The role of Psychiatric-physical multimorbidity and continuity of care in seniors’ medical emergency visits

The role of Psychiatric-physical multimorbidity and continuity of care in seniors’ medical emergency visits | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article The role of Psychiatric-physical multimorbidity and continuity of care in seniors’ medical emergency visits Jonathan Hunter, Paul Kurdyak, Arun Radhakrishnan, Hong Lu, Rachel Strauss, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6345887/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Multimorbidity contributes to complexity in seniors, but the impact of co-occurring physical and psychiatric illnesses on emergency department (ED) visits has received little attention. We investigated relationships between trans-diagnostic psychiatric severity, physical multimorbidity, and their interaction with non-psychiatric ED use; and tested the impact of continuity of primary care on these relationships. A retrospective cohort design (n = 2,560,986), measuring exposures to physical multimorbidity, psychiatric severity, and continuity in primary care. The main outcome was number of medical ED visits. At each level of physical multimorbidity, non-psychiatric ED visits increased with psychiatric severity. There were direct effects of physical multimorbidity (OR 1.35, 95%CI 1.35–1.35), psychiatric severity (OR 1.52, 95%CI 1.49–1.54), and continuity of care (low vs high OR 1.26, 95%CI 1.24–1.28) on frequent non-psychiatric ED use. Continuity of care did not mediate the relationships of physical multimorbidity, psychiatric severity or their interaction on frequent non-medical ED use. Transdiagnostic psychiatric severity contributes to seniors using the ED for non-psychiatric reasons, especially for repeated visits, in addition to the expected contribution of physical multimorbidity. Continuity of primary care does not mediate this relationship. Understanding the contribution of regular primary care requires further investigation. Health sciences/Health care/Geriatrics Health sciences/Health care Health sciences/Health care/Health policy Figures Figure 1 INTRODUCTION The co-occurrence of multiple chronic medical conditions is a common source of complexity in healthcare which challenges “evidence-based medicine's dominant focus on single-conditions” ( 1 ) and is associated with markedly lower quality of life ( 2 ). It is the norm in seniors. For example, an observational study of primary care centres found that the prevalence of multimorbidity rose from 13% in those aged 15–44 years to 67% in those 65 or older ( 3 ). Multimorbidity is also consistently correlated with lower socioeconomic status ( 4 ). Psychiatric disorders occurring in addition to physical disorders may be a special case of multimorbidity. The more physical diseases a person has, the more likely they are to also have a psychiatric disorder ( 5 ). Furthermore, the combination of psychiatric disorder and physical multimorbidity (which we term psychiatric-physical multimorbidity) may have a greater impact on outcomes that include distress and healthcare utilization than physical multimorbidity alone ( 6 , 7 ), although this combination has received less study than physical multimorbidity alone. There is little evidence on how to effectively manage the complexity that results from multimorbidity. Commentators have advocated for a person-centered approach to medical care, which emphasizes partnership between professionals and patients, shared decision-making, and enhancing patient self-management ( 1 , 8 , 9 ). While person-centered care benefits from continuity of treatment relationships, often in primary care ( 10 ), there is little evidence regarding the impact of continuity of care in the context of multimorbidity, especially psychiatric-physical multimorbidity. We sought to understand the relationship between psychiatric-physical multimorbidity, continuity of primary care, and emergency department (ED) visits for non-psychiatric reasons in adults 65 years and older. Specifically, we aimed to determine the prevalence of trans-diagnostic levels of severity of psychiatric morbidity in seniors across levels of physical multimorbidity, and the relationship between each of these two types of exposure and frequency of medical ED visits. We hypothesized that as psychiatric severity increased, medical ED visits would increase across levels of physical multimorbidity. Furthermore, we aimed to test the contribution of continuity of primary care to medical ED use. We hypothesized that within each category of psychiatric and physical multimorbidity, individuals with continuity of care would have fewer ED visits than individuals without continuity of care. METHODS This study used a retrospective cohort design that included all Ontario residents 65 years and older as of January 1, 2019, conducted via the Institute for Clinical Evaluation Sciences. Individuals with an invalid health card number, invalid birth date, or invalid sex at birth were excluded because of an inability to link databases at the individual level or an inability to accurately determine age and/or sex. We excluded individuals over 105 years of age for fear of data inaccuracy. Finally, we excluded individuals who were not eligible for publicly funded health services in Ontario (Ontario Health Insurance Plan, OHIP) in the two years prior to January 1, 2019, because we were unable to characterize their prior health service utilization or psychiatric comorbidity. All individuals were followed until death, loss of OHIP eligibility, or December 31, 2019, whichever came first. The use of the data in this project is authorized under section 45 of Ontario’s Personal Health Information Protection Act (PHIPA) and does not require review by a Research Ethics Board. Databases The OHIP database was used to capture physician visits and comorbidity diagnoses captured in ambulatory settings. Outpatient physician visits consisted of any psychiatrist visit or a visit to a primary care physician with the following ICD9 diagnostic codes: 291–292, 295–299, 300–304, 306–307, 309, 311, 313–315, 897 − 902, 904 − 906, 909. The algorithm for mental health-related outpatient physician visits has previously been validated ( 11 ). The National Ambulatory Care Reporting System (NACRS) was used to identify our outcome of medical ED visits as well as capture both medical and psychiatric ED visits prior to the index date of January 1, 2019. Psychiatric ED visits were defined as those with a primary diagnosis involving an ICD10 code F06-F99 or a secondary diagnosis of ICD10 codes X60-X84, Y10-Y19, Y28 (intentional self-harm codes) and an ICD10 code of F06-F99 in any diagnostic fields. The Canadian Institute of Health Information Discharge Abstract Database (CIHI DAD) captured all medical hospitalizations and psychiatric hospitalizations that did not occur in psychiatric beds. Psychiatric hospitalizations in CIHI DAD were those with the same ICD10 codes as for psychiatric ED visits. The Ontario Mental Health Reporting System captured all psychiatric hospitalizations occurring in psychiatric hospital beds. Finally, we used the Census database to capture neighbourhood-level income for all individuals. Missing data accounted for a maximum of 0.9% in any category, suggesting that it is irrelevant for the analysis. Outcome Our outcome was the number of medical ED visits between January 1 and December 31, 2019. Medical ED visits were any ED visit that was not categorized as a psychiatric ED visit. Physical Multimorbidity We measured physical multimorbidity from the start of each of our databases used to capture such events (1991 for OHIP – outpatient events, 2003 for the NACRS – ED events, and 1988 for CIHI-DAD – medical hospitalizations). For each individual, we counted the number of lifetime chronic conditions from this list of 14 possible conditions, as has been developed for prior studies ( 12 ): Acute Myocardial Infarction, Arthritis (Excluding Rheumatoid Arthritis), Asthma, Cancer, Cardiac Arrhythmia, Chronic Coronary Syndrome, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Diabetes, Hypertension, Osteoporosis, Renal Failure, Rheumatoid Arthritis, Stroke (excluding TIA). This list did not include mental health (MH) or addiction conditions or dementia, as these diagnoses were captured in our psychiatric multimorbidity exposure (see below). Individuals were then sorted into five categories by the number of lifetime physical conditions: zero, one, two, three, four or more. Trans-diagnostic Severity of Psychiatric Conditions We captured MH treatment events in the two years prior to January 1, 2019 for all individuals. We restricted the observation to two years to ensure that the psychiatric comorbidity was current; this was based on an understanding that psychiatric conditions can be episodic – e.g., a depressive episode that occurred ten years prior may not be relevant as a psychiatric comorbidity. Psychiatric severity in the 2 years prior to January 1, 2019 was defined using a gradient with 4-levels: no psychiatric utilization; outpatient physician visits for MH-related care; ED visit for psychiatric care; and hospital admission for psychiatric care ( 13 ). Each individual was assigned only to the highest level of psychiatric utilization during their prior 2-year period, creating mutually exclusive categories of service use intensity. This psychiatric utilization intensity gradient was a proxy for psychiatric disease severity, with the assumption that, on average, individuals who have experienced psychiatric hospitalizations have a greater psychiatric illness severity than those with lower levels of psychiatric utilization intensity. Continuity of Care Continuity in primary care was measured for individuals who had at least three primary care visits during the two years prior to January 1, 2019, using the usual provider of care (UPC) index, defined as the fraction of an individual’s visits to the usual primary care physician out of all outpatient visits ( 14 ). Individuals were sorted into four categories: Low continuity of care ( 79.9% of visits to UPC); Unable to calculate (those who don’t meet criteria of > = 3 visits). Other characteristics Ascertained on the index date of January 1, 2019: Age, sex, urban/rural (community with population < 10,000), neighborhood income quintile (Q1 is lowest to Q5, highest). Analysis Descriptive analyses were used to compare proportions of characteristics across physical multimorbidity categories. We then evaluated the relationship between physical multimorbidity and number of non-psychiatric ED visits across the four psychiatric severity categories. For this analysis, we dichotomized psychiatric severity to low (no treatment or outpatient care only) or high (psychiatric ED visits or psychiatric hospitalization in the 2-year look-back period). Physical multimorbidity was measured as a count. We then conducted a logistic regression to measure the relationship between these exposures and non-psychiatric ED visits, dichotomized to low (< 3) or high (≥3) visits, adjusted for other variables (age, sex, UPC, and neighbourhood income quintile). We then conducted a regression that included the comorbidity-by-psychiatric severity interaction term to test whether the observed increase in ED visits across psychiatric severity categories within each physical multimorbidity categories was a statistically significant interaction effect. Finally, we conducted a mediation analysis to understand whether UPC mediated the association between physical comorbidity, psychiatric severity, or their interaction on frequent non-psychiatric ED visits. RESULTS On the index date, 2,560,986 people in Ontario aged 65 years or older met inclusion criteria. Of the 14 chronic physical conditions we considered 164,921 individuals (6.4%) had none, 324,529 (12.7%) had one, 509,556 (19.9%) had two, 555,279 (21.7%) had three, and 1,006,701 (39.3%) had four or more. During the 2-year lookback period, 2,298,999 (89.8%) had no identified MH event, 233,523 (9.1%) had at least 2 MH outpatient visits but no other event, 19,097 (0.7%) had a MH ED visit but no MH hospitalization, and 9,347 (0.4%) had a MH hospitalization. Baseline characteristics Baseline characteristics of the multimorbidity groups (Table 1 ), indicates that there is equal distribution of subjects across income quintile levels but the preponderance of subjects (87.2%) are urban living. There is a greater proportion of females and older persons as physical multimorbidity increases. The prevalence of MH treatment approximately triples from the lowest to the highest category of physical multimorbidity. For example, any MH treatment during the 2-year lookback increased stepwise with each multimorbidity category from 3.7% in those with no physical multimorbidity up to 12.9% in those with four or more chronic conditions. The most severe categories (MH emergency visit or hospitalization) increased from 0.5% in those with no physical multimorbidity up to 1.5% in those with four or more chronic conditions. The strongest trend regarding continuity of primary care concerns continuity being unmeasurable because of fewer than 3 outpatients visits, which occurs more frequently at lower levels of multimorbidity. Specifically, continuity is unmeasurable in 74.4% of individuals with no chronic conditions and decreases with rising multimorbidity, to a prevalence of 14.8% in individuals with four or more chronic conditions. The prevalence of high continuity increased in stepwise increments from those with no chronic conditions to those with four or more chronic conditions, whether measured as a proportion of all participants (which rises from 16.1–57.6%, as shown in Table 1 , supplemental data) or as a proportion of only those for whom continuity was measurable (which rises from 63.0–67.6%). Prevalence and frequency of medical ED visits by physical multimorbidity and severity of psychiatric illness. Figure 1 illustrates the associations of physical multi-morbidity and psychiatric illness severity with emergency department use for physical reasons over a 1-year period. Three trends are apparent. First, at any level of psychiatric severity, the use of the emergency department increases in a stepwise fashion with increasing level of physical multimorbidity. This stepwise trend appears steeper at lower levels of psychiatric severity, suggesting an interaction. Second, at any level of multimorbidity, the proportion of individuals visiting the emergency department for a non-psychiatric reason increases with increasing severity of psychiatric condition. For example, for individuals with no chronic physical conditions at least one emergency department visit for physical reasons was found in 12.9% of those receiving no psychiatric treatment, and rose stepwise with each category of psychiatric severity, as high as 65.7% in individuals who had had a psychiatric hospitalization. The corresponding prevalence rates for individuals in the highest category of multimorbidity rose from 54.4–88.4%. Third, the excess of emergency department visits that is related to severity of psychiatric illness is largely accounted for by individuals with three or more such emergency visits (observed visually as the increase in darkly shaded bar segments on the right-hand side of Fig. 1 ). Predictors of high emergency department use for medical indications Logistic regression analysis was used to assess the contributions of psychiatric severity, physical multimorbidity, and other variables to high emergency department use for medical conditions, set at three or more visits in one year (Table 2 ). For this analysis, psychiatric severity was dichotomized as low (none or MH outpatient visits only) vs. high (at least one MH ED visit and/or at least one MH hospitalization). The results show significant direct effects of psychiatric severity, physical multimorbidity, low income, and male sex on visiting the emergency department three or more times in one year for nonpsychiatric indications. The effect of age is statistically significant but very small. Including an interaction term for the interaction between physical comorbidity and psychiatric severity was significant (Table 3 ), suggesting that the increases in ED visits across psychiatric severity categories within each physical multimorbidity category are statistically significant. Continuity of primary care as a mediator of the relationship between psychiatric-physical multimorbidity and emergency department visits for non-psychiatric reasons Finally, a mediation analysis was conducted to determine if continuity of primary care mediates the relationship between psychiatric-physical multimorbidity and high ED use for medical indications. The results (Table 4 ) indicate that the percent of this relationship that is mediated is negligible. DISCUSSION This study finds that each of physical multimorbidity and psychiatric severity contribute to frequent non-psychiatric ED visits in seniors. Psychiatric severity and physical multimorbidity were strongly associated with each other. For example, the prevalence of severe psychiatric disorder was more than three times greater in those with four or more chronic physical conditions than in those with no chronic physical conditions, a relationship which is particularly important because high physical multimorbidity is very common in seniors. This relationship is similar to that found in a study of seniors in rural Australia, for whom psychological distress was higher among those with more physical conditions, and that psychological distress and non-psychiatric multimorbidity independently predicted emergency department use ( 7 ). Patients whose care is complex due to physical multimorbidity very often also experience psychiatric disorder which can contribute to repeated presentations ( 15 ). For patients with severe psychiatric disorder, the impact of mental health may be even greater than the impact of physical multimorbidity on their non-psychiatric ED use (as is apparent in Fig. 1 ) identifying them as a uniquely vulnerable segment of the population. The role of mental illness may be under-appreciated in these visits when the identified reason for care is non-psychiatric. For example, the contribution of depression or anxiety to weakness or pain may be overlooked. Furthermore, mental illness may impair a patient’s ability to manage the complex challenges of physical multimorbidity, leading to ED visits. Given that one in four seniors in Canada take more than ten medications ( 16 ), and that subjective difficulties with concentration and memory increase with multi-morbidity ( 17 ), the potential for mental illness to further challenge self-management and medication adherence is high. As well, the possibility of the individual being delirious due to an interplay of medical and psychiatric disease is high, and merits attention. Our hypothesis that within each category of psychiatric and physical multimorbidity, individuals with continuity of care would have fewer ED visits than individuals without continuity of care was not supported. There was no significant indirect effect of multimorbidity, psychiatric severity or their interaction through continuity of primary care to high medical ED use. Although continuity of care was greater in seniors with higher physical multimorbidity, within these strata continuity of care did not act as a mediator. As continuity of primary care does not mediate between these sources of complexity and medical ED use, effective solutions remain challenging. Increased awareness and assessment of psychiatric illness for elderly patients presenting frequently to the ED for non-psychiatric reasons is warranted. Novel pathways in the ED for evaluation and management of these patients, with an emphasis on both physical and psychiatric morbidity, should be considered. The inability to demonstrate mediation by continuity of care on the link between psychiatric-physical multimorbidity and ED use could be due to actual ineffectiveness of continuity of care on this outcome. The latter would be consistent with a pragmatic cluster-randomised trial of patient-centred strategies that reflected international consensus on best care for complex patients in primary care, which found no impact on patients’ quality of life ( 18 ). A meta-analysis of interventions to reduce a utilization marker of ineffective care for complex conditions (30-day readmission rates) indicated that more effective interventions were designed to augment patient capacity for self-care, had multiple components, and were delivered by teams of two or more providers ( 19 ), suggesting the need for more complex, team-based interventions. Alternatively the failure to demonstrate mediation could be due to limitations of the UPC measure of continuity, which does not assess quality of care or distinguish between care by teams or individual physicians, and requires at least 3 visits to the same clinician to calculate. In the future, it would be useful to extend this inquiry to younger patients, especially as Nicholson demonstrates that the highest proportion of patients in Canada with multimorbidity were younger than 65 ( 20 ), and patterns of healthcare utilization are substantially different in younger adults ( 21 ). This study is limited by its correlative nature and the definition of psychiatric comorbidity. We opted for a highly specific definition of that based on recent MH healthcare use. This measure likely underestimates the true burden of psychiatric comorbidity by excluding less recent markers of psychiatric illness and individuals with poor access to care. It is also likely biased towards more severe cases because it requires individuals to access care. Given the known challenges of access to mental health services, the prevalence of psychiatric severity is likely an underestimate. In summary this study demonstrates that severity of psychiatric illness contributes to repeated emergency department visits for non-psychiatric reasons in seniors with physical multimorbidity. We also found that low continuity of care contributes to frequent emergency department visits but higher continuity of care does not substantially reduce the impact of multimorbidity on that aspect of healthcare utilization. Emergency department teams focused on detection and response to the vulnerable multi-morbid elderly could address this issue.</p Declarations Author Contribution Study conceptualization: JH, RM, AR, PKData Acquisition: RS, AM, WYData Management and Analysis: PK, HL, RMData Interpretation: RM, PKManuscript preparation and revision: JH, RM, AR, PK Data Availability Data Availability Statement: The dataset from this study is held securely in coded form at ICES. The full dataset creation plan and underlying analytic code are available from the authors upon request, understanding that the computer programs may rely upon coding templates or macros that are unique to ICES and are therefore either inaccessible or may require modification. While legal data sharing agreements between ICES and data providers (e.g., healthcare organizations and government) prohibit ICES from making the dataset publicly available, access may be granted to those who meet pre-specified criteria for confidential access, available at www.ices.on.ca/DAS (email: [email protected] ). Access requests should be otherwise directed to [email protected] . References Sturmberg, J. P., Getz, L. O., Stange, K. C., Upshur, R. E. G. & Mercer, S. W. Beyond multimorbidity: What can we learn from complexity science? J. Eval Clin. Pract. 27 (5), 1187–1193 (2021). Li, J. et al. Patterns of multimorbidity and their association with health outcomes within Yorkshire, England: Baseline results from the Yorkshire Health Study. BMC Public Health [Internet]. 2016 Jul 27 [cited 2023 Dec 21];16(1):1–9. Available from: https://bmcpublichealth.biomedcentral.com/articles/ 10.1186/s12889-016-3335-z Prados-Torres, A. et al. Multimorbidity Patterns in Primary Care: Interactions among Chronic Diseases Using Factor Analysis. PLoS One [Internet]. Feb 29 [cited 2023 Dec 21];7(2):e32190. (2012). Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0032190 Violan, C. et al. Prevalence, Determinants and Patterns of Multimorbidity in Primary Care: A Systematic Review of Observational Studies. PLoS One [Internet]. Jul 21 [cited 2023 Dec 21];9(7):e102149. (2014). Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0102149 Barnett, K. et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: A cross-sectional study. The Lancet [Internet]. Jul 7 [cited 2023 Dec 21];380(9836):37–43. (2012). Available from: http://www.thelancet.com/article/S0140673612602402/fulltext Gaulin, M. et al. Combined impacts of multimorbidity and mental disorders on frequent emergency department visits: A retrospective cohort study in Quebec, Canada. Jul 2 [cited 2023 Dec 21];191(26):E724–32. (2019). Available from: https://www-cmaj-ca.myaccess.library.utoronto.ca/content/191/26/E724 Asante, D., Rio, J., Stanaway, F., Worley, P. & Isaac, V. Psychological distress, multimorbidity and health services among older adults in rural South Australia. J. Affect. Disord . 309 , 453–460 (2022). Wolf, A. et al. The realities of partnership in person-centred care: a qualitative interview study with patients and professionals. BMJ Open [Internet]. Jul 1 [cited 2023 Dec 21];7(7):e016491. (2017). Available from: https://bmjopen.bmj.com/content/7/7/e016491 Pearson-Stuttard, J., Ezzati, M. & Gregg, E. W. Multimorbidity—a defining challenge for health systems. Lancet Public Health [Internet]. 2019 Dec 1 [cited 2023 Dec 21];4(12):e599–600. Available from: http://www.thelancet.com/article/S2468266719302221/fulltext Aramrat, C. et al. Advancing multimorbidity management in primary care: a narrative review. Prim Health Care Res Dev [Internet]. 2022 Jul 1 [cited 2023 Dec 21];23:e36. Available from: https://www.cambridge.org/core/journals/primary-health-care-research-and-development/article/advancing-multimorbidity-management-in-primary-care-a-narrative-review/E7BFE7F00186A048AB876FF6C600DFD6 Using Administrative Data to Measure Ambulatory Mental Health Service Provision. in Primary Care [Internet]. [cited 2024 May 13]. Available from: https://oce-ovid-com.myaccess.library.utoronto.ca/article/00005650-200410000-00004/HTML Pefoyo, A. J. et al. The increasing burden and complexity of multimorbidity. BMC Public Health [Internet]. 2015/04/24. ;15:415. (2015). Available from: https://www.ncbi.nlm.nih.gov/pubmed/25903064 Nguyen, L. et al. The impact of a cancer diagnosis on nonfatal self-injury: a matched cohort study in Ontario. Canadian Medical Association Open Access Journal [Internet]. 2023 Mar 1 [cited 2024 Apr 21];11(2):E291–7. Available from: https://www.cmajopen.ca/content/11/2/E291 Breslau, N. & Haug, M. R. Service Delivery Structure and Continuity of Care: A Case Study of a Pediatric Practice in Process of Reorganization. Source: Journal of Health and Social Behavior. ;17(4):339–52. (1976). Schäfer, I. et al. Multimorbidity Patterns in the Elderly: A New Approach of Disease Clustering Identifies Complex Interrelations between Chronic Conditions. PLoS One [Internet]. [cited 2024 Nov 18];5(12):e15941. (2010). Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0015941 Drug use among seniors in. Canada | CIHI [Internet]. [cited 2024 Feb 14]. Available from: https://www.cihi.ca/en/drug-use-among-seniors-in-canada Jacob, L., Haro, J. M. & Koyanagi, A. Physical multimorbidity and subjective cognitive complaints among adults in the United Kingdom: a cross-sectional community-based study. Scientific Reports. 9:1 [Internet]. 2019 Aug 27 [cited 2024 Feb 14];9(1):1–11. (2019). Available from: https://www.nature.com/articles/s41598-019-48894-8 Salisbury, C. et al. Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. The Lancet [Internet]. Jul 7 [cited 2024 Feb 14];392(10141):41–50. (2018). Available from: http://www.thelancet.com/article/S0140673618313084/fulltext Leppin, A. L. et al. Preventing 30-Day Hospital Readmissions: A Systematic Review and Meta-analysis of Randomized Trials. JAMA Intern Med [Internet]. Jul 1 [cited 2024 Feb 14];174(7):1095–107. (2014). Available from: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1868538 Nicholson, K. et al. Prevalence, characteristics, and patterns of patients with multimorbidity in primary care: a retrospective cohort analysis in Canada. British Journal of General Practice [Internet]. 2019 Sep 1 [cited 2024 Feb 14];69(686):e647–56. Available from: https://bjgp.org/content/69/686/e647. Kalseth, J. & Halvorsen, T. Health and care service utilisation and cost over the life-span: A descriptive analysis of population data. BMC Health Serv. Res. ; 20 (1). (2020). Tables Table 1. Baseline characteristics of Ontario seniors by level of non-psychiatric multimorbidity Physical multimorbidity (number of non-psychiatric chronic conditions) Zero N = 164,921 One N = 324,529 Two N = 509,556 Three N = 555,279 Four or more N = 1,006,701 Median (IQR) Median (IQR) Median (IQR) Median (IQR) Median (IQR) Age 70 (67-75) 70 (67-75) 71 (68-77) 73 (69-79) 76 (71-83) n % n % n % n % n % Sex Male 89,653 54.4 161,016 49.6 232,295 45.6 239,067 43.1 450,989 44.8 Female 75,268 45.6 163,513 50.4 277,261 54.4 316,212 56.9 555,712 55.2 Income Quintile 1 (lowest) 35,100 21.3 59,902 18.5 93,108 18.3 107,169 19.3 222,865 22.1 2 34,359 20.8 65,023 20.0 102,883 20.2 114,120 20.6 217,850 21.6 3 31,712 19.2 64,588 19.9 101,603 19.9 111,012 20.0 199,227 19.8 4 30,418 18.4 63,783 19.7 99,348 19.5 106,487 19.2 180,688 17.9 5 (highest) 32,750 19.9 70,315 21.7 111,241 21.8 115,036 20.7 183,146 18.2 Missing 582 0.4 918 0.3 1373 0.3 1,455 0.3 2,925 0.3 Size of Community Urban 143,748 87.2 278,284 85.8 439,868 86.3 484,491 87.3 889,805 88.4 Rural 20,660 12.5 45,437 14.0 68,466 13.4 69,507 12.5 114,292 12.8 Missing 513 0.3 808 .02 1,222 0.2 1281 0.2 2,604 0.3 UPC Continuity High 26,579 16.1 123,653 38.1 252,287 49.5 306,808 55.3 579,556 57.6 Moderate 10,498 6.4 42,985 13.2 83,759 16.4 97,252 17.5 178,417 17.7 Low 5,125 3.1 21,514 6.6 42,273 8.3 50,582 9.1 99,674 9.9 Cannot calculate (<3 visits) 122,719 74.4 136,377 42.0 131,237 25.8 100,637 18.1 149,054 14.8 Mental health category No event 158,856 96.3 302,157 93.1 464,118 91.1 469,919 89.5 876,949 87.1 2+ outpatient visits 5,199 3.2 19,855 6.1 40,849 8.0 52,714 9.5 114,896 11.4 MH ED visit 537 0.3 1,610 0.5 3,058 0.6 3,787 0.7 10,105 1.0 MH hospitalization 329 0.2 907 0.3 1,531 0.3 1,859 0.3 4,751 0.5 Any MH event 6,065 3.7 22,372 6.9 45,438 8.9 85,360 10.5 129,752 12.9 Table 2. Logistic regression testing direct effect of exposures on high non-psychiatric ED use (> 2 visits in one year). Odds Ratio Estimate 95% confidence limits p Lower Upper High psychiatric severity 1 1.52 1.49 1.54 <.0001 Number of comorbid physical conditions 1.35 1.35 1.35 <.0001 Male 1.13 1.12 1.15 <.0001 Age 1.03 1.03 1.03 <.0001 Income quintile: 1 (lowest) vs 5 (highest) 1.48 1.45 1.50 <.0001 Income quintile: 2 vs 5 1.26 1.24 1.29 <.0001 Income quintile: 3 vs 5 1.20 1.18 1.22 0.55 Income quintile: 4 vs 5 1.13 1.11 1.15 <.0001 1. High psychiatric severity is a binary variable: No mental health treatment or only outpatient treatment vs psychiatric ED visit or psychiatric hospitalization. Table 3. Logistic regression testing effect of the interaction between psychiatric severity and physical comorbidity on high non-psychiatric ED use (> 2 visits in one year). Parameter DF Estimate Standard Error Wald Chi-Square p Intercept 1 -6.34 0.029 47361.25 <.0001 High psychiatric severity (psych) 1 0.61 0.020 960.30 <.0001 Number of comorbid physical conditions (comorbid) 1 0.31 0.0017 33126.93 <.0001 Psych*comorbid 1 -0.04 0.004 117.73 <.0001 Male 1 0.13 0.0060 446.22 <.0001 Age 1 0.03 0.00038 6493.67 <.0001 Income quintile 1 1 0.20 0.0055 1369.62 <.0001 Income quintile 2 1 0.05 0.0057 66.55 <.0001 Income quintile 3 1 -0.004 0.0059 0.35 0.55 Income quintile 4 1 -0.06 0.0062 100.81 <.0001 Odds Ratio Estimates Effect Point Estimate 95% Wald Confidence Limits Low High Male 1.134 1.121 1.147 Age 1.031 1.031 1.032 Income quintile: 1 (lowest) vs 5 (highest) 1.476 1.449 1.503 Income quintile: 2 vs 5 1.26 1.237 1.284 Income quintile: 3 vs 5 1.199 1.176 1.222 Income quintile: 4 vs 5 1.13 1.108 1.153 Odds Ratio Odds Ratio Estimate 95% Confidence Limits Low High Comorbid at High psychiatric severity 1.302 1.292 1.311 Comorbid at Low psychiatric severity 1.359 1.355 1.364 Table 4. Continuity of primary care does not mediate between psychiatric-physical multimorbidity and emergency department visits for non-psychiatric reasons Direct Effect Indirect Effect Total Effect % mediated Comparison of Continuity (UPC) groups Estimate (95%CI) Estimate (95%CI) Estimate (95%CI) % (95% CI) Low vs. High 0.03 (0.03-0.03) 0.00 (0.00-0.00) 0.03 (0.03-0.03) 1.7 (1.5-1.9) Low vs. Moderate 0.04 (0.04-0.04) 0.00 (0.00-0.00) 0.04 (0.04-0.04) 0.6 (0.4-0.8) Moderate vs. High 0.03 (0.03-0.03) 0.00 (0.00-0.00) 0.03 (0.03-0.03) 0.4 (0.3-0.5) Additional Declarations No competing interests reported. Supplementary Files SupplementaldataMM.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 04 Nov, 2025 Reviews received at journal 25 Aug, 2025 Reviews received at journal 20 Aug, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers agreed at journal 09 Aug, 2025 Reviewers invited by journal 07 Aug, 2025 Editor assigned by journal 29 Jul, 2025 Editor invited by journal 05 May, 2025 Submission checks completed at journal 02 May, 2025 First submitted to journal 31 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6345887","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":498605936,"identity":"9b48e93a-9bdf-4606-81c5-2499439ca32e","order_by":0,"name":"Jonathan Hunter","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIie3PMUvDQBTA8RcOmuXV4HalxXyFl0URxH6VBNcKuggi1ILwXKJz/BhdSscrB2Y5O3co2BKwa4qTm2mrTh5xdLj/9ODej8cBuFz/MH8AIHajUBADIAF4yhvYifdFJEAj/iagJn8j22WAenL/oMQlz/tB27yXy/Fp58i/W+j1GMLAwrx0GosnfpOtx/ORTMwZHqfPpCYGokxZSNYj0WQtyTRHkLBAmsUV4epfdaRrsCgTvkV6XZVbElrI/s8VRJAJ6+oK7q6QhbTRkMapbmWmcViRHMn0LtQLy2hoIXt+GhV4pYMgFcX6g2+6lOfDxTWfhAcWsunXJ2nfd7lcLldtn5L9X+ObOuThAAAAAElFTkSuQmCC","orcid":"","institution":"University of Toronto, University of Toronto","correspondingAuthor":true,"prefix":"","firstName":"Jonathan","middleName":"","lastName":"Hunter","suffix":""},{"id":498605938,"identity":"bd6c0a10-f3a5-41ed-bf81-913f56fb994d","order_by":1,"name":"Paul Kurdyak","email":"","orcid":"","institution":"Institute for Clinical Evaluative Sciences","correspondingAuthor":false,"prefix":"","firstName":"Paul","middleName":"","lastName":"Kurdyak","suffix":""},{"id":498605939,"identity":"606ecdbe-3f9a-4a30-8e7f-f782da808e68","order_by":2,"name":"Arun Radhakrishnan","email":"","orcid":"","institution":"University of Ottawa","correspondingAuthor":false,"prefix":"","firstName":"Arun","middleName":"","lastName":"Radhakrishnan","suffix":""},{"id":498605941,"identity":"df1560f0-903b-49fc-9d7a-81beb70ef5c4","order_by":3,"name":"Hong Lu","email":"","orcid":"","institution":"Institute for Clinical Evaluative Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hong","middleName":"","lastName":"Lu","suffix":""},{"id":498605943,"identity":"bd5b7d0d-c9f8-4b03-922e-87f2ffbe3b30","order_by":4,"name":"Rachel Strauss","email":"","orcid":"","institution":"Institute for Clinical Evaluative Sciences","correspondingAuthor":false,"prefix":"","firstName":"Rachel","middleName":"","lastName":"Strauss","suffix":""},{"id":498605945,"identity":"6b1a9877-8fba-4891-833d-eeb82fc5f091","order_by":5,"name":"Andrea Mataruga","email":"","orcid":"","institution":"Institute for Clinical Evaluative Sciences","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Mataruga","suffix":""},{"id":498605946,"identity":"0142d7cc-aae9-4076-882b-d7fff8ee5d12","order_by":6,"name":"Winnie Yu","email":"","orcid":"","institution":"Institute for Clinical Evaluative Sciences","correspondingAuthor":false,"prefix":"","firstName":"Winnie","middleName":"","lastName":"Yu","suffix":""},{"id":498605948,"identity":"95a65e0d-0b77-4587-a1fa-60abf9d60a9d","order_by":7,"name":"Robert Maunder","email":"","orcid":"","institution":"University of Toronto, University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"Maunder","suffix":""}],"badges":[],"createdAt":"2025-03-31 14:53:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6345887/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6345887/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89019611,"identity":"91c95264-a421-4ba7-9423-079aa49f6678","added_by":"auto","created_at":"2025-08-13 19:48:45","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":68747,"visible":true,"origin":"","legend":"\u003cp\u003eAssociation of physical multimorbidity and psychiatric severity with prevalence and frequency of medical emergency department visits\u003c/p\u003e\n\u003cp\u003eNote. Medical emergency department visits are those with no identified psychiatric indication.\u003c/p\u003e\n\u003cp\u003eLevels of chronic illness multimorbidity are abbreviated as Chr Ill:0 (no lifetime non-psychiatric chronic illnesses); Chr Ill:1 (one lifetime non-psychiatric chronic illness); Chr Ill:2 (two lifetime non-psychiatric chronic illnesses); Chr Ill:3 (three lifetime non-psychiatric chronic illnesses); Chr Ill:4+ (four or more lifetime non-psychiatric chronic illnesses).\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6345887/v1/c07c3f01856bbb505055391d.jpg"},{"id":89020218,"identity":"435a4247-16ec-4bb2-af96-7a64737b6c20","added_by":"auto","created_at":"2025-08-13 20:04:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":971225,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6345887/v1/d20c910c-bf22-427f-bc14-7bf270866fb3.pdf"},{"id":89019613,"identity":"e8418b97-7227-419c-93d3-617f2d6020ec","added_by":"auto","created_at":"2025-08-13 19:48:45","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":14600,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaldataMM.docx","url":"https://assets-eu.researchsquare.com/files/rs-6345887/v1/e88eaf4fdff628a70d1318f0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The role of Psychiatric-physical multimorbidity and continuity of care in seniors’ medical emergency visits","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe co-occurrence of multiple chronic medical conditions is a common source of complexity in healthcare which challenges \u0026ldquo;evidence-based medicine's dominant focus on single-conditions\u0026rdquo; (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) and is associated with markedly lower quality of life (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). It is the norm in seniors. For example, an observational study of primary care centres found that the prevalence of multimorbidity rose from 13% in those aged 15\u0026ndash;44 years to 67% in those 65 or older (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Multimorbidity is also consistently correlated with lower socioeconomic status (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePsychiatric disorders occurring in addition to physical disorders may be a special case of multimorbidity. The more physical diseases a person has, the more likely they are to also have a psychiatric disorder (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Furthermore, the combination of psychiatric disorder and physical multimorbidity (which we term psychiatric-physical multimorbidity) may have a greater impact on outcomes that include distress and healthcare utilization than physical multimorbidity alone (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), although this combination has received less study than physical multimorbidity alone.\u003c/p\u003e\u003cp\u003eThere is little evidence on how to effectively manage the complexity that results from multimorbidity. Commentators have advocated for a person-centered approach to medical care, which emphasizes partnership between professionals and patients, shared decision-making, and enhancing patient self-management (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). While person-centered care benefits from continuity of treatment relationships, often in primary care (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), there is little evidence regarding the impact of continuity of care in the context of multimorbidity, especially psychiatric-physical multimorbidity.\u003c/p\u003e\u003cp\u003eWe sought to understand the relationship between psychiatric-physical multimorbidity, continuity of primary care, and emergency department (ED) visits for non-psychiatric reasons in adults 65 years and older. Specifically, we aimed to determine the prevalence of trans-diagnostic levels of severity of psychiatric morbidity in seniors across levels of physical multimorbidity, and the relationship between each of these two types of exposure and frequency of medical ED visits. We hypothesized that as psychiatric severity increased, medical ED visits would increase across levels of physical multimorbidity. Furthermore, we aimed to test the contribution of continuity of primary care to medical ED use. We hypothesized that within each category of psychiatric and physical multimorbidity, individuals with continuity of care would have fewer ED visits than individuals without continuity of care.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis study used a retrospective cohort design that included all Ontario residents 65 years and older as of January 1, 2019, conducted via the Institute for Clinical Evaluation Sciences. Individuals with an invalid health card number, invalid birth date, or invalid sex at birth were excluded because of an inability to link databases at the individual level or an inability to accurately determine age and/or sex. We excluded individuals over 105 years of age for fear of data inaccuracy. Finally, we excluded individuals who were not eligible for publicly funded health services in Ontario (Ontario Health Insurance Plan, OHIP) in the two years prior to January 1, 2019, because we were unable to characterize their prior health service utilization or psychiatric comorbidity. All individuals were followed until death, loss of OHIP eligibility, or December 31, 2019, whichever came first. The use of the data in this project is authorized under section 45 of Ontario\u0026rsquo;s Personal Health Information Protection Act (PHIPA) and does not require review by a Research Ethics Board.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eDatabases\u003c/h2\u003e\u003cp\u003eThe OHIP database was used to capture physician visits and comorbidity diagnoses captured in ambulatory settings. Outpatient physician visits consisted of any psychiatrist visit or a visit to a primary care physician with the following ICD9 diagnostic codes: 291\u0026ndash;292, 295\u0026ndash;299, 300\u0026ndash;304, 306\u0026ndash;307, 309, 311, 313\u0026ndash;315, 897\u0026thinsp;\u0026minus;\u0026thinsp;902, 904\u0026thinsp;\u0026minus;\u0026thinsp;906, 909. The algorithm for mental health-related outpatient physician visits has previously been validated (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The National Ambulatory Care Reporting System (NACRS) was used to identify our outcome of medical ED visits as well as capture both medical and psychiatric ED visits prior to the index date of January 1, 2019. Psychiatric ED visits were defined as those with a primary diagnosis involving an ICD10 code F06-F99 or a secondary diagnosis of ICD10 codes X60-X84, Y10-Y19, Y28 (intentional self-harm codes) and an ICD10 code of F06-F99 in any diagnostic fields. The Canadian Institute of Health Information Discharge Abstract Database (CIHI DAD) captured all medical hospitalizations and psychiatric hospitalizations that did not occur in psychiatric beds. Psychiatric hospitalizations in CIHI DAD were those with the same ICD10 codes as for psychiatric ED visits. The Ontario Mental Health Reporting System captured all psychiatric hospitalizations occurring in psychiatric hospital beds. Finally, we used the Census database to capture neighbourhood-level income for all individuals. Missing data accounted for a maximum of 0.9% in any category, suggesting that it is irrelevant for the analysis.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOutcome\u003c/h3\u003e\n\u003cp\u003eOur outcome was the number of medical ED visits between January 1 and December 31, 2019. Medical ED visits were any ED visit that was not categorized as a psychiatric ED visit.\u003c/p\u003e\n\u003ch3\u003ePhysical Multimorbidity\u003c/h3\u003e\n\u003cp\u003eWe measured physical multimorbidity from the start of each of our databases used to capture such events (1991 for OHIP \u0026ndash; outpatient events, 2003 for the NACRS \u0026ndash; ED events, and 1988 for CIHI-DAD \u0026ndash; medical hospitalizations). For each individual, we counted the number of lifetime chronic conditions from this list of 14 possible conditions, as has been developed for prior studies (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e): Acute Myocardial Infarction, Arthritis (Excluding Rheumatoid Arthritis), Asthma, Cancer, Cardiac Arrhythmia, Chronic Coronary Syndrome, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Diabetes, Hypertension, Osteoporosis, Renal Failure, Rheumatoid Arthritis, Stroke (excluding TIA). This list did not include mental health (MH) or addiction conditions or dementia, as these diagnoses were captured in our psychiatric multimorbidity exposure (see below). Individuals were then sorted into five categories by the number of lifetime physical conditions: zero, one, two, three, four or more.\u003c/p\u003e\n\u003ch3\u003eTrans-diagnostic Severity of Psychiatric Conditions\u003c/h3\u003e\n\u003cp\u003eWe captured MH treatment events in the two years prior to January 1, 2019 for all individuals. We restricted the observation to two years to ensure that the psychiatric comorbidity was current; this was based on an understanding that psychiatric conditions can be episodic \u0026ndash; e.g., a depressive episode that occurred ten years prior may not be relevant as a psychiatric comorbidity. Psychiatric severity in the 2 years prior to January 1, 2019 was defined using a gradient with 4-levels: no psychiatric utilization; outpatient physician visits for MH-related care; ED visit for psychiatric care; and hospital admission for psychiatric care (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Each individual was assigned only to the highest level of psychiatric utilization during their prior 2-year period, creating mutually exclusive categories of service use intensity. This psychiatric utilization intensity gradient was a proxy for psychiatric disease severity, with the assumption that, on average, individuals who have experienced psychiatric hospitalizations have a greater psychiatric illness severity than those with lower levels of psychiatric utilization intensity.\u003c/p\u003e\n\u003ch3\u003eContinuity of Care\u003c/h3\u003e\n\u003cp\u003eContinuity in primary care was measured for individuals who had at least three primary care visits during the two years prior to January 1, 2019, using the usual provider of care (UPC) index, defined as the fraction of an individual\u0026rsquo;s visits to the usual primary care physician out of all outpatient visits (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Individuals were sorted into four categories: Low continuity of care (\u0026lt;\u0026thinsp;50% of visits to UPC); Moderate continuity of care (50\u0026ndash;79.9% of visits to UPC); High continuity of care (\u0026gt;\u0026thinsp;79.9% of visits to UPC); Unable to calculate (those who don\u0026rsquo;t meet criteria of \u0026gt;\u0026thinsp;=\u0026thinsp;3 visits).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eOther characteristics\u003c/h2\u003e\u003cp\u003eAscertained on the index date of January 1, 2019: Age, sex, urban/rural (community with population\u0026thinsp;\u0026lt;\u0026thinsp;10,000), neighborhood income quintile (Q1 is lowest to Q5, highest).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003eDescriptive analyses were used to compare proportions of characteristics across physical multimorbidity categories. We then evaluated the relationship between physical multimorbidity and number of non-psychiatric ED visits across the four psychiatric severity categories. For this analysis, we dichotomized psychiatric severity to low (no treatment or outpatient care only) or high (psychiatric ED visits or psychiatric hospitalization in the 2-year look-back period). Physical multimorbidity was measured as a count. We then conducted a logistic regression to measure the relationship between these exposures and non-psychiatric ED visits, dichotomized to low (\u0026lt;\u0026thinsp;3) or high (\u0026ge;3) visits, adjusted for other variables (age, sex, UPC, and neighbourhood income quintile). We then conducted a regression that included the comorbidity-by-psychiatric severity interaction term to test whether the observed increase in ED visits across psychiatric severity categories within each physical multimorbidity categories was a statistically significant interaction effect. Finally, we conducted a mediation analysis to understand whether UPC mediated the association between physical comorbidity, psychiatric severity, or their interaction on frequent non-psychiatric ED visits.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eOn the index date, 2,560,986 people in Ontario aged 65 years or older met inclusion criteria. Of the 14 chronic physical conditions we considered 164,921 individuals (6.4%) had none, 324,529 (12.7%) had one, 509,556 (19.9%) had two, 555,279 (21.7%) had three, and 1,006,701 (39.3%) had four or more. During the 2-year lookback period, 2,298,999 (89.8%) had no identified MH event, 233,523 (9.1%) had at least 2 MH outpatient visits but no other event, 19,097 (0.7%) had a MH ED visit but no MH hospitalization, and 9,347 (0.4%) had a MH hospitalization.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eBaseline characteristics\u003c/h2\u003e\u003cp\u003eBaseline characteristics of the multimorbidity groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), indicates that there is equal distribution of subjects across income quintile levels but the preponderance of subjects (87.2%) are urban living. There is a greater proportion of females and older persons as physical multimorbidity increases. The prevalence of MH treatment approximately triples from the lowest to the highest category of physical multimorbidity. For example, any MH treatment during the 2-year lookback increased stepwise with each multimorbidity category from 3.7% in those with no physical multimorbidity up to 12.9% in those with four or more chronic conditions. The most severe categories (MH emergency visit or hospitalization) increased from 0.5% in those with no physical multimorbidity up to 1.5% in those with four or more chronic conditions.\u003c/p\u003e\u003cp\u003eThe strongest trend regarding continuity of primary care concerns continuity being unmeasurable because of fewer than 3 outpatients visits, which occurs more frequently at lower levels of multimorbidity. Specifically, continuity is unmeasurable in 74.4% of individuals with no chronic conditions and decreases with rising multimorbidity, to a prevalence of 14.8% in individuals with four or more chronic conditions. The prevalence of high continuity increased in stepwise increments from those with no chronic conditions to those with four or more chronic conditions, whether measured as a proportion of all participants (which rises from 16.1\u0026ndash;57.6%, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, supplemental data) or as a proportion of only those for whom continuity was measurable (which rises from 63.0\u0026ndash;67.6%).\u003c/p\u003e\u003cp\u003e\u003cb\u003ePrevalence and frequency of medical ED visits by physical multimorbidity and severity of psychiatric illness.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the associations of physical multi-morbidity and psychiatric illness severity with emergency department use for physical reasons over a 1-year period. Three trends are apparent. First, at any level of psychiatric severity, the use of the emergency department increases in a stepwise fashion with increasing level of physical multimorbidity. This stepwise trend appears steeper at lower levels of psychiatric severity, suggesting an interaction. Second, at any level of multimorbidity, the proportion of individuals visiting the emergency department for a non-psychiatric reason increases with increasing severity of psychiatric condition. For example, for individuals with no chronic physical conditions at least one emergency department visit for physical reasons was found in 12.9% of those receiving no psychiatric treatment, and rose stepwise with each category of psychiatric severity, as high as 65.7% in individuals who had had a psychiatric hospitalization. The corresponding prevalence rates for individuals in the highest category of multimorbidity rose from 54.4\u0026ndash;88.4%. Third, the excess of emergency department visits that is related to severity of psychiatric illness is largely accounted for by individuals with three or more such emergency visits (observed visually as the increase in darkly shaded bar segments on the right-hand side of Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003ePredictors of high emergency department use for medical indications\u003c/h2\u003e\u003cp\u003eLogistic regression analysis was used to assess the contributions of psychiatric severity, physical multimorbidity, and other variables to high emergency department use for medical conditions, set at three or more visits in one year (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). For this analysis, psychiatric severity was dichotomized as low (none or MH outpatient visits only) vs. high (at least one MH ED visit and/or at least one MH hospitalization). The results show significant direct effects of psychiatric severity, physical multimorbidity, low income, and male sex on visiting the emergency department three or more times in one year for nonpsychiatric indications. The effect of age is statistically significant but very small. Including an interaction term for the interaction between physical comorbidity and psychiatric severity was significant (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), suggesting that the increases in ED visits across psychiatric severity categories within each physical multimorbidity category are statistically significant.\u003c/p\u003e\u003cp\u003e\u003cb\u003eContinuity of primary care as a mediator of the relationship between psychiatric-physical multimorbidity and emergency department visits for non-psychiatric reasons\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFinally, a mediation analysis was conducted to determine if continuity of primary care mediates the relationship between psychiatric-physical multimorbidity and high ED use for medical indications. The results (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) indicate that the percent of this relationship that is mediated is negligible.\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study finds that each of physical multimorbidity and psychiatric severity contribute to frequent non-psychiatric ED visits in seniors. Psychiatric severity and physical multimorbidity were strongly associated with each other. For example, the prevalence of severe psychiatric disorder was more than three times greater in those with four or more chronic physical conditions than in those with no chronic physical conditions, a relationship which is particularly important because high physical multimorbidity is very common in seniors. This relationship is similar to that found in a study of seniors in rural Australia, for whom psychological distress was higher among those with more physical conditions, and that psychological distress and non-psychiatric multimorbidity independently predicted emergency department use (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePatients whose care is complex due to physical multimorbidity very often also experience psychiatric disorder which can contribute to repeated presentations (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). For patients with severe psychiatric disorder, the impact of mental health may be even greater than the impact of physical multimorbidity on their non-psychiatric ED use (as is apparent in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e) identifying them as a uniquely vulnerable segment of the population. The role of mental illness may be under-appreciated in these visits when the identified reason for care is non-psychiatric. For example, the contribution of depression or anxiety to weakness or pain may be overlooked. Furthermore, mental illness may impair a patient\u0026rsquo;s ability to manage the complex challenges of physical multimorbidity, leading to ED visits. Given that one in four seniors in Canada take more than ten medications (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), and that subjective difficulties with concentration and memory increase with multi-morbidity (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), the potential for mental illness to further challenge self-management and medication adherence is high. As well, the possibility of the individual being delirious due to an interplay of medical and psychiatric disease is high, and merits attention.\u003c/p\u003e\u003cp\u003eOur hypothesis that within each category of psychiatric and physical multimorbidity, individuals with continuity of care would have fewer ED visits than individuals without continuity of care was not supported. There was no significant indirect effect of multimorbidity, psychiatric severity or their interaction through continuity of primary care to high medical ED use. Although continuity of care was greater in seniors with higher physical multimorbidity, within these strata continuity of care did not act as a mediator.\u003c/p\u003e\u003cp\u003eAs continuity of primary care does not mediate between these sources of complexity and medical ED use, effective solutions remain challenging. Increased awareness and assessment of psychiatric illness for elderly patients presenting frequently to the ED for non-psychiatric reasons is warranted. Novel pathways in the ED for evaluation and management of these patients, with an emphasis on both physical and psychiatric morbidity, should be considered.\u003c/p\u003e\u003cp\u003eThe inability to demonstrate mediation by continuity of care on the link between psychiatric-physical multimorbidity and ED use could be due to actual ineffectiveness of continuity of care on this outcome. The latter would be consistent with a pragmatic cluster-randomised trial of patient-centred strategies that reflected international consensus on best care for complex patients in primary care, which found no impact on patients\u0026rsquo; quality of life (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). A meta-analysis of interventions to reduce a utilization marker of ineffective care for complex conditions (30-day readmission rates) indicated that more effective interventions were designed to augment patient capacity for self-care, had multiple components, and were delivered by teams of two or more providers (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), suggesting the need for more complex, team-based interventions. Alternatively the failure to demonstrate mediation could be due to limitations of the UPC measure of continuity, which does not assess quality of care or distinguish between care by teams or individual physicians, and requires at least 3 visits to the same clinician to calculate.\u003c/p\u003e\u003cp\u003eIn the future, it would be useful to extend this inquiry to younger patients, especially as Nicholson demonstrates that the highest proportion of patients in Canada with multimorbidity were younger than 65 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), and patterns of healthcare utilization are substantially different in younger adults (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study is limited by its correlative nature and the definition of psychiatric comorbidity. We opted for a highly specific definition of that based on recent MH healthcare use. This measure likely underestimates the true burden of psychiatric comorbidity by excluding less recent markers of psychiatric illness and individuals with poor access to care. It is also likely biased towards more severe cases because it requires individuals to access care. Given the known challenges of access to mental health services, the prevalence of psychiatric severity is likely an underestimate.\u003c/p\u003e\u003cp\u003eIn summary this study demonstrates that severity of psychiatric illness contributes to repeated emergency department visits for non-psychiatric reasons in seniors with physical multimorbidity. We also found that low continuity of care contributes to frequent emergency department visits but higher continuity of care does not substantially reduce the impact of multimorbidity on that aspect of healthcare utilization. Emergency department teams focused on detection and response to the vulnerable multi-morbid elderly could address this issue.\u003c/p\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eStudy conceptualization: JH, RM, AR, PKData Acquisition: RS, AM, WYData Management and Analysis: PK, HL, RMData Interpretation: RM, PKManuscript preparation and revision: JH, RM, AR, PK\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData Availability Statement: The dataset from this study is held securely in coded form at ICES. The full dataset creation plan and underlying analytic code are available from the authors upon request, understanding that the computer programs may rely upon coding templates or macros that are unique to ICES and are therefore either inaccessible or may require modification. While legal data sharing agreements between ICES and data providers (e.g., healthcare organizations and government) prohibit ICES from making the dataset publicly available, access may be granted to those who meet pre-specified criteria for confidential access, available at www.ices.on.ca/DAS (email: [email protected]). Access requests should be otherwise directed to [email protected].\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSturmberg, J. P., Getz, L. O., Stange, K. C., Upshur, R. E. G. \u0026amp; Mercer, S. W. Beyond multimorbidity: What can we learn from complexity science? \u003cem\u003eJ. Eval Clin. Pract.\u003c/em\u003e \u003cb\u003e27\u003c/b\u003e (5), 1187\u0026ndash;1193 (2021).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi, J. et al. Patterns of multimorbidity and their association with health outcomes within Yorkshire, England: Baseline results from the Yorkshire Health Study. BMC Public Health [Internet]. 2016 Jul 27 [cited 2023 Dec 21];16(1):1\u0026ndash;9. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://bmcpublichealth.biomedcentral.com/articles/\u003c/span\u003e\u003cspan address=\"https://bmcpublichealth.biomedcentral.com/articles/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12889-016-3335-z\u003c/span\u003e\u003cspan address=\"10.1186/s12889-016-3335-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePrados-Torres, A. et al. Multimorbidity Patterns in Primary Care: Interactions among Chronic Diseases Using Factor Analysis. PLoS One [Internet]. Feb 29 [cited 2023 Dec 21];7(2):e32190. (2012). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://journals.plos.org/plosone/article?id=10.1371/journal.pone.0032190\u003c/span\u003e\u003cspan address=\"https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0032190\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eViolan, C. et al. Prevalence, Determinants and Patterns of Multimorbidity in Primary Care: A Systematic Review of Observational Studies. PLoS One [Internet]. Jul 21 [cited 2023 Dec 21];9(7):e102149. (2014). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://journals.plos.org/plosone/article?id=10.1371/journal.pone.0102149\u003c/span\u003e\u003cspan address=\"https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0102149\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBarnett, K. et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: A cross-sectional study. The Lancet [Internet]. Jul 7 [cited 2023 Dec 21];380(9836):37\u0026ndash;43. (2012). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.thelancet.com/article/S0140673612602402/fulltext\u003c/span\u003e\u003cspan address=\"http://www.thelancet.com/article/S0140673612602402/fulltext\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGaulin, M. et al. Combined impacts of multimorbidity and mental disorders on frequent emergency department visits: A retrospective cohort study in Quebec, Canada. Jul 2 [cited 2023 Dec 21];191(26):E724\u0026ndash;32. (2019). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www-cmaj-ca.myaccess.library.utoronto.ca/content/191/26/E724\u003c/span\u003e\u003cspan address=\"https://www-cmaj-ca.myaccess.library.utoronto.ca/content/191/26/E724\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAsante, D., Rio, J., Stanaway, F., Worley, P. \u0026amp; Isaac, V. Psychological distress, multimorbidity and health services among older adults in rural South Australia. \u003cem\u003eJ. Affect. Disord\u003c/em\u003e. \u003cb\u003e309\u003c/b\u003e, 453\u0026ndash;460 (2022).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWolf, A. et al. The realities of partnership in person-centred care: a qualitative interview study with patients and professionals. BMJ Open [Internet]. Jul 1 [cited 2023 Dec 21];7(7):e016491. (2017). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://bmjopen.bmj.com/content/7/7/e016491\u003c/span\u003e\u003cspan address=\"https://bmjopen.bmj.com/content/7/7/e016491\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePearson-Stuttard, J., Ezzati, M. \u0026amp; Gregg, E. W. Multimorbidity\u0026mdash;a defining challenge for health systems. Lancet Public Health [Internet]. 2019 Dec 1 [cited 2023 Dec 21];4(12):e599\u0026ndash;600. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.thelancet.com/article/S2468266719302221/fulltext\u003c/span\u003e\u003cspan address=\"http://www.thelancet.com/article/S2468266719302221/fulltext\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAramrat, C. et al. Advancing multimorbidity management in primary care: a narrative review. Prim Health Care Res Dev [Internet]. 2022 Jul 1 [cited 2023 Dec 21];23:e36. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cambridge.org/core/journals/primary-health-care-research-and-development/article/advancing-multimorbidity-management-in-primary-care-a-narrative-review/E7BFE7F00186A048AB876FF6C600DFD6\u003c/span\u003e\u003cspan address=\"https://www.cambridge.org/core/journals/primary-health-care-research-and-development/article/advancing-multimorbidity-management-in-primary-care-a-narrative-review/E7BFE7F00186A048AB876FF6C600DFD6\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUsing Administrative Data to Measure Ambulatory Mental Health Service Provision. in Primary Care [Internet]. [cited 2024 May 13]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://oce-ovid-com.myaccess.library.utoronto.ca/article/00005650-200410000-00004/HTML\u003c/span\u003e\u003cspan address=\"https://oce-ovid-com.myaccess.library.utoronto.ca/article/00005650-200410000-00004/HTML\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePefoyo, A. J. et al. The increasing burden and complexity of multimorbidity. BMC Public Health [Internet]. 2015/04/24. ;15:415. (2015). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pubmed/25903064\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pubmed/25903064\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNguyen, L. et al. The impact of a cancer diagnosis on nonfatal self-injury: a matched cohort study in Ontario. Canadian Medical Association Open Access Journal [Internet]. 2023 Mar 1 [cited 2024 Apr 21];11(2):E291\u0026ndash;7. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cmajopen.ca/content/11/2/E291\u003c/span\u003e\u003cspan address=\"https://www.cmajopen.ca/content/11/2/E291\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBreslau, N. \u0026amp; Haug, M. R. Service Delivery Structure and Continuity of Care: A Case Study of a Pediatric Practice in Process of Reorganization. Source: Journal of Health and Social Behavior. ;17(4):339\u0026ndash;52. (1976).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSch\u0026auml;fer, I. et al. Multimorbidity Patterns in the Elderly: A New Approach of Disease Clustering Identifies Complex Interrelations between Chronic Conditions. PLoS One [Internet]. [cited 2024 Nov 18];5(12):e15941. (2010). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://journals.plos.org/plosone/article?id=10.1371/journal.pone.0015941\u003c/span\u003e\u003cspan address=\"https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0015941\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDrug use among seniors in. Canada | CIHI [Internet]. [cited 2024 Feb 14]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cihi.ca/en/drug-use-among-seniors-in-canada\u003c/span\u003e\u003cspan address=\"https://www.cihi.ca/en/drug-use-among-seniors-in-canada\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJacob, L., Haro, J. M. \u0026amp; Koyanagi, A. Physical multimorbidity and subjective cognitive complaints among adults in the United Kingdom: a cross-sectional community-based study. Scientific Reports. 9:1 [Internet]. 2019 Aug 27 [cited 2024 Feb 14];9(1):1\u0026ndash;11. (2019). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nature.com/articles/s41598-019-48894-8\u003c/span\u003e\u003cspan address=\"https://www.nature.com/articles/s41598-019-48894-8\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalisbury, C. et al. Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. The Lancet [Internet]. Jul 7 [cited 2024 Feb 14];392(10141):41\u0026ndash;50. (2018). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.thelancet.com/article/S0140673618313084/fulltext\u003c/span\u003e\u003cspan address=\"http://www.thelancet.com/article/S0140673618313084/fulltext\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLeppin, A. L. et al. Preventing 30-Day Hospital Readmissions: A Systematic Review and Meta-analysis of Randomized Trials. JAMA Intern Med [Internet]. Jul 1 [cited 2024 Feb 14];174(7):1095\u0026ndash;107. (2014). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1868538\u003c/span\u003e\u003cspan address=\"https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1868538\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNicholson, K. et al. Prevalence, characteristics, and patterns of patients with multimorbidity in primary care: a retrospective cohort analysis in Canada. British Journal of General Practice [Internet]. 2019 Sep 1 [cited 2024 Feb 14];69(686):e647\u0026ndash;56. Available from: https://bjgp.org/content/69/686/e647.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKalseth, J. \u0026amp; Halvorsen, T. Health and care service utilisation and cost over the life-span: A descriptive analysis of population data. \u003cem\u003eBMC Health Serv. Res.\u003c/em\u003e ;\u003cb\u003e20\u003c/b\u003e(1). (2020).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Baseline characteristics of Ontario seniors by level of non-psychiatric multimorbidity\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 468px;\"\u003e\n \u003cp\u003ePhysical multimorbidity\u003c/p\u003e\n \u003cp\u003e(number of non-psychiatric chronic conditions)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eZero\u003c/p\u003e\n \u003cp\u003eN = 164,921\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eOne\u003c/p\u003e\n \u003cp\u003eN = 324,529\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eTwo\u003c/p\u003e\n \u003cp\u003eN = 509,556\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eThree\u003c/p\u003e\n \u003cp\u003eN = 555,279\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eFour or more\u003c/p\u003e\n \u003cp\u003eN = 1,006,701\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e70 (67-75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e70 (67-75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e71 (68-77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e73 (69-79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e76 (71-83)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e89,653\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e54.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e161,016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e49.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e232,295\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e45.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e239,067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e43.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e450,989\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e44.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e75,268\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e45.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e163,513\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e50.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e277,261\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e54.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e316,212\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e56.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e555,712\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e55.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eIncome Quintile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1 (lowest)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e35,100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e21.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e59,902\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e18.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e93,108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e18.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e107,169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e19.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e222,865\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e22.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e34,359\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e20.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e65,023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e102,883\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e20.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e114,120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e20.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e217,850\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e21.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e31,712\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e19.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e64,588\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e19.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e101,603\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e19.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e111,012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e199,227\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e19.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e30,418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e18.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e63,783\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e19.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e99,348\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e19.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e106,487\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e19.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e180,688\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e17.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e5 (highest)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e32,750\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e19.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e70,315\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e21.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e111,241\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e21.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e115,036\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e20.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e183,146\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e18.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e582\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e918\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1373\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1,455\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2,925\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eSize of Community\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e143,748\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e87.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e278,284\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e85.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e439,868\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e86.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e484,491\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e87.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e889,805\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e88.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e20,660\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e45,437\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e14.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e68,466\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e13.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e69,507\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e114,292\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e12.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e513\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e808\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1,222\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1281\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2,604\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eUPC Continuity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e26,579\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e16.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e123,653\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e38.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e252,287\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e49.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e306,808\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e55.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e579,556\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e57.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e10,498\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e42,985\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e83,759\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e16.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e97,252\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e17.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e178,417\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e17.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e5,125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e21,514\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e42,273\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e50,582\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e99,674\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e9.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eCannot calculate (\u0026lt;3 visits)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e122,719\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e74.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e136,377\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e42.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e131,237\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e25.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e100,637\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e18.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e149,054\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e14.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eMental health category\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eNo event\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e158,856\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e96.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e302,157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e93.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e464,118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e91.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e469,919\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e89.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e876,949\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e87.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e2+ outpatient visits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e5,199\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e19,855\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e40,849\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e52,714\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e114,896\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e11.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMH ED visit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e537\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1,610\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3,058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3,787\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e10,105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eMH hospitalization\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e329\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e907\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1,531\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1,859\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e4,751\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eAny MH event\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e6,065\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e22,372\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e6.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e45,438\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e85,360\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e129,752\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e12.9\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. Logistic regression testing direct effect of exposures on high non-psychiatric ED use (\u0026gt; 2 visits in one year).\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 133px;\"\u003e\n \u003cp\u003eOdds Ratio Estimate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 162px;\"\u003e\n \u003cp\u003e95% confidence limits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 274px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 133px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003eLower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003eUpper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 274px;\"\u003e\n \u003cp\u003eHigh psychiatric severity\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 133px;\"\u003e\n \u003cp\u003e1.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026lt;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 274px;\"\u003e\n \u003cp\u003eNumber of comorbid physical conditions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 133px;\"\u003e\n \u003cp\u003e1.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026lt;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 274px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 133px;\"\u003e\n \u003cp\u003e1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026lt;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 274px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 133px;\"\u003e\n \u003cp\u003e1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026lt;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 274px;\"\u003e\n \u003cp\u003eIncome quintile: 1 (lowest) vs 5 (highest)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 133px;\"\u003e\n \u003cp\u003e1.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026lt;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 274px;\"\u003e\n \u003cp\u003eIncome quintile: 2 vs 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 133px;\"\u003e\n \u003cp\u003e1.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026lt;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 274px;\"\u003e\n \u003cp\u003eIncome quintile: 3 vs 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 133px;\"\u003e\n \u003cp\u003e1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 274px;\"\u003e\n \u003cp\u003eIncome quintile: 4 vs 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 133px;\"\u003e\n \u003cp\u003e1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026lt;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e1. High psychiatric severity is a binary variable: No mental health treatment or only outpatient treatment vs psychiatric ED visit or psychiatric hospitalization.\u003c/p\u003e\n\u003cp\u003eTable 3. Logistic regression testing effect of the interaction between psychiatric severity and physical comorbidity on high non-psychiatric ED use (\u0026gt; 2 visits in one year).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEstimate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStandard Error\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWald\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eChi-Square\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 302px;\"\u003e\n \u003cp\u003eIntercept\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e-6.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e47361.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026lt;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 302px;\"\u003e\n \u003cp\u003eHigh psychiatric severity (psych)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e960.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026lt;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 302px;\"\u003e\n \u003cp\u003eNumber of comorbid physical conditions (comorbid)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0.0017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e33126.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026lt;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 302px;\"\u003e\n \u003cp\u003ePsych*comorbid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e-0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e117.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026lt;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 302px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0.0060\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e446.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026lt;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 302px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0.00038\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e6493.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026lt;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 302px;\"\u003e\n \u003cp\u003eIncome quintile 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0.0055\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e1369.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026lt;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 302px;\"\u003e\n \u003cp\u003eIncome quintile 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0.0057\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e66.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026lt;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 302px;\"\u003e\n \u003cp\u003eIncome quintile 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e-0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0.0059\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 302px;\"\u003e\n \u003cp\u003eIncome quintile 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e-0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0.0062\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e100.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026lt;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 623px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio Estimates\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEffect\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePoint Estimate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% Wald Confidence Limits\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e1.134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1.121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e1.147\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e1.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e1.032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003eIncome quintile: 1 (lowest) vs 5 (highest)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e1.476\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1.449\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e1.503\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003eIncome quintile: 2 vs 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e1.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1.237\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e1.284\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003eIncome quintile: 3 vs 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e1.199\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1.176\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e1.222\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003eIncome quintile: 4 vs 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1.108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e1.153\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio Estimate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% Confidence Limits\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003eComorbid at High psychiatric severity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e1.302\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1.292\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e1.311\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003eComorbid at Low psychiatric severity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e1.359\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1.355\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e1.364\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 4. Continuity of primary care does not mediate between psychiatric-physical multimorbidity and emergency department visits for non-psychiatric reasons\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eDirect Effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eIndirect Effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eTotal Effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e% mediated\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eComparison of Continuity (UPC) groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eEstimate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eEstimate\u003c/p\u003e\n \u003cp\u003e(95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eEstimate\u003c/p\u003e\n \u003cp\u003e(95%CI)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e%\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eLow vs. High\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.03\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.03-0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.00\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.00-0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003cp\u003e(0.03-0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1.7\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(1.5-1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eLow vs. Moderate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.04\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.04-0.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.00\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.00-0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003cp\u003e(0.04-0.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.6\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.4-0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eModerate vs. High\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.03\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.03-0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.00\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.00-0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.03\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.03-0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.4\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.3-0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6345887/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6345887/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMultimorbidity contributes to complexity in seniors, but the impact of co-occurring physical and psychiatric illnesses on emergency department (ED) visits has received little attention. We investigated relationships between trans-diagnostic psychiatric severity, physical multimorbidity, and their interaction with non-psychiatric ED use; and tested the impact of continuity of primary care on these relationships. A retrospective cohort design (n\u0026thinsp;=\u0026thinsp;2,560,986), measuring exposures to physical multimorbidity, psychiatric severity, and continuity in primary care. The main outcome was number of medical ED visits.\u003c/p\u003e\u003cp\u003eAt each level of physical multimorbidity, non-psychiatric ED visits increased with psychiatric severity. There were direct effects of physical multimorbidity (OR 1.35, 95%CI 1.35\u0026ndash;1.35), psychiatric severity (OR 1.52, 95%CI 1.49\u0026ndash;1.54), and continuity of care (low vs high OR 1.26, 95%CI 1.24\u0026ndash;1.28) on frequent non-psychiatric ED use. Continuity of care did not mediate the relationships of physical multimorbidity, psychiatric severity or their interaction on frequent non-medical ED use.\u003c/p\u003e\u003cp\u003eTransdiagnostic psychiatric severity contributes to seniors using the ED for non-psychiatric reasons, especially for repeated visits, in addition to the expected contribution of physical multimorbidity. Continuity of primary care does not mediate this relationship. Understanding the contribution of regular primary care requires further investigation.\u003c/p\u003e","manuscriptTitle":"The role of Psychiatric-physical multimorbidity and continuity of care in seniors’ medical emergency visits","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-13 19:48:40","doi":"10.21203/rs.3.rs-6345887/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-04T20:48:29+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-25T08:12:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-20T17:39:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"109646995500240333117894661343650364317","date":"2025-08-14T05:26:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"103651821461459545547708593911166964779","date":"2025-08-09T19:57:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-07T17:46:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-29T05:31:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-06T02:28:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-02T13:31:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-03-31T14:42:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"724dbe19-3336-4220-8f60-cec727aeaa31","owner":[],"postedDate":"August 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":52952086,"name":"Health sciences/Health care/Geriatrics"},{"id":52952087,"name":"Health sciences/Health care"},{"id":52952088,"name":"Health sciences/Health care/Health policy"}],"tags":[],"updatedAt":"2026-02-17T17:38:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-13 19:48:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6345887","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6345887","identity":"rs-6345887","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}