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1.  Media Coverage of Youth Suicides and Its Impact on Paediatric Mental Health Emergency Department Presentations 
Healthcare Policy  2014;10(1):97-107.
Background: To examine mental health (MH) presentations to the emergency department (ED) of a paediatric hospital following two highly publicized local teen suicides.
Methods: Youths aged 12–18 years with a MH chief complaint and/or diagnosis were included. Differences in frequencies were analyzed using chi-square tests, and relative risks were evaluated using generalized linear modelling.
Results: Significant increases in the number of ED presentations were found within the months of the publicized suicides compared to the same months of previous years. No differences were found in symptom acuity, suicidal status and psychiatric hospitalization rates. Significant increases were found in relative risk of presenting to the ED 28 and 90 days post both publicized suicides.
Conclusions: Results suggest there was an association between highly publicized suicides and an increase in the number of MH presentations to the local paediatric ED. Considerations of media's potentially positive role in MH awareness are needed.
PMCID: PMC4253889  PMID: 25410699
2.  Letter to The Editor 
Healthcare Policy  2014;10(1):8-9.
PMCID: PMC4253890  PMID: 25410691
4.  The Untold Story: Examining Ontario's Community Health Centres' Initiatives to Address Upstream Determinants of Health 
Healthcare Policy  2014;10(1):14-29.
Background: Unlike traditional primary care centres, part of the Community Health Centre (CHC) mandate is to address upstream health determinants. In Ontario, CHCs refer to these activities as Community Initiatives (CIs); yet, little is known about how CIs operate. The objective of this study was to examine the scope, resource requirements, partnerships, successes and challenges among selected Ontario CIs.
Methods: We conducted qualitative interviews with 10 CHC staff members representing 11 CIs across Ontario. CIs were identified through an online inventory, recruited by e-mail and interviewed between March and June 2011.
Results: Most CIs aim to increase community participation, while addressing social isolation and poverty. They draw minimal financial resources from their CHC, and employ highly skilled staff to support implementation. Most enlist support from various partners, and use numerous methods for community engagement. Successes include improved community relations, increased opportunities for education and employment and rewarding partnerships, while insufficient funding was a commonly identified challenge.
Conclusions: Despite minimal attention from researchers and funders, our findings suggest that CIs play key capacity-building roles in vulnerable communities across Ontario, and warrant further investigation.
PMCID: PMC4253893  PMID: 25410693
5.  Primary Care Reform and Service Use by People with Serious Mental Illness in Ontario 
Healthcare Policy  2014;10(1):31-45.
Purpose: To examine service use by adults with serious mental illness (SMI) rostered in new primary care models: enhanced fee-for-service (FFS), blended-capitation (CAP) and team-based capitation (TBC) models with and without mental health workers (MHW) in Ontario.
Methods: This cross-sectional study used administrative health service databases to compare use of mental health and general health services among persons with SMI enrolled in new models (n = 125,233).
Results: Relative to persons rostered in enhanced FFS, those in CAP and TBC had fewer mental health primary care visits (adjusted rate ratios and 95% confidence limits: CAP: 0.77 [0.74, 0.81]; TBC with MHW: 0.72 [0.68, 0.76]; TBC with no MHW: 0.81 [0.72, 0.93]). Compared to patients in enhanced FFS, those in TBC models also had more mental health hospital admissions (TBC with MHW: 1.12 [1.05, 1.20]; TBC with no MHW: 1.22 [1.05, 1.41]). Patterns of use of general services were similar.
Conclusion: Further attention to financial incentives in capitation that influence care of persons with SMI is necessary to determine if they are aligned with aims of primary care reform.
PMCID: PMC4253894  PMID: 25410694
6.  Gaps in Primary Healthcare Electronic Medical Record Research and Knowledge: Findings of a Pan-Canadian Study 
Healthcare Policy  2014;10(1):46-59.
While the barriers to electronic medical record (EMR) adoption by physicians are well-known, we have much less knowledge about the broader challenges regarding EMR use faced by primary healthcare (PHC) EMR stakeholders in Canada. Therefore, we conducted interviews (from June 2009 to September 2010) and consultation sessions (in October and November 2009) with these stakeholders, as well as carrying out a research capacity assessment, to identify, describe and prioritize gaps in PHC EMR knowledge and research. Twelve thematic gaps emerged; four were identified as the most important: the need to ascertain the value of EMRs, the need to better understand elements of EMR implementation and adoption, the need to develop innovative data entry and extraction procedures, and a lack of agreement and understanding of data sharing. To advance EMR use, Canada needs to address these gaps; yet, we currently have a lack of research capacity with which to accomplish this.
PMCID: PMC4253895  PMID: 25410695
7.  Optometry Services in Ontario: Supply – and Demand-Side Factors from 2011 to 2036 
Healthcare Policy  2014;10(1):60-72.
Optometric labour market projections are provided. First, population growth and ageing-based estimates of the rate of increase of eye-care services in Ontario from 2011 to 2036 are presented, holding the age–sex structure of utilization constant. Then, using data on the 2011 supply and working hours of Ontario's optometrists, the number of optometrists needed to keep the level of optometric services per age–sex-adjusted person comparable over time is estimated. The projections suggest that the number of Ontario optometrists should grow by approximately 30–40 full-time equivalents per year; to offset retirements and account for decreasing work hours, this suggests 77–90 new practitioners are required each year. However, in recent years, the number of Ontario optometrists has been growing faster than this, suggesting either that demand has exceeded supply and/or surpluses will accumulate if this trend continues.
PMCID: PMC4253896  PMID: 25410696
8.  Improving Health Equity: The Promising Role of Community Health Workers in Canada 
Healthcare Policy  2014;10(1):73-85.
This article reports findings from an applied case study of collaboration between a community-based organization staffed by community health workers/multicultural health brokers (CHWs/MCHBs) serving immigrants and refugees and a local public health unit in Alberta, Canada. In this study, we explored the challenges, successes and unrealized potential of CHWs/MCHBs in facilitating culturally responsive access to healthcare and other social services for new immigrants and refugees. We suggest that health equity for marginalized populations such as new immigrants and refugees could be improved by increasing the role of CHWs in population health programs in Canada. Furthermore, we propose that recognition by health and social care agencies and institutions of CHWs/MCHBs, and the role they play in such programs, has the potential to transform the way we deliver healthcare services and address health equity challenges. Such recognition would also benefit CHWs and the populations they serve.
PMCID: PMC4253897  PMID: 25410697
9.  Inadequate Performance Measures Affecting Practices, Organizations and Outcomes of Ontario's Family Health Teams 
Healthcare Policy  2014;10(1):86-96.
Background: Emphasis on quantity as the main performance measure may be posing challenges for Family Health Team (FHT) practices and organizational structures. This study asked: What healthcare practices and organizational structures are encouraged by the FHT model?
Methods: An exploratory qualitative design guided by discourse analysis was used. This paper presents findings from in-depth semi-structured interviews conducted with seven policy informants and 29 FHT leaders.
Results: Participants report that performance measures value quantity and are not inclusive of the broad scope of attributes that comprise primary healthcare. Performance measures do not appear to be accurately capturing the demand for healthcare services, or the actual amount of services being provided by FHTs. Results suggest that unintended consequences of performance measures may be posing challenges to access and health outcomes.
Conclusion: It is recommended that performance measures be developed and used to measure, support and encourage FHTs to achieve the goals of PHC.
PMCID: PMC4253898  PMID: 25410698
10.  Mind the Gap: Governance Mechanisms and Health Workforce Outcomes 
Healthcare Policy  2014;10(1):e108-e114.
Attempts at health system reform have not been as successful as governments and health authorities had hoped. Working from the premise that health system governance and changes to the workforce are at the heart of health system performance, we conducted a systematic review examining how they are linked. Key messages from the report are that: (1) leadership, communication and engagement are crucial to workforce change; (2) workforce outcomes need to be considered in conjunction with patient outcomes; and (3) decision-makers and researchers need to work together to develop an evidence base to inform future reform planning.
PMCID: PMC4253899  PMID: 25410700
11.  Primary Care – First Line of Defence 
Healthcare Policy  2014;10(1):10-11.
PMCID: PMC4253891  PMID: 25410692
13.  Economic Evaluation of Manitoba Health Lines in the Management of Congestive Heart Failure 
Healthcare Policy  2013;9(2):36-50.
Objective:
This one-year study investigated whether the Manitoba Provincial Health Contact program for congestive heart failure (CHF) is a cost-effective intervention relative to the standard treatment.
Design:
Individual patient-level, randomized clinical trial of cost-effective model using data from the Health Research Data Repository at the Manitoba Centre for Health Policy, University of Manitoba.
Methods:
A total of 179 patients aged 40 and over with a diagnosis of CHF levels II to IV were recruited from Winnipeg and Central Manitoba and randomized into three treatment groups: one receiving standard care, a second receiving Health Lines (HL) intervention and a third receiving Health Lines intervention plus in-house monitoring (HLM). A cost-effectiveness study was conducted in which outcomes were measured in terms of QALYs derived from the SF-36 and costs using 2005 Canadian dollars. Costs included intervention and healthcare utilization. Bootstrap-resampled incremental cost-effectiveness ratios were computed to take into account the uncertainty related to small sample size.
Results:
The total per-patient mean costs (including intervention cost) were not significantly different between study groups. Both interventions (HL and HLM) cost less and are more effective than standard care, with HL able to produce an additional QALY relative to HLM for $2,975. The sensitivity analysis revealed that there is an 85.8% probability that HL is cost-effective if decision-makers are willing to pay $50,000.
Conclusion:
Findings demonstrate that the HL intervention from the Manitoba Provincial Health Contact program for CHF is an optimal intervention strategy for CHF management compared to standard care and HLM.
PMCID: PMC3999537  PMID: 24359716
14.  Waste, Economists and American Healthcare 
Healthcare Policy  2013;9(2):12-20.
Twenty-five years ago, Uwe Reinhardt pointed out that sheer bureaucratic waste, particularly in the private sector, accounted for much of the extraordinarily high cost of American health-care. Last year an expert panel of the Institute of Medicine reconfirmed his point, estimating that in 2009, administrative waste accounted for $190 billion out of a total of $765 billion in various forms of waste – 31% of overall American spending on healthcare. Reinhardt recently noted a peculiar schizophrenia among American economists, simultaneously deploring this monumental waste while celebrating the contribution of healthcare, and particularly medical research, to the American economy. The apparent paradox may arise from a confusion between the meanings of “value” in economic and everyday language, and from economists' tendency to create pseudo-aggregates of diverse and non-commensurate entities.
PMCID: PMC3999538  PMID: 24359713
15.  Health Canada and the Pharmaceutical Industry: A Preliminary Analysis of the Historical Relationship 
Healthcare Policy  2013;9(2):22-29.
In the past two decades, Health Canada has been accused of favouring the pharmaceutical industry over the public in areas of pharmaceutical policy. This orientation has been tied to the introduction of user fees by the industry in 1994 that help finance key aspects of drug regulation. This paper provides a preliminary examination of the history of the relationship starting in 1939 until the mid-1980s in an attempt to discern whether 1994 really represented a key turning point. Clientele pluralism, a theory that explains the relationship between the state and interest groups, is used to explain the nature of the events described.
PMCID: PMC3999539  PMID: 24359714
16.  Active Referral: An Innovative Approach to Engaging Traditional Healthcare Providers in TB Control in Burkina Faso 
Healthcare Policy  2013;9(2):51-64.
Background and objective:
The involvement of traditional healthcare providers (THPs) has been suggested among strategies to increase tuberculosis case detection. Burkina Faso has embarked on such an attempt. This study is a preliminary assessment of that model.
Methods:
Qualitative data were collected using unstructured key informant interviews with policy makers, group interviews with THPs and health workers, and field visits to THPs. Quantitative data were collected from program reports and the national tuberculosis (TB) control database.
Results and analysis:
The distribution of tasks among THPs, intermediary organizations and clinicians is appealing, especially the focus on active referral. THPs are offered incentives based on numbers of suspected cases confirmed by health workers at the clinic, based on microscopy results or clinical assessment. The positivity rate was 23% and 9% for 2006 and 2007, respectively. The contribution of the program to national case detection was estimated at 2% for 2006. Because it relied totally on donor funding, the program suffered from irregular disbursements, resulting in periodic decreases in activities and outcomes.
Conclusions:
The study shows that single interventions require a broader positive policy environment to be sustainable. Even if the active referral approach seems effective in enhancing TB case detection, more complex policy work and direction, domestic financial contribution and additional evidence for cost-effectiveness are needed before the approach can be established as a national policy.
PMCID: PMC3999540  PMID: 24359717
17.  Looking for Lithotripsy: Accessibility and Portability of Canadian Healthcare 
Healthcare Policy  2013;9(2):65-75.
Background:
Extracorporeal shock wave lithotripsy (ESWL) is a definitive, ambulatory and non-invasive modality for treating kidney stones. ESWL is not available in all urban centres and many Canadians must either travel, sometimes out of province, or wait to have this procedure performed. We sought to evaluate the variability in access to ESWL treatment.
Method:
We compiled a comprehensive list of ESWL centres in Canada and contacted all centres in 2011 to assess their wait times, out-of-province patient fees, and roles and responsibilities of the referring physician.
Results:
We contacted all 23 ESWL facilities across Canada (100% response rate). Wait times for elective ESWL procedures ranged from one day to over one year, with a mean of 8.4 weeks (SD, 16.76 weeks). No centres refused out-of-province patients, although five discouraged travel to their centre owing to their prolonged wait times. No facilities charged extra fees for out-of-province patients. Ten (43%) facilities required a secondary consultation by a urolo-gist at the centre before booking. Twelve (52%) of the centres indicated the waiting time could be shortened if the referring physician were to advocate on the patient's behalf. Contact was repeated one year later in 2012 with five centres, and the results were similar.
Interpretation:
There is marked variation in wait times across Canada for ESWL but there are few barriers to care. Patients' waits may be shortened by physician advocacy.
PMCID: PMC3999541  PMID: 24359718
18.  Fee Increases and Target Income Hypothesis: Data from Quebec on Physicians' Compensation and Service Volumes 
Healthcare Policy  2013;9(2):30-35.
Recent years have witnessed important public investments in physicians' compensation across Canada. The current paper uses data from Quebec to assess the impact of those investments on the volumes of services provided to the population. While total physician compensation costs, average physician compensation and average unit cost per service all rose extremely fast, the total number of services, number of services per capita and average number of services per physician either stagnated or declined. This pattern is compatible with the economic target income hypothesis and raises important policy questions.
PMCID: PMC3999543  PMID: 24359715
19.  Achieving Healthcare Reform: By the Numbers 
Healthcare Policy  2013;9(2):8-9.
PMCID: PMC3999542  PMID: 24359712
20.  High-Cost Users of Ontario's Healthcare Services 
Healthcare Policy  2013;9(1):44-51.
Approximately 1.5% of Ontario's population, represented by the top 5% highest cost-incurring users of Ontario's hospital and home care services, account for 61% of hospital and home care costs. Similar studies from other jurisdictions also show that a relatively small number of people use a high proportion of health system resources. Understanding these high-cost users (HCUs) can inform local healthcare planners in their efforts to improve the quality of care and reduce burden on patients and the healthcare system. To facilitate this understanding, we created a profile of HCUs using demographic and clinical characteristics. The profile provides detailed information on HCUs by care type, geography, age, sex and top clinical conditions.
PMCID: PMC3999548  PMID: 23968673
21.  Alternative Level of Care: Canada's Hospital Beds, the Evidence and Options 
Healthcare Policy  2013;9(1):26-34.
Patients designated as alternative level of care (ALC) are an ongoing concern for healthcare policy makers across Canada. These patients occupy valuable hospital beds and limit access to acute care services. The objective of this paper is to present policy alternatives to address underlying factors associated with ALC bed use. Three alternatives, and their respective limitations and structural challenges, are discussed. Potential solutions may require a mix of policy options proposed here.
Inadequate policy jeopardizes new acute care activity-based funding schemes in British Columbia and Ontario. Failure to address this issue could exacerbate pressures on the existing bottlenecks in the community care system in these and other provinces.
PMCID: PMC3999549  PMID: 23968671
22.  The Association between Health Information Technology Adoption and Family Physicians' Practice Patterns in Canada: Evidence from 2007 and 2010 National Physician Surveys 
Healthcare Policy  2013;9(1):89-90.
Objective:
To describe the association between health information technology (HIT) adoption and family physicians' patient visit length in Canada after controlling for physician and practice characteristics.
Method:
HIT adoption is defined in terms of four types of HIT usage: no HIT use (NO), basic HIT use without electronic medical record system (HIT), basic HIT use with electronic medical record (EMR) and advanced HIT use (EMR + HIT). The outcome variable is the average time spent on a patient visit (visit length). The data for this study came from the 2007 and 2010 National Physician Surveys. A log-linear model was used to analyze our visit length outcome.
Results:
The average time worked per week was found to be in the neighbourhood of 36 hours in both 2007 and 2010, but users of EMR and EMR + HIT were undertaking fewer patient visits per week relative to NO users. Multivariable analysis showed that EMR and EMR + HIT were associated with longer average time spent per patient visit by about 7.7% (p<0.05) and 6.7% (p<0.01), respectively, compared to NO users in 2007. In 2010, EMR was not statistically significant and EMR + HIT was associated with a 4% (p<0.1) increased visit length. A variety of practice-related variables such as the mode of remuneration, work setting and interprofessional practice influenced visit length in the expected direction.
Conclusion:
Use of HIT is found to be associated with fewer patient visits and longer visit length among family physicians in Canada relative to NO users, but this association weakened in the multivariable analysis of 2010.
PMCID: PMC3999550  PMID: 23968677
23.  Product Listing Agreements (PLAs): A New Tool for Reaching Quebec's Pharmaceutical Policy Objectives? 
Healthcare Policy  2013;9(1):65-75.
Product listing agreements (PLAs) with pharmaceutical manufacturers are increasingly viewed as an innovative and useful tool in the effort to control drug expenditures. To date, Quebec is the only province that has been reluctant to enter into such agreements, arguing that their confidential nature may lead to a disparity in coverage between individuals covered by the public plan and those covered by private insurance. While PLAs may, in fact, present such a risk, in this paper we will argue that when used correctly, these agreements are actually tools that could help attain all four of the objectives set out in Quebec's policy on medications, namely: (a) improved access to drugs, (b) fair and reasonable drug pricing, (c) optimal drug use and (d) maintaining a dynamic biopharmaceutical industry in Quebec.
PMCID: PMC3999551  PMID: 23968675
25.  Adverse Events Associated with Hospitalization or Detected through the RAI-HC Assessment among Canadian Home Care Clients 
Healthcare Policy  2013;9(1):76-88.
Background:
The occurrence of adverse events (AEs) in care settings is a patient safety concern that has significant consequences across healthcare systems. Patient safety problems have been well documented in acute care settings; however, similar data for clients in home care (HC) settings in Canada are limited. The purpose of this Canadian study was to investigate AEs in HC, specifically those associated with hospitalization or detected through the Resident Assessment Instrument for Home Care (RAI-HC).
Method:
A retrospective cohort design was used. The cohort consisted of HC clients from the provinces of Nova Scotia, Ontario, British Columbia and the Winnipeg Regional Health Authority.
Results:
The overall incidence rate of AEs associated with hospitalization ranged from 6% to 9%. The incidence rate of AEs determined from the RAI-HC was 4%. Injurious falls, injuries from other than fall and medication-related events were the most frequent AEs associated with hospitalization, whereas new caregiver distress was the most frequent AE identified through the RAI-HC.
Conclusion:
The incidence of AEs from all sources of data ranged from 4% to 9%. More resources are needed to target strategies for addressing safety risks in HC in a broader context. Tools such as the RAI-HC and its Clinical Assessment Protocols, already available in Canada, could be very useful in the assessment and management of HC clients who are at safety risk.
PMCID: PMC3999553  PMID: 23968676

Results 1-25 (477)