Predictive risk modelling of high resource users under different prescription drug coverage policies in Ontario and Manitoba, Canada

INTRODUCTION: Studying high resource users (HRUs) across jurisdictions is a challenge due to variation in data availability and health services coverage. In Canada, coverage for pharmaceuticals varies across provinces under a mix of public and private plans, which has implications for ascertaining HRUs. We examined sociodemographic and behavioural predictors of HRUs in the presence of different prescription drug coverages in the provinces of Manitoba and Ontario. METHODS: Linked Canadian Community Health Surveys were used to create two cohorts of respondents from Ontario (n = 58,617, cycles 2005–2008) and Manitoba (n = 10,504, cycles 2007–2010). HRUs (top 5%) were identified by calculating health care utilization 5 years following interview date and computing all costs in the linked administrative databases, with three approaches used to include drug costs: (1) costs paid for by the provincial payer under age-based coverage; (2) costs paid for by the provincial payer under income-based coverage; (3) total costs regardless of the payer (publicly insured, privately insured, and out-of-pocket). Logistic regression estimated the association between sociodemographic, health, and behavioral predictors on HRU risk. RESULTS: The strength of the association between age (≥ 80 vs. <30) and becoming an HRU were attenuated with the inclusion of broader drug data (age based: OR 37.29, CI: 30.08–46.24; income based: OR 27.34, CI: 18.53–40.33; all drug payees: OR 29.08, CI: 19.64–43.08). With broader drug coverage, the association between heavy smokers vs. non-smokers on odds of becoming an HRU strengthened (age based: OR 1.58, CI: 1.32–1.90; income based: OR 2.97, CI: 2.18–4.05; all drug payees: OR 3.12, CI: 2.29–4.25). Across the different drug coverage policies, there was persistence in higher odds of becoming an HRU in low income households vs. high income households and in those with a reported chronic condition vs. no chronic conditions. CONCLUSIONS: The study illustrates that jurisdictional differences in how HRUs are ascertained based on drug coverage policies can influence the relative importance of some behavioural risk factors on HRU status, but most observed associations with health and sociodemographic risk factors were persistent, demonstrating that predictive risk modelling of HRUs can occur effectively across jurisdictions, even with some differences in public drug coverage policies. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12913-023-09722-y.