Continuity of Mental Health Care for Canadian
Children and Youth
CIHI consultation with external advisory group
October, 2014
1
Presentation Objectives
1. Introduce CIHI’s children and youth mental health
project
2. Present our policy and research questions
3. Present some preliminary CIHI data
4. Gather thoughts and reactions on the data and some
input in terms of any potential gaps or additional ideas
for analysis
2
Background
• An estimated 10-20% of youth are affected by a mental health
disorder– only 1 in 5 get the help they need.
– Similarly, rates in U.S. and Australia reported as 13% and 14%,
respectively.
• In 2009, nearly one in four deaths among youth 15-19 was due to
suicide.
• Surpassed only by injuries, mental disorders in youth are ranked
as the second highest hospital care expenditure in Canada.
• In FY 2012-2013, 13% of inpatient stays among those aged 5-17
were for a mental disorder (using ICD-10-CA diagnosis codes).
– This is compared to 10% of those aged 18-24, 6% aged 25-64
and 4% of those aged 65+
• Most are discharged back to the community – CIHI data is limited
to emergency department and inpatient/acute care stays
3
Policy Question #1
How prevalent are mental disorders among
children and youth in Canada? What are some
common elements in child and youth mental
health strategies or policies across the
province?
4
How we intend to answer the question
• Start with a discussion on state of child and youth mental
health in Canada using summary statistics, for example:
– Canadian Community Health Survey – Mental Health, 2012
(Statistics Canada)
– National Longitudinal Study of Children and Youth, 1994-2009
(Statistics Canada)
– Survey of Young Canadians, 2012 (Statistics Canada)
• Compare provincial policies addressing mental health and
substance abuse (commonalities: More resources, better
trained staff, integrate mental health promotion in schools)
• Discuss data availability / gaps
5
Policy Question #2
Who are the children and youth using
Emergency and Acute Care services for
mental disorders?
6
How we intend to answer the question
• Discharge Abstract Database/Hospital Mental Health
Database (FY 2006-07 to 2012-2013 – 2013-14 if
possible) will provide pan-Canadian information on
acute inpatient stays among youth 5-24.
• National Ambulatory Care Reporting System (FY200607 to 2013-2014) will provide data on emergency
department use among children and youth aged 5-24.
• Ontario Mental Health Reporting System (FY2006-07
to 2012-2013) will provide information on youth using
adult psychiatric beds in Ontario.
7
Overview of the population
ED Visits
Ages 5-17
Related
to…
Inpatient Stays
Ages 18-24
Ages 5-17
Mental
Health
NonMental
Health
Mental
Health
NonMental
Health
Visits
(% of all
visits)
41,798
(4%)
1,126,859
(96 %)
67,865
(6%)
989,154
(94%)
14,920
(13%)
98,044
(86%)
14,922
(10%)
135,499
(90%)
Unique
Patients
31,252
727,083
46,008
546,919
11,596
78,428
10,841
112,179
Mental
Health
NonMental
Health
Ages 18-24
Mental
Health
NonMental
Health
Source: Discharge Abstract Database, CIHI, 2013.
National Ambulatory Care Reporting System, CIHI, 2014.
Note: Records with missing/invalid Health Care Numbers were removed for this analysis
Defining the population
• Restrict to ages 5-24 (5-17 = children and youth, 18-24 = youth in transition)
• All ICD-10-CA codes in the following categories: Anxiety, Mood, Organic, Personality, Schizophrenic and
other Psychotic, Substance Related, Unspecified Eating, Youth and Other Disorders.
Exclusions
• Newborns, children under the age of 5 and people >18 years of age
• In-hospital deaths
• ED visits ending as ‘Left without been seen’ as they do not have diagnosis information
8
The percent of hospitalizations for children and youth under 18 years of
age for mental disorders has risen 5 percentage points over the last 8
years.
40
35
Percent
30
25
20
(N=14,920)
13
15
8
8
9
9
10
11
4
4
4
4
5
5
5
2006-07
2007-08
2008-09
2009-10
2010-11
2011-12
2012-13
(N=9,370)
10
5
0
Fiscal Year
% of Inpatient Admissions
Source: Discharge Abstract Database, CIHI, 2013.
National Ambulatory Care Reporting System, CIHI, 2014.
% of ED Visits
9
Characteristics of children and youth with ED visits for mental
disorders, FY2013-14.
Description
Mental Health ED Visits
(N=109,663)
Non-Mental Health ED Visits
(N=2,116,013)
77,260
1,274,002
3%
13%
25%
60%
53%
22%
20%
16%
43%
49%
21%
19%
20%
20%
19%
0.1%
80%
20%
19%
20%
21%
19%
0%
73%
1.6%
18%
0.8%
4%
Unique Patients
Age Group (%)
5-9
10-14
15-17
18-24
Female (%)
Income Quintile (%)
Low
Low-Medium
Medium
Medium-High
High
Homeless (%)
% Urban
% Return to ED within 48 hours,
all cause
% Left Against Medical Advice
% Admitted to Acute
Top 3 Main Problems
Females
Males
Females
Males
Anxiety disorders
32%
Mood disorders 26%
Substance-related
29%
Anxiety disorders
26%
Substance-related
21%
Mood disorders 17%
Injury, poisoning
26%
Symptoms, signs,
abnormal findings
18%
Respiratory
problems 13%
Injury, poisoning
43%
Symptoms, signs,
abnormal findings
13%
Respiratory
problems 12%
Source: National Ambulatory Care Reporting System, CIHI, 2014.
10
Characteristics of children and youth with hospitalizations for
mental disorders, FY2012-13.
Description
Mental Health Discharges (N=27,500)
Non-Mental Health Discharges
(N=206,100)
20,800
1.3
71%
169,830
1.2
48%
1%
17%
36%
46%
16%
15%
16%
53%
57%
63%
23%
19%
19%
19%
18%
6
2%
74%
24%
20%
19%
19%
17%
2
<1%
71%
Unique Patients
Mean Number of Visits this year
% Admitted from ED
Age Group (%)
5-9
10-14
15-17
18-24
Female (%)
Income Quintile (%)
Low
Low-Medium
Medium
Medium-High
High
Median LOS (Days)
Homeless (%)
% Urban
Top 3 Main Problems
Females
Males
Females
Males
Mood disorders –
37%
Schizophrenia and
Psychotic disorders –
28%
Mood disorders –
25%
Substance Use
Disorders – 19%
Complication of labour
– 24%
Appendicitis – 10%
Maternal Care – 11%
Specific procedures
and health care – 5%
Head injuries – 4%
Other Mental Health
Disorders – 30%
Anxiety Disorders –
10%
Appendicitis – 4%
Source: Discharge Abstract Database, CIHI, 2013.
11
Percent of Discharges with Mental
Health Diagnosis
The rate of hospitalizations for children and youth with mental
disorders varies by province (Fiscal Year 2012-2013).
100
90
80
70
60
50
40
30
20
10
0
Province
Source: Discharge Abstract Database, CIHI, 2013.
12
Policy Question #3
Is there a repeating cycle of care for young
patients with mental disorders? Are they
frequent users of the health care system?
13
How we intend to answer the question
• Two potential analyses are being considered:
1. Identify a patient cohort in acute care in 2006-07 and follow
them forward to see their pattern of hospital utilization
•
i.e. a unique group of patients followed from a specified date,
are these frequent users of the acute care/ED system?
2. Identify patient pathways by linking DAD and NACRS, and
describing patients who are admitted into acute via the ED
•
i.e. building episodes, examine profile of patients admitted to
acute through ED, looking at multiple visits in one year
• Using external resources, identify community programs
targeted at children and youth with recent discharges from
inpatient care
– Where is follow up occurring? With PHC provider? In school?
14
Children and youth with mental disorders are
frequent users of hospital services.
• In 2006-07, 7,418 children and youth between 5 and
17 had hospitalizations for mental disorders.
– 18% had four or more visits for a mental disorder that year
– 21% returned the following year, and of these 40% came
back at least twice
– In 2012, nearly half of these same patients were seen in
the ED for a (the same?) mental disorder
15
ED Discharge Disposition, 2013-2014
109,663 ED visits for
mental health disorders
18% are admitted
Of those admitted:
• 52% are female
• 31% are between 15-17
• 30% were admitted with
a mood disorder
Admitted
Discharged Home
Transferred
Other
Source: National Ambulatory Care Reporting System, CIHI, 2013.
16
Other items to be discussed in report
• Youth in transition 18-24
– Leaving high school, there is hesitancy to access adult
services, but they may no longer qualify for youth services
– may get lost in the cracks
– According to CCHS – MH, these youth are at increased
risk for mental illness and substance abuse
– 10% of hospitalizations among 18-24 year olds are for
mental disorders (includes substance abuse)
• Other vulnerable populations (e.g. First Nations
communities)
• Encounters with justice system, corrections,
family/social services
17
Policy Question #4
What is the dollar amount associated with children and
youth seeking mental health services in emergency or
acute care? Can we compare it or relate it to the cost of
care in the community or cost of intervention in schools?
Can we determine the current proportion of health dollars
specifically allocated to mental health?
18
How we intend to answer the question
• Using the Resource Intensity Weight and Cost per
Weighted Case formula to determine cost associated
with a stay in the hospital for a mental health diagnosis
• Potentially use Canadian Patient Costing Database to
get exact hospital stay costs for a subset of patients
• National Physician Database to calculate how much
physicians are billing for psychiatric services, therapy
or counseling for children and youth under 20
• Grey literature addressing cost of mental health care
in Canada, and what the long term cost would be if
nothing is done for these youth today
19
Physician billing for Psychiatric services and
counseling, NPDB, 2011-2012
• In 2011, nearly 5% of all physician payments in Canada
was for psychotherapy / counseling services
– Additional assessment and consultation services for mental
health may have been billed, but they are not distinguishable
from non-psychology/psychiatry assessments and consultations.
• This varied from 8% in Alberta to <2% in Nova Scotia
• Ontario paid just under $50,000,000 for
psychotherapy/counseling services – 56% was paid to
psychiatrists
• Alberta paid just over $20,000,000 for
psychotherapy/counseling services – 68% was paid to
psychiatrists
Source: National Physician Database, CIHI, 2012.
DRAFT RESULTS – Do not circulate
20
Policy Question #5
What are the options for these patients at
the end of their inpatient stay? What are
the community treatment options? What
does the evidence say is successful?
21
How we intend to answer this question
• Environmental scanning / literature review
– Discuss known effective interventions
• Identify community data (e.g. Alberta Child Lab data),
school board data (e.g. Toronto District School Board
student survey)
• A separate analysis will look at drugs prescribed to
youth 15-24 in Western provinces that are typically
indicated for mental disorders.
22
General Questions for External Advisory Group
• Have we asked the right questions?
• Are we missing any important questions?
• Does the preliminary data resonate with you?
• Can you share any initiatives you are aware of to
address children and youth mental health that we can
highlight?
• Are you aware of data sources outside of CIHI or
Statistics Canada that could strengthen our report?
23
Technical Questions for External Advisory Group
• Inclusion of children and youth who arrive at the ED
for self-harm or potential self-harm in absence of a
mental health diagnosis?
• Inclusion of a group who have “emotional state,
suicidal ideation” as their diagnosis?
• What age break downs are most informative?
• We are considering excluding certain diagnoses such
as developmental delay and organic disorders – would
you agree or disagree?
24
Timelines and next steps
• Consult with external advisors and incorporate feedback
into methodology – Now-October, 2014
• Complete preliminary analyses and determine key findings
– September – November, 2014
• Consult with external advisors and incorporate feedback,
develop storyline – November-December, 2014
• Complete analyses and write-up, share externally,
incorporate feedback – January-February, 2015
• Finalize and submit for translation and editing– March,
2015
• Public Release – Spring 2015
25
THANK YOU!
Questions?
26