Search

A significant minority of unspecified psychosis presentations progress to schizophrenia. Clinical risk factors can inform targeted referral to specialized treatment programs, but few population studies have examined this. In this study, we used health administrative data for a population-based cohort from Manitoba, Canada to characterize the risk and identify vulnerable subgroups for a future diagnosis of schizophrenia after a diagnosis of unspecified psychotic disorder. Individuals aged 13–60 years with an inpatient or outpatient diagnosis of unspecified psychotic disorder between April 1, 2007 and March 31, 2012, and without any prior diagnosis of schizophrenia or related disorder, were identified (N = 3, 289). The primary outcome was a diagnosis of schizophrenia recorded after the index diagnosis of unspecified psychotic disorder and before March 31, 2015. Adjusted hazard ratios were computed controlling for age, sex, urbanicity, income, prior diagnosis of unspecified psychotic disorder, provider making the diagnosis, prior 12-month psychiatric hospitalization, and prior 12-month diagnoses of mood, anxiety, substance use, or personality disorders, and substance-induced psychosis. A classification tree identified vulnerable subgroups. The cumulative risk of a future diagnosis of schizophrenia was 26% during the follow-up period (mean 4.5 years), with a mean time to diagnosis of 2.0 years. The most vulnerable subgroup was diagnosed by a psychiatrist, younger than 27 years, without a mood or anxiety disorder, male, and residing in a low-income neighborhood; the rate of a subsequent schizophrenia diagnosis was 61.2%. These results support that identification of specific sociodemographic and clinical factors can help clinicians counsel and intervene with those at highest risk.

IntroductionChildren who have a history of involvement in child protection services (CPS) are over-represented in the youth and adult criminal justice systems. There are significant health and socioeconomic implications for individuals involved in either or both CPS and the justice system. Understanding the ‘overlap’ between these two systems would provide insight into the health and social needs of this population. This protocol describes a research programme on the relationship between the child welfare and the youth justice systems, looking specifically at the population involved in both CPS and the youth justice system. We will examine the characteristics associated with involvement in these systems, justice system trajectories of individuals with a history of CPS involvement and early adult outcomes of children involved in both systems.Methods and analysisAdministrative data sets will be linked at the individual level for three cohorts born 1991, 1994 and 1998 in Manitoba, Canada. Involvement in CPS will be categorised as ‘placed in out-of-home care’, ‘received in-home services, but was not placed in care’ or ‘no involvement’. Involvement in the youth justice system will be examined through contacts with police between ages 12 and 17 that either led to charges or did not proceed. Individual, maternal and neighbourhood characteristics will be examined to identify individuals at greatest risk of involvement in one or both systems.Ethics and disseminationThe study was approved by the University of Manitoba Health Research Ethics Board and permission to access data sets has been granted by all data providers. We also received approval for the study from the First Nations Health and Social Secretariat of Manitoba’s Health Information Research Governance Committee and the Manitoba Metis Federation. Strategies to disseminate study results will include engagement of stakeholders and policymakers through meetings and workshops, scientific publications and presentations, and social media.

Objective:To examine health services, social services, education, and justice system outcomes among First Nations children and youth with fetal alcohol spectrum disorder (FASD).Methods:In this retrospective cohort study, health and social services, education, and justice data were linked with clinical records on First Nations (FN) individuals aged 1 to 25 and diagnosed with FASD between 1999 and 2010 ( n = 743). We compared the FN FASD group to non-FN individuals with FASD (non-FN FASD; n = 315) and to First Nations individuals (matched on age, sex, and income) not diagnosed with FASD (FN non-FASD; n = 2229). Rates and relative risks (RRs) were calculated using generalized linear models.Results:FN FASD individuals had similar health services use to non-FN FASD individuals but had greater involvement with child welfare (RR, 1.20; 95% confidence interval [CI], 1.02 to 1.41) and the justice system (RR, 1.37; 95% CI, 1.07 to 1.74) and were more likely to be charged with a crime (RR, 1.40; 95% CI, 1.05 to 1.86). There were no suicides/suicide attempts among the non-FN FASD individuals during the study, but the crude rate/100 person-years of suicides among FN FASD individuals (0.22 for females; 1.06 for males) was substantially higher than for FN non-FASD individuals (0.08 for females; 0.32 for males). There were no significant differences between groups in the education outcomes we measured.Conclusions:Young people with FASD are at risk for poor health, education, and social outcomes, but First Nations young people with FASD face comparably higher risks, particularly with child welfare and justice system involvement. The study emphasizes a critical need for appropriate resources for First Nations children with FASD.

IntroductionAlcohol use disorders (AUDs) – mental and/or physical health diagnoses due to harmful alcohol consumption – are associated with compromised quality of life for the individual. Over the past two decades, pharmacotherapies have been developed to treat alcohol addiction and may help mitigate the harmful outcomes linked with excessive alcohol. Objectives and ApproachThe objectives were to examine the pharmacotherapy dispensation patterns among individuals with an AUD and their mental health comorbidities. We used ICD codes from medical claims and hospital discharge data to identify anyone with a physical / mental health diagnosis due to harmful alcohol consumption – AUD, April 1, 1996-March 31, 2015. We identified mental health comorbidities using administrative health records. Drug dispensation data were used to identify all first-time prescriptions for acamprosate, naltrexone, or disulfiram occurring after an initial AUD diagnosis. Generalized linear models tested for predictors of receiving a prescription and to identify differences in mental health comorbidities. ResultsWe identified 53,556 treatment niave individuals with an AUD who were eligible to receive one of these three prescriptions. 493 of these received a prescription for acamprosate, naltrexone, or disulfiram. The majority of prescriptions came from general practitioners from urban centers. Those with a prescription were significantly more likely to have a comorbid mood or anxiety diagnosis. Those with a prescription were more likely to have a physician visit for a mental health issue a year to two years before diagnosis compared with those who did not have a prescription; and, they were more likely to be dispensed a selective serotonin, a sedative, and an anti-anxiety medication prior to receiving an AUD diagnosis. Conclusion/ImplicationsDrug therapies to aid in the recovery from AUD are being underutilized. Diagnosis of and treatment for mental health disorders is more common among those dispensed these medications. Programs that study clinicians’ use of AUD-targeted drug therapies should be considered, while psychiatric services in addiction care require significant improvement.

IntroductionThe relationship between childhood/adolescent mental disorders and adult outcomes has been studied using surveys and clinical samples. These studies are prone to selection, recall and self-reporting biases. No previous studies have used population-based administrative databases linking individual-level data that could address these biases and further elucidate this relationship. Objectives and ApproachUsing de-identified administrative databases housed at the Manitoba Centre for Health Policy, we aimed to determine whether people diagnosed with mental disorders in childhood/adolescence, compared to those without, were at higher risk of early adverse adult outcomes. We created a birth cohort of 60,838 residents of Manitoba, Canada, born from fiscal years 1980/81 to 1984/85 and followed them to the end of study period in 2014/15. Through a scrambled health identifier, health, education, social services and justice system data were linked at an individual level. Survival analysis was used to test for differences controlling for key childhood covariates. ResultsWe found that 16.5% of the cohort had a diagnosed mental disorder at some point in their childhood/adolescence. Having a diagnosed mental disorder in childhood/adolescence increased the risk of being diagnosed with the same disorder in early adulthood (at age 30 to 34 years old). It also increased the risk of suicidal death (hazard ratio (HR): 2.41), suicide attempts (HR: 3.05), public housing use (HR: 1.44), income assistance use (HR: 2.07), criminal accusation (HR:1.53), and criminal victimization (HR:1.54) in adulthood. Similarly, but to a greater extent, suicide attempts in adolescence increased the risk of suicidal death (HR: 3.65), suicide attempts (HR: 5.68), public housing use (HR: 1.64), income assistance use (HR: 1.68), criminal accusation (HR: 2.18), or criminal victimization (HR: 2.43) in adulthood. Conclusion/ImplicationsYoung people’s mental health has significant influence on their health and well-being trajectories into adulthood. This knowledge could directly inform policy and practice to provide better population-based mental health promotion, prevention and early interventions for children/adolescents with mental disorders and subsequently prevent adverse adult outcomes in the future.

IntroductionManitoba has one of the highest rates of children taken into care of child welfare services (Child and Family Services; CFS) in the world, and also one of the highest youth incarceration rates in Canada. Policy-makers recognize there is overlap between these systems; the extent of that overlap is unknown. Objectives and ApproachWe linked CFS, Justice, and Population Health Registry data to quantify the overlap between having a history of CFS during childhood (0-17 years) and being charged with a crime as a youth (12-17 years). Using a cohort approach, we selected all individuals in Manitoba who were born in 1988 (N=28,178); those not in the province at any time from 12-17 years were excluded, leaving a final cohort of 18,182. The cohort was divided into 3 groups according to CFS involvement: CFS out-of-home care (1,148); CFS in-home services (3,395); no CFS (13,639). Criminal charges between 12-17 years were identified. Results6.3% of our cohort had CFS out-of-home care, 18.7% received CFS in-home services, and 75% had no CFS involvement. 10.5% of the cohort were charged of a crime between 12-17 years. Almost half (46.6%) of youth who had CFS out-of-home care had criminal charges, compared to 19.4% of youth who had CFS in-home services, and 5.3% of youth with no CFS. Despite accounting for only 6.3% of the cohort, youth who had out-of-home care accounted for 28.0% of youth with criminal charges. Indigenous (First Nations (FN) and Metis) children/youth were over-represented in both systems; for example, 24.5% of FN youth had been in care compared to 3.1% of non-Indigenous; and 32.2% of FN youth were charged with a crime compared to 6.6% of non-Indigenous youth. Conclusion/ImplicationsThere is substantial overlap between the child welfare and youth justice systems, with overrepresentation of Indigenous youth in both systems. Culturally appropriate programs and policies aimed at supporting parents, families and communities to care for their own children will likely have long-term positive impacts on the youth justice system.

ObjectivesManitoba has one of the highest rates of children in out-of-home care in the world. Our aims were to: 1) describe characteristics of children in care; 2) determine differences in educational outcomes for children in care, children receiving in-home protection services and children not involved with child welfare; and, 3) identify factors contributing to educational success for children in care. ApproachPopulation-level administrative data from the Population Health Research Data Repository at the Manitoba Centre for Health Policy, were used. Several data sources were linked together at an individual level: child welfare services (e.g., in care, in-home services; hospital birth records (e.g., birth weight, gestational age); health status (e.g., from hospitalizations, physician visits); family risk factors (e.g., maternal prenatal smoking and/or drinking, maternal education); family characteristics (e.g., number of children in family, receipt of income assistance); education assessments at kindergarten, grades 3, 7, 8, 9 and 12. Children in care from 1998 onward were included. Number of children analyzed differed depending on the educational outcome examined: e.g., analyses at kindergarten include 1,893 children in care, 4,229 children receiving in-home services, and 32,280 children not involved with child welfare services; for high school completion these numbers were 11,234, 40,671, and 162,265 respectively. Multivariate regressions identified characteristics associated with educational outcomes for children in care. ResultsOver one-third of children in care first entered care as infants, and of those, close to half were apprehended at birth. 5.5% of children in Manitoba spent some time in care before their 15th birthday, with an almost tenfold difference for Indigenous (16.6%) and non-Indigenous (1.7%) children. Across the range of educational outcomes, children in care did more poorly than children receiving in-home services, who in turn did more poorly than children with no child welfare involvement. For example, only 33.4% of children in care completed high school compared to 66.8% of children receiving in-home services and 89.3% of children with no child welfare involvement. Adjusting covariates reduced differences but all remained statistically significant. Factors associated with positive outcomes for children in care differed depending on the outcome and included measures like poverty (at Kindergarten, p

ObjectiveThe objective of this population health research is to identify the social burden associated with having an alcohol related diagnosis. MethodsWe used linkable population-based administrative data files held in the Population Health Research Data Repository to conduct our research, fiscal years 1990/91 to 2014/15. Data came from several domains including health, social services, justice, and the Canadian Census. We used ICD-9/10-CA codes from the hospital abstract database, medical claims data, and prescription drug data to identify individuals with an alcohol-related diagnosis. Individuals’ socioeconomic status was determined using neighbourhood-level income data from the Canadian Census. We matched, 3:1, diagnosed cases to individuals in our repository using on age, sex, income, and community area. We linked cases and matches to administrative data from justice and social services to identify social outcomes associated with having an alcohol-related diagnosis. Outcomes included receipt of income assistance, residence in publically funded social housing, having a child apprehended by child and family protective services, having a charge for driving under the influence recorded in the justice data, and having a charge for domestic violence recorded in the justice data. We modelled rates using generalized estimating equations from 5 years before date of diagnosis to a maximum of 20 years after date of diagnosis. Models tested for significant differences in rates between cases and matches both before and after diagnosis; as well, we tested for time trends in rates both before and after diagnosis. ResultsWe identified 52,991 individuals with an alcohol related diagnosis between 1990/91 and 2014/15: 34,145 males and 18,846 females. 80.3% of cases had a mental-health related alcohol diagnosis. Diagnoses followed a socioeconomic gradient with the greatest number of cases coming from low-income neighbourhoods. Cases had a significant spike in rates from one year before to one year after diagnosis date, compared with matches, across all indicators. When we followed individuals for 20 years after diagnosis, we found a significantly elevated rate of social service use and involvement with the justice system, across all outcomes, for all years. ConclusionReceiving an alcohol-related diagnosis is associated with subsequent increased use of social services and contacts with the justice system. Upstream efforts to reduce alcohol-related diagnoses may result in reduced use of social services and justice contacts.

This paper explores the relative importance of social factors and health measures in predicting educational achievement in early and late adolescence using population-based administrative data. The sample was made up of 41,943 children born in Manitoba, Canada between 1982 and 1989 and remaining in the province until age 18. Multilevel modeling nests each individual (level 1) within a family (level 2) residing within a neighborhood (level 3). Most important in predicting adolescent achievement were a broad socioeconomic status index (and a narrower measure of household income), being on social assistance, mother’s age at first birth, gender, residential mobility, the presence of ADHD/Conduct disorders, and measures of family functioning (child taken into care or offered protection services and family structure history). Family size, birth order, and newborn characteristics (birthweight, APGAR, gestational age) were statistically significant but of little importance in explaining the outcomes. Both examining regression coefficients and systematically omitting variables showed social factors (often emphasized by epidemiologists) to have markedly greater effects than the combination of health measures (often stressed by economists) in predicting achievement. However, mental health in childhood is identified as among the important predictors. Record linkage across population datasets from health, education, and family services ministries allowed: tracking health and educational attainment at different times in a child’s life, following a large number of cases across childhood, considerable sensitivity testing, controlling for unmeasured family and neighborhood effects, generating an extensive list of predictors, estimating effect sizes, and comparing Manitoba results with those of well-known American studies.

Information-rich environments in Canada, Australia, and the United Kingdom have been built using record linkage techniques with population-based health insurance systems and longitudinal administrative data. This paper discusses the issues in extending population-based administrative data from health to additional topics more generally connected with well being. The scope of work associated with a multi-faceted American survey, the Panel Study in Income Dynamics (PSID), is compared with that of the administrative data in Manitoba, Canada. Both the PSID and the Manitoba database go back over 30 years, include families, and have good information on residential location. The PSID has emphasized research design to maximize the opportunities associated with expensive primary data collection. Information-rich environments such as that in Manitoba depend on registries and record linkage to increase the range of variables available for analysis. Using new databases on education and income assistance to provide information on the whole Manitoba population has involved linking files while preserving privacy, scaling educational achievement, assessing exposure to a given neighborhood, and measuring family circumstances. Questions being studied concern the role of the socioeconomic gradient and infant health in child development, the comparative influence of family and neighborhood in later well being, and the long-term effects of poverty reduction. Issues of organization of research, gaps in the data, and productivity are discussed.

An inverse relationship exists between socio-economic status (SES) and osteoporotic fractures. In publicly funded health-care systems there should be no barriers to accessing bone mineral density (BMD) testing, especially for those at increased fracture risk. Our hypothesis was that there would be a positive association between SES and BMD utilization (i.e. higher utilization rates in higher income women), resulting in disparities that disadvantage lower SES or lower income women.A population-based BMD database from the Manitoba Bone Density Program was utilized to assess the association between SES (defined using income quintiles) and BMD utilization rates in women aged 50 years and older (n=107,944) for the 2001-2002 fiscal year. Analyses were stratified by age (50-64 years old and 65 years or older) and by a morbidity index obtained from the Johns Hopkins University Adjusted Clinical Group Case-Mix Adjustment System.Regression models demonstrated significantly higher BMD utilization rates among high SES women in all age and morbidity strata. Rate ratios varied from 1.76 (95% CI: 1.52-2.04) in 50- to 64-year-old women to 2.36 (95% CI: 1.60-3.49) in low morbidity women aged 65 or older.Within the context of a publicly funded health-care system significant inverse associations are demonstrated between SES and BMD utilization rates. Further research is needed to better understand the nature of these associations and how they may contribute to health outcomes.

Background: In publicly funded health care systems, the utilization of health care services should be equitable, irrespective of socioeconomic status (SES). Although the association between SES and health care utilization has been examined in Canada relative to surgical, cardiac and preventive health care services, no published studies have specifically explored the association between SES and diagnostic imaging. Methods: We examined over 300 000 diagnostic imaging claims made in the Winnipeg Regional Health Authority between Apr. 1, 2001, and Mar. 31, 2002. Using patient postal codes, we assigned SES on the basis of average household incomes in Canada9s 1996 census. Using multiple regression, we examined the association between income quintile, patient age group (≤16, 17–64, ≥ 65 years), patient morbidity level according to the Johns Hopkins University Adjusted Clinical Group method (high, moderate, low), and imaging modality (general radiology, vascular, computed tomography, magnetic resonance, and general and obstetric ultrasound). Results: Relative rates (RR) of diagnostic imaging utilization (highest v. lowest income quintile) were significantly increased in pediatric and adult patient groups at all morbidity levels receiving general radiology (highest RR 2.47, 95% confidence interval [CI] 2.07–2.93); pediatric and adult patient groups at high and low morbidity levels and elderly patient groups at low morbidity levels receiving general ultrasound (highest RR 2.26, 95% CI 1.20–4.26); pediatric and adult patient groups at all morbidity levels and elderly patients at high and moderate morbidity levels receiving magnetic resonance imaging (highest RR 2.51, 95% CI 1.78– 3.52); and adult patient groups at all morbidity levels receiving computed tomography (highest RR 1.46, 95% CI 1.35– 1.59). A lower RR of diagnostic imaging utilization in the highest income quintile was found only among patients receiving obstetric ultrasound (RR 0.80, 95% CI 0.73–0.87). No significant associations were found among elderly patients receiving general radiology or computed tomography or adult patients receiving vascular imaging. Interpretation: We found a pattern of increased diagnostic imaging utilization in patient groups with a higher SES. Further research is needed to better understand the nature of this finding and how it contributes to health outcomes.

Utilization of dual-energy X-ray absorptiometry (DXA) for the initial diagnostic assessment of osteoporosis and in monitoring treatment has risen dramatically in recent years. Population-based studies of the impact of DXA and osteoporosis remain challenging because of incomplete and fragmented test data that exist in most regions. Our aim was to create and assess completeness of a database of all clinical DXA services and test results for the province of Manitoba, Canada and to present descriptive data resulting from testing. A regionally based bone density program for the province of Manitoba, Canada was established in 1997. Subsequent DXA services were prospectively captured in a program database. This database was retrospectively populated with earlier DXA results dating back to 1990 (the year that the first DXA scanner was installed) by integrating multiple data sources. A random chart audit was performed to assess completeness and accuracy of this dataset. For comparison, testing rates determined from the DXA database were compared with physician administrative claims data. There was a high level of completeness of this database (>99%) and accurate personal identifier information sufficient for linkage with other health care administrative data (>99%). This contrasted with physician billing data that were found to be markedly incomplete. Descriptive data provide a profile of individuals receiving DXA and their test results. In conclusion, the Manitoba bone density database has great potential as a resource for clinical and health policy research because it is population based with a high level of completeness and accuracy.

Being able to anticipate future needs for health services presents a challenge for health planners. Using existing population projections, two models are presented to estimate the demand for hospital beds in regions of Manitoba in 2020. The first, a current-use projection model, simply projects the average use for a recent three-year period into the future. The second, a 10-year trend analysis, uses Poisson regression to project future demand. The current-use projection suggests a substantial increase in the demand for hospital beds, while the trend analysis projects a decline. The last projections are consistent with ongoing increases in rates of day surgeries and declines in lengths of stay. The current-use projections need to be considered in the context of relatively low occupancy rates in rural hospitals and previous research on appropriateness of stays in acute care hospitals. If measures are taken to ensure more appropriate use of acute care hospital beds in the future, then the current-use projections of bed shortages are not a cause for concern.

Bone density measurement plays a key role in the initial diagnostic assessment of osteoporosis and in targeting pharmacologic therapies. The impact of access to dual-energy X-ray absorptiometry (DXA) on physician prescribing habits is unclear, however. We were able to directly evaluate the change in physician osteoporosis testing and prescribing following introduction of a DXA testing service in a geographic region that had previously had very limited access. This evaluation was conducted in the province of Manitoba, Canada, which has a provincially based bone density testing program and maintains a population-based bone density database that can be linked with administrative health data sources including drug prescriptions. The province of Manitoba was geographically partitioned into the urban and rural health regions serviced by the new program (urban(new )and rural(new)) and the remaining urban and rural health regions which had relatively unchanged DXA access during this period (urban(control) and rural(control)). Regression models of DXA testing rates and osteoporosis prescription rates were created for all older women in these regions. There was a statistically significant increase in bone density testing and BMD-guided osteoporosis treatment in the urban(new) and rural(new) regions following introduction of the DXA testing service, relative to the control regions. Although the overall rate of empiric postfracture and preventive osteoporosis treatment did not show a specific region effect, when analysis was limited to nonhormonal agents there was a significant reduction in preventive and empiric postfracture treatment in some subgroups of women. These results suggest that the local availability of the bone density testing service led to an increase in objective test-guided therapy with some reduction in the use of empiric and preventive strategies and had a neutral effect on overall use of these agents.

Objectives: Although the increased risk of hospitalization and mortality during influenza seasons has been documented extensively, there is a relative paucity of research on the impact of influenza-related illnesses on other health care use indicators, such as physician use. The purpose of this study was to examine the impact of influenza-associated respiratory illnesses on the Winnipeg health care system, including hospitalizations, physician visits and emergency room visits. Their impact on mortality was also examined. Methods: Administrative data were used to track health care use and mortality over four influenza seasons (1995–96 to 1998–99). Excess health care use and deaths were calculated by subtracting rates during influenza seasons from those during weeks when influenza viruses were not circulating. Results: Significant excess hospitalization, physician visit, and emergency room visit rates emerged for influenza and pneumonia, acute respiratory diseases, and chronic lung disease, especially among children and adults aged 65 and over. Considerable excess mortality due to influenza and pneumonia and chronic lung disease among individuals aged 65 and over also emerged, particularly among nursing home residents. Discussion: Influenza-associated respiratory illnesses have a substantial impact on the health care system. Given the burden of illness among children during influenza seasons, the study further suggests that influenza vaccination might be considered for this age group.

This study examined whether Winnipeg hospitals experience predictable “high-volume periods” in order to determine whether hospital overcrowding might be anticipated and, therefore, avoided. We found that high-volume periods among medical patients occurred during all but one year between 1987 and 1998. Most high-volume periods occurred during influenza seasons. Preventing such recurrent bed pressures requires a multi-faceted approach, involving preventive efforts to reduce hospital admissions (influenza vaccination) and alternatives to managing the hospital system.

Background Early reports of the 2009 A/H1N1 influenza pandemic (pH1N1) indicated that a disproportionate burden of illness fell on First Nations reserve communities. In addition, the impact of the pandemic on different communities may have been influenced by differing provincial policies. We compared hospitalization rates for pneumonia and influenza (P&I) attributable to pH1N1 influenza between residents of First Nations reserve communities and the general population in three Canadian provinces. Methods Hospital admissions were geocoded using administrative claims data from three Canadian provincial data centres to identify residents of First Nations communities. Hospitalizations for P&I during both waves of pH1N1 were compared to the same time periods for the four previous years to establish pH1N1-attributable rates. Results Residents of First Nations communities were more likely than other residents to have a pH1N1-attributable P&I hospitalization (rate ratio [RR] 2.8-9.1). Hospitalization rates for P&I were also elevated during the baseline period (RR 1.5-2.1) compared to the general population. There was an average increase of 45% over the baseline in P&I admissions for First Nations in all 3 provinces. In contrast, admissions overall increased by approximately 10% or less in British Columbia and Manitoba and by 33% in Ontario. Subgroup analysis showed no additional risk for remote or isolated First Nations compared to other First Nations communities in Ontario or Manitoba, with similar rates noted in Manitoba and a reduction in P&I admissions during the pandemic period in remote and isolated First Nations communities in Ontario. Conclusions We found an increased risk for pH1N1-related hospital admissions for First Nations communities in all 3 provinces. Interprovincial differences may be partly explained by differences in age structure and socioeconomic status. We were unable to confirm the assumption that remote communities were at higher risk for pH1N1-associated hospitalizations. The aggressive approach to influenza control in remote and isolated First Nations communities in Ontario may have played a role in limiting the impact of pH1N1 on residents of those communities.

The authors introduce the Population Health Information System, its conceptual framework, and the data elements required to implement such a system in other jurisdictions. Among other innovations, the Population Health Information System distinguishes between indicators of health status (outcomes measures) and indicators of need for health care (socioeconomic measures of risk for poor health). The system also can be used to perform needs-based planning and challenge delivery patterns.

Because the health status of a population does not usually respond immediately to interventions, whether social or medical, the ability to analyze change over time is important. Therefore, patterns of change and stability in health status and health care use of Manitoba residents during a 3-year period from 1990 to 1992 were analyzed using the Population-based Health Information System. This article presents summary findings and discusses methodological and policy issues arising from the analyses. A small but significant decrease in premature mortality (the primary health status indicator) was observed in most regions of the province, but two remote, northern regions, those whose residents scored at high socioeconomic risk, remained distinguished for their poor health status. These "poor health" regions also had the highest contact rates with primary caregivers, raising questions about the role of the health care system in improving the health of the population. A persistent increase in surgery was observed in several regions, led by increases in outpatient surgery over and above increases in the elderly population and beyond substitution for inpatient procedures. This trend (not obvious before these analyses) is important as hospitals move to expand their outpatient facilities in response to restraints on inpatient care.

Use of medical services by the elderly population is increasing. While rising numbers of elderly persons account for much of the overall increase, per capita increases in use of medical services within this group have been substantial. This phenomenon is commonly attributed to greater need due to the “aging” of the elderly population (i.e. an increased proportion of those 85 years of age and over) and to changing patterns of morbidity or to changing patterns of servicing the old and sick. Research to date suggests that the impact of the aging of the elderly population has been small. However, because the relationship between morbidity and rising utilization has not yet been studied, there is considerable debate about the extent to which increased “need” for care contributes to patterns of rising utilization. This research studied the impact of changes in numbers, demographics, and morbidity patterns of the elderly on per capita and aggregate consumption of ambulatory physician services at two points in time. Linked survey and physician claims data for representative samples of the elderly in 1971 and 1983 were used to study patterns of utilization of total ambulatory, consultative and non-consultative care by age and health status. The research found that per capita utilization of both consult and non-consult visits rose across all categories, with older individuals and those in poor health experiencing greater increases in utilization than younger and healthier individuals. At the aggregate level, a large percentage of the increase in utilization of medical services was related to increased numbers of elderly. Changes in ‘need’ attributable to aging of the elderly population and increased morbidity had only minor effects. At least 35 per cent of the increase in non-consult visits and 50 per cent of the increase in consult visits were not specifically related to changes in need of the elderly population and remain as unexplained changes in patterns of servicing individuals. While some of this increase was directed to individuals in poor health, the majority of increased servicing (32% of the increase in non-consultative visits and 58% of the increase in consultation visits) was directed to individuals in good health. Policy implications are discussed.

In this study, population-based data were used to examine the appropriateness of Papanicolaou (Pap) testing from the perspective of the women being tested and their physicians. The approach used is unique in its assessment of overtesting and undertesting in the primary care setting. From the data base of the province of Manitoba's universal health insurance plan, 4-year health histories (1981 to 1984) were constructed for each woman from a random sample of the population of women who, in 1982, were between the ages of 25 to 64 years (n = 22,287). At the last visit to a general practitioner, gynecologist, or general surgeon in 1984 (termed the current visit), the authors determined whether a Pap test was given for each woman. Using decision rules from a Canadian task force report on cervical screening and previous health history, the authors evaluated the appropriateness of screening by determining whether a Pap test was given and was needed, or whether a women who had not received a Pap test required one. Overall, 55.7% of women were tested appropriately. Of the 5352 women who received a Pap test at the current visit, 62.8% were overtested. Of the 16,935 women not tested at the current visit, 38.5% required screening (i.e. were undertested). Characteristics of a physician's practice that were significantly related to compliance with the guidelines included having a high proportion of patients visiting for obstetric or gynecologic reasons. Variables that were associated with negative compliance were 1) being a gynecologist; and 2) having a high proportion of patients who lived in inner city or rural areas. Because physicians are paid a fee for every Pap smear taken and the guidelines were well disseminated, these results should be reasonably representative of fee-for-service practice in North America, where preventive care is not subject to user charges. This study supports previous findings that a passive approach to dissemination of guidelines is insufficient to effect practice.

Since anaesthesia, unlike medical or surgical specialties, does not constitute treatment, this study sought to determine if methods used to assess medical or surgical outcomes (that is the determination of adverse outcome) are applicable to anaesthesia. Anaesthetists collected information on patient, surgical and anaesthetic factors while data on recovery room and postoperative events were evaluated by research nurses. Data on 27,184 inpatients were collected and the analysis of outcomes determined for the intraoperative, post-anaesthetic care unit and postoperative time periods. Logistic regression was used to control for differences in patient populations across the four hospitals. In addition, a random selection of 115 major events was classified by a panel of anaesthetists into anaesthesia, surgical and patient-disease contributions. Across the three time periods, large variations in minor outcomes were found across the four hospitals; these variations ranged from two-to five-fold after case-mix adjustment (age, physical status, sex, emergency versus elective and length of anaesthesia). The rates of major events and deaths were similar across three hospitals; one hospital had a lower mortality rate (P < 0.001) but had a higher rate of all major events (P < 0.0001). Of major events assessed by physician panels, 18.3% had some anaesthetic involvement and no deaths were attributable partially or wholly to anaesthesia. Possible reasons to account for these variations in outcome include compliance in recording events, inadequate case-mix adjustment, differences in interpretation of the variables (despite guidelines) and institutional differences in monitoring, charting and observation protocols. The authors conclude that measuring quality of care in anaesthesia by comparing major outcomes is unsatisfactory since the contribution of anaesthesia to perioperative outcomes is uncertain and that variations may be explained by institutional differences which are beyond the control of the anaesthetist. It is suggested that minor adverse events, particularly those of concern to the patient, should be the next focus for quality improvement in anaesthesia.

Objective We examined medical, educational and social risks to children of teen mothers and children of nonadolescent mothers with a history of teen birth (prior teen mothers) and considered these risks at both the individual and societal level. Methods A population-based, retrospective cohort study tracked outcomes through young adulthood for children born in Manitoba, Canada (n = 32 179). χ 2 and logistic regression analyses examined risk of childhood death or hospitalization, failure to graduate high school, intervention by child protective services, becoming a teen mother, and welfare receipt as a young adult. Results For children of both teen and prior teen mothers, adjusted likelihoods of death during infancy, school-aged years, and adolescence were more than 2-fold higher than for other children. Risks for hospitalization, high hospital use, academic failure, and poor social outcomes were also substantially higher. At a societal level, only 16.5% of cohort children were born to teen and prior teen mothers. However, these children accounted for 27% of first-year hospitalizations, 34% of deaths (birth to 17 years), 30% of failures to graduate high school, 51% in foster care, 44% on welfare as young adults, and 56% of next-generation young teen mothers. Conclusions Children of prior teen mothers had increased risks for poor health and for educational and social outcomes nearly equal to those seen in children of teen mothers. Combined, these relatively few children experienced a large share of the negative outcomes occurring among young people. Our results suggest the need to expand the definition of risk associated with adolescent motherhood and target their children for enhanced medical and social services.

La surpopulation des hopitaux constitue un fleau a Winnipeg et dans d'autres villes canadiennes depuis des annees. Cette etude aborde divers facteurs lies a cette surpopulation. Les dossiers des hopitaux ont servi a l'evaluation des fluctuations relativement a l'utilisation des hopitaux pour les exercices 1996/1997 a 1999/2000. Un examen des dossiers a ete mene afin de determiner la pertinence des admissions et des sejours a l'ho pital pendant une semaine de forte affluence. Les resultats revelent que les periodes d'affluence du systeme hospitalier etaient dues a l'afflux de personnes âgees souffrant de maladies respiratoires associees a la grippe. Par ailleurs, l'examen d'une semaine de forte affluence en particulier a revele qu'au moins une centaine de lits etaient occupes par des patients qui n'avaient probablement pas besoin de soins de courte duree. L'examen des dossiers a revele qu'une proportion substantielle de jours-patients qui n'etaient pas de courte duree ont ete passes a attendre des soins a domicile, des soins de longue duree ou des examens paracliniques. Ces conclusions semblent indiquer que l'on pourrait eviter d'eventuelles periodes de forte affluence au moyen de vaccinations contre la grippe ainsi que d'une augmentation de la disponibilite des autres niveaux de soins et de transferts rapides vers ceux-ci. Cette recherche decoule de projets entrepris par le Manitoba Centre for Health Policy en vertu d'un contrat avec le ministere de la Sante du Manitoba. Les resultats et les conclusions n'engagent que les auteurs, et le ministere de la Sante du Manitoba n'a pas endosse cette etude de quelque maniere que ce soit. Le Dr Menec a obtenu le prix New Investigator Career de la part des Instituts de recherche en sante du Canada. Hospital overcrowding has plagued Winnipeg and other Canadian cities for years. This study explored factors related to overcrowding. Hospital files were used to examine patterns of hospital use from fiscal years 1996/1997 to 1999/2000. Chart reviews were conducted to examine appropriateness of admissions and hospital stays during one pressure week. Results indicate that pressure periods in the hospital system were driven by an influx of older adults with influenza associated respiratory illnesses. Moreover, examination of one specific pressure week showed that at least 100 beds were occupied by patients who likely did not require acute care. The chart review revealed that a substantial proportion of non-acute patient-days were spent awaiting home care, long-term care, or diagnostic testing services. These findings suggest future bed pressures might be prevented through influenza vaccination and an increase in the availability of - and timely transfer to - alternative levels of care.

Les tendances relatives a l'etat de sante de toute la population du Manitoba âgee de 65 ans ou plus ont ete etudiees sur une periode de 14 ans, au moyen de donnees administratives (environ 150 000 personnes). Des gains considerables en sante ont ete observes pour un certain nombre d'indicateurs, notamment du point de vue des infarctus aigus du myocarde, des accidents cerebraux vasculaires, des cancers et des fractures de la hanche. Cependant, certains de ces gains n'ont ete observes que dans les zones urbaines. Les ameliorations relatives a ces indicateurs de la sante sont importantes, puisqu'elles peuvent avoir des consequences majeures sur les besoins des personnes en matiere de soins de sante et sur leur aptitude a vivre de facuon autonome. Par contre, la prevalence de maladies chroniques a augmente ; le diabete, l'hypertension et la demence ayant augmente de facuon substantielle au cours de la periode de 14 ans. Ces tendances laissent supposer qu'il faut mettre l'accent sur les politiques de prevention, afin notamment de reduire la prevalence de l'obesite, qui constitue l'un des facteurs de risque du diabete. Par ailleurs, il faudra se pencher sur la question de savoir si l'on dispose de suffisamment d'options en matiere de soins pour le nombre croissant de personnes atteintes de demence. Trends in the health status of the entire senior population aged 65 years or older in Manitoba were examined over a 14-year period (1985Ð1999) using administrative data (about 150,000 individuals). Significant health gains were apparent for a number of important indicators, including acute myocardial infarction, stroke, cancer, and hip fractures, although some of these gains were restricted to urban areas. Improvements in these health indicators are significant, as they can have major implications for individuals' need for health services and ability to live independently. In contrast, chronic diseases were on the rise, with the prevalence of diabetes, hypertension, and dementia increasing substantially over the 14-year period. These trends suggest a need for a policy emphasis on prevention, such as reducing the prevalence of obesity, which is one risk factor for diabetes. Moreover, having sufficient care options in place for the growing number of individuals with dementia is an issue that will have to be addressed.

A team of health researchers of the Manitoba Centre for Health Policy at the University of Manitoba was asked to forecast the number of acute care hospital beds that will be required to meet the needs of residents of the province of Manitoba by the year 2020. Methodological considerations for this request included identification of factors expected to affect bed use in the future, and how to account for these factors. The objective of this paper is to describe these methodological considerations, how decisions were made, and steps taken in our approach to this problem. The actual projections and their implications are the subject of another contribution in this issue of the journal (Finlayson, Stewart, Tate, MacWilliam & Roos, 2005).

Many argue that "free" medical care leads to unnecessary use of health resources. Evidence suggests that user fees do discourage physician use, at least by those of low socioeconomic status. In this study, we compare health care utilization and health among socioeconomic groups to determine whether people of low socioeconomic status see physicians more than would be expected given their health status.We examined the use of health care services (physicians and hospitals) by residents of Winnipeg, Manitoba, in 1999. The cost of physician services was drawn directly from the claims filed, and the cost of hospital services was estimated using the Case Mix Group and Day Procedure Group methods linked to resource intensity weights and Manitoba hospital costs. We used neighbourhood indicators of socioeconomic status from the 1996 census and measured health status by examining rates of premature mortality, acute myocardial infarction, hip fracture (1995-1999) and diabetes (1999). Using these measures, we compared health status and health care use of residents living in areas with low average household incomes with those living in areas with high average household incomes. All rates were age- and sex-adjusted across the groups.The province spent 44% more providing hospital and physician services to residents of Winnipeg neighbourhoods with the lowest household incomes (820 dollars/person annually v. 596 dollars/person for residents of the neighbourhoods with highest household incomes). However, expenditures were strongly related to health status. The 70% of the population on which the province spends 10% of its health care dollars scored well on all health indicators, and the 10% of the population on which 74% of the dollars are spent scored poorly. In each expenditure group, those with lower socioeconomic status had poorer health. In the highest expenditure group, those with lowest socioeconomic status had 82% higher premature mortality rates (23.0 v. 12.6 per 100,000 population) and 53% higher hip fracture rates (5.5 v. 3.6 per 100,000 population) than those with the highest socioeconomic status. Despite their poorer health, in each expenditure group, residents of the neighbourhoods with the lowest household incomes incurred physician expenditures that were similar to those of residents of wealthier neighbourhoods.Most people use little health care; high-cost users are a small group of very sick people drawn from all neighbourhoods and all income groups. People living in areas with low average household incomes use fewer physician services than might be expected, despite their poor health status.

To assess the ability of an Adjusted Clinical Group (ACG)-based morbidity measure to assess the overall health service needs of populations. Data Sources/Study Setting. Three population-based secondary data sources: registration and health service utilization data from fiscal year 1995-1996; mortality data from vital statistics reports from 1996-1999; and Canadian census data. The study included all continuously enrolled residents in the universal health care plan in Manitoba.Using 60 small geographic areas as the units of analysis, we compared a population-based "ACG morbidity index," derived from individual ACG assignments in fiscal year 1995-1996, with the standardized mortality ratio (ages75 years) for 1996-1999. Key variables included a population-based socioeconomic status measure and age- and sex-standardized physician utilization ratios.The ACGs were assigned based on the complement of diagnoses assigned to persons on physician claims and hospital separation abstracts. The ACG index was created by weighting the ACGs using average health care expenditures.The ACG morbidity index had a strong positive linear relationship with the subsequent rate of premature death in the small areas of Manitoba. The ACG index was able to explain the majority of the relationships between mortality and both socioeconomic status and physician utilization.In Manitoba, ACGs are closely related to premature mortality, commonly accepted as the best single indicator for health service need in populations. Issues in applying ACGs in settings where needs adjustment is a primary objective are discussed.

BACKGROUND While the adjusted clinical group (ACG) system has been extensively validated in the United States, its use in other developed nations has been limited. This article examines the performance of the system in 2 Canadian provinces and assesses the extent to which ACGs can account for same-year and next-year health care expenditures. METHODS The study population included all residents of Manitoba and British Columbia who were continuously enrolled in the provincial health plans from April 1, 1995, to March 31, 1997. ACGs were assigned through diagnoses from fee-for-service physician claims and hospital separation records. "Physician" costs were calculated from the fee-for-service tariffs, and for Manitobans, "total" costs were also computed by combining physician and hospital costs. Linear regression was used to examine the ability of the ACG system to explain variation in individual costs (truncated at the 99th percentile). RESULTS The British Columbia and Manitoba data were generally acceptable, with fewer than 2% rejected diagnoses. Higher costs were associated with both the accumulation of morbidities and their relative severity. For physician costs, the ACG system explained approximately 50% and approximately 25% of the variation in same-year and next-year truncated costs, respectively. For total costs, the system explained approximately 40% and approximately 14% of these respective costs. CONCLUSIONS The application of ACGs in Canada is feasible using existing data. The ability of the ACG system to explain variation in costs is similar to that found in US health systems. While application of ACGs in Canada shows promise, further research is required to examine how closely they reflect population morbidity burdens and health care needs.

Objective: To estimate the proportion of Canadian National Breast Screening Study (NBSS) participants who went outside the trial for a mammogram, based on health insurance claims data. Method: Prospective cohort study linking trial subjects with population-based administrative data. Subjects: All NBSS participants enrolled in the Winnipeg screening center who had health insurance claims to Manitoba Health (n = 9,780). Analysis: Claims for bilateral mammograms were compared by screening arm allocation and age group at enrollment. Mammograms likely to be “screening” were defined based on prior claim history. Results: For women aged 40 to 49 at enrollment, 5.3% in the intervention group and 21.8% in the control group had a claim for at least one bilateral mammogram. After excluding nonscreening mammograms these proportions fell to 2.2% and 14.1% (P < 0.0001). For women aged 50 to 59, 4.5% in the intervention group and 16.7% of the control group had at least one claim for a bilateral mammogram. These proportions were 2.1% and 10.5% for screening (P < 0.0001). Conclusion: Health care utilization data can be used to estimate contamination in a screening trial. The levels of contamination resulting from participants going outside the study for a screening test can have an impact on the power of the study and need to be considered when interpreting results and planning future screening studies.

Criticisms of the Canadian National Breast Screening Study (NBSS) assert that reported findings (more deaths in women aged 40–49 allocated to mammography versus no mammography and no difference in mortality between women who had mammography and physical examination versus physical examination alone for those aged 50–59) may be due to more women with prior breast disease being allocated to the mammography arms of the study. The possibility that allocation was not random was examined for NBSS participants in Manitoba, Canada, using health insurance data that were external to and independent of the NBSS. The study design consisted of a retrospective observation study using health insurance (claims) data to construct health histories of breast disease prior to NBSS entry. Self-reported breast disease from the NBSS entry questionnaires was compared to breast disease histories on the basis of health insurance claims. The setting consisted of one NBSS screening center in Winnipeg, Canada. The patient population consisted of 9477 women with at least one health insurance claim in the 24 months prior to NBSS entry. We determined the proportions of women within each study arm who had claims for breast disease, breast disease investigation, or xeromammograms in the 24 months prior to NBSS entry, and compared the proportion of women's self-reports of breast disease or xeromammography with the presence/absence of a claim prior to NBSS entry for breast disease or xeromammography. No significant differences in the proportion of women with prior histories of benign breast disease, investigation, or xeromammograms ( p > 0.05) were found across the study arms. Nine women in the mammography group versus one in the no mammography group had one prior health insurance claim for breast cancer, but eight of these women had no subsequnt claims for breast cancer. There were no differences across the study arms in the proportion of women who reported a prior history of breast disease or a prior xeromammogram for whom an insurance claim was found. Using data external to the NBSS for Manitoba participants, the study found no definitive evidence to support a nonrandom allocation of women with prior breast disease to the mammography arms of the study. However, generalizability to the other NBSS centers cannot be assured.

A set of 102 population-based indicators was developed from multiple administrative data sources; these indicators were used to compare the health status of 1 million Manitoba residents across eight administrative regions for 1 year. Marked variations in health status were shown. Despite theoretically equal access to care in a universally insured system and high rates of utilization of hospital and physician services, residents of Manitoba's two northern, more remote regions scored most poorly--consistently and with statistical significance--across a variety of health status indicators. The strength of the various indicators was evaluated, and premature mortality emerged as the most useful "flagship" indicator for future analyses. Indicators that purport to be sensitive to how well a health care system is performing showed patterns similar to those derived from more classic measures (eg, mortality, low birth weight). Furthermore, the "system sensitive indicators" did not appear to be sufficiently independent of utilization biases.

OBJECTIVES University-based researchers in Manitoba, Canada, have used administrative data routinely collected as part of the national health insurance plan to design an integrated database and population-based health information system. This information system is proving useful to policymakers for answering such questions as: Which populations need more physician services? Which need fewer? Are high-risk populations poorly served? or do they have poor health outcomes despite being well served? Does high utilization represent overuse? or is it related to high need? More specifically, this system provides decision makers with the capability to make critical comparisons across regions and subregions of residents' health status, socioeconomic risk characteristics and use of hospitals, nursing homes, and physicians. The system permits analyses of demographic changes, expenditure patterns, and hospital performance in relation to the population served. The integrated database has also facilitated outcomes research across hospitals and countries, utilization review within a single hospital, and longitudinal research on health reform. The discussion highlights the strengths of integrated population-based information in analyzing the health care system and raising important questions about the relationship between health care and health.

OBJECTIVES The Manitoba Centre for Health Policy and Evaluation worked in support of a provincial Physician Resource Committee to address questions pertinent to assessing Manitoba's supply of specialist physicians. RESEARCH DESIGN Because there was no direct method of determining whether the province's supply of specialists was adequate, three types of evidence were reviewed: the supply of specialists relative to recommended population/physician ratios; the supply of specialists relative to other Canadian provinces; and the level of care delivered by specialists in Manitoba relative to other provinces. Four additional questions were addressed: is a problem developing from the aging of Manitoba's specialist physicians? and will the supply of specialists be sufficient to keep up with the aging of the population? How well do specialists serve as a provincial resource? and how well do specialists serve high-need populations?

All children born in Manitoba in 1984 were tracked for 18 years to assess their grade ‐ 12 performance on a provincial examination according to a student’s socio ‐ economic status. The proportion of youths in families receiving social assistance judged to have passed their language arts exam dropped from 80 per cent to 12 per cent, depending on whether one counts only those in the cohort who took the test on time in 2002 or all youths born in 1984 who should have taken the test in 2002. Getting better data on performance and doing something about the discrepancies should become a Canadian priority. Key words: educational opportunity, exam performance, socio ‐ economic status, testing, longitudinal studies Tous les enfants nes au Manitoba en 1984 ont ete suivis sur une periode de 18 ans en vue d’evaluer leur rendement en 12 e annee lors d’un examen provincial, tenant compte de leur statut socioeconomique. La proportion de jeunes issus des familles recevant de l’aide sociale et consideres comme ayant reussi leur examen au plan des competences linguistiques passe de 80 % a 12 %, selon que l’on compte seulement ceux qui, dans la cohorte, ont subi l’examen a temps en 2002 ou tous les jeunes nes en 1984 qui auraient du subir l’examen. En matiere d’egalite des chances, la performance du systeme scolaire actuel au Canada laisse a desirer. Mots cles: possibilites educatives, resultats d’examen, statut socioeconomique, analyse longitudinale.

University-based researchers in Manitoba, Canada, have used administrative data routinely collected as part of the national health insurance plan to design an integrated database and population-based health information system. This information system is proving useful to policymakers for providing answers to such questions as: which populations need more physician services? Which need fewer? Are high-risk populations poorly served or do they have poor health outcomes despite being well served? Does high utilization represent overuse or utilization related to high need? More specifically, this system provides decision-makers with the capability to make critical comparisons across regions and subregions of residents' health status, socioeconomic risk characteristics, and use of hospitals, nursing homes, and physicians. The system permits analyses of demographic changes, expenditure patterns, and hospital performance in relation to the population served. The integrated database has also facilitated outcomes research across hospitals and counties, utilization review within a single hospital, and longitudinal research on health reform. A particularly interesting application to planning physician supply and distribution is discussed. The discussion highlights the strengths of integrated population-based information in analyzing the health care system and raising important questions about the relationship between health care and health.

BACKGROUND: Numerous studies have established that socio-economic position is positively related to health status, but we know little about the real costs of these differences across an entire population. This paper estimates the potential savings in morbidity and dollars from reducing the inequalities in health among Winnipeg residents. METHODS: We measure excess morbidity by examining rates of premature death, hip fracture, and heart attack according to the relative affluence of the Winnipeg neighbourhood. We also assess the total expenditures on physician and hospital care by neighbourhood of residence. We then estimate the savings that could have been achieved if 1) the health of the two poorest quintiles had been raised to the level of the middle quintile, and 2) the health of the poorest four quintiles had been raised to the level of the top quintile. RESULTS: Thirty-seven percent of Winnipeg’s premature deaths, 22% of the heart attacks, 20% of the hip fractures and 15% of total expenditures on hospitals and physicians ($62 million in 1 999 dollars) could have been avoided if residents of the less wealthy 80% of neighbourhoods enjoyed health similar to those in the wealthiest neighbourhoods. CONCLUSION: The potential savings from reducing the socio-economic-related differences in health are high, whether they are measured in terms of morbidity or dollars. Research is needed to determine the extent to which these potential savings are achievable.