ICES Mental Health & Addictions Symposium Pt 3: Paul Kurdyak

The second person I'm pleased to introduce is Dr Paul Kurdyak who as I mentioned before is the lead of the of the Institute for Clinical Evaluative Sciences Mental Health and Addictions Research Program

He's also the medical director of performance improvement at CAMH and associate professor in the department of psychiatry at U of T He is well known I think probably to everybody in the room because he advises just about every organization, ministry and service provider that has anything to do with mental health in Ontario So I was really looking forward to coming up to this microphone because earlier on I saw a bird flying around which I normally only see in churches and this sound from this microphone is kind of like those Sunday morning televangelists So while I have a near religious devotion to work, if I lapse into fervor that's unbecoming I'm hoping Mike Schull will let me know I do want to take a little bit of a break

We've talked about the need for integration amongst ourselves but I wanted to take a little bit of a break and remind us why we are all here, why we're doing this And I was driving with my wife on the weekend and we were listening to a CBC documentary and the documentary maker was a an individual who had struggled with OCD One of the segments was an interview with a mother with two daughters and this for this family lightning really struck twice One daughter had come down with cancer and the other was struggling with OCD and one quote really struck me and that was when the mother said "If I had to choose between between OCD and cancer I choose cancer hands-down

" That's not because cancer is such a great situation to be dealing with, but when you listen to the relative experiences of struggling with cancer versus OCD and cancer – they were given great information about what they were dealing with, the treatment occurred right when it needed to occur, and they got exactly what they needed and even after the treatment the daughter with cancer through Make-a-Wish Foundation and all these other agencies part of her recovery was being with other other kids to have these amazing experiences By contrast the mother described how she had to fight and fight and fight and fight for people to understand what her daughter's OCD was, to get services to get treatment, and that's why she would choose cancer, hands down, which is a remarkable phenomenon I think some of what you saw in Astrid's presentation and our work kind of reflects that and to me that's what gives meaning to the work – in addition to all the importance to policymakers – is that we use large, we have we have the privilege of using large data to validate, at a population level, these individuals' experiences In the spirit of integration this work is embedded in in a larger bit of work so we've heard about the leadership advisory council and Uppala Chandrasekera and I co-chaired a task force for data performance and measurement, and the goal of that task force was to develop a scorecard and then subsequently need to work on a data strategy to move things forward This was no small achievement for the first time (and believe me I don't expect you to read that) for the first time we have a sector-wide scorecard performance measurement scorecard – whereas previously there would be a little pocket of measurement in the addiction sector, a little pocket of measurement the community mental health sector, a little pocket of measurement in the acute care sector – we all got together with representation from all those sectors and said, "Enough – we need commonality, we need standardization, and we all need to be measuring the same things

" So with that there isn't a – it's not an apology, it's just a fact – that what I'm going to be presenting to you is largely representative of the acute care sector and that fact is based on the notion that that's really the data that we currently have access to, but I'll also be talking to you about efforts to rectify that The top part of the scorecard are indicators that we can currently measure The bottom part are indicators which we believe are of tremendous strategic importance Things like wait times You can't have system accountability without wait times

We can't do that currently So that's an example of something we need to keep as a high priority as we move forward with the data strategy Frst, so what I'm going to be showing you now is a combination of work that we're developing for the adult scorecard which will be released later this year In addition to that I'm going to be showing you a little bit of the highlights of this sort of a deeper dive work that Astrid referred to, that gives context to the indicators we do So the first is a map that shows the patient visits per population by region, where dark refers to higher rates and light refers to fewer rates, and the range you can't see it is in the light light rates is about as low as 40 visits per hundred individuals and in the dark which would be sort of the Toronto central LHIN, they're up to 95 visits per hundred so there's a two-fold difference and this refers to primary care mental health related visits and psychiatrists

And this is the same kind of regional disparity that Astrid showed The next drills down on to psychiatrists, and here we see the same spread, but here the range is six visits per hundred thousand and the lightly shaded areas all the way up to 47 so we're getting into an eight-fold difference in the number of visits to psychiatrist by region Why would that be? This is a part of the deeper dive There are two things on this map, this is a similar shading – the black refers to areas with very high numbers of psychiatrist per capita, the lightly shaded areas are areas with very low psychiatrist per capita I'm going to only focus on the red crosses that you can see, and the red crosses refer to areas where more than half the psychiatrists in the area are more than thirty years from med school graduation

In otherwords, saying more than half the psychiatrista are near retirement So when you have a new white or a gray area paired with a red cross you are in trouble, and those same areas are the areas where this very little psychiatrist access to begin with, so when you put this all together we have a real crisis because we have areas that are already struggling with access to psychiatrists, where our psychiatrists are about to leave the system, and there's no clear plan to replace them Next I'm going to be talking about the acute care access issue and the transitions piece We are seeing as we saw, although less dramatically than in the child and youth scorecard, increases in emergency department use for mental health and addiction reasons and small increases in hospitalizations This is age stratified 30 day readmission so the first point is that even though we're seeing increases in the number of hospitalizations it doesn't seem to be – if readmissions is kind of the canary in the coalmine of the hospitalization system, if you start to stress the hospitalization system you might assume that you start to see higher readmission rates

That's not occurring yet, but but what's more troubling is what we see in terms of the age issue, that is that younger patients who've been discharged are much more likely to bounce back than older patients, and we have seen – we're starting to see – an actual reduction in our already low rate of post-discharge follow-up So it goes from 2006 overall 37 percent down to 35, a small reduction The yellow line refers to primary care follow-up, and primary care physicians are doing the lion's share, and that's where we're observing the reduction in follow-up And as we've seen before, there is tremendous regional variability and we've already seen where there are providers there's better follow-up so where you live really determines the success of your transition leaving the hospital Astrid talked about this access indicator and I want to talk a little bit more about it because I think it's so important

Every story we hear when we work clinically, what was talked about by the mother on CBC, is access And we have virtually no – until the development of these indicators – virtually no indication of access And the way this indicator works, is we take somebody who's shown up to the emergency department for a mental health and addiction reason, use the fact that we can stitch together the physician information to the emergency department information, look back two years and if they've had no contact with the physician for mental health and addictions issues, which is primary care or psychiatrists That means that that individual showed up to the emergency department virtually unknown to the system prior to that contact and again this doesn't involve the community mental health and addictions systems, but it's the best we can do You have no benchmark for what this should be, but one in three individuals are showing up to the emergency department invisible to the system prior to presentation

And in the absence of the benchmark, I would hazard to guess that that's actually quite high, that we would like to see that – I don't think we'd ever get that to zero – but we would like for fewer than one in three individuals to have no access to care prior to their visit The good thing is that there is a severity gradient Individuals with the diagnosis of schizophrenia are much less likely to be invisible to the system, whereas individuals with anxiety disorders and substance use are much more likely to have been in invisible to the system A bit of a deeper dive over the last 15 years – there's been a widespread implementation of early psychosis intervention programs Dr Kelly Anderson, an affiliate scientist with our research program took a look at individuals at their first time of diagnosis for a psychotic illness -and again we have regional programs to increase access – what she found was that within a month of your first diagnosis, guidelines are you should be seen within a week unless there's an acute issue, that you should be seen within 48 hours- but 40 percent of individuals saw no physician after their date of the first diagnosis, 60 percent did not see a psychiatrist, this is so critical for this population to get the services they need exactly when they need it, they can't wait, there's a clear relationship between timeliness of care and outcomes, so this is an extremely important study

And this is a little old so we're going to replicate it, we may find that the systematic rollout of the early psychosis intervention programs have rectified this to some degree This reflects the indicator we have – we can which was – what is the mortality – this is what we call a big dot- what's the mortality story for people with mental illnesses in Ontario? This is the work of one of our epidemiologists, Jenny Gatov, and the rest of the team, what I'm showing here is a story of early death The indicator is years of potential life lost – it's a way of measuring likelihood to die early – weighted for people who die when they're young – and if you have a diagnosis of schizophrenia, you're five times more likely to die early And what – we actually did a larger study that's coming out in CMHA and the bigger story is actually fascinating, because over the past twenty years, and this is Laura Rosella's work, we've seen a remarkable reduction in mortality in the general population And that reduction in mortality is due to people surviving or being less likely to die from cardiovascular illnesses, and what we were able to show is that if you have schizophrenia you have completely missed out on that public health phenomenon of reduced mortality

Your likelihood to die from cardiovascular illnesses has been flat, if you have schizophrenia in the same time period And in addition to that, you're likely to die, you have a much higher likelihood to die for all reasons, so this is a really important area where it's not just about providing mental health care to vulnerable individuals, but to figure out ways to integrate care And I don't think – it's not just our jurisdiction – nobody in the world has figured this out There is a real cost to the mortality and the medical care issue And this is work by Clara de Oliveira, a health economist at CAMH and an affiliate scientist, and again – I realize the lighting's bad – what Clare did was she took everybody with the diagnosis of schizophrenia and I think it was 2013, let's say it's in one year, and calculated cost

So what we had was an entire population Ontario with schizophrenia and you could see health care costs over the lifespan essentially and overall over two billion dollars spent to treat Ontarians with psychotic disorders But the really interesting piece of it was where the healthcare dollars are going – not surprisingly at the age of first diagnosis you see a very large spike in psychiatric hospitalizations What really struck me in a study was that starting at the age of 45, you started seeing nursing home costs and medical costs and this is one of those things where the data actually tells you something that's kind of obvious What happens at the age of 45 and over for people with schizophrenia is if they've had family who provided support and those family get elderly, the parents get elderly or pass away, and our system has no response other than to place these individuals with nursing homes at the age of 50 to live the rest of their lives amidst people who are 80 years old with dementia This is – – what Claire's work shows is that not only is this a terrible outcome for that individual, it's also costing us an enormous amount of money, because the cost of a nursing home care is far greater than supportive housing, which is what these individuals really would benefit from

I really do feel like this is very church-like so I'll move on to future directions and try and lighten up the mood So in moving on, we are – this was just sort of a taste of what we're doing – we are developing actual indicators and performance indicators and the scorecard We are busy pulling it together it will come out later this year We are working in close collaboration with the data task force that I described to you before and the Ministry of Health and Long-Term Care to help shape a data strategy that moves forward the preliminary work that we've been able to do And I mentioned the huge gap in our ability to map the trajectory of the entire system, and specifically we don't know what the intersectionality is between individuals who end up in hospitals and emergency departments, versus community, over the 180 community-based addiction services and all the community mental health services

And we are currently in the Toronto central LHIN, we have community-based mental health and addictions data links to ICES and we have a working group busy doing really innovative – actually I think it's unique to the world, probably – the ability to to map what's happening across the entire sector We have linked the Ontario community assessments of need data which is provincial data collected in community mental health agencies and we are very very very close with colleagues at data as to drug and alcohol treatment information system to bring in addictions services data to really understand in much greater detail what is happening across the entire sector, which is so critical to really understanding the true performance I just wanted to take a bit of time acknowledging the team we have working It's just an amazing team and we work very hard We have a lot of fun

We also have had a lot of input into – we get a lot of input into these reports and an army of analysts at ICES does the analytic work for us, we even added geographer help us with our maps we've had analytic input from MCYS and we've had real experts provide external review to make sure that the message is on point finally we've received data from other sources outside of ICES and an acknowledgement that ICES receives fund the Ministry of Health and Long-Term Care With that, I'll end, thank you very much

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