Changes in mental health and substance use associated with the COVID-19 pandemic

1. Health and health service
utilization outcomes associated
with low access to and low
continuity of physician care in New
Brunswick
Dr. Chris Folkins, PhD, BScPhm
Nov 30, 2022

2. Acknowledgements
2
This work was supported by the Department of Health and the Department of Social
Development of the Province of New Brunswick under a contract with the New Brunswick
Institute for Research, Data and Training at the University of New Brunswick. The results
and conclusions are those of the authors and no official endorsement by the Government
of New Brunswick was intended or should be inferred.

3. 3
Research Team – NB-IRDT Pathways to Professions
Sof Mehlitz
Kay Mills
Vanessa Dairo-Singerr
Olivia Hamilton
● Bachelor of Science in
Kinesiology
● Graduation Year: 2024
● katherine.mills@unb.ca
● Bachelor of Science
● Major: Psychology
● Minor: Biology
● Graduation Year: 2023
● smehlitz@unb.ca
● Bachelor of Philosophy
● Major: Leadership
● Minor: Biology
● Graduation Year: 2023
● olivia.hamilton@unb.ca
● Bachelor of Science
● Major: Medicinal Chemistry
● Graduation Year: 2022
● vanessa.dairosingerr@unb.ca
Madeleine Gorman-Asal
Research Assistant, NB-IRDT
Data analysis:

4. 4
Background: Access to physician care in NB
Source: Statistics Canada. Table 13-10-0096-01 Health characteristics, annual estimates.
From: Canadian Community Health Survey – Annual Component 2021
In 2021, 90% of NB residents age 12+ reported having a regular healthcare provider
– a higher proportion than all other provinces.
0
10
20
30
40
50
60
70
80
90
100
%

5. 5
NB has among the highest number of family physicians per capita among Canadian provinces
Source: Canadian Institute for Health Information. Supply, Distribution and Migration of Physicians in Canada, 2020
0
20
40
60
80
100
120
140
160
180
Family physicians per
100,000 population

6. 6
Citizens who most often
go to their family MD
when in need of care
Citizens who can get an
appointment with their
family MD within 5 days
Source: NB Health Council
Primary Health Survey 2020
Measures of access to care in NB

7. 7
Source: Glazier et al. The impact of not having a primary care physician among people with chronic conditions. ICES
Investigative Report. Institute for Clinical Evaluative Sciences, Toronto, ON 2008.
Among people with chronic conditions, low access to and low continuity of care were
associated with:
Increased likelihood of Emergency Department visits (~1.2x)
Potential impact of low access to physician care – Findings from
Ontario
Increased likelihood of non-elective hospital admission (~1.5x)

8. 8
- How prevalent is low access to physician care in NB?
- Who experiences low access to physician care in NB (demographic, geographic,
socioeconomic characteristics)?
- What are the consequences of low access to physician care in NB (associated health
and health service utilization outcomes)?
Research Questions

9. 9
Examining access to care using administrative data – proxy
measures
1. Frequency of physician/NP visits among individuals with chronic conditions
< 3 physician/NP visits classified as LOW ACCESS
3+ physician/NP visits classified as HIGH ACCESS
Within 2-year period:
Method adapted from: Glazier et al. ICES 2008

10. 10
2. Continuity of care among individuals with chronic conditions having 3+ MD visits/2 years
Usual Provider of Care (UPC) Index =
# visits with most frequently seen MD in 2-year period
# total MD visits in 2-year period
UPC < 0.5 classified as LOW CONTINUITY
UPC 0.5+ classified as HIGH CONTINUITY
Method adapted from: Glazier et al. ICES 2008

11. 11
Study Design
Study population – NB residents age 20+ with one or more chronic conditions
Study period – Jan 1 2017 – Dec 31 2018 (for most outcomes)
Data Source: CCDSS – Canadian Chronic Disease Surveillance System
• Acute myocardial infarction
• Asthma
• COPD
• Dementia
• Diabetes
• Epilepsy
• Heart Failure
• Hypertension
• Ischemic heart disease
• Mental illness
• Mood & anxiety disorders
• Parkinson’s disease
• Schizophrenia
• Stroke
n = 338, 400

12. 12
Study population
Low
Access
High
Access
Low
Continuity
High
Continuity
Data Source: NB Physician Billing data
1. Access to care
2. Continuity of care
UPC index
Frequency of physician visits
< 3 MD visits/2 yrs 3+ MD visits/2 yrs
UPC < 0.5 UPC 0.5+

13. 13
1. Prevalence of low access to and continuity of physician
care
Low Access
6.9%
Low Continuity
25.7%
…among NB residents age 20+ with
one or more chronic conditions
(n = 338,400)
…among NB residents age 20+ with
one or more chronic conditions
classified as ‘High Access’
(n = 309,600)
(Ontario 2008: 5.2%) (Ontario 2008: 10.1%)

14. 14
2. Characteristics associated with low access to/continuity of
care Multivariate regression
Dependant variable: low vs. high access; low vs. high continuity
Independent variables:
• Age, sex, rural/urban residence, health zone of residence
• Preferred language (English, French)
• Social assistance use, income quintile
• Canadian Index of Multiple Deprivation
• Chronic health conditions (total number and by condition)

15. 15
Data sources:
Citizen Data – demographic, geographic
Social Assistance Data (NB Case) – social assistance use
Canadian Chronic Disease Surveillance System – chronic conditions
Statistics Canada (area-level) – income quintile, CIMD (deprivation index),
preferred language

16. 16
Characteristics associated with LOW ACCESS to physician care in NB
0 5 10 15 20
Male
Age 20-64 (vs 65+)
Rural
English language
Dementia
Odds Ratio (+/- 95% CI)
2.2
2.2
1.2
1.2
17.7
(Ontario 2008: male, younger age, rural)
n = 338,385

17. 17
Characteristics associated with LOW CONTINUITY of physician care in NB
(Ontario 2008: female, younger age, urban)
Female
Age 20-64 (vs 65+)
Urban
French language
No dementia
0.9 1 1.1 1.2 1.3 1.4
Odds Ratio (+/- 95% CI)
1.08
1.05
1.3
1.05
1.17
n = 338,385

18. 18
3. Health outcomes associated with low access and low
continuity Multivariate regression
Dependant variable: health/health service use outcome within 2-year period
Independent variables:
• Age, sex, rural/urban residence, health zone of residence
• Preferred language (English, French)
• Social assistance use, income quintile
• Canadian Index of Multiple Deprivation
• Chronic health conditions (total number and by condition)
+ number of physician
visits (in continuity
analyses)
+ number of hospital
stays (in post-discharge
mortality analysis)

19. 19
Outcome Data Source
Hospitalizations Discharge Abstract Data
Mortality Citizen Data
Immunizations NB Physician Billing
Mammograms NB Breast Cancer Screening
HbA1c testing Hemoglobin (HbA1c)
Outcomes and Data sources:

20. Non-elective (urgent/emergent) hospital admissions
Dependant variable: non-elective hospitalizations per person in 2017-18
0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8
Low Access (vs high)
Low Continuity (vs high)
Incident Rate Ratio (+/- 95% CI)
Access: n = 338,385
Continuity: n = 309,570
0.31
1.59
Hospitalization
less likely
Hospitalization
more likely
(Ontario 2008: IRR 1.19)
(Ontario 2008: IRR 1.35)

21. Non-elective hospital admissions for Ambulatory Care-Sensitive Conditions
ACSC – Conditions for which adequate ambulatory care could potentially prevent
hospitalization
Angina
Asthma
COPD
Diabetes
Epilepsy
Heart Failure
Hypertension
- defined by CIHI

22. Non-elective hospital admissions for Ambulatory Care-Sensitive Conditions
Dependant variable: non-elective hospitalizations for ACSC per person in 2017-18
Access: n = 338,385
Continuity: n = 309,570
0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6
Low Access (vs high)
Low Continuity (vs high)
Incident Rate Ratio (+/- 95% CI)
0.26
1.43
Hospitalization
less likely
Hospitalization
more likely

23. Readmission (urgent/emergent) to hospital within 30 days of discharge
0.4 0.6 0.8 1 1.2 1.4
Access: n = 140,720
Continuity: n = 138,660
Low Access (vs high)
Low Continuity (vs high)
Hazard Ratio (+/- 95% CI)
0.26
1.43
Readmission
less likely
Readmission
more likely
Dependant variable: urgent readmissions per admission in 2017-18

24. Length of hospital stay
Dependant variable: average length of stay (days) in 2017-18
-0.4 -0.3 -0.2 -0.1 0 0.1 0.2 0.3 0.4
Low Access (vs high)
Low Continuity (vs high)
Shorter
stay
GLM regression coefficient (+/- 95% CI)
Access: n = 40,220
Continuity: n = 39,210
0.05
-0.12

25. Length of hospital stay among seniors age 65+
Dependant variable: average length of stay (days) in 2017-18
0 0.5 1 1.5 2 2.5 3 3.5 4
Low Access
Age 65+ (vs 20-64)
High Access
Age 65+ (vs 20-64)
2.49
1.24
GLM regression coefficient (+/- 95% CI)
Low Access: n = 770
High Access: n = 39,450
Older age associated
with longer stays,
particularly in low
access group

26. Mortality in hospital
Dependant variable: deaths in hospital per admission in 2019-20
0 0.5 1 1.5 2 2.5
Low Access (vs high)
Low Continuity (vs high)
Odds Ratio (+/- 95% CI)
Access: n = 145,710
Continuity: n = 140,370
0.98
1.67
More likely
to die in
hospital

27. Mortality within 1 year after hospital discharge
Dependant variable: deaths within 1 yr of index admission/person with 1+ admits in 2019-20
0 0.5 1 1.5 2
Low Access (vs high)
Low Continuity (vs high)
Hazard Ratio (+/- 95% CI)
Access: n = 83,610
Continuity: n = 80,130
Higher
likelihood
of death

28. Immunizations for influenza and pneumococcal disease among individuals age 65+
Dependant variable: Immunizations/person age 65+ in 2017-18
 Both are recommended for persons age 65+
Low Access (vs high)
Low Continuity (vs high)
Low Access (vs high)
Low continuity (vs high)
Influenza
Pneumococcal
0 0.2 0.4 0.6 0.8 1
Incident Rate Ratio (+/- 95% CI)
Access: n = 119,065
Continuity: n = 113,285
0.069
0.71
0.10
0.83
Immunizations
less likely

29. Mammograms among females
 Recommended every 2-3 years for age 50-74
Dependant variable: mammograms/female in 2015-16
0 0.2 0.4 0.6 0.8 1 1.2
Incident Rate Ratio (+/- 95% CI)
Low Access (vs high)
Low Continuity (vs high)
Access: n = 152,225
Continuity: n = 143,390
0.50
0.97
Mammograms
less likely

30. Monitoring of glycemic control by HbA1c blood test in individuals with diabetes
 Recommended at minimum every 6 months for people with diabetes
Dependant variable: HbA1c tests/individual with diabetes in 2017-18
0 0.2 0.4 0.6 0.8 1 1.2
Low Access (vs high)
Low Continuity (vs high)
Incident Rate Ratio (+/- 95% CI)
0.26
0.96
Access: n = 70,810
Continuity: n = 67,590
Glycemic
monitoring
less likely

31. 31
HbA1c: Individuals in the low access group are not being tested as often as recommended
Group Avg # tests/person/year
Low Access 0.5
High Access 2
Low Continuity 2
High Continuity 2
HbA1c guidelines: - every 6 months if blood glucose well controlled
- every 3 months if blood glucose not well controlled or
making adjustments

32. Prevalence of good glycemic control in individuals with diabetes
 Target HbA1c is </=7% for most adults with Type 1 or 2 diabetes
Dependant variable: proportion of HBA1c results </=7% among diabetic individuals in 2017-18
0.9 0.95 1 1.05 1.1 1.15 1.2 1.25 1.3
Incident Rate Ratio (+/- 95% CI)
Access: n = 272,790
Continuity: n = 267,255
Low Access (vs high)
Low Continuity (vs high)
1.195
1.006
Good glycemic
control more
likely

33. Summar
y
Low frequency of physician visits among those with chronic conditions in NB (proxy for
low ACCESS to care) associated with:
• Decreased likelihood of immunization among seniors 65+
• Decreased likelihood of preventive screening (mammograms)
• Decreased likelihood of chronic disease monitoring (HbA1c)
• Longer hospital stays among seniors 65+
• Increased likelihood of death in hospital and within 1 year of discharge
• Individuals with dementia have greatly increased likelihood of low access to care

34. Low CONTINUITY of physician care in NB associated with:
Summar
y
• Decreased likelihood of immunization among seniors 65+
• Increased likelihood of all-cause and ACSC-related hospitalization
• Increased likelihood of hospital readmission within 30 days of discharge

35. Next Steps
• Classify access/continuity based solely on visits to primary care providers
• Examine Emergency Department visits
• Similar work comparing people with/without a regular primary care provider

36. Contact
Dr. Chris Folkins
Research Scientist
NB-IRDT
chris.folkins@unb.ca
www.unb.ca/nbirdt