintile 2	373 (5.7)	1715 (11.3)	293 752 (17.6)
Quintile 3	611 (9.3)	2526 (16.6)	296 501 (17.7)
Quintile 4	1328 (20.2)	3528 (23.2)	325 170 (19.4)
Quintile 5 (highest)	3960 (60.2)	5980 (39.3)	443 292 (26.5)
Material deprivation^†
Quintile 1 (lowest)	337 (5.1)	1278 (8.4)	278 032 (16.6)
Quintile 2	494 (7.5)	1828 (12.0)	307 538 (18.4)
Quintile 3	795 (12.1)	2528 (16.6)	319 847 (19.1)
Quintile 4	1354 (20.6)	2838 (18.7)	341 218 (20.4)
Quintile 5 (highest)	3510 (53.4)	6561 (43.1)	413 047 (24.7)
Dependency^†
Quintile 1 (lowest)	1533 (23.3)	2890 (19.0)	416 126 (24.9)
Quintile 2	1477 (22.5)	2660 (17.5)	325 971 (19.5)
Quintile 3	1250 (19.0)	2878 (18.9)	299 413 (17.9)
Quintile 4	1069 (16.3)	3068 (20.2)	283 751 (17.0)
Quintile 5 (highest)	1161 (17.7)	3537 (23.3)	334 421 (20)
Ethnic concentration^†
Quintile 1 (lowest)	1101 (16.7)	4076 (26.8)	257 281 (15.4)
Quintile 2	1227 (18.7)	2679 (17.6)	285 263 (17.0)
Quintile 3	1089 (16.6)	2032 (13.4)	320 477 (19.2)
Quintile 4	1727 (26.3)	3034 (20.0)	366 559 (21.9)
Quintile 5 (highest)	1346 (20.5)	3212 (21.1)	430 102 (25.7)
Recent immigrant status^‡	148 (2.3)	560 (3.7)	65 024 (3.9)
Rural residence^§	214 (3.3)	2958 (19.5)	164 704 (9.8)
Rostered to family physician	2029 (30.9)	4467 (29.4)	1 368 951 (81.8)
Mental-health–related care^¶^**
Psychotic disorder	1596 (24.3)	3587 (23.6)	180 503 (10.8)
Nonpsychotic disorder	3680 (56.0)	8011 (52.7)	934 312 (55.8)
Substance use disorder	2832 (43.1)	3250 (21.4)	182 173 (10.9)
Other mental health	1234 (18.8)	2359 (15.5)	238 961 (14.3)
Comorbidities
Asthma^††	1700 (25.9)	3765 (24.8)	313 695 (18.7)
COPD^††	1360 (20.7)	3026 (19.9)	204 227 (12.2)
Diabetes^††	1073 (16.3)	2815 (18.5)	249 948 (14.9)
Hypertension^††	1738 (26.4)	4973 (32.7)	541 200 (32.0)
Infective endocarditis^**	48 (0.7)	21 (0.1)	1089 (0.1)
Rheumatoid arthritis^**	55 (0.8)	116 (0.8)	4985 (0.3)
Congestive heart failure^††	146 (2.2)	455 (3.0)	45 813 (2.7)
Chronic liver disease^**	1394 (21.2)	1400 (9.2)	65 287 (3.9)
Chronic kidney disease^**	459 (7.0)	1183 (7.8)	82 278 (4.9)
Crohn disease/ulcerative colitis^**	51 (0.8)	163 (1.1)	18 461 (1.1)
HIV infection^††	23 (0.3)	21 (0.1)	758 (< 0.1)
Comorbidities within 1 yr before index date
Skin/soft-tissue infection	1094 (16.6)	1742 (11.5)	105 782 (6.3)
Chronic pain	1690 (25.7)	3783 (24.9)	224 204 (13.4)

Note: CHC = Community Health Centre, COPD = chronic obstructive pulmonary disease.
↵* Percentages may not total 100% owing to missing data.
↵† Drawn from the Ontario Marginalization Index. (24), (25)
↵‡ Presence in the Immigration, Refugees and Citizenship Canada Permanent Residents database with a landing date less than 10 years before the index date.
↵§ Settlement of less than 10 000 people.
↵¶ Includes any hospital admission or 2 claims in 2 years or less of any eligible diagnostic or fee code (Appendix 1, Supplemental Table S1).
↵** Within 3 years before the index date.
↵†† Any diagnosis before the index date.

Table 2:

Unadjusted outcomes within 1 year of the index date

Outcome	No. (%) of people^*
Outcome	Priority-population CHC n = 6575	Nonpriority-population CHC n = 15 208	Community control n = 1 673 200
Specialist visit
Psychiatrist	2514 (38.2)	5891 (38.7)	265 417 (15.9)
Respirologist	624 (9.5)	1399 (9.2)	67 295 (4.0)
Endocrinologist	270 (4.1)	1016 (6.7)	60 415 (3.6)
Cardiologist	2262 (34.4)	3750 (24.7)	117 933 (7.0)
Primary health care visit, rate per 1000 patients (95% CI)	34.41 (34.27–34.55)	25.53 (25.45–25.61)	16.30 (16.29–16.30)
Emergency department visit, rate per 1000 patients (95% CI)	2.55 (2.51–2.58)	1.50 (1.48–1.52)	0.71 (0.71–0.71)
Hospital admission, rate per 1000 patients (95% CI)	0.26 (0.25–0.28)	0.20 (0.19–0.21)	0.13 (0.13–0.13)

Note: CHC = Community Health Centre, CI = confidence interval.
↵* Except where noted otherwise.

Table 3:

Odds of psychiatric care and emergency department use within 1 year of the index date

Outcome; group	Unadjusted OR (95% CI)	Adjusted OR (95% CI)
Psychiatric care^*
Community control	1.00 (referent)	1.00 (referent)
Priority-population CHC	1.47 (1.42–1.52)	1.26 (1.20–1.33)
Nonpriority-population CHC	1.50 (1.46–1.54)	1.47 (1.41–1.53)
Emergency department use^†
Community control	1.00 (referent)	1.00 (referent)
Priority-population CHC	1.52 (1.47–1.58)	1.15 (1.10–1.20)
Nonpriority-population CHC	1.13 (1.10–1.16)	1.13 (1.09–1.17)

Note: CHC = Community Health Centre, CI = confidence interval, OR = odds ratio.
↵* Variables adjusted for: age, sex, income quintile, residential instability, material deprivation, dependency, ethnic concentration, recent immigrant status, rural residence, mental-health–related health care, CHC use in prior 3 years, rostered to family physician at index date (we accounted for clustering of family physician at index date using the STRATA statement in PROC LOGISTIC).
↵† Variables adjusted for: as above, and comorbidities in prior 3 years (i.e., chronic liver disease, chronic kidney disease, Crohn disease or ulcerative colitis, rheumatoid arthritis, infective endocarditis), any diagnosis of comorbidity before index date (i.e., asthma, chronic obstructive pulmonary disease, diabetes, hypertension, congestive heart failure, HIV infection), comorbidities in prior year (i.e., skin or soft-tissue infection, chronic pain).