Introduction
Alcohol‐related hospitalizations are common and associated with high rates of short‐term readmission and mortality. Providing rapid access to physician‐based mental health and addiction ...(MHA) services post‐discharge may help to reduce the risk of adverse outcomes in this population. This study used population‐based data to evaluate the prevalence of outpatient MHA service use following alcohol‐related hospitalizations and its association with downstream harms.
Methods
This was a population‐based historical cohort study of individuals who experienced an alcohol‐related hospitalization between 2016 and 2018 in Ontario, Canada. The primary exposure was whether an individual received follow‐up outpatient MHA services from either a psychiatrist or primary care physician within 30 days of discharge from the index hospitalization. The outcomes of interest were alcohol‐related hospital readmission and all‐cause mortality in the year following discharge from the index alcohol‐related hospitalization. Information on health service use and mortality was captured using comprehensive health administrative databases. The associations between receiving outpatient MHA services and the time to each outcome were assessed using multivariable time‐to‐event regression.
Results
A total of 43,343 individuals were included. 19.8% of the cohort received outpatient MHA services within 30 days of discharge. Overall, 19.1% of the cohort was readmitted to hospital and 11.5% of the cohort died in the year following discharge. Receiving outpatient MHA services was associated with a reduced hazard of alcohol‐related hospital readmission (adjusted hazard ratio aHR 0.94, 95% confidence interval CI: 0.88–0.99) and all‐cause mortality (aHR: 0.74, 95% CI: 0.66–0.83) after adjusting for demographic and clinical covariates.
Conclusions
Short‐term outcomes following alcohol‐related hospitalizations are poor. Facilitating rapid access to follow‐up MHA services may help to reduce the risk of recurrent harm and death in this population.
Alcohol-related harm is a major public health concern and appears to be particularly problematic in rural and remote communities. Evidence from several countries has shown that the prevalence of ...harmful alcohol use and alcohol-attributable hospitalisations and emergency department visits are higher in rural and remote communities than in urban centres. The extents of this rural-urban disparity in alcohol-related harm as well as the factors that mediate it are poorly understood. The objective of this scoping review is to synthesise the international research on the factors that influence the prevalence or risk of alcohol-related harm in rural and remote communities. This will help to clarify the conceptual landscape of rural and remote alcohol research and identify the gaps in knowledge that need to be addressed.
This scoping review will access published literature through search strategies developed for Medline, PsycINFO, Embase, CINAHL and Sociological Abstracts. There will be no date, country or language restrictions placed on the search. Title and abstract, followed by full-text screening, will be conducted by two independent reviewers to evaluate all identified articles against a set of prespecified inclusion and exclusion criteria. Data from selected articles will be extracted and compiled into a final manuscript that adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist guidelines.
The results of this review will be helpful in guiding future research on rural and remote alcohol use and alcohol-related harm, which will inform more effective, evidence-based public health strategies to reduce alcohol-related harm in rural and remote communities. The results will be disseminated via field-specific conference presentations and peer-reviewed publication.
Rates of alcohol-related harm are higher in rural versus urban Canada. This study characterized the spatial distribution and regional determinants of alcohol-related emergency department (ED) visits ...and hospitalizations in Ontario to better understand this rural-urban disparity.
This was a cross-sectional spatial analysis of rates of alcohol-related ED visits and hospitalizations by Ministry of Health subregion (n = 76) in Ontario, Canada between 2016 and 2019. Regional hot- and cold-spots of alcohol-related harm were identified using spatial autocorrelation methods. Rurality was measured as the population weighted geographic remoteness of a subregion. The associations between rurality and rates of alcohol-related ED visits and hospitalizations were evaluated using hierarchical Bayesian spatial regression models.
Rates of alcohol-related ED visits and hospitalizations varied substantially between subregions, with high rates clustering in Northern Ontario. Overall, increasing rurality was associated with higher subregion-level rates of alcohol-related ED visits (males adjusted relative rate aRR: 1.67, 95% credible interval CI: 1.49-1.87; females aRR: 1.78, 95% CI: 1.60-1.98) and hospitalizations (males aRR: 1.34, 95% CI: 1.24-1.45; females aRR: 1.59, 95% CI: 1.45-1.74). However, after the province was separated into Northern and Southern strata, this association only held in Northern subregions. In contrast, increasing rurality was associated with lower rates of alcohol-related ED visits in Southern subregions (males aRR: 0.87, 95% CI: 0.79-0.96; females aRR: 0.88, 95% CI: 0.81-0.97).
There are regional differences in the association between rurality and alcohol-related health service use. This regional variation should be considered when developing health policies to minimize geographic disparities in alcohol-related harm.
Alcohol use is a major risk factor for death and disease worldwide and alcohol-related harms appear to be more prevalent in rural and remote, relative to urban, communities. This Review synthesised ...international research on rural–urban disparities in hazardous and harmful alcohol use and risk factors for these outcomes within rural and remote communities. 280 studies from 49 countries were included in the Scoping Review. Most studies (60%) found rural, relative to urban, residence to be associated with an increased likelihood of hazardous alcohol use or alcohol-related harm. This proportion increased between 1990 and 2019 and varied by country, age group, and outcome type, being highest in Australia, among young adults, and for more severe alcohol-related harms, such as drink driving and alcohol-related suicide. Improved public health strategies to reduce the burden of alcohol use in rural communities are required but their efficacy will depend on how well they are tailored to the unique needs of the region they are implemented in.
•Psychiatric comorbidity decreases the odds of client dropout from treatment using medications for opioid use disorder (MOUD).•Psychiatric comorbidity increases the odds of MOUD termination by the ...treatment facility.•These associations vary substantially between states.
Psychiatric illness complicates the clinical course of opioid use disorder (OUD) including treatment using medication for OUD (MOUD). The purpose of this study was to assess the relationship between psychiatric comorbidity and MOUD discontinuation, stratified by whether the client dropped out of treatment or whether MOUD was terminated by the addiction facility.
The study population consisted of individuals with OUD receiving MOUD. Data was derived from the 2015–2017 Treatment Episodes Dataset – Discharges (TEDS-D), which includes discharge records from addiction treatment centers across the United States. The association between psychiatric comorbidity and MOUD discontinuation (including client dropout and facility termination) was assessed using multivariable logistic regression models that included clinically relevant covariates (age, sex, race, education, employment status, living arrangement, prior addiction treatment, intravenous opioid use, primary opioid used at admission, polysubstance use, previous arrests, length of stay, and referral source).
Psychiatric comorbidity decreased the odds of client dropout (adjusted odds ratio (aOR): 0.88, 95 % confidence interval (CI): 0.86 – 0.89) but increased the odds of MOUD being terminated by the treatment facility (aOR: 1.59, 95 % CI: 1.56–1.63). The association between psychiatric comorbidity and MOUD discontinuation varied considerably between states.
Individuals with psychiatric illness are slightly less likely to drop out of MOUD treatment but are more likely to have their treatment prematurely terminated by the treatment facility. This emphasizes the importance of considering psychiatric illness when providing OUD treatment and suggests that measures to improve MOUD retention for individuals with psychiatric illness are required.
•Latent class analysis identified five clinically distinct subgroups of individuals who experience alcohol-related emergency department (ED) visits.•There were differences in clinical characteristics ...and sociodemographic composition between subgroups.•There was a small group of individuals with severe alcohol use disorder (AUD) and related comorbidities that were at the highest risk of hospital admission and mortality.•There was a small group of individuals with high-frequency health service use that were at the highest risk of recurrent alcohol-related ED visits.•The presence of these distinct subgroups merits consideration in future work on this topic.
Alcohol-related emergency department (ED) visits are common and associated with adverse clinical outcomes, including premature mortality. This population-based retrospective cohort study identified clinically distinct subgroups of individuals who experience alcohol-related ED visits and characterized differences in the risk of adverse outcomes between them. 73,658 individuals who experienced an alcohol-related ED visit in Ontario, Canada between 2017 and 2018 were identified. Latent class analysis (LCA) revealed five clinically distinct subgroups within the overall cohort. These subgroups followed a severity gradient from low-frequency service use for acute intoxication to high-frequency service use for alcohol use disorder (AUD) and related comorbidities. Relative to those presenting for acute intoxication, those presenting for AUD and comorbidities had a much higher risk of hospital admission (adjusted odds ratio aOR: 8.26, 95 % confidence interval CI: 7.81–8.75) and post-discharge mortality (adjusted hazard ratio aHR: 3.07, 95 % CI: 2.81–3.37). There was a subgroup of individuals with a history of high frequency alcohol-related health service use who were at the highest risk of experiencing another alcohol-related ED visit after the index event (aHR: 4.76, 95 % CI: 4.55–4.99). Individuals who experience alcohol-related ED visits are not a homogenous population, but a constellation of subgroups with different clinical characteristics and risk of adverse outcomes.
Following the legalisation of non-medical cannabis in 2018, the number of cannabis stores in Canada has rapidly expanded with limited regulation on their geographic placement. This study ...characterised the clustering of cannabis stores in Canadian cities and evaluated the association of clustering with provincial policy and sociodemographic variables.
Cross-sectional spatial analysis of cannabis store density in dissemination areas ('neighbourhoods', n = 39,226) in Canadian cities in September 2022. Cannabis store density was defined as the count of stores within 1000 m of a neighbourhood centre. Clusters of high-density cannabis retail were identified using Local Indicators of Spatial Autocorrelation. Associations between provincial policy (privatised vs. public market), sociodemographic variables and cannabis store density were evaluated using multivariable regression.
Clusters of high-density cannabis retail were identified in 86% of Canadian cities, and neighbourhoods in clusters had a median of 5 stores within 1000 m. Toronto, Canada's most populous city, had the most extreme clustering where neighbourhoods in clusters had a median of 10 stores (and a maximum of 25 stores) within 1000 m. Neighbourhoods in private versus public retail markets had a significantly higher neighbourhood-level density of cannabis stores (adjusted rate ratio aRR 63.37, 95% confidence interval CI 25.66-156.33). Lower neighbourhood income quintile was also associated with a higher neighbourhood-level density of cannabis stores (Q5 vs. Q1, aRR 1.28, 95% CI 1.17-1.40).
Since cannabis was legalised, clusters of high-density cannabis retail have emerged in most Canadian cities and were more likely to form lower income neighbourhoods and in private retail markets.
Objectives
In 2015, Ontario partially deregulated alcohol sales by allowing grocery stores to sell alcohol. The purpose of this study was to evaluate (1) whether neighbourhood-level socioeconomic ...status (SES) impacted the likelihood that a grocery store began selling alcohol, and (2) whether increases in alcohol retail availability following deregulation differed between neighbourhoods based on SES.
Methods
This was a repeated cross-sectional analysis of 1062 grocery stores in 17,096 neighbourhoods in urban Ontario. The association between neighbourhood-level SES and whether a grocery store began selling alcohol was modeled using mixed effect logistic regression. The annual change in drive-distance from a neighbourhood to the closest off-premise alcohol outlet between 2015 and 2020 was modeled using mixed effect linear regression. An interaction between time and SES was included to evaluate whether this change differed between neighbourhoods based on SES.
Results
Grocery stores in neighbourhoods in the lowest SES quintile were 39% less likely to start selling alcohol than grocery stores in neighbourhoods in the highest SES quintile (odds ratio (OR): 0.61, 95% confidence interval (CI): 0.39–0.94). As grocery store sales expanded, the distance to the closest off-premise alcohol outlet decreased by 51.8 m annually (95% CI: 48.8–54.9,
p
< 0.01). A significant interaction between year and SES was observed whereby this trend was more pronounced in high- versus low-SES neighbourhoods.
Conclusion
The expansion of grocery store alcohol sales increased alcohol availability, but this increase was proportionately larger in high- versus low-SES neighbourhoods. This reduced historic disparities in alcohol availability between low- and high-SES neighbourhoods.
Limited access to mental health and addiction (MHA) services in rural areas may increase the risk of recurrent alcohol-related harm among rural, relative to urban, residents. This study evaluated (1) ...rural-urban differences in clinical trajectories following alcohol-related hospitalizations and (2) whether limited access to MHA services mediates an increased risk of adverse post-discharge outcomes in rural areas.
This was a population-based retrospective cohort study of individuals in Ontario, Canada, who experienced an alcohol-related hospitalization between 2016 and 2018. The primary exposure was rurality. The outcomes of interest were outpatient MHA care, alcohol-related emergency department visits, alcohol-related hospitalizations, and all-cause mortality within one-year of discharge from the index alcohol-related hospitalization. Data were collected using provincial health administrative databases. The associations between rurality and the time to each outcome were assessed using multivariable time-to-event regression. Mediation analyses were conducted using a counterfactual approach.
46,657 individuals were included. 11.5% of the cohort died within one year of discharge from the index alcohol-related hospitalization. Relative to urban residents, rural residents were less likely to receive MHA outpatient care (adjusted hazard ratio (aHR): 0.80, 95% confidence interval (CI): 0.75–0.86) and more likely to die (aHR: 1.19, 95% CI: 1.06–1.34) in the year following discharge. The lower likelihood of post-discharge MHA-related care among rural residents mediated 31% (95% CI: 13–46%) of the increased risk of mortality.
A lack of follow-up MHA care mediates an increased risk of short-term mortality following alcohol-related hospitalizations in rural, relative to urban, communities.
•1 in 10 individuals who were hospitalized for an alcohol-related health condition died within one year of discharge.•Individuals living in urban-adjacent rural, relative to urban, areas were at a higher risk of post-discharge mortality.•Reduced access to mental health and addiction services partially mediated the increased risk of death among rural patients.
Introduction
An increasing number of countries are inthe process of legalising non‐medical cannabis. We described how the legal market has changed over the first 4 years following legalisation in ...Canada.
Methods
We collected longitudinal data on operating status and location of all legal cannabis stores in Canada for the first 4 years following legalisation. We examined per capita stores and sales, store closures, and the drive time between stores and each neighbourhood in Canada. We compared measures between public and private retail systems.
Results
Four years after legalisation, there were 3305 cannabis stores open in Canada (10.6 stores per 100,000 individuals aged 15+ years). Canadians spent $11.85CAD a month on cannabis per individual aged 15+ years, and 59% of neighbourhoods were within a 5‐minute drive of a cannabis store. Over 4 years, per capita stores and per capita sales increased each year by an average of 122.3% and 91.7%, respectively, with larger increases in private versus public systems (4.01 times greater for per capita stores and 2.46 times greater for per capita sales). The annual increase in per capita stores and sales during the first 3 years was 6.0 and 15.5 times greater, respectively, than the increase in the fourth year following legalisation. Over 4 years, 7% of retail store locations permanently closed.
Discussion and Conclusion
The legal cannabis market in Canada expanded enormously over the first 4 years following legalisation, with considerable variation in access between jurisdictions. The rapid retail expansion has implications for evaluation of health impacts of non‐medical legalisation.
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