Follow-up after post-partum psychiatric emergency department visits: an equity-focused population-based study in Canada,The Lancet Psychiatry

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Follow-up after post-partum psychiatric emergency department visits: an equity-focused population-based study in Canada
The Lancet Psychiatry ( IF 64.3 ) Pub Date : 2022-04-14 , DOI: 10.1016/s2215-0366(22)00099-2
Lucy C Barker ₁ , Hilary K Brown ₂ , Susan E Bronskill ₃ , Paul Kurdyak ₄ , Peter C Austin ₅ , Neesha Hussain-Shamsy ₆ , Kinwah Fung ₇ , Simone N Vigod ₁

Affiliation

Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada; Women's College Hospital, Toronto, ON, Canada.
Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Scarborough Campus, Department of Health & Society, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada; Women's College Hospital, Toronto, ON, Canada.
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada; Women's College Hospital, Toronto, ON, Canada.
Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto, ON, Canada.
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada.
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Women's College Hospital, Toronto, ON, Canada.
ICES, Toronto, ON, Canada.

Background

Emergency department visits for a psychiatric reason in the post-partum period represent an acute need for mental health care at a crucial time, but little is known about the extent of timely outpatient follow-up after these visits or how individual and intersecting social determinants of health influence this outcome. This study aimed to examine outpatient mental health care follow-up by a physician in the 30 days after an individual attended the emergency department for a psychiatric reason in the post-partum period and understand how social determinants of health affect who receives follow-up care.

Methods

In this population-based cohort study, routinely collected health data from Ontario, Canada were accessed through ICES to identify all post-partum individuals whose sex was listed as female on their health card and who had attended an emergency department in Ontario before the COVID-19 pandemic for a psychiatric reason. Individuals admitted to hospital at the time of the emergency department visit, who died during the visit, or who left without being seen were excluded from the study. Ethnicity data for individuals were not collected. The primary outcome was the proportion of individuals with any outpatient physician (psychiatrist or family physician) visit for a mental health reason within 30 days of the index emergency department visit. Family physician mental health visits were identified using a validated algorithm for Ontario Health Insurance Plan-billed visits and mental health diagnostic codes for community health centre visits. We examined the associations between social determinants of health (age, neighbourhood income, community size, immigration, neighbourhood ethnic diversity) and who received an outpatient mental health visit. We used modified Poisson regression adjusting for the other social determinants of health, clinical, and health services characteristics to examine independent associations with follow-up, and conditional inference trees to explore how social determinants of health intersect with each other and with clinical and health services characteristics in relation to follow-up.

Findings

We analysed data collected between April 1, 2008, and March 10, 2020, after exclusions we identified 12 158 people who had attended the emergency department for a psychiatric reason in the post-partum period (mean age 26·9 years [SD 6·2]; range 13–47); 9848 individuals lived in an urban area, among these 1518 (15·5%) were immigrants and 2587 (26·3%) lived in areas with high ethnic diversity. 5442 (44·8%) of 12 158 individuals received 30-day follow-up. In modified Poisson regression models, younger age, lower neighbourhood income, smaller community size, and being an immigrant were associated with a lower likelihood of follow-up. In the CTREE, similar variables were important, with several intersections between social determinants of health and between social determinants of health and other variables.

Interpretation

Fewer than half of emergency department visits for a psychiatric reason in the post-partum period were followed by timely outpatient care, with social-determinants-of-health-based disparities in access to care. Improvements in equitable access to post-emergency department mental health care are urgently needed in this high-risk post-partum population.

Funding

Department of Psychiatry, University of Toronto; Canadian Institutes of Health Research.

中文翻译：

产后精神科急诊就诊后的随访：加拿大一项以公平为重点的人群研究

背景

产后因精神原因到急诊科就诊代表了在关键时刻对精神卫生保健的迫切需求，但对于这些就诊后及时门诊随访的程度或个体和交叉社会决定因素如何影响我们知之甚少。健康影响这一结果。本研究旨在检查个人在产后期间因精神原因到急诊科就诊后 30 天内由医生进行的门诊心理健康护理随访，并了解健康的社会决定因素如何影响接受后续护理的人群.

方法

在这项基于人群的队列研究中，通过 ICES 访问了从加拿大安大略省常规收集的健康数据，以识别所有在其健康卡上性别列为女性并且在 COVID- 19 出于精神原因的大流行。在急诊科就诊时入院、在就诊期间死亡或未见人离开的个体被排除在研究之外。没有收集个人的种族数据。主要结果是在索引急诊科就诊后 30 天内因心理健康原因接受任何门诊医生（精神科医生或家庭医生）就诊的个体比例。家庭医生心理健康就诊是使用经过验证的安大略省健康保险计划计费就诊算法和社区健康中心就诊心理健康诊断代码确定的。我们检查了健康的社会决定因素（年龄、社区收入、社区规模、移民、社区种族多样性）与接受门诊心理健康访问的人之间的关联。我们使用修正的泊松回归调整了健康的其他社会决定因素、临床和健康服务特征，以检查与随访的独立关联，并使用条件推理树来探索健康的社会决定因素如何相互交叉以及与临床和卫生服务相交与随访有关的特征。

发现

我们分析了 2008 年 4 月 1 日至 2020 年 3 月 10 日期间收集的数据，排除后我们确定了 12 158 名在产后期间因精神原因到急诊室就诊的人（平均年龄 26·9 岁 [SD 6· 2]；范围 13–47)；9848人居住在城市地区，其中移民1518人（15·5%），2587人（26·3%）居住在种族多样性较高的地区。12 158 人中有 5442 人 (44·8%) 接受了 30 天的随访。在修正的泊松回归模型中，年龄较小、社区收入较低、社区规模较小以及作为移民与较低的随访可能性相关。在 CTREE 中，类似的变量很重要，健康的社会决定因素之间以及健康的社会决定因素与其他变量之间有几个交叉点。