- Open Access
Profiles of quality of outpatient care use, associated sociodemographic and clinical characteristics, and adverse outcomes among patients with substance-related disorders
Substance Abuse Treatment, Prevention, and Policy volume 18, Article number: 5 (2023)
This study identified patient profiles in terms of their quality of outpatient care use, associated sociodemographic and clinical characteristics, and adverse outcomes based on frequent emergency department (ED) use, hospitalization, and death from medical causes.
A cohort of 18,215 patients with substance-related disorders (SRD) recruited in addiction treatment centers was investigated using Quebec (Canada) health administrative databases. A latent class analysis was produced, identifying three profiles of quality of outpatient care use, while multinomial and logistic regressions tested associations with patient characteristics and adverse outcomes, respectively.
Profile 1 patients (47% of the sample), labeled “Low outpatient service users”, received low quality of care. They were mainly younger, materially and socially deprived men, some with a criminal history. They had more recent SRD, mainly polysubstance, and less mental disorders (MD) and chronic physical illnesses than other Profiles. Profile 2 patients (36%), labeled “Moderate outpatient service users”, received high continuity and intensity of care by general practitioners (GP), while the diversity and regularity in their overall quality of outpatient service was moderate. Compared with Profile 1, they were older, less likely to be unemployed or to live in semi-urban areas, and most had common MD and chronic physical illnesses. Profile 3 patients (17%), labeled “High outpatient service users”, received more intensive psychiatric care and higher quality of outpatient care than other Profiles. Most Profile 3 patients lived alone or were single parents, and fewer lived in rural areas or had a history of homelessness, versus Profile 1 patients. They were strongly affected by MD, mostly serious MD and personality disorders. Compared with Profile 1, Profile 3 had more frequent ED use and hospitalizations, followed by Profile 2. No differences in death rates emerged among the profiles.
Frequent ED use and hospitalization were strongly related to patient clinical and sociodemographic profiles, and the quality of outpatient services received to the severity of their conditions. Outreach strategies more responsive to patient needs may include motivational interventions and prevention of risky behaviors for Profile 1 patients, collaborative GP-psychiatrist care for Profile 2 patients, and GP care and intensive specialized treatment for Profile 3 patients.
Patients with substance-related disorders (SRD), including substance-induced or substance use disorders, substance intoxication or withdrawal, are known to use acute care frequently [1, 2]. A 2014–18 US study reported that 9.4% of annual emergency department (ED) use and 11.9% of hospitalizations were related to substance use disorders . ED use by patients with SRD may be related to intoxication, overdose, withdrawal, or associated health conditions . Frequent ED use and hospitalizations are costly, and are key indicators of adverse outcomes , often indicating lack of appropriate outpatient care as well . More intensive and continuous outpatient care by various health professionals is usually required for patients affected by multimorbidity . Patients with SRD are often affected by co-occurring chronic physical illnesses and mental disorders (MD), increasing the risk of acute care use  and premature death . SRD also increases the risk of death by accident, suicide, or homicide [10, 11]. Yet, high quality of care, defined as higher SRD treatment frequency  and overall continuity of care [12, 13], reportedly decrease ED use and hospitalizations among patients with SRD. SRD treatment completion is also linked to improved health conditions and lower risk of death . Strengthening the quality of outpatient care and treatment adherence in response to the needs of patients with SRD and co-occurring disorders are thus key issues. Identifying profiles of patients with SRD based on the quality of outpatient care received may support the formulation of strategies adapted to each specific profile, to reduce risks of frequent ED use, hospitalizations, and death.
Few studies have elaborated profiles of outpatient service use among patients with SRD [15,16,17,18,19]. These studies mostly assessed the types of services patients used, comparing in hospital settings profiles of patients with higher use of SRD, MD or other programs [15, 17], or main SRD treatment (e.g., Alcoholics Anonymous) , principal clinicians consulted (e.g., psychiatrist, psychologist) [16, 18, 19], or outpatient versus acute care used [15, 18]. Most studies included patients with SRD in general [15, 17, 18], whereas a few focused on MD-SRD  or alcohol-related disorders only . Some studies investigated the evolution of service use profiles according to age  over a three- to eight-year period, leading to treatment disengagement  or reduced alcohol use . Profiles related to low [15, 18, 19] and multiple [16, 19] service users have been identified, as well as profiles of patients using mainly Alcoholics Anonymous , psychiatric services [15, 17,18,19] or general practitioners (GP) . Most studies have linked patient service use profiles to their sociodemographic and clinical characteristics, with MD as the main associated clinical variable tested. Most profiles of low service users have consisted of men and younger patients , whereas profiles showing more GP use included more women and older patients . More multiple service users had several SRD or MD . Profiles of patients who used mainly psychiatric services included more patients with co-occurring SRD and serious MD .
Previous typologies have rarely integrated quality of care indicators and considered a limited number of services used by patients with SRD in only one or few settings. Patients using addiction treatment centers or specialized SRD care, who often present complex health issues and poor social conditions , may experience reduced adverse outcomes if given intensive diversified services along with high regularity and continuity of care. As well, patients with SRD often require multiple episodes of care as treatment adherence is a key issue for them, affecting their recovery. Yet no typology to date has linked profiles of outpatient service use with acute care use and risk of death. Identifying such profiles may help improve services and patient conditions, especially if associated with sociodemographic and clinical patient characteristics, which also remain insufficiently investigated. This study thus seeks to identify outpatient service use profiles among patients with SRD recruited in addiction treatment centers, based on quality-of-care indicators, and linked the profiles with sociodemographic and clinical characteristics, and the adverse outcomes associated with frequent ED use, hospitalization, or death.
The province of Quebec (Canada) has a public healthcare system. Specialized public SRD services are provided by addiction treatment centers, treating roughly 10% of the most vulnerable SRD populations . These centers offer SRD programs like detoxification, opioid agonist treatment and rehabilitation, and include brief intervention units accessible through self-referral, referral from primary care services, or court order. They complement primary care services, including care provided by GP, most of whom work in family medicine groups, or psychosocial teams operating in community healthcare centers. Family medicine groups integrating clinicians like nurses and social workers require patient registration and provide extended medical coverage to ensure better continuity of care.
Study sample, sources, and design
Data were taken from a cohort of 18,697 patients with SRD who used one of 14 Quebec addiction treatment centers (of 16, in total) from April 1, 2012 to March 31, 2013. Administrative data on these patients had to be available in the databases of these centers (SIC-SRD) for the financial years 2009–10 to 2015–16. Patients also had to be Quebec residents, 12+ years old, and eligible for the Quebec Health Insurance Plan (Régie de l’assurance maladie du Québec, RAMQ) between 1996–97 and 2015–16. Patients were excluded if they were hospitalized > 90 days in 2014–15, which would have hindered the assessment of outpatient quality of care, or if they died between 2012–13 and 2014–15. Data from addiction treatment centers included patient sociodemographic characteristics, type of SRD, and services received in these centers. The RAMQ keeps billing data for most physician services, excluding 6% occurring outside the public system  and integrates various sub-databases: e.g., on ED use, hospitalization, psychosocial interventions in community healthcare centers, and death records. The data from all databases were merged for each patient and each year using a unique RAMQ identifier matched with the SIC-SRD database. Figure 1, the analytical framework for the study, identifies databases linked to each study variable, including the timeframe for their measurement. RAMQ diagnostic codes were framed by the International Classification of Diseases, Ninth and Tenth Revisions (Appendix 1). The SIC-SRD integrated standardized instruments which measured the presence of SRD (yes/no), based on the Addiction Severity Index [22, 23] or the Global Appraisal of Individual Needs .
Profiles of patients with SRD were created based on their outpatient service use in 2014–15, except for percentages of dropouts from any SRD programs in addiction treatment centers measured from 2009–10 to 2014–15. Patient sociodemographic characteristics were measured in 2014–15 or in the last year for which data were available, excluding criminal history or history of homelessness, which were measured from 2009–10 to 2014–15. Patient clinical characteristics were measured from 2012–13 to 2014–15, except for number of years with SRD, which was measured from 1996–97 to 2014–15. Adverse outcomes were measured in 2015–16. The Quebec Commission for Access to Information granted access to the databases without requiring informed consent from patients. The ethics review board of a health and social service organization approved the study protocol.
Outpatient service use characteristics included: having a usual outpatient physician and frequency of patient consultations with this physician; high continuity of physician care; frequency of psychosocial interventions received in community healthcare centers or from any SRD service in addiction treatment centers; percentage of patient dropouts from any SRD programs in addiction treatment centers; and regularity of outpatient care. “Usual GP”, a proxy for family doctor, was defined as having at least two consultations with the same GP, or with at least two GP working in the same family medicine group. “Usual psychiatrist” was also defined by a minimum of two consultations, or only one if the patient had also consulted a usual GP, which was considered a proxy for collaborative care . Minimal acceptable intensity of care was defined as receiving 4+ consultations or interventions/year [26,27,28]. Continuity of physician care was measured with the Usual Provider Continuity Index, which describes the proportion of consultations with the usual GP or psychiatrist, of all GP and psychiatrists consulted in outpatient care, including in walk-in clinics; a score of ≥0.80 is considered high continuity of care . SRD treatment dropout referred to any episode of SRD treatment, as registered in the databases of addiction treatment centers. Regularity of outpatient care was measured considering all outpatient providers in the study and expressed as the number of 3-month periods during which patients used at least one outpatient service. Outpatient service use thus included five quality of care measurements: diversity (biopsychosocial services), intensity, continuity and regularity of service use, and adhesion to SRD services.
Sociodemographic characteristics included: sex, age group, living alone or as a single parent, occupation (work or study, unemployed, retired), living in more materially and socially deprived areas, type of residential area (e.g., urban), criminal history, and history of homelessness. Based on the smallest dissemination areas corresponding to zip codes used in the 2011 Canadian census, the Material Deprivation Index integrated ratios for population employment, average income, and education levels lower than high school. The Social Deprivation Index was used to estimate the proportion of patients living alone, patients with single civil status, and single-parent families . Data taken from both indexes were classified in quintiles, then regrouped as less deprived (1–2-3) or more deprived areas (4–5, or not assigned: e.g., nursing home residents, homeless individuals).
Clinical characteristics included: type of SRD, number of years with SRD, principal MD, and chronic physical illnesses. Type of SRD included exclusive groups of disorders related to alcohol only, drugs only, and polysubstance use. Also referring to exclusive groups, principal MD included serious MD (schizophrenia spectrum and other psychotic disorders, bipolar disorders), personality disorders, and common MD (e.g., anxiety, depressive and adjustment disorders), in that order.
Adverse outcomes included frequent ED use and hospitalizations for any medical reason, and death from any medical cause. Frequent ED use was defined as 3+ visits/year, a standard designation for this variable [7, 31].
Latent class analysis (LCA) [32, 33] was used to identify patient profiles based on quality of outpatient service use. Compared to standard cluster analysis with an arbitrarily chosen distance measure, LCA allows for statistical testing of model fit with membership probabilities computed from the estimated model parameters . The optimal number of latent classes was determined during the initial step of the analyses, where a serie of increasingly complex models (adding classes) was estimated. In relation to the pertinence of clinical results observed, Akaike Information Criteria (AIC) , Bayesian Information Criteria (BIC)  and the entropy value  were used for selecting the final analytical classification model. Associations between latent class memberships, patient sociodemographic and clinical characteristics were then tested using bivariate analyses (chi-squared tests adjusted with the Holm-Bonferroni method) and a multivariate multinomial logistic regression. As a final step, relationships between class memberships and adverse outcomes were tested using logistic regressions, adjusted for age and sex. LCA was performed with SAS 9.4 , and other analyses using Stata 17 .
Of the initial 18,697-member cohort, 115 patients hospitalized 91+ days in 2014–15 were excluded, as were 367 who died between 2012-13 and 2014–15. Of 18,215 patients studied, 65% were men, 45% were 25–44 years old, 46% lived alone or were single parents, 54% were unemployed, while 56% lived in more materially deprived areas and 62% in more socially deprived areas (Table 1). Some patients had a criminal history (19%) or a history of homelessness (13%). Nearly half of patients (49%) had polysubstance-related disorders, while 55% had SRD for more than 2 years. Most patients (69%) had MD, 37% of which were mainly common MD and 22% serious MD, while 37% of patients had chronic physical illnesses. Almost half of patients (47%) had no usual physician. A minority of them received intensive care (4+ consultations/year) with their usual GP (23%) or psychiatrist (10%), or with psychosocial clinicians in either community healthcare centers (20%) or in addiction treatment centers (21%). A minority of patients (44%) received high continuity of physician care; 43% had high rates of treatment dropout from addiction treatment centers; and 30% received high regularity of outpatient care. At 12-month follow-up, 18% were found to be frequent ED users, 17% were hospitalized, and 1% had died.
A three-class model was selected as the final analytical classification model, based on the largest entropy value (0.99) and smaller AIC and BIC criteria. Accounting for 47% of the sample, Profile 1 was labeled “Low outpatient service users”. Profile 1 included only patients without a usual physician and without continuity of physician care. A few of these patients received psychosocial interventions either from community healthcare centers (30%) or addiction treatment centers (23%), with only 12–15% receiving more intensive care (4+ interventions/year). Profile 1 had the highest dropout rate from addiction treatment centers (46%) and included the smallest percentage of patients receiving high regularity of outpatient care (9%).
Representing 36% of the sample, Profile 2 was labeled “Moderate outpatient service users”. Profile 2 included patients with at least two consultations with their usual GP, with 48% receiving more intensive GP care (Table 2). Profile 2 featured the most patients with high continuity of physician care (84%), although none had a usual psychiatrist. This profile had the second highest number of patients receiving psychosocial interventions in community healthcare centers (44%) and SRD treatments in addiction treatment centers (35%), with one quarter of them receiving more intensive care. Most patients were provided with high (38%) or moderate (31%) regularity of outpatient care.
Representing 17% of the sample, Profile 3 was labeled “High outpatient service users” and included patients with both a usual GP and psychiatrist (59%) or a usual psychiatrist only (41%). This profile had the most patients (56%) who received intensive psychiatric care and the second highest rating (80%) for high continuity of physician care. These patients also received the highest percentage (59%) of follow-up by community healthcare centers (59%) and addiction treatment centers (44%), with one third receiving intensive care in these centers. This profile featured the highest patient percentage for regularity of outpatient care (70%).
Patient sociodemographic and clinical characteristics associated with profiles
Compared to Profile 1 (Low outpatient service users: reference group), Profiles 2 (Moderate outpatient service users) and 3 (High outpatient service users) included more women, more patients having SRD for 3+ years as well as serious MD, personality disorders, common MD, and chronic physical illnesses. More particularly, Profile 3 included patients with 53-, 24- and 9-times higher risk of serious MD, personality disorders, and common MD, respectively, than those in Profile 1. Compared with Profile 1 patients, fewer of those in Profiles 2 and 3 lived in more materially and socially deprived areas or had a criminal history. Profile 2 patients were more likely to be 25+ years old and less likely to be either unemployed, living in semi-urban areas or affected by polysubstance-related disorders compared with Profile 1 patients. Those in Profile 3 were more likely to live alone or to be single parents and were less likely to be 45+ years old, to live in rural areas, or to have a history of homelessness compared with their Profile 1 counterparts (Table 3).
Patient adverse outcomes associated with the profiles
Controlling for patient age and sex, the odds of being frequent ED users or hospitalized for any medical reason were higher in Profile 3 (High outpatient service users) followed by Profile 2 (Moderate outpatient service users), than in Profile 1 (Low outpatient service users) (Table 4). No significant differences were found among the three profiles regarding death rates from any medical cause.
This study demonstrated that only a minority of patients received diversified, intensive, continuous, and regular outpatient follow-up care, even though roughly half of them had complex social and health conditions. More than 40% also experienced high frequencies of SRD treatment dropout. Three profiles regarding quality of outpatient care received were identified among patients with SRD. Profiles 1 and 3 resembled the low [15, 18, 19] and multiple or high service user profiles respectively described in previous studies [16, 19], while results for Profile 2 (Moderate outpatient service users) were similar to findings in previous studies in terms of GP care profiles . This study was original in investigating quality of care issues, as opposed to service use only. It demonstrated that for a great majority of patients with SRD, quality of care needs to be significantly improved and adjusted to their needs.
It was not surprising to find that Profile 1 (Low outpatient service users) was the largest group with 47% of patients, as those with SRD are known to use few outpatient services [40, 41] and to exhibit high dropout rates [42, 43]. Compared with Profiles 2 and 3, Profile 1 patients received very low overall quality of care and had the highest SRD dropout rate, which is easily explained by their sociodemographic and clinical characteristics. Profile 1 included more men and more patients 12–24 years old than other profiles, that is, two groups known to use outpatient services more as a last resort as opposed to women and older patients [15, 18]. Moreover, with more materially and socially deprived patients than those in Profiles 2 and 3, also neighborhoods often associated with criminal activities [44, 45], Profile 1 patients may have faced particularly strong stigma. Previous studies have reported that young people, mainly those affiliated with a “sub-culture of poverty” , are more likely to use drugs, deny their SRD, and show reluctance to receive treatment . Moreover, access to SRD treatment [15, 48] and treatment dropout [49, 50] were identified as more associated with younger age groups in previous studies.
Compared with Profiles 2 and 3, Profile 1 also included patients with better health conditions, less chronic or co-occurring MD and chronic physical illnesses, as only a minority had these conditions. These characteristics may explain, in part, why these patients received less outpatient care and had less frequent ED use and hospitalizations than those in other profiles. However, no Profile 1 patient had a usual GP or psychiatrist, and frequent ED use was about twice the rate found in the general Quebec patient population without SRD or MD , suggesting that outpatient care needs to be greatly improved. As well, few of these patients received services from either addiction treatment or community healthcare centers, despite being materially and socially deprived patients with SRD for the most part. As patient conditions may rapidly deteriorate with age and chronic SRD , prevention and outreach strategies may need particular reinforcement for Profile 1, especially for men and younger patients, who are more reluctant to use outpatient services. In acute care settings, screening, brief intervention, and treatment referral (SBIRT)  and motivational interventions might also be deployed to increase access to and continuity of patient care.
As the second largest group (36%), Profile 2 (Moderate outpatient service users) showed more frequent ED use and hospitalizations than Profile 1. However, of all the profiles, Profile 2 patients received the highest continuity and intensity of GP care. The fact that most of these patients had more “chronic” SRD, nearly half SRD co-occurring with chronic physical illnesses or common MD, and were 45+ years of age may explain both their frequent ED use and hospitalizations as well as intense GP care. Older patients are more likely than younger ones to be followed by a GP , who more likely treat common MD, especially co-occurring with chronic physical health conditions, than serious MD . Compared with Profile 1 patients, the fact that profile 2 patients were both less likely to be unemployed and live in semi-urban areas might be explained by their older age, better social and material conditions, and less criminal history, as well as by the usually higher percentage of GP working in urban areas . Taken together, the conditions affecting Profile 2 patients, along with the moderate quality of outpatient care they received, including no psychiatric care, might explain their high ED use and hospitalizations. Collaborative care between MD-SRD health specialists might be suggested to facilitate better treatment among Profile 2 patients, most of whom were faced with multimorbidity [57, 58].
Accounting for less than one fifth of the study sample, Profile 3 (High outpatient service users) included patients with more complex health and social conditions, most with chronic multimorbidity especially serious MD and personality disorders, which explains their intensive psychiatric care, more intensive treatment for SRD, and high regularity of care. Profile 3 also had the highest percentage of patients with frequent ED use and hospitalizations, roughly twice the percentage found in Profile 1. Chronic SRD , serious MD [59, 60] and personality disorders  have been found to increase the risk of frequent ED use and hospitalizations. A majority of patients in Profile 3 also lived alone or were single parents, conditions usually related to more adverse outcomes [62, 63]. The lower proportion of patients living in rural areas found in Profile 3 compared with Profile 1 may be explained by the fact that patients with complex health conditions tend to live in larger cities close to specialized care facilities. All Profile 3 patients had a usual psychiatrist. The intensive psychiatric care received by Profile 3 patients may have also explained why they had less history of homelessness than Profile 1 patients. More Profile 3 patients may have been referred to supervised housing with support, as they tended to be older and to have more chronic morbidity – conditions favoring integration into programs like Housing First [64, 65]. Finally, more than 40% of Profile 3 patients did not receive GP follow-up care, and only a third received intensive SRD treatment, which argues for improving outpatient care even for this patient profile. More GP care and intensive psychosocial interventions including SRD treatments , and integration into programs like assertive community treatment  or intensive case management  could thus be recommended for Profile 3 patients. Further implementation of integrated SRD-MD treatment  may also be recommended for these patients, as treatment coordination for MD and SRD in Quebec is insufficient .
This study has some limitations. First, administrative health databases were primarily developed for financial purposes, not research. These data are thus only proxy measures for patient needs. Second, some variables that may have impacted profiles of outpatient quality of care or adverse outcomes were not available for this study, including the race or ethnicity of patients as well as the receipt of hospital-based psychosocial care services, and private sector services from psychologists and groups like Alcohol Anonymous, Narcotic Anonymous or harm reduction resources. Finally, the findings may not be generalizable to other contexts, especially healthcare systems or populations with no public insurance or limited access to specialized SRD services.
Findings from this study demonstrated that high ED use and hospitalizations were strongly related to clinical and sociodemographic characteristics of patients, and that the quality of outpatient services received was proportional to the complexity and severity of their health and social conditions. The percentage of patient deaths did not differ between profiles, probably due to the insufficient sample size within the cohort. Unfortunately, the study found that the overall quality of care for patients with SRD needs to be greatly improved. Only Profile 3 patients received relatively higher quality of care, and these represented one fifth only of all the study patients. About half of the study patients (Profile 1) received almost no service at all. From two thirds (Profile 1) to four out of ten (Profile 3) of the study patients received SRD treatment for the last 12-month period of the study follow-up, and overall dropout from treatment was very high in the cohort. Based on the study results, outreach strategies might include motivational interventions, and prevention of risky behaviors for Profile 1 patients, collaborative GP-psychiatrist care for Profile 2 patients, and GP care and intensive specialized treatment for Profile 3 patients with a view toward better responding to the needs of these patients.
Availability of data and materials
In accordance with the applicable ethics regulations in the province of Quebec, the principal investigator is responsible for keeping data confidential.
Akaike Information Criteria
Bayesian Information Criteria
Latent class analysis
Régie de l’Assurance maladie du Québec
Screening, brief intervention, and treatment referral
Addiction Treatment Center Database (Système d’information sur la clientèle des services de réadaptation en dépendances)
Cederbaum JA, Guerrero EG, Mitchell KR, Kim T. Utilization of emergency and hospital services among individuals in substance abuse treatment. Subst Abuse Treat Prev Policy. 2014;9:16.
Minassian A, Vilke GM, Wilson MP. Frequent emergency department visits are more prevalent in psychiatric, alcohol abuse, and dual diagnosis conditions than in chronic viral illnesses such as hepatitis and human immunodeficiency virus. J Emerg Med. 2013;45:520–5.
Suen LW, Makam AN, Snyder HR, Repplinger D, Kushel MB, Martin M, et al. National Prevalence of alcohol and other substance use disorders among emergency department visits and hospitalizations: NHAMCS 2014-2018. J Gen Intern Med. 2021.
Venkatesh AK, Janke AT, Kinsman J, Rothenberg C, Goyal P, Malicki C, et al. Emergency department utilization for substance use disorders and mental health conditions during COVID-19. PLoS One. 2022;17:e0262136.
Davies S, Schultz E, Raven M, Wang NE, Stocks CL, Delgado MK, et al. Development and validation of the Agency for Healthcare Research and Quality measures of potentially preventable emergency department (ED) visits: the ED prevention quality indicators for general health conditions. Health Serv Res. 2017;52:1667–84.
Nesper AC, Morris BA, Scher LM, Holmes JF. Effect of Decreasing County mental health services on the emergency department. Ann Emerg Med. 2016;67:525–30.
Gaulin M, Simard M, Candas B, Lesage A, Sirois C. Combined impacts of multimorbidity and mental disorders on frequent emergency department visits: a retrospective cohort study in Quebec, Canada. CMAJ. 2019;191:E724–32.
Armoon B, Grenier G, Cao Z, Huynh C, Fleury MJ. Frequencies of emergency department use and hospitalization comparing patients with different types of substance or polysubstance-related disorders. Subst Abuse Treat Prev Policy. 2021;16:89.
Fridell M, Backstrom M, Hesse M, Krantz P, Perrin S, Nyhlen A. Prediction of psychiatric comorbidity on premature death in a cohort of patients with substance use disorders: a 42-year follow-up. BMC Psychiatry. 2019;19:150.
Arendt M, Munk-Jorgensen P, Sher L, Jensen SO. Mortality following treatment for cannabis use disorders: predictors and causes. J Subst Abus Treat. 2013;44:400–6.
Hjemsaeter AJ, Bramness JG, Drake R, Skeie I, Monsbakken B, Benth JS, et al. Mortality, cause of death and risk factors in patients with alcohol use disorder alone or poly-substance use disorders: a 19-year prospective cohort study. BMC Psychiatry. 2019;19:101.
Blodgett JC, Maisel NC, Fuh IL, Wilbourne PL, Finney JW. How effective is continuing care for substance use disorders? A meta-analytic review. J Subst Abus Treat. 2014;46:87–97.
McKay JR. Impact of continuing care on recovery from substance use disorder. Alcohol Res. 2021;41:01.
Simsek M, Dinç M, Ögel K. Determinants of the addiction treatment drop-out rates in an addiction counseling center: a cross-sectional study. Psychiatr Clin Psychopharmacol. 2019;29:446–54.
Crable EL, Drainoni ML, Jones DK, Walley AY, Milton HJ. Predicting longitudinal service use for individuals with substance use disorders: a latent profile analysis. J Subst Abus Treat. 2022;132:108632.
Mowbray O, Glass JE, Grinnell-Davis CL. Latent class analysis of alcohol treatment utilization patterns and 3-year alcohol related outcomes. J Subst Abus Treat. 2015;54:21–8.
Evans E, Padwa H, Li L, Lin V, Hser YI. Heterogeneity of mental health service utilization and high mental health service use among women eight years after initiating substance use disorder treatment. J Subst Abus Treat. 2015;59:10–9.
Huynh C, Tremblay J, Fleury MJ. Typologies of individuals attending an addiction rehabilitation center based on diagnosis of mental disorders. J Subst Abus Treat. 2016;71:68–78.
Woodward AT. A latent class analysis of age differences in choosing service providers to treat mental and substance use disorders. Psychiatr Serv. 2013;64:1087–94.
Association des centres de réadaptation en dépendance du Québec. Rapport annuel 2013-2014. Baliser l'action. Protéger l'offre de service en dépendance Montréal: Association des centres de réadaptation en dépendance, 2014.
Régie de l'assurance maladie du Québec. Rapport annuel de gestion, 2016–2017. Québec: Régie de l'assurance maladie du Québec, 2017.
Bergeron J, Landry M, Ishak A, Vaugeois P and Trepanier M. Validation d'un instrument d'évaluation de la gravité des problèmes reliés à la consommation de drogues et d'alcool. L'indice de Gravité d'une Toxicomanie. Montréal: Cahier de recherche du RISQ. 1992.
McLellan AT, Luborsky L, Woody GE, O'Brien CP. An improved diagnostic evaluation instrument for substance abuse patients: the addiction severity index. J Nerv Ment Dis. 1980;168:26–33.
Dennis ML, White M, Titus J, Unsicker J. Global Appaisal of individual needs (GAIN): administration guide for the GAIN and related measures (version 5). Bloomington: Chestnut Health Systems; 2008.
Dreiher J, Comaneshter DS, Rosenbluth Y, Battat E, Bitterman H, Cohen AD. The association between continuity of care in the community and health outcomes: a population-based study. Isr J Health Policy Res. 2012;1:21.
Wang PS, Demler O, Kessler RC. Adequacy of treatment for serious mental illness in the United States. Am J Public Health. 2002;92:92–8.
Menear M, Duhoux A, Roberge P, Fournier L. Primary care practice characteristics associated with the quality of care received by patients with depression and comorbid chronic conditions. Gen Hosp Psychiatry. 2014;36:302–9.
Young AS, Klap R, Shoai R, Wells KB. Persistent depression and anxiety in the United States: prevalence and quality of care. Psychiatr Serv. 2008;59:1391–8.
Breslau N, Reeb KG. Continuity of care in a university-based practice. J Med Educ. 1975;50:965–9.
Pampalon R, Hamel D, Gamache P, Raymond G. A deprivation index for health planning in Canada. Chronic Dis Can. 2009;29:178–91.
Krieg C, Hudon C, Chouinard MC, Dufour I. Individual predictors of frequent emergency department use: a scoping review. BMC Health Serv Res. 2016;16:594.
Goodman LA. Exploratory latent structure analysis using both identifiable and unidentifiable models. Biometrika. 1974;61:215–31.
Lazarsfeld PF, Henry NW. Latent structure analysis. Boston: Hougton Mifflin; 1968.
Vermunt JK, Magidson J. Latent class cluster analysis. In: Hagenaars JA, Mccutcheon AL, editors. Advances in latent class analysis. Cambridge: Cambridge University Press; 2002. p. 89–106.
Akaike H. Factor analysis and AIC. Psychometrika. 1987;52:317–22.
Swarz G. Estimating the dimension of a model. Ann Stat. 1978;6:461–4.
Celeux G, Soromenho G. An entropy criterion for assessing the number of clusters in a mixture model. J Classif. 1996;13:195–212.
Lanza ST, Collins LM, Lemmon DR, Schafer JL. PROC LCA: a SAS procedure for latent class analysis. Struct Equ Modeling. 2007;14:671–94.
StataCorp. Stata statistical software: release 17. College Station: StataCorp LLC; 2021.
Borg B, Douglas IS, Hull M, Keniston A, Moss M, Clark BJ. Alcohol misuse and outpatient follow-up after hospital discharge: a retrospective cohort study. Addict Sci Clin Pract. 2018;13:24.
Urbanoski K, Inglis D, Veldhuizen S. Service use and unmet needs for substance use and mental disorders in Canada. Can J Psychiatr. 2017;62:551–9.
Stahler GJ, Mennis J, DuCette JP. Residential and outpatient treatment completion for substance use disorders in the U.S.: moderation analysis by demographics and drug of choice. Addict Behav. 2016;58:129–35.
Lappan SN, Brown AW, Hendricks PS. Dropout rates of in-person psychosocial substance use disorder treatments: a systematic review and meta-analysis. Addiction. 2020;115:201–17.
Finegan M, Firth N, Delgadillo J. Adverse impact of neighbourhood socioeconomic deprivation on psychological treatment outcomes: the role of area-level income and crime. Psychother Res. 2020;30:546–54.
Andersen HS. Why do residents want to leave deprived neighbourhoods? The importance of residents’ subjective evaluations of their neighbourhood and its reputation. J Hous Built Environ. 2008;23:79–101.
Murali V, Oyebode F. Poverty, social inequality and mental health. Adv Psychiatr Treat. 2004;10:216–24.
Bobakova D, Madarasova Geckova A, Reijneveld SA, van Dijk JP. Subculture affiliation is associated with substance use of adolescents. Eur Addict Res. 2012;18:91–6.
Hadland SE, Marshall BD, Kerr T, Zhang R, Montaner JS, Wood E. A comparison of drug use and risk behavior profiles among younger and older street youth. Subst Use Misuse. 2011;46:1486–94.
Brorson HH, Ajo Arnevik E, Rand-Hendriksen K, Duckert F. Drop-out from addiction treatment: a systematic review of risk factors. Clin Psychol Rev. 2013;33:1010–24.
Marcovitz DE, McHugh RK, Volpe J, Votaw V, Connery HS. Predictors of early dropout in outpatient buprenorphine/naloxone treatment. Am J Addict. 2016;25:472–7.
Fleury M-J, Fortin M, Rochette L, Lesage A, Vasiliadis H-M, Huỳn C, et al. Surveillance de l’utilisation des urgences au Québec par les patients ayant des troubles mentaux. Québec: Institut national de santé publique du Québec (INSPQ); 2019.
Bachi K, Sierra S, Volkow ND, Goldstein RZ, Alia-Klein N. Is biological aging accelerated in drug addiction? Curr Opin Behav Sci. 2017;13:34–9.
Bray JW, Del Boca FK, McRee BG, Hayashi SW, Babor TF. Screening, brief intervention and referral to treatment (SBIRT): rationale, program overview and cross-site evaluation. Addiction. 2017;112(Suppl 2):3–11.
Woodward S, Berry K, Bucci S. A systematic review of factors associated with service user satisfaction with psychiatric inpatient services. J Psychiatr Res. 2017;92:81–93.
Dezetter A, Briffault X, Bruffaerts R, De Graaf R, Alonso J, König HH, et al. Use of general practitioners versus mental health professionals in six Europeans countries: the decisive role of the organization of mental health-care systems. Soc Psychiatry Psychiatr Epidemiol. 2013;48:137–49.
Wenghofer EF, Kam SM, Timony PE, Strasser R, Sutinen J. Geographic variation in FP and GP scope of practice in Ontario: comparative provincial study. Can Fam Physician. 2018;64:e274–82.
Gentil L, Grenier G, Vasiliadis HM, Huynh C, Fleury MJ. Predictors of recurrent high emergency department use among patients with mental disorders. Int J Environ Res Public Health. 2021;18.
Ramanuj P, Ferenchik E, Docherty M, Spaeth-Rublee B, Pincus HA. Evolving models of integrated behavioral health and primary care. Curr Psychiatry Rep. 2019;21:4.
Vu F, Daeppen JB, Hugli O, Iglesias K, Stucki S, Paroz S, et al. Screening of mental health and substance users in frequent users of a general Swiss emergency department. BMC Emerg Med. 2015;15:27.
Sirotich F, Durbin A, Durbin J. Examining the need profiles of patients with multiple emergency department visits for mental health reasons: a cross-sectional study. Soc Psychiatry Psychiatr Epidemiol. 2016;51:777–86.
Slankamenac K, Heidelberger R, Keller DI. Prediction of recurrent emergency department visits in patients with mental disorders. Front Psychiatry. 2020;11:48.
Choi BY, DiNitto DM, Marti CN, Choi NG. Emergency department visits and overnight hospital stays among persons aged 50 and older who use and misuse opioids. J Psychoactive Drugs. 2019;51:37–47.
Connor JP, Gullo MJ, Chan G, Young RM, Hall WD, Feeney GF. Polysubstance use in cannabis users referred for treatment: drug use profiles, psychiatric comorbidity and cannabis-related beliefs. Front Psychiatry. 2013;4:79.
Mackelprang JL, Collins SE, Clifasefi SL. Housing first is associated with reduced use of emergency medical services. Prehosp Emerg Care. 2014;18:476–82.
Holmes A, Carlisle T, Vale Z, Hatvani G, Heagney C, Jones S. Housing first: permanent supported accommodation for people with psychosis who have experienced chronic homelessness. Australas Psychiatry. 2017;25:56–9.
Hunt GE, Siegfried N, Morley K, Brooke-Sumner C, Cleary M. Psychosocial interventions for people with both severe mental illness and substance misuse. Cochrane Database Syst Rev. 2019;12:CD001088.
Fries HP, Rosen MI. The efficacy of assertive community treatment to treat substance use. J Am Psychiatr Nurses Assoc. 2011;17:45–50.
Morandi S, Silva B, Golay P, Bonsack C. Intensive case Management for Addiction to promote engagement with care of people with severe mental and substance use disorders: an observational study. Subst Abuse Treat Prev Policy. 2017;12:26.
Drake RE, Mercer-McFadden C, Mueser KT, McHugo GJ, Bond GR. Review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophr Bull. 1998;24:589–608.
Fleury MJ, Perreault M, Grenier G, Imboua A, Brochu S. Implementing key strategies for successful network integration in the Quebec substance-use disorders Programme. Int J Integr Care. 2016;16:7.
We gratefully acknowledge the support of Health Canada’s Substance Use and Addiction Program, the Quebec Ministry of Health and Social Services (MSSS) and the University Institute on Addictions (IUD).
This study was funded by Health Canada’s Substance Use and Addiction Program, and by the Quebec Ministry of Health and Social Services (MSSS, Addiction and Homelessness Division). The sponsors had no further role in the study design or in the collection, analysis, and interpretation of data, nor in writing the report or in the decision to submit it for publication.
Ethics approval and consent to participate
The ethics committee of the Integrated University Health and Social Services Centers (CIUSSS) Centre-Sud-de-l’Île-de-Montréal approved the multi-site research protocol (MP-51-2016-483, CÉRD-2015-173).
Consent for publication
The authors declare no conflicts of interest associated with this study.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Additional file 1: Appendix 1.
Codes for substance-related disorders, mental disorders, chronic physical illnesses, and death according to the International Classification of Diseases, Ninth and Tenth revisions.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
About this article
Cite this article
Fleury, MJ., Cao, Z., Grenier, G. et al. Profiles of quality of outpatient care use, associated sociodemographic and clinical characteristics, and adverse outcomes among patients with substance-related disorders. Subst Abuse Treat Prev Policy 18, 5 (2023). https://doi.org/10.1186/s13011-022-00511-0
- Substance-related disorders
- Outpatient service use
- Quality of care profiles
- Latent class analysis
- Sociodemographic and clinical characteristics
- Adverse outcomes