Universal coverage without universal access: a study of psychiatrist supply and practice patterns in Ontario.
Bibliographic record
Abstract
BACKGROUND: We studied the relationships among psychiatrist supply, practice patterns, and access to psychiatrists in Ontario Local Health Integration Networks (LHINs) with differing levels of psychiatrist supply. METHODS: We analyzed practice patterns of full-time psychiatrists (n = 1379) and postdischarge care to patients who had been admitted to hospital for psychiatric care, according to LHIN psychiatrist supply in 2009. We measured the characteristics of psychiatrists' patient panels, including sociodemographic characteristics, outpatient panel size, number of new patients, inpatient and outpatient visits per psychiatrist, and percentages of psychiatrists seeing fewer than 40 and fewer than 100 unique patients. Among patients admitted to hospital with schizophrenia, bipolar disorder, or major depression (n = 21,123), we measured rates of psychiatrist visits, readmissions, and visits to the emergency department within 30 and 180 days after discharge. RESULTS: Psychiatrist supply varied from 7.2 per 100 000 residents in LHINs with below-average supply to 62.7 per 100 000 in the Toronto Central LHIN. Population-based outpatient and inpatient visit rates and psychiatric admission rates increased with LHIN psychiatrist supply. However, as the supply of psychiatrists increased, outpatient panel size for full-time psychiatrists decreased, with Toronto psychiatrists having 58% smaller outpatient panels and seeing 57% fewer new outpatients relative to LHINs with the lowest psychiatrist supply. Similar patterns were found for inpatient practice. Moreover, as supply increased, annual outpatient visit frequency increased: the average visit frequency was 7 visits per outpatient for Toronto psychiatrists and 3.9 visits per outpatient in low-supply LHINs. One-quarter of Toronto psychiatrists and 2% of psychiatrists in the lowest-supply LHINs saw their outpatients more than 16 times per year. Of full-time psychiatrists in Toronto, 10% saw fewer than 40 unique patients and 40% saw fewer than 100 unique patients annually; the corresponding proportions were 4% and 10%, respectively, in the lowest-supply LHINs. Overall, follow-up visits after psychiatric discharge were low, with slightly higher rates in LHINs with a high psychiatrist supply. INTERPRETATION: Full-time psychiatrists who practised in Ontario LHINs with high psychiatrist supply saw fewer patients, but they saw those patients more frequently than was the case for psychiatrists in low-supply LHINs. Increasing the supply of psychiatrists while funding unlimited frequency and duration of psychotherapy care may not improve access for patients who need psychiatric services.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.003 |
| Meta-epidemiology (narrow) | 0.000 | 0.001 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.001 | 0.005 |
| Science and technology studies | 0.002 | 0.001 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".