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Healthcare Utilisation and Characteristics of Adults with Fetal Alcohol Syndrome: A Descriptive Population-Based Cohort Study in Ontario, Canada

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Title: Healthcare Utilisation and Characteristics of Adults with Fetal Alcohol Syndrome: A Descriptive Population-Based Cohort Study in Ontario, Canada
Language: English
Authors: Danijela Dozet, Claire de Oliveira, Yona Lunsky, Andrew Calzavara, Svetlana Popova
Source: Journal of Intellectual & Developmental Disability. 2025 50(3):339-352.
Availability: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 14
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Descriptors: Health Services, Health Behavior, Access to Health Care, Adults, Fetal Alcohol Syndrome, Foreign Countries, Hospitals, Mental Health, Addictive Behavior, Alcoholism, Mortality Rate, Patients, Psychiatric Services, Emergency Programs, Comorbidity, Substance Abuse, Home Programs
Geographic Terms: Canada
DOI: 10.3109/13668250.2025.2449677
ISSN: 1366-8250
1469-9532
Abstract: Background: Adults with Fetal Alcohol Syndrome (FAS) experience many adverse health and social outcomes, yet their healthcare utilisation is under-researched. Method: This population-based descriptive cohort study utilised ICES provincial administrative health databases and Canadian Death Vital Statistics to identify adults with FAS via usage of hospital-based services (2002-2013) and examine their demographics, healthcare utilisation, mental health and addiction diagnoses, and mortality during follow-up (2014-2017). Results: 565 adults with FAS were included in the cohort. During the follow-up period, 27% used in-patient psychiatric care; 30% the emergency department 12 + times; 28% were hospitalised at least once; and 17% used home care services. They displayed high rates of physical and mental health comorbidities, substance use disorders, history of abuse, and income from social assistance. Conclusion: Adults with FAS require accessible and extensive healthcare services to address their complex needs and improve long-term outcomes.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1480753
Database: ERIC
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  Value: <anid>AN0187408992;ddi01sep.25;2025Aug21.03:30;v2.2.500</anid> <title id="AN0187408992-1">Healthcare utilisation and characteristics of adults with fetal alcohol syndrome: a descriptive population-based cohort study in Ontario, Canada </title> <p>Background: Adults with Fetal Alcohol Syndrome (FAS) experience many adverse health and social outcomes, yet their healthcare utilisation is under-researched. Method: This population-based descriptive cohort study utilised ICES provincial administrative health databases and Canadian Death Vital Statistics to identify adults with FAS via usage of hospital-based services (2002-2013) and examine their demographics, healthcare utilisation, mental health and addiction diagnoses, and mortality during follow-up (2014-2017). Results: 565 adults with FAS were included in the cohort. During the follow-up period, 27% used in-patient psychiatric care; 30% the emergency department 12 + times; 28% were hospitalised at least once; and 17% used home care services. They displayed high rates of physical and mental health comorbidities, substance use disorders, history of abuse, and income from social assistance. Conclusion: Adults with FAS require accessible and extensive healthcare services to address their complex needs and improve long-term outcomes.</p> <p>Keywords: Fetal alcohol syndrome; prenatal alcohol exposure; developmental disability; morbidity; mortality; healthcare utilisation</p> <p>Alcohol is a teratogen that can result in numerous adverse health outcomes, such as stillbirth, spontaneous abortion, prematurity, intrauterine growth restriction, birth defects, and Fetal Alcohol Spectrum Disorder (FASD) (Henriksen et al., [<reflink idref="bib9" id="ref1">9</reflink>]; Lebel et al., [<reflink idref="bib11" id="ref2">11</reflink>]; Nykjaer et al., [<reflink idref="bib22" id="ref3">22</reflink>]; O'Connor et al., [<reflink idref="bib23" id="ref4">23</reflink>]; Patra et al., [<reflink idref="bib26" id="ref5">26</reflink>]; Popova et al., [<reflink idref="bib27" id="ref6">27</reflink>]; Popova, Dozet, Shield, et al., [<reflink idref="bib28" id="ref7">28</reflink>]; Popova, Temple, Dozet, et al., [<reflink idref="bib35" id="ref8">35</reflink>]). Even low amounts of alcohol use during pregnancy can significantly increase the risk of FASD (Chambers et al., [<reflink idref="bib4" id="ref9">4</reflink>]), which is characterised by neurodevelopmental impairment with or without facial dysmorphology, congenital anomalies and poor growth (Popova et al., [<reflink idref="bib27" id="ref10">27</reflink>]). Due to the damage to the central nervous system and other organs, individuals with FASD typically have many physical and mental conditions including learning disorders, cognitive and behavioural issues, ADHD, conduct disorder, receptive and expressive language disorders, as well as other neurodevelopmental conditions (Popova et al., [<reflink idref="bib27" id="ref11">27</reflink>]). Fetal Alcohol Syndrome (FAS) is the dysmorphic subtype of FASD, associated with the presence of sentinel facial features (Cook et al., [<reflink idref="bib6" id="ref12">6</reflink>]) and the most adverse physical and mental outcomes. In Canada, approximately 2-3% of the general population has FASD (Popova, Lange, Poznyak, et al., [<reflink idref="bib32" id="ref13">32</reflink>]), which is higher than the prevalence of the following five disorders combined: Down syndrome (trisomy 21), Edwards syndrome (trisomy 18), spina bifida, anencephaly (Parker et al., [<reflink idref="bib25" id="ref14">25</reflink>]), and autism spectrum disorders (Zablotsky et al., [<reflink idref="bib42" id="ref15">42</reflink>]). In certain sub-populations, such as correctional populations (e.g., incarcerated or on probation), children in care (e.g., foster or adoptive care) and specialised clinical populations (e.g., psychiatric care), the prevalence of FASD is 10–40 times higher as compared to the general population (Popova, Lange, Shield, et al., [<reflink idref="bib33" id="ref16">33</reflink>]).</p> <p>FASD affects not only the individual, but the family, community and service systems as well. Over 400 physical and mental health conditions are associated with FASD (Popova, Lange, Shield, et al., [<reflink idref="bib34" id="ref17">34</reflink>]), greatly increasing the need for and utilisation of healthcare services. Additionally, the numerous neurodevelopmental impairments and related conditions experienced by affected individuals often lead to adverse psychosocial outcomes, such as difficulty obtaining and/or maintaining employment, inability to live independently, social/academic problems, and higher risk of incarceration and victimisation (Popova, Dozet, Shield, et al., [<reflink idref="bib28" id="ref18">28</reflink>]; Popova, Temple, Dozet, et al., [<reflink idref="bib35" id="ref19">35</reflink>]; Streissguth et al., [<reflink idref="bib37" id="ref20">37</reflink>]). Due to these factors, individuals with FASD are prominent in several service systems, such as health care, adoptive/foster care and the criminal justice system, all of which pose a high service demand and economic burden nationally (Popova, Lange, Burd, et al., [<reflink idref="bib31" id="ref21">31</reflink>]; Popova, Lange, Poznyak, et al., [<reflink idref="bib32" id="ref22">32</reflink>]; Popova, Lange, Shield, et al., [<reflink idref="bib33" id="ref23">33</reflink>]). In Canada, it was estimated that the annual cost attributable to FASD is about $1.8 billion (Popova, Lange, Burd, et al., [<reflink idref="bib31" id="ref24">31</reflink>]) and the healthcare cost to the system was the third contributor to the total economic burden after productivity losses due to morbidity and premature mortality and cost of corrections (Popova, Lange, Burd, et al., [<reflink idref="bib31" id="ref25">31</reflink>]; Popova, Lange, Shield, et al., [<reflink idref="bib34" id="ref26">34</reflink>]). Furthermore, individuals with FASD are also at greater risk for premature mortality due to the increased rate of morbidity, with some evidence suggesting a shorter life expectancy among individuals with FAS as compared to those in the general population (Thanh & Jonsson, [<reflink idref="bib39" id="ref27">39</reflink>]).</p> <p>Studying the impact of FASD on service systems is severely limited by the fact that the vast majority of individuals are undiagnosed (Burd & Popova, [<reflink idref="bib1" id="ref28">1</reflink>]; Popova, Dozet, Temple, et al., [<reflink idref="bib29" id="ref29">29</reflink>]). In addition, the diagnosis and associated data in health care systems are limited to FAS, one subtype of FASD in the International Classification of Diseases (ICD) 10th Revision (e.g., Q86.0: Fetal alcohol syndrome (dysmorphic)). Lastly, the province of Ontario does not have a registry for FAS. As such, administrative health database data pertaining to FASD severely underestimate the prevalence and associated comorbidities of FASD (Streissguth et al., [<reflink idref="bib37" id="ref30">37</reflink>]).</p> <p>Studying the demographics, health conditions and healthcare utilisation patterns of individuals with FAS can be a valuable step towards understanding the unique needs of individuals living with this condition and the associated demand on service systems. This can assist with the eventual design and implementation of interventions that work to address existing gaps in the system, address unmet needs and help individuals with FAS work towards healthy, fulfilling lives. The purpose of this population-based descriptive cohort study, using provincial administrative healthcare data for Ontario, Canada, was to examine the following:</p> <p></p> <ulist> <item> The number of adult individuals (18 + years) for whom FAS was recorded as a diagnosis using the ICD-10 code Q86.0: Fetal alcohol syndrome (dysmorphic) while receiving healthcare services during hospitalisation, an emergency department (ED) visit, or same-day surgery in 2002-2013;</item> <p></p> <item> The healthcare utilisation (rate and types) of the above cohort as documented by Ontario administrative health databases during follow-up (2014-2017);</item> <p></p> <item> The socio-demographic characteristics, mental health conditions, substance use, and mortality of the above cohort during follow-up (2014–2017).</item> </ulist> <hd id="AN0187408992-2">Method</hd> <p></p> <hd id="AN0187408992-3">Study design, setting and population</hd> <p>This descriptive, population-based cohort study analysed administrative health data housed at ICES for all adult individuals (18 + years) living in Ontario, Canada. As mentioned above, FASD could not be examined using these data (there is no specific ICD-10 code), the current study examined FAS exclusively using ICD-10 code Q86.0. A comparison group was not included due to funding limitations and the exploratory nature of this study in being the first to specifically identify and study adults with FAS using linked databases in Ontario. Data from similar studies on the healthcare utilisation of the general population of Canada were used for the purpose of comparison in the Discussion section.</p> <p>Individuals were included in the study cohort if (<reflink idref="bib1" id="ref31">1</reflink>) they were aged 18 years of age or older on 1 January 2014; and (<reflink idref="bib2" id="ref32">2</reflink>) the FAS diagnosis was recorded during any hospitalisation, ED visit, or same-day surgery in the period between 1 April 2002 and 31 December 2013. Individuals were excluded from the cohort if they left the province or died before 1 January 2014. Individuals with FAS in the cohort were then followed from 1 January 2014–31 December 2017 or up until their death event within that period using the linked databases listed above.</p> <hd id="AN0187408992-4">Study data sources</hd> <p>Several provincial administrative health databases were linked using unique encoded identifiers at ICES in Ontario, Canada. ICES is an independent, non-profit research institute whose legal status under Ontario's health information privacy law allows it to collect and analyse health care and demographic data, without consent, for health system evaluation and improvement. ICES holds a variety of population health data sources and databases in Ontario, Canada, including demographic and healthcare-related data, population-based health surveys, and clinical and administrative databases. Data available at ICES include record-level linkable datasets, which include information on the most publicly funded health services available in the province.</p> <p>To compile a cohort for this study, the intermediate algorithm designed by Lin and colleagues (Lin et al., [<reflink idref="bib12" id="ref33">12</reflink>]) that identified individuals with developmental disabilities in Ontario, was modified (unvalidated) and used to retrospectively identify adults (18+) diagnosed with FAS in the administrative databases from 2002 to 2013. The starting point of 2002 the study was chosen because hospitalisation data provided by the Canadian Institute for Health Information (CIHI) were first classified using ICD-10-CA in fiscal year 2001-2002. The National Ambulatory Care Reporting System (NACRS) and the Discharge Abstract Database (DAD) databases were utilised to compile the cohort as per the algorithm.</p> <p>To study the demographic and clinical profiles, as well as characteristics of all healthcare service utilisation. The Registered Persons Database (RPDB), linked to census data, was used for information on age and sex. The NACRS was used to examine the number and characteristics of ED visits, same-day surgeries and ambulatory clinic visits, main diagnosis, and main intervention. The DAD and Ontario Mental Health Reporting System (OMHRS) were used to examine the characteristics of adults with FAS receiving hospitalisations and inpatient psychiatric care, including general mental health diagnostic groups, substance use, mental health disorders, history and interventions received, and length of stay. The Continuing Care Reporting System (CCRS) was used to examine age at admission, living circumstances and physical/mental health comorbidities among adults with FAS in the cohort who were residents of complex continuing care and/or long-term care services in hospitals or long-term care homes and length of stay. The Home Care Database (HCD) was used to examine the number and characteristics of home and community care services, source of referral, and requested program for the subgroup who received in home health related services such as nursing care, occupational therapy, or assistance with daily living. The Ontario Registrar General (ORG)-Death Vital Statistics was used to examine mortality events and causes of death.</p> <hd id="AN0187408992-5">Ethics approval</hd> <p>The study was conducted according to the Tri-Council Policy Statement 2 (TCPS 2) guidelines and Section 45 of Ontario's Personal Health Information Protection Act (PHIPA). Section 45. This study was conducted by ICES, and approved by ICES' Privacy and Legal Office and the Centre for Addiction and Mental Health (CAMH) Research Ethics Board (#014/2017).</p> <hd id="AN0187408992-6">Data analysis</hd> <p>The analysis was undertaken at ICES. ICES is a prescribed entity under Ontario's Personal Health Information Protection Act (PHIPA). Section 45 of PHIPA authorises ICES to collect personal health information, without consent, for the purpose of analysis or compiling statistical information with respect to the management, evaluation, or monitoring of the allocation of resources to, or planning for all or part of the health system. Projects that use data collected by ICES under section 45 of PHIPA, and use no other data, are exempt from the Research Ethics Board (REB) review. The use of the data in this project is authorised under section 45 and approved by ICES" Privacy and Legal Office. Descriptive statistics including frequencies, percentages, means, standard deviations, medians, and interquartile ranges were derived using SAS version 9.4 statistical software. Cells with counts below 6 were suppressed in accordance with privacy obligations to reduce the risk of patient reidentification.</p> <hd id="AN0187408992-7">Results</hd> <p></p> <hd id="AN0187408992-8">Study population</hd> <p>A total of 605 adults with FAS were identified in the study whose health encounters included hospitalisation, an emergency department visit, or same-day surgery between 2002 and 2013 in Ontario. Forty individuals were excluded from the cohort because they had died prior to 2014. The final study population included 565 adults diagnosed with FAS (347 from DAD/SDS databases; 218 from NACRS) who were included in the cohort and then followed for a total of four years (2014–2017). An average of 47 adults with FAS entered the cohort each year. The average age was 27.7 years (SD: 9.8); 55% were males. Based on the diagnoses recorded during ED visits, hospitalisations and same-day surgeries during follow-up, a profile of mental health conditions and substance use disorders can be found in Table 1. Among mental health diagnoses listed in these encounters (as any diagnosis) are anxiety/OCD/PTSD: 32%; mood disorder: 21%; schizophrenia or psychosis: 15%; among mental and behavioural disorders due to substance use are: alcohol: 16%; multiple substance use: 12%; opioids: 6%; recorded during the study period.</p> <p>Table 1. Demographic characteristics, mental health and substance use diagnoses of adults with FAS who utilised health care services, 2014–2017 (<emph>N</emph> = 565).</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Characteristics</td><td>Adults with FAS (<italic>N</italic> = 565)</td></tr></thead><tbody><tr><td>Age at index</td></tr><tr><td> Mean (SD)</td><td char="(">27.7 (9.8)</td></tr><tr><td> Median (IQR)</td><td char="(">25 (21-31)</td></tr><tr><td>Sex</td><td char="(" /></tr><tr><td> Female</td><td char="(">254 (45.0)</td></tr><tr><td> Male</td><td char="(">311 (55.0)</td></tr><tr><td>Diagnoses recorded in hospitalisations, emergency department and same-day surgery visits – <italic>n</italic> (%)</td></tr><tr><td>Mental health diagnoses*</td><td char="(" /></tr><tr><td> Anxiety/OCD/PTSD (F4)</td><td char="(">178 (31.5)</td></tr><tr><td> Mood disorder (F30-F34)</td><td char="(">120 (21.2)</td></tr><tr><td> Schizophrenia or psychosis (F2)</td><td char="(">87 (15.4)</td></tr><tr><td> Personality disorder (F6)</td><td char="(">64 (11.3)</td></tr><tr><td> Developmental disorder (F7-F8)</td><td char="(">45 (8.0)</td></tr><tr><td> Behavioural disorder (F5)</td><td char="(">12 (2.1)</td></tr><tr><td>Substance use disorders*</td><td char="(" /></tr><tr><td> Mental and behavioural disorders due to use of alcohol (F10)</td><td char="(">89 (15.8)</td></tr><tr><td> Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances (F19)</td><td char="(">65 (11.5)</td></tr><tr><td> Mental and behavioural disorders due to use of opioids (F11)</td><td char="(">34 (6.0)</td></tr><tr><td> Mental and behavioural disorders due to use of other stimulants, including caffeine (F15)</td><td char="(">33 (5.8)</td></tr><tr><td> Mental and behavioural disorders due to use of cannabinoids (F12)</td><td char="(">22 (3.9)</td></tr><tr><td> Mental and behavioural disorders due to use of cocaine (F14)</td><td char="(">21 (3.7)</td></tr><tr><td> Mental and behavioural disorders due to use of hallucinogens (F16)</td><td char="(">7 (1.2)</td></tr></tbody></table> </ephtml> </p> <p>1 Source: ICES data holdings, including: DAD, NACRS, OHIP, RPDB.</p> <ulist> <item>2 Note: SD: standard deviation; IQR: interquartile range; OCD: Obsessive compulsive disorder; PTSD: post-traumatic stress disorder.</item> <item>3 *Any diagnosis, not the "most responsible diagnosis" (MRD) or reason for hospital encounter.</item> </ulist> <hd id="AN0187408992-9">Healthcare utilisation</hd> <p>Table 2 shows that during the follow-up period, 27% (152 out of 565) of adults with FAS utilised psychiatric inpatient care, with a greater proportion of males compared to females. 28% of people with FAS had urgent hospitalisations and 12% had elective hospitalisations. The average length of stay (LOS) in inpatient psychiatric care was 15.2 days (SD: 24.6), urgent admission 3.9 days (SD: 4.9), and elective admissions 4.2 days (SD: 6.6). In this period, 23% had same-day surgery and 4.1% had an ambulatory clinic visit.</p> <p>Table 2. Utilisation of health care services among adults with FAS by sex, 2014–2017 (N = 565).</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Type of healthcare service</td><td>Total<bold /><italic>N</italic> = 565</td><td>Male<bold /><italic>n</italic> = 311</td><td>Female<bold /><italic>n</italic> = 254</td></tr></thead><tbody><tr><td>Inpatient admission – psychiatric</td></tr><tr><td> Number of patients – <italic>n</italic> (%)</td><td>152 (26.9%)</td><td char="(">88 (28.3%)</td><td char="(">64 (25.2%)</td></tr><tr><td> Mean age on January 1, 2014, (SD)</td><td>27.64 (9.2)</td><td char="(" /><td char="(" /></tr><tr><td> Age range</td><td>18–67</td><td char="(" /><td char="(" /></tr><tr><td> Mean LOS (days), SD</td><td>15.27 (24.6)</td><td char="(" /><td char="(" /></tr><tr><td> LOS range (days)</td><td>1–181</td><td char="(" /><td char="(" /></tr><tr><td>Urgent hospitalisations<xref ref-type="fn" rid="tfn6" /></td></tr><tr><td> Number of patients – <italic>n</italic> (%)</td><td>158 (28.0%)</td><td char="(">81 (26.0%)</td><td char="(">77 (30.3%)</td></tr><tr><td> Mean age on January 1, 2014, (SD)</td><td>30.47 (11.28)</td><td char="(" /><td char="(" /></tr><tr><td> Age range</td><td>18–74</td><td char="(" /><td char="(" /></tr><tr><td> Mean LOS (days), SD</td><td>3.92 (4.93)</td><td char="(" /><td char="(" /></tr><tr><td> LOS range (days)</td><td>1–32</td><td char="(" /><td char="(" /></tr><tr><td>Elective hospitalisations<xref ref-type="fn" rid="tfn7" /></td></tr><tr><td> Number of patients – <italic>n</italic> (%)</td><td>68 (12.0%)</td><td char="(">14 (4.5%)</td><td char="(">54 (21.3%)</td></tr><tr><td> Mean age on January 1, 2014, (SD)</td><td>25.91 (8.97)</td><td char="(" /><td char="(" /></tr><tr><td> Age range</td><td>18–67</td><td char="(" /><td char="(" /></tr><tr><td> Mean LOS (days), SD</td><td>4.24 (6.55)</td><td char="(" /><td char="(" /></tr><tr><td> LOS range (days)</td><td>1–40</td><td char="(" /><td char="(" /></tr><tr><td>Emergency department visit (any reason)</td></tr><tr><td> Number of patients (any visits) – <italic>n</italic> (%)</td><td>464 (82.1%)</td><td char="(">248 (79.7%)</td><td char="(">216 (85.0%)</td></tr><tr><td> Mean age on January 1, 2014, (SD)</td><td>28.0 (10.0)</td><td char="(" /><td char="(" /></tr><tr><td> Age range</td><td>18–74</td><td char="(" /><td char="(" /></tr><tr><td> 0 visits</td><td>101 (17.9%)</td><td char="(">63 (20.3%)</td><td char="(">38 (15.0%)</td></tr><tr><td> 1–2 visits</td><td>104 (18.4%)</td><td char="(">58 (18.6%)</td><td char="(">46 (18.1%)</td></tr><tr><td> 3–5 visits</td><td>96 (17.0%)</td><td char="(">60 (19.3%)</td><td char="(">36 (14.2%)</td></tr><tr><td> 6–11 visits</td><td>99 (17.5%)</td><td char="(">50 (16.1%)</td><td char="(">49 (19.3%)</td></tr><tr><td> 12 + visits</td><td>165 (29.2%)</td><td char="(">80 (25.7%)</td><td char="(">85 (33.5%)</td></tr><tr><td>Same-day surgery</td></tr><tr><td> Number of patients – <italic>n</italic> (%)</td><td>129 (22.8%)</td><td char="(">54 (17.4%)</td><td char="(">75 (29.5%)</td></tr><tr><td> Mean age on January 1, 2014, (SD)</td><td>28.04 (9.4)</td><td char="(" /><td char="(" /></tr><tr><td> Age range</td><td>18–59</td><td char="(" /><td char="(" /></tr><tr><td>Ambulatory clinic visit</td></tr><tr><td> Number of patients – <italic>n</italic> (%)</td><td>23 (4.1%)</td><td char="(">8 (2.6%)</td><td char="(">15 (5.9%)</td></tr><tr><td> Mean age on January 1, 2014, (SD)</td><td>27.87 (9.25)</td><td char="(" /><td char="(" /></tr><tr><td> Age range</td><td>18–59</td><td char="(" /><td char="(" /></tr><tr><td>Complex continuing care</td></tr><tr><td> Number of patients – <italic>n</italic> (%)</td><td>6 (1.1%)</td><td char="("><6 (S)</td><td char="("><6 (S)</td></tr><tr><td> Mean age at admission, SD</td><td>43.28 (22.1)</td><td char="(" /><td char="(" /></tr><tr><td> Age range (time of admission)</td><td>19–70</td><td char="(" /><td char="(" /></tr><tr><td> LOS (days) – mean, SD</td><td>65.25 (34.4)</td><td char="(" /><td char="(" /></tr><tr><td> LOS (days) – range</td><td>20–102</td><td char="(" /><td char="(" /></tr><tr><td>Long-term care</td></tr><tr><td> Patients – <italic>n</italic> (%)</td><td>9 (1.6%)</td><td char="("><6 (S)</td><td char="("><6 (S)</td></tr><tr><td> Age at admission – mean (SD)</td><td>51.0 (15.2)</td><td char="(" /><td char="(" /></tr><tr><td> Age at admission – range</td><td>23–70</td><td char="(" /><td char="(" /></tr><tr><td>Home/community care</td></tr><tr><td> Age on January 1, 2014 – mean (SD)</td><td>31.56 (12.7)</td><td char="(">54 (17.4%)</td><td char="(">41 (16.1%)</td></tr><tr><td> Age range</td><td>18–74</td><td char="(" /><td char="(" /></tr><tr><td> Patients receiving any care – <italic>n</italic> (%)</td><td>95 (16.8%)</td><td char="(" /><td char="(" /></tr><tr><td> Case management</td><td>91 (16.1%)</td><td char="(">51 (16.4%)</td><td char="(">40 (15.7%)</td></tr><tr><td> Nursing</td><td>59 (10.4%)</td><td char="(">34 (10.9%)</td><td char="(">25 (9.8%)</td></tr><tr><td> Occupational therapy</td><td>31 (5.5%)</td><td char="(">17 (5.5%)</td><td char="(">14 (5.5%)</td></tr><tr><td> Physiotherapy</td><td>19 (3.4%)</td><td char="(">9 (2.9%)</td><td char="(">10 (3.9%)</td></tr><tr><td> Personal services/respite</td><td>18 (3.2%)</td><td char="(">8 (2.6%)</td><td char="(">10 (3.9%)</td></tr></tbody></table> </ephtml> </p> <ulist> <item>4 Source: DAD, NACRS, CCRS, HCD, and OMHRS.</item> <item>5 Note: S-suppressed; LOS-length of stay.</item> <item>6 Patient admitted for a serious or life-threatening condition or requires immediate assessment and treatment.</item> <item>7 Patient admitted for the scheduled treatment and/or assessment.</item> </ulist> <p>A total of 95 adults with FAS (16.8%) in the cohort had accessed home and/or community care services. These adults with FAS were typically referred by general hospital inpatient (33%) or outpatient (26%) departments. They were most often classified as "adult – short stay" (44%) at the time of service and requested in-home care services (94%). A very small subset (n = 15; 3%) of adults with FAS in the cohort utilised complex or continuing care services. Among these 15 adults with FAS, less than half were indicated to be decision-makers for their personal care (47%) or property (<47%). A large portion (73%) had a history of mental illness or developmental disability diagnoses indicated in their chart. Compared to all other healthcare utilisation types, where the mean age of the patients ranged between 25 and 35, patients using complex continuing care or long-term care were older on average, with average ages of 43.4 and 51.0 years at the time of admission, respectively.</p> <p>Among adults with FAS in this cohort, 82% had at least one ED visit during follow-up, with 47% of them visiting the ED six or more times, and 29% visiting 12 or more times. Table 3 presents the number of visits to ED and ambulatory care services, which indicated that based on the total number of adults with FAS in the cohort who utilised the ED (n = 464, 82.1%; Table 2) or ambulatory clinic visits (n = 23, 4.1%; Table 2), there were a total of 10,424 visits combined (Table 3). Patients were often referred to this care service by a family member, caretaker/guardian, or themselves (82%) and all of them received a face-to-face visit, indicating telehealth options were not utilised at that time.</p> <p>Table 3. Number and characteristics of NACRS emergency department and ambulatory clinic visits utilised by adults with FAS (2014–2017).</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Characteristics of emergency department or ambulatory clinic visit</td><td>Frequency</td><td>Percent</td></tr></thead><tbody><tr><td>Number of visits</td><td>10,424</td><td char=".">100</td></tr><tr><td>Referral source</td><td /><td char="." /></tr><tr><td> Self/family member, caretaker, guardian</td><td char=".">8594</td><td char=".">82.4</td></tr><tr><td> Legal service (police, parole officer, court)</td><td char=".">651</td><td char=".">6.3</td></tr><tr><td> Ambulatory care service (reporting or other facility)</td><td char=".">364</td><td char=".">3.5</td></tr><tr><td> Residential Care Facility</td><td char=".">269</td><td char=".">2.6</td></tr><tr><td> Other</td><td char=".">173</td><td char=".">1.7</td></tr><tr><td>Main diagnosis at time of visit (top 10)</td></tr><tr><td> Poisoning by nonopioid analgesics, antipyretics and antirheumatics (T39)</td><td char=".">699</td><td char=".">6.7</td></tr><tr><td> Reaction to severe stress, and adjustment disorders (F43)</td><td char=".">477</td><td char=".">4.6</td></tr><tr><td> Symptoms and signs involving emotional state (R45)</td><td char=".">444</td><td char=".">4.3</td></tr><tr><td> Abdominal and pelvic pain (R10)</td><td char=".">435</td><td char=".">4.2</td></tr><tr><td> Mental and behavioural disorders due to use of alcohol (F10)</td><td char=".">432</td><td char=".">4.1</td></tr><tr><td> Persons encountering health services in other circumstances (Z76)</td><td char=".">336</td><td char=".">3.2</td></tr><tr><td> Epilepsy (G40)</td><td char=".">275</td><td char=".">2.6</td></tr><tr><td> Specific personality disorders (F60)</td><td char=".">241</td><td char=".">2.3</td></tr><tr><td> Convulsions, not elsewhere classified (R56)</td><td char=".">234</td><td char=".">2.2</td></tr><tr><td> Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances (F19)</td><td char=".">221</td><td char=".">2.1</td></tr><tr><td>Main intervention at time of visit (top 10)</td></tr><tr><td> None</td><td char=".">6571</td><td char=".">63.0</td></tr><tr><td> Assessment, mental health and addictions for other reason</td><td char=".">549</td><td char=".">5.3</td></tr><tr><td> Xray, thoracic cavity without contrast</td><td char=".">539</td><td char=".">5.2</td></tr><tr><td> Assessment, mental health and addictions for capacity for harm (to self or others)</td><td char=".">325</td><td char=".">3.1</td></tr><tr><td> Xray, abdominal cavity without contrast</td><td char=".">201</td><td char=".">1.9</td></tr><tr><td> Counseling, mental health for mood (e.g., anger, anxiety, relaxation, leisure)</td><td char=".">127</td><td char=".">1.2</td></tr><tr><td> Ultrasound, abdominal cavity alone</td><td char=".">114</td><td char=".">1.1</td></tr><tr><td> Counseling, mental health for other reasons</td><td char=".">106</td><td char=".">1.0</td></tr><tr><td> Electrophysiological measurement, heart external application using recording electrodes (or ECG NOS)</td><td char=".">100</td><td char=".">1.0</td></tr><tr><td> Specimen collection (for diagnostic testing), total body blood by venous puncture</td><td char=".">100</td><td char=".">1.0</td></tr></tbody></table> </ephtml> </p> <p>8 Source: NACRS and RPDB.</p> <hd id="AN0187408992-10">Mental health and substance use outcomes</hd> <p>Among all 10,424 ED visits and ambulatory clinic visits, seven of the top ten main (i.e., most responsible) diagnoses at the time of the visit were related to mental health and substance use (Table 3). Furthermore, 27% (152 out of 565) of adults with FAS were admitted for psychiatric inpatient care during the study (Table 4). 135 adults with FAS were captured in the OHMRS database and 17 were captured by the DAD. Based on the general mental health and addictions diagnostic groupings that have been created and validated within the OHMRS and the DAD databases for psychiatric hospitalisations, the most common diagnostic categories of patients with FAS were "schizophrenia spectrum and other psychotic disorders" (20%) and "substance-related and addictive disorders" addiction (20%; Table 4). Table 4 also presents characteristics of adults with FAS with FAS upon admission at their first psychiatric hospitalisation, as captured in the OHMRS database (n = 135). Most of these adults were never married (70%) and the majority spoke primarily English (74%). The most frequently listed source of income was a pension (43%), which is noteworthy since these adults with FAS were typically between the ages of 21 and 31. Only 5.2% completed some college/ university; 17% completed high school; 25% completed grades 9-11; and 39% indicated they had dropped out of an education programme at some point in their past.</p> <p>Table 4. Characteristics of adults with FAS during time of first admission to psychiatric inpatient care (2014-2017) (N = 135)</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Patient characteristics</td><td>Frequency</td><td>Percentage</td></tr></thead><tbody><tr><td>Database of record<xref ref-type="table-fn" rid="tfn11">a</xref></td></tr><tr><td> DAD</td><td char=".">17</td><td char=".">11.2</td></tr><tr><td> OMHRS</td><td char=".">135</td><td char=".">88.8</td></tr><tr><td>General Mental Health and Addiction (MHA) diagnostic groups<sup>a,</sup>*</td></tr><tr><td> Schizophrenia spectrum and other psychotic disorders</td><td char=".">31</td><td char=".">20.4</td></tr><tr><td> Substance-related and addictive disorders</td><td char=".">31</td><td char=".">20.4</td></tr><tr><td> Others</td><td char=".">22</td><td char=".">14.5</td></tr><tr><td> Deliberate self-harm</td><td char=".">17</td><td char=".">11.2</td></tr><tr><td> Mood disorders – depressive</td><td char=".">11</td><td char=".">7.2</td></tr><tr><td> Personality Disorders</td><td char=".">10</td><td char=".">6.6</td></tr><tr><td> Trauma/stressor-related disorders</td><td char=".">10</td><td char=".">6.6</td></tr><tr><td> Mood disorders – bipolar</td><td char=".">7</td><td char=".">4.6</td></tr><tr><td> Anxiety</td><td><6</td><td char=".">S</td></tr><tr><td> Delirium</td><td><6</td><td char=".">S</td></tr><tr><td> Dementia/Alzheimer's disease</td><td><6</td><td char=".">S</td></tr><tr><td> Mood disorders – Other</td><td><6</td><td char=".">S</td></tr><tr><td>Sex</td></tr><tr><td> Female</td><td char=".">57</td><td char=".">42.2</td></tr><tr><td> Male</td><td char=".">78</td><td char=".">57.8</td></tr><tr><td>Marital status</td></tr><tr><td> Never married</td><td char=".">95</td><td char=".">70.4</td></tr><tr><td> Married or in a common-law relationship</td><td char=".">7</td><td char=".">5.2</td></tr><tr><td> Living with a partner/significant other</td><td><6</td><td char=".">S</td></tr><tr><td> Separated</td><td><6</td><td char=".">S</td></tr><tr><td>Language spoken = English</td><td char=".">100</td><td char=".">74.1</td></tr><tr><td>Level of education obtained</td></tr><tr><td> 9–11 grades</td><td char=".">34</td><td char=".">25.2</td></tr><tr><td> High school</td><td char=".">23</td><td char=".">17.0</td></tr><tr><td> 8th grade/less</td><td char=".">13</td><td char=".">9.6</td></tr><tr><td> Unknown</td><td char=".">10</td><td char=".">7.4</td></tr><tr><td> Some college/university</td><td char=".">7</td><td char=".">5.2</td></tr><tr><td> Technical or trade school</td><td><6</td><td char=".">S</td></tr><tr><td> Diploma/bachelor's degree</td><td><6</td><td char=".">S</td></tr><tr><td> No schooling</td><td><6</td><td char=".">S</td></tr><tr><td>Income source</td></tr><tr><td> Pension</td><td char=".">58</td><td char=".">43.0</td></tr><tr><td> Disability insurance</td><td char=".">27</td><td char=".">20.0</td></tr><tr><td> Social assistance</td><td char=".">17</td><td char=".">12.6</td></tr><tr><td> Employment</td><td char=".">11</td><td char=".">8.2</td></tr><tr><td> Other</td><td char=".">8</td><td char=".">5.9</td></tr><tr><td> Employment insurance</td><td><6</td><td char=".">S</td></tr><tr><td> No income</td><td><6</td><td char=".">S</td></tr><tr><td>Reason for assessment – initial assessment</td><td char=".">72</td><td char=".">53.3</td></tr><tr><td>Inpatient status at time of assessment</td></tr><tr><td> Voluntary</td><td char=".">74</td><td char=".">54.8</td></tr><tr><td> Involuntary</td><td char=".">29</td><td char=".">21.5</td></tr><tr><td> Application for psychiatric assessment (exclude forensics)</td><td char=".">24</td><td char=".">17.8</td></tr><tr><td> Informal</td><td><6</td><td char=".">S</td></tr><tr><td> Forensic (including forensic assessment, unfit to plead, not criminally responsible)</td><td><6</td><td char=".">S</td></tr><tr><td><italic>Person has a guardian/substitute decision-maker acting on his or her behalf for either financial or personal affairs</italic></td><td char=".">11</td><td char=".">8.2</td></tr><tr><td>Reason(s) for admission**</td></tr><tr><td> Threat or danger to self</td><td char=".">93</td><td char=".">68.9</td></tr><tr><td> Specific psychiatric symptoms</td><td char=".">74</td><td char=".">54.8</td></tr><tr><td> Inability to care for self-due to mental illness</td><td char=".">51</td><td char=".">37.8</td></tr><tr><td> Problem with addiction/dependency</td><td char=".">47</td><td char=".">34.8</td></tr><tr><td> Threat or danger to others</td><td char=".">30</td><td char=".">22.2</td></tr><tr><td> Involvement with criminal justice system, forensic admission</td><td char=".">12</td><td char=".">8.9</td></tr><tr><td>Alcohol use (reported by patient and/or others)</td></tr><tr><td> No alcoholic drinks were consumed in the last 14 days</td><td char=".">88</td><td char=".">65.2</td></tr><tr><td> 1–4 alcoholic drinks at any given sitting in the last 14 days</td><td char=".">18</td><td char=".">13.3</td></tr><tr><td> 5 or more alcoholic drinks at any given sitting in the last 14 days</td><td char=".">29</td><td char=".">21.5</td></tr><tr><td>Past-year use of inhalants (any)</td><td><6</td><td char=".">S</td></tr><tr><td>Past-year use of hallucinogens (any)</td><td char=".">11</td><td char=".">8.1</td></tr><tr><td>Cocaine/crack</td></tr><tr><td> No past year use, or used more than one year ago</td><td char=".">105</td><td char=".">77.8</td></tr><tr><td> Used in past year, but not in last 3 months</td><td><6</td><td char=".">S</td></tr><tr><td> Used in past 3 months, but not in last month</td><td char=".">9</td><td char=".">6.7</td></tr><tr><td> Used in last month, but not in last 7 days</td><td char=".">6</td><td char=".">4.4</td></tr><tr><td> Used 4–7 days ago</td><td><6</td><td char=".">S</td></tr><tr><td> Used in last 3 days</td><td char=".">8</td><td char=".">5.9</td></tr><tr><td>Stimulant(s)</td></tr><tr><td> No past year use, or used more than one year ago</td><td char=".">113</td><td char=".">83.7</td></tr><tr><td> Used in past year, but not in last 3 months</td><td><6</td><td char=".">S</td></tr><tr><td> Used in past 3 months, but not in last month</td><td><6</td><td char=".">S</td></tr><tr><td> Used in last month, but not in last 7 days</td><td><6</td><td char=".">S</td></tr><tr><td> Used 4–7 days ago</td><td><6</td><td char=".">S</td></tr><tr><td> Used in last 3 days</td><td char=".">9</td><td char=".">6.7</td></tr><tr><td>Opiates</td></tr><tr><td> No past year use, or used more than one year ago</td><td char=".">115</td><td char=".">85.2</td></tr><tr><td> Used in past year, but not in last 3 months</td><td char=".">7</td><td char=".">5.2</td></tr><tr><td> Used in past 3 months, but not in last month</td><td><6</td><td char=".">S</td></tr><tr><td> Used in last month, but not in last 7 days</td><td><6</td><td char=".">S</td></tr><tr><td> Used 4–7 days ago</td><td><6</td><td char=".">S</td></tr><tr><td> Used in last 3 days</td><td><6</td><td char=".">S</td></tr><tr><td>Cannabis</td></tr><tr><td> No past year use, or used more than one year ago</td><td char=".">73</td><td char=".">54.1</td></tr><tr><td> Used in past year, but not in last 3 months</td><td><6</td><td char=".">S</td></tr><tr><td> Used in past 3 months, but not in last month</td><td><6</td><td char=".">S</td></tr><tr><td> Used in last month, but not in last 7 days</td><td char=".">6</td><td char=".">4.4</td></tr><tr><td> Used 4–7 days ago</td><td char=".">22</td><td char=".">16.3</td></tr><tr><td> Used in last 3 days</td><td char=".">24</td><td char=".">17.8</td></tr><tr><td>Tobacco</td></tr><tr><td> Does not smoke or chew tobacco</td><td char=".">30</td><td char=".">22.2</td></tr><tr><td> Daily smoker, but none in last 3 days</td><td char=".">22</td><td char=".">16.3</td></tr><tr><td> Smoked/chewed in last 3 days</td><td char=".">39</td><td char=".">28.9</td></tr><tr><td><italic>Gambled excessively/uncontrollably in last 3 months</italic></td><td><6</td><td char=".">S</td></tr><tr><td><italic>Self-rated health</italic> = <italic>good or excellent</italic></td><td char=".">52</td><td char=".">38.5</td></tr><tr><td>Police intervention for violent behaviour</td></tr><tr><td> Never</td><td char=".">75</td><td char=".">55.6</td></tr><tr><td> More than 1 year ago</td><td char=".">25</td><td char=".">18.5</td></tr><tr><td> 31 days to 1 year ago</td><td char=".">16</td><td char=".">11.8</td></tr><tr><td> 8–30 days ago</td><td><6</td><td char=".">S</td></tr><tr><td> 4–7 days ago</td><td><6</td><td char=".">S</td></tr><tr><td> In the last 3 days</td><td char=".">10</td><td char=".">7.4</td></tr><tr><td>Police intervention for non-violent behaviour</td></tr><tr><td> Never</td><td char=".">57</td><td char=".">42.2</td></tr><tr><td> More than 1 year ago</td><td char=".">22</td><td char=".">16.3</td></tr><tr><td> 31 days to 1 year ago</td><td>S</td><td char=".">S</td></tr><tr><td> 8–30 days ago</td><td>S</td><td char=".">S</td></tr><tr><td> 4–7 days ago</td><td char=".">11</td><td char=".">8.2</td></tr><tr><td> In the last 3 days</td><td char=".">29</td><td char=".">21.5</td></tr><tr><td>Life events and history**</td></tr><tr><td> Emotional abuse</td><td char=".">67</td><td char=".">49.6</td></tr><tr><td> Physical assault/abuse</td><td char=".">56</td><td char=".">41.5</td></tr><tr><td>Failed or dropped out of an education programme</td><td char=".">52</td><td char=".">38.5</td></tr><tr><td> Parental abuse of alcohol or drugs</td><td char=".">50</td><td char=".">37.0</td></tr><tr><td> Conflict-laden or severed relationship</td><td char=".">49</td><td char=".">36.3</td></tr><tr><td> Sexual assault/abuse</td><td char=".">41</td><td char=".">30.4</td></tr><tr><td> Death of a close family member or friend</td><td char=".">36</td><td char=".">26.7</td></tr><tr><td> Serious accident or physical impairment</td><td char=".">24</td><td char=".">17.8</td></tr><tr><td> Distressed about health of another person</td><td char=".">24</td><td char=".">17.8</td></tr><tr><td> Child custody issues, birth, or adoption of child</td><td char=".">22</td><td char=".">16.3</td></tr><tr><td> Major loss of income or serious economic hardship due to poverty</td><td char=".">20</td><td char=".">14.8</td></tr><tr><td> Review hearing</td><td char=".">15</td><td char=".">11.1</td></tr><tr><td> Witness to severe accident, disaster, act of terrorism, violence, or abuse</td><td char=".">10</td><td char=".">7.4</td></tr><tr><td> Victim of crime</td><td char=".">7</td><td char=".">5.2</td></tr><tr><td> Immigration/refugee status</td><td><6</td><td char=".">S</td></tr><tr><td> Lived in war zone or area of violent conflict</td><td><6</td><td char=".">S</td></tr><tr><td>Life event(s) and history causes sense of horror or intense fear</td></tr><tr><td> No or not applicable</td><td char=".">91</td><td char=".">67.4</td></tr><tr><td> Yes</td><td char=".">21</td><td char=".">15.6</td></tr><tr><td> Could not (would not) respond</td><td char=".">9</td><td char=".">6.7</td></tr><tr><td>Received formal care from provider in the last 7 days, for at least 15 min</td></tr><tr><td> Psychiatrist</td><td char=".">83</td><td char=".">61.5</td></tr><tr><td> Social worker</td><td char=".">51</td><td char=".">37.8</td></tr><tr><td> Nurse practitioner or MD</td><td char=".">46</td><td char=".">34.1</td></tr><tr><td> Recreational therapist</td><td char=".">27</td><td char=".">20.0</td></tr><tr><td> Occupational therapist</td><td char=".">20</td><td char=".">14.8</td></tr><tr><td> Dietician</td><td char=".">10</td><td char=".">7.4</td></tr><tr><td> Psychologist or Psychometrist</td><td><6</td><td char=".">S</td></tr><tr><td> Addiction counsellor</td><td><6</td><td char=".">S</td></tr><tr><td>Received interventions in last 7 days, for at least 15 min</td></tr><tr><td> Nursing – one-to-one counselling, teaching</td><td char=".">66</td><td char=".">48.9</td></tr><tr><td> Nursing – medical interventions</td><td char=".">40</td><td char=".">29.6</td></tr><tr><td> Nursing – crisis intervention</td><td char=".">34</td><td char=".">25.2</td></tr><tr><td> Nursing – family support/consultation</td><td char=".">20</td><td char=".">14.8</td></tr><tr><td>Focus of intervention received in last 7 days or to be received in next 7 days</td></tr><tr><td> Community reintegration</td><td char=".">49</td><td char=".">36.3</td></tr><tr><td> Psychosocial rehabilitation</td><td char=".">44</td><td char=".">32.6</td></tr><tr><td> Social/family functioning</td><td char=".">35</td><td char=".">25.9</td></tr><tr><td> Behavioural Management</td><td char=".">34</td><td char=".">25.2</td></tr><tr><td> Alcohol/drug treatment/smoking cessation</td><td char=".">20</td><td char=".">14.8</td></tr><tr><td> Anger Management</td><td char=".">17</td><td char=".">12.6</td></tr><tr><td> Pain management</td><td char=".">12</td><td char=".">8.9</td></tr><tr><td> Alternative/non-traditional therapy</td><td char=".">6</td><td char=".">4.4</td></tr><tr><td> Detoxification</td><td><6</td><td char=".">S</td></tr><tr><td> Vocational counselling</td><td><6</td><td char=".">S</td></tr><tr><td> Eating disorder</td><td><6</td><td char=".">S</td></tr><tr><td> Post-traumatic Stress</td><td><6</td><td char=".">S</td></tr></tbody></table> </ephtml> </p> <ulist> <item>9 Source: DAD, OMHRS and RPDB databases.</item> <item>10 Note: S, Suppressed.</item> <item>11 Statistics generated for all patients who were admitted to psychiatric inpatient care (<emph>N</emph> = 152).</item> <item>12 *General diagnostic groups created and validated by OHMRS and DAD databases.</item> <item>13 **Categories that are not mutually exclusive.</item> </ulist> <p>Just over half (55%) of the adults with FAS accessing inpatient psychiatric care were admitted voluntarily. The reason(s) for admission most commonly were stated as posing a threat to themselves or others (69%); having specific psychiatric symptoms (55%); being unable to care for themselves (38%); and/or having problems with substance addiction/dependence (35%). Police assistance was high, as 44% received a police intervention for violent behaviour in the past, and 58% received a police intervention for non-violent behaviour. Among these adults with FAS who utilised psychiatric inpatient care, the recorded life events and history of patients revealed a high degree of adversity and challenges. Rates of experienced emotional, physical, and sexual assault/abuse were high (50%; 42%; and 30%, respectively), 25 (19%) adults with FAS had a documented history of abuse, seven (5%) were reported as being victims of crime and ten (7%) were witnesses to violence/disaster, severe accidents, or terrorism, indicating a high level of trauma exposure captured. Adults with FAS also experienced disruptions to family life, as indicated by conflict-laden or severed relationships (36%), being distressed about the health of another person (18%), child custody issues or birth/adoption of a child (16%) and poverty/serious economic hardship (15%).</p> <p>Among adults with FAS accessing inpatient psychiatric care, 35% reported binge drinking alcohol (i.e., 4 or more drinks in one sitting) in the last two weeks prior to admission (Table 4). Reported use of cocaine/crack, stimulants and opiates was very low (suppressed), but tobacco (over 75%) and cannabis use (38%) were comparatively high in the preceding weeks. Notably, 62% reported their self-rated health as being poor or fair. Furthermore, 37% reported parental abuse of alcohol or drugs in the past, indicating significant proportions of personal and family history with substances.</p> <p>Adults with FAS admitted to inpatient psychiatric care also received formal care from a range of providers during their admission, including psychiatrists (62%), social workers (38%), nurse practitioners (34%), recreational therapists (e.g., using leisure activities to improve quality of life) (20%) and occupational therapists (15%) (Table 4). Adults with FAS received a range of nursing mental health interventions, including one-to-one counselling (49%), medical (30%) and crisis (25%) interventions, benefiting from both individual (46%) and group therapy (31%) modalities. Interventions most commonly focused on community reintegration (36%), psychosocial rehabilitation (33%) and social/family functioning (26%).</p> <hd id="AN0187408992-11">Mortality</hd> <p>Among the 565 adults with FAS in the whole study population, 14 (2.5%) died during follow-up (2014-2017); they were 38.7 years old on average at the beginning of the study period (1 January 2014). These individuals were on average 11 years older at the beginning of the study as compared to those who remained alive throughout. Causes of death among individuals in this cohort who died included chronic conditions, communicable diseases, and intentional/ unintentional injuries. To protect the privacy of these 14 individuals, the percentages for sex (male/female) and causes of death were not reported. Notably, 40 individuals met the inclusion criteria via the algorithm, but were excluded from the cohort because they had died before the index date of 1 January 2014. The ages and leading causes of death among these 40 individuals were not examined.</p> <hd id="AN0187408992-12">Discussion</hd> <p>Prior research using data derived from administrative health databases in Ontario has focused on the demographic and clinical profiles of individuals with intellectual and developmental disabilities, but not on FAS specifically (Lin et al., [<reflink idref="bib13" id="ref34">13</reflink>]; Lin et al., [<reflink idref="bib14" id="ref35">14</reflink>]; Lunsky et al., [<reflink idref="bib16" id="ref36">16</reflink>]; Lunsky & Lin, [<reflink idref="bib17" id="ref37">17</reflink>]). This is the first population-based cohort study, which was created using provincial administrative health data, to identify adults with FAS in Ontario using an algorithm that specifically identifies those who have been used the ED, been hospitalised or had a same-day surgery across the province (2003-2013) and had a diagnosis of FAS during one of these health encounters.</p> <p>Among the 565 adults with FAS studied during follow-up (2014-2017), 82% utilised the ED at least once in the four-year period (2014-2017), 48% of them utilised it 6 or more times, and one-third utilised it 12 or more times during four years. This is much higher ED utilisation as compared to the general population of Ontario. For example, one study reported that 57% of adults in the general population did not utilise the ED at all in a span of five years and only 3% utilised it more than 5 times (McConkey et al., [<reflink idref="bib19" id="ref38">19</reflink>]). Furthermore, the majority (90%) of the adult population in Ontario who utilises the ED, do so once a year, whereas high-frequency users (10% of all users) tend to visit the ED four times a year. Based on these findings, adults with FAS are high-frequency users of the ED (Popova et al., [<reflink idref="bib30" id="ref39">30</reflink>]).</p> <p>More than one-quarter (28%) of the adults with FAS in this cohort were admitted to urgent inpatient care at least once during the follow-up period, which indicates immediate assessment/treatment for a serious or life-threatening condition. This may be a reflection of unmet needs among individuals with FAS that are related to poor overall health, living conditions, limited access to or utilisation of primary health care (Coles et al., [<reflink idref="bib5" id="ref40">5</reflink>]; Marquis et al., [<reflink idref="bib18" id="ref41">18</reflink>]) or risk-taking behaviour often seen in individuals with FAS (Tsang et al., [<reflink idref="bib40" id="ref42">40</reflink>]). Home and continuing care services were the least utilised healthcare types, with a higher average age at the time of admission in the current study. This may be influenced by the increased risk of morbidity and mortality with age (Popova, Lange, Shield, et al., [<reflink idref="bib34" id="ref43">34</reflink>]; Thanh & Jonsson, [<reflink idref="bib39" id="ref44">39</reflink>]) or the nature of home and continuing care services, which provide attention to medical issues that tend to emerge later in life. Adults with FAS may also have limited access to home and continuing care services, due to eligibility criteria, payment options and/or wait times for these services.</p> <p>Overall, healthcare utilisation data from hospitalisation, ED visits and ambulatory care, demonstrated that people with FAS experience mental health and substance use issues. Anxiety (32%), mood disorder (21%) and schizophrenia/psychosis (15%) were the most common, which is also in line with the high rate of mental health comorbidities among individuals with FAS as identified in other studies (Popova, Lange, Shield, et al., [<reflink idref="bib34" id="ref45">34</reflink>]). An examination of the main diagnoses present at ED visits or ambulatory clinic visits (NACRS) shows that seven of the top 10 main diagnoses were related to mental health and substance use. This is in stark contrast to national NACRS data for the general population, wherein mental health and substance use were not included in the top 10 main diagnoses among adults with FAS admitted to the ED in 2016 or 2017 (Canadian Institute for Health Information, [<reflink idref="bib2" id="ref46">2</reflink>]; Canadian Institute for Health Information, [<reflink idref="bib3" id="ref47">3</reflink>]). Indeed, adults with FAS are a high-frequency service user group and suffer disproportionately from mental health and substance use issues, which are common adverse psychosocial outcomes associated with FAS (McLachlan et al., [<reflink idref="bib20" id="ref48">20</reflink>]; Popova, Dozet, Shield, et al., [<reflink idref="bib28" id="ref49">28</reflink>]; Popova, Temple, Dozet, et al., [<reflink idref="bib35" id="ref50">35</reflink>]; Streissguth et al., [<reflink idref="bib37" id="ref51">37</reflink>]). This is in line with literature on youth with FAS, which shows that youth and adults with FAS are more likely to visit the ED for anxiety, depression, psychotic disorders and substance use disorders compared to youth with no intellectual or developmental disability (Marquis et al., [<reflink idref="bib18" id="ref52">18</reflink>]).</p> <p>Just over one-quarter of the sample (27%) were admitted to psychiatric inpatient care at least once during the study, with an average LOS of 15 days. Common diagnoses among these patients with FAS were schizophrenia and other psychotic disorders, and substance-related and addictive disorders. Among psychiatric inpatients with FAS, there was a high prevalence of recent tobacco use (over 75%) and cannabis use (38%) and binge drinking (35%), which is consistent with previous studies (Popova, Dozet, Shield, et al., [<reflink idref="bib28" id="ref53">28</reflink>]; Popova, Temple, Dozet, et al., [<reflink idref="bib35" id="ref54">35</reflink>]). Combined with the fact that 37% reported parental abuse of alcohol or drugs, these data demonstrate the high risk of alcohol-exposed pregnancies and FASD recurrence within families (McQuire et al., [<reflink idref="bib21" id="ref55">21</reflink>]). Individuals with FAS are in need of FASD-informed, strengths-based and compassionate interventions for addictions (Flannigan et al., [<reflink idref="bib8" id="ref56">8</reflink>]), which can work to decrease the service demand on EDs, psychiatric care facilities and may even work to reduce the risk of future alcohol-exposed pregnancies and new cases of FASD.</p> <p>Data from psychiatric inpatient care admissions revealed many adverse social outcomes experienced by adults living with FAS. Among adults with FAS who used psychiatric care, a staggering amount experienced emotional abuse (50%), physical abuse (42%) and sexual abuse (30%), as listed in their chart as life events and history. Though the timing of these life events is unknown, this may be indicative of adverse childhood experiences (ACEs), which are more likely for individuals living with FASD due to factors typically associated with their postnatal environment, including being more likely to be in foster or adoptive care, or being more likely to be a victim of crime (Kambeitz et al., [<reflink idref="bib10" id="ref57">10</reflink>]). It is well-documented that ACEs of people with FASD also increase the risk for the development of comorbid neurodevelopmental disorders such as attention deficit disorders, sleep disorders and cognitive impairments (Kambeitz et al., [<reflink idref="bib10" id="ref58">10</reflink>]). Furthermore, 43% of patients with FAS in psychiatric inpatient care reported that the most common source of income is pension, 39% reported dropping out of an education programme, and 28% were unable to care for themselves. These findings are in line with previous studies showcasing common adverse social outcomes in children and adults with FASD (McLachlan et al., [<reflink idref="bib20" id="ref59">20</reflink>]; Streissguth et al., [<reflink idref="bib37" id="ref60">37</reflink>]). This emphasises the need for individuals living with FAS to have access to support services that will focus on their strengths and will support them to have the best outcomes, such as employment, community involvement and independent living (Temple et al., [<reflink idref="bib38" id="ref61">38</reflink>]).</p> <p>These healthcare utilisation data illuminate the huge service utilisation associated with FAS among a cohort of individuals identified in hospital-based records, which is in line with previous studies indicated a high cost associated with FAS in the healthcare system (Popova, Lange, Burd, et al., [<reflink idref="bib31" id="ref62">31</reflink>]; Rosella et al., [<reflink idref="bib36" id="ref63">36</reflink>]). The cohort in the current study would greatly benefit from access to FASD- and trauma-informed therapy, careful ED care plans, sexual assault treatment services, employment services, family court services and access to mental health and substance use programmes. Based on research in Toronto, where over one-tenth of the study population resides, receiving an FASD diagnosis in adulthood can facilitate employment and healthy relationships for adults with FASD (Temple et al., [<reflink idref="bib38" id="ref64">38</reflink>]). The cohort in the current study is 28 years old on average and has the potential to achieve the most successful long-term outcomes possible with access to the appropriate services. To prevent new cases of FASD women of reproductive age, access to healthy parenting programmes, screening and brief interventions can facilitate alcohol-free pregnancies (McQuire et al., [<reflink idref="bib21" id="ref65">21</reflink>]) and possibly prevent new cases of FASD. Support services that offer integrated service delivery, for example, can address employment, counselling, medical and/or housing needs that may be experienced by individuals with FASD (Flannigan et al., [<reflink idref="bib8" id="ref66">8</reflink>]). Support services can also work to address the needs of caregivers of individuals with FASD, including relief services such as free time for parents/family and short-term accommodation for children with FASD (Weinmann et al., [<reflink idref="bib41" id="ref67">41</reflink>]). Improvements in continuity in healthcare services overall (e.g., careful ED plans), implementation of integrated service delivery (Flannigan et al., [<reflink idref="bib8" id="ref68">8</reflink>]) and having a crisis or care plan in place may reduce the impact of FAS on the healthcare system (Durbin et al., [<reflink idref="bib7" id="ref69">7</reflink>]; Lunsky et al., [<reflink idref="bib15" id="ref70">15</reflink>]), and improve the quality of life for individuals with FAS and their families (Flannigan et al., [<reflink idref="bib8" id="ref71">8</reflink>]). Community support services and supportive, FASD-informed environments have the potential to mitigate adverse health and social outcomes and help individuals with FAS have the best outcomes possible (Flannigan et al., [<reflink idref="bib8" id="ref72">8</reflink>]).</p> <hd id="AN0187408992-13">Strengths and limitations</hd> <p>This study has several notable strengths, including being the first to use the ICD-10 FAS-specific code to compile a cohort of adults with FAS, an under-researched sub-population, and to use linked healthcare databases to study this cohort and to examine their healthcare utilisation and characteristics over time, including emergency, ambulatory, hospital-based, long-term, complex continuing care and home care services in Ontario. There are also several limitations that must be noted. First, the study was only able to identify adults with FAS, and therefore does not capture adults with other FASD diagnoses (partial FAS (pFAS), alcohol-related neurodevelopmental disorder (ARND) and alcohol-related birth defects (ARBD)). Secondly, the number of individuals with FAS who received healthcare services in 2002–2013 as estimated by this study's algorithm, is underestimated because (a) the majority of individuals with FAS are underdiagnosed or misdiagnosed (Popova, Dozet, Temple et al., [<reflink idref="bib29" id="ref73">29</reflink>]); and (b) the OHMRS database on inpatient mental health services was not utilised due to the absence of a DSM specific code attributable to FAS. Other studies also revealed the challenges in using administrative health databases in identifying cases of FASD(O'Donnell et al., [<reflink idref="bib24" id="ref74">24</reflink>]).</p> <p>Thirdly, because the cohort was identified through diagnoses recorded during ED visits or hospitalisations, the cohort likely overrepresents adults with FAS who are in poorer general health, as compared to adults with FAS who did not seek health care services or whose diagnosis of FAS was not recognised or recorded during such visits.</p> <p>Fourthly, based on mortality data, it is not possible to make conclusions about the life expectancy or mortality rate for adults with FAS, as they may have left Ontario and died in another location. In addition, the length of follow-up was only four years (2014-2017).</p> <p>Fifthly, the data on race/ethnicity and Indigenous identity were not collected, and neighbourhood-level income data were not part of the analysis; therefore, it is not possible to make inferences about variations in healthcare utilisation in adults with FAS based on intersectional identities. Furthermore, the validity of the data on income sources obtained from the Ontario Mental Health Reporting System is unknown.</p> <p>Lastly, this study did not contain a comparison group (e.g., individuals without FAS) and, therefore, conclusions cannot be made about the relative risks for various outcomes associated with being an adult diagnosed with FAS in Ontario. Future studies in Ontario may compare adults with FAS to adults with no documented intellectual or developmental disabilities, such as in the study conducted by Marquis et al. ([<reflink idref="bib18" id="ref75">18</reflink>]) in British Columbia, Canada.</p> <hd id="AN0187408992-14">Conclusion</hd> <p>Adults with FAS who access hospital-based care (e.g., ED visits, hospitalisations) are frequent users of healthcare services, especially emergency and urgent care, and have substantial service needs for mental health and substance use disorders, which need to be addressed by existing service systems. These findings highlight the need for a comprehensive, multi-tiered systems approach that can improve long-term outcomes, including accessible FASD-informed services in community-based and non-acute healthcare settings; early interventions for comorbidities and adverse social outcomes; and continuity of care across the healthcare and service systems serving adults with FAS.</p> <hd id="AN0187408992-15">Acknowledgements</hd> <p>This document used data adapted from the Statistics Canada Postal CodeOM Conversion File, which is based on data licensed from Canada Post Corporation, and/or data adapted from the Ontario Ministry of Health Postal Code Conversion File, which contains data copied under license from ©Canada Post Corporation and Statistics Canada. Parts of this material are based on data and information compiled and provided by the Ontario Ministry of Health. The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred.</p> <hd id="AN0187408992-16">Disclosure statement</hd> <p>No potential conflict of interest was reported by the author(s).</p> <hd id="AN0187408992-17">Data availability statement</hd> <p>The dataset from this study is held securely in coded form at ICES. 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 <ulink href="http://www.ices.on.ca/DAS">http://www.ices.on.ca/DAS</ulink> (email: das@ices.on.ca). 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Pediatrics, 144 (4), e20190811. https://doi.org/10.1542/peds.2019-0811</bibtext> </blist> </ref> <aug> <p>By Danijela Dozet; Claire de Oliveira; Yona Lunsky; Andrew Calzavara and Svetlana Popova</p> <p>Reported by Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib11" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib22" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib23" firstref="ref4"></nolink> <nolink nlid="nl4" bibid="bib26" firstref="ref5"></nolink> <nolink nlid="nl5" bibid="bib27" firstref="ref6"></nolink> <nolink nlid="nl6" bibid="bib28" firstref="ref7"></nolink> <nolink nlid="nl7" bibid="bib35" firstref="ref8"></nolink> <nolink nlid="nl8" bibid="bib32" firstref="ref13"></nolink> <nolink nlid="nl9" bibid="bib25" firstref="ref14"></nolink> <nolink nlid="nl10" bibid="bib42" firstref="ref15"></nolink> <nolink nlid="nl11" bibid="bib33" firstref="ref16"></nolink> <nolink nlid="nl12" bibid="bib34" firstref="ref17"></nolink> <nolink nlid="nl13" bibid="bib37" firstref="ref20"></nolink> <nolink nlid="nl14" bibid="bib31" firstref="ref21"></nolink> <nolink nlid="nl15" bibid="bib39" firstref="ref27"></nolink> <nolink nlid="nl16" bibid="bib29" firstref="ref29"></nolink> <nolink nlid="nl17" bibid="bib12" firstref="ref33"></nolink> <nolink nlid="nl18" bibid="bib13" firstref="ref34"></nolink> <nolink nlid="nl19" bibid="bib14" firstref="ref35"></nolink> <nolink nlid="nl20" bibid="bib16" firstref="ref36"></nolink> <nolink nlid="nl21" bibid="bib17" firstref="ref37"></nolink> <nolink nlid="nl22" bibid="bib19" firstref="ref38"></nolink> <nolink nlid="nl23" bibid="bib30" firstref="ref39"></nolink> <nolink nlid="nl24" bibid="bib18" firstref="ref41"></nolink> <nolink nlid="nl25" bibid="bib40" firstref="ref42"></nolink> <nolink nlid="nl26" bibid="bib20" firstref="ref48"></nolink> <nolink nlid="nl27" bibid="bib21" firstref="ref55"></nolink> <nolink nlid="nl28" bibid="bib10" firstref="ref57"></nolink> <nolink nlid="nl29" bibid="bib38" firstref="ref61"></nolink> <nolink nlid="nl30" bibid="bib36" firstref="ref63"></nolink> <nolink nlid="nl31" bibid="bib41" firstref="ref67"></nolink> <nolink nlid="nl32" bibid="bib15" firstref="ref70"></nolink> <nolink nlid="nl33" bibid="bib24" firstref="ref74"></nolink>
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  Label: Title
  Group: Ti
  Data: Healthcare Utilisation and Characteristics of Adults with Fetal Alcohol Syndrome: A Descriptive Population-Based Cohort Study in Ontario, Canada
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Danijela+Dozet%22">Danijela Dozet</searchLink><br /><searchLink fieldCode="AR" term="%22Claire+de+Oliveira%22">Claire de Oliveira</searchLink><br /><searchLink fieldCode="AR" term="%22Yona+Lunsky%22">Yona Lunsky</searchLink><br /><searchLink fieldCode="AR" term="%22Andrew+Calzavara%22">Andrew Calzavara</searchLink><br /><searchLink fieldCode="AR" term="%22Svetlana+Popova%22">Svetlana Popova</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Journal+of+Intellectual+%26+Developmental+Disability%22"><i>Journal of Intellectual & Developmental Disability</i></searchLink>. 2025 50(3):339-352.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 14
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2025
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Health+Services%22">Health Services</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Behavior%22">Health Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22Access+to+Health+Care%22">Access to Health Care</searchLink><br /><searchLink fieldCode="DE" term="%22Adults%22">Adults</searchLink><br /><searchLink fieldCode="DE" term="%22Fetal+Alcohol+Syndrome%22">Fetal Alcohol Syndrome</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Hospitals%22">Hospitals</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Addictive+Behavior%22">Addictive Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22Alcoholism%22">Alcoholism</searchLink><br /><searchLink fieldCode="DE" term="%22Mortality+Rate%22">Mortality Rate</searchLink><br /><searchLink fieldCode="DE" term="%22Patients%22">Patients</searchLink><br /><searchLink fieldCode="DE" term="%22Psychiatric+Services%22">Psychiatric Services</searchLink><br /><searchLink fieldCode="DE" term="%22Emergency+Programs%22">Emergency Programs</searchLink><br /><searchLink fieldCode="DE" term="%22Comorbidity%22">Comorbidity</searchLink><br /><searchLink fieldCode="DE" term="%22Substance+Abuse%22">Substance Abuse</searchLink><br /><searchLink fieldCode="DE" term="%22Home+Programs%22">Home Programs</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Canada%22">Canada</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.3109/13668250.2025.2449677
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1366-8250<br />1469-9532
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: Adults with Fetal Alcohol Syndrome (FAS) experience many adverse health and social outcomes, yet their healthcare utilisation is under-researched. Method: This population-based descriptive cohort study utilised ICES provincial administrative health databases and Canadian Death Vital Statistics to identify adults with FAS via usage of hospital-based services (2002-2013) and examine their demographics, healthcare utilisation, mental health and addiction diagnoses, and mortality during follow-up (2014-2017). Results: 565 adults with FAS were included in the cohort. During the follow-up period, 27% used in-patient psychiatric care; 30% the emergency department 12 + times; 28% were hospitalised at least once; and 17% used home care services. They displayed high rates of physical and mental health comorbidities, substance use disorders, history of abuse, and income from social assistance. Conclusion: Adults with FAS require accessible and extensive healthcare services to address their complex needs and improve long-term outcomes.
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  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1480753
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1480753
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  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.3109/13668250.2025.2449677
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 14
        StartPage: 339
    Subjects:
      – SubjectFull: Health Services
        Type: general
      – SubjectFull: Health Behavior
        Type: general
      – SubjectFull: Access to Health Care
        Type: general
      – SubjectFull: Adults
        Type: general
      – SubjectFull: Fetal Alcohol Syndrome
        Type: general
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Hospitals
        Type: general
      – SubjectFull: Mental Health
        Type: general
      – SubjectFull: Addictive Behavior
        Type: general
      – SubjectFull: Alcoholism
        Type: general
      – SubjectFull: Mortality Rate
        Type: general
      – SubjectFull: Patients
        Type: general
      – SubjectFull: Psychiatric Services
        Type: general
      – SubjectFull: Emergency Programs
        Type: general
      – SubjectFull: Comorbidity
        Type: general
      – SubjectFull: Substance Abuse
        Type: general
      – SubjectFull: Home Programs
        Type: general
      – SubjectFull: Canada
        Type: general
    Titles:
      – TitleFull: Healthcare Utilisation and Characteristics of Adults with Fetal Alcohol Syndrome: A Descriptive Population-Based Cohort Study in Ontario, Canada
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            NameFull: Danijela Dozet
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            NameFull: Yona Lunsky
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            NameFull: Andrew Calzavara
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            NameFull: Svetlana Popova
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          Dates:
            – D: 01
              M: 01
              Type: published
              Y: 2025
          Identifiers:
            – Type: issn-print
              Value: 1366-8250
            – Type: issn-electronic
              Value: 1469-9532
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            – Type: volume
              Value: 50
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              Value: 3
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