George Kephart

Equity in health services use and intensity of use in Canada

BackgroundThe Canadian health care system has striven to remove financial or other barriers to access to medically necessary health care services since the establishment of the Canada Health Act 20 years ago. Evidence has been conflicting as to what extent the Canadian health care system has met this goal of equitable access. The objective of this study was to examine whether and where socioeconomic inequities in health care utilization occur in Canada.MethodsWe used a nationally representative cross-sectional survey, the 2000/01 Canadian Community Health Survey, which provides a large sample size (about 110,000) and permits more comprehensive adjustment for need indicators than previous studies. We separately examined general practitioner, specialist, and hospital services using two-part hurdle models: use versus non-use by logistic regression, and the intensity of use among users by zero-truncated negative binomial regression.ResultsWe found that lower income was associated with less contact with general practitioners, but among those who had contact, lower income and education were associated with greater intensity of use of general practitioners. Both lower income and education were associated with less contact with specialists, but there was no statistically significant relationship between these socioeconomic variables and intensity of specialist use among the users. Neither income nor education was statistically significantly associated with use or intensity of use of hospitals.ConclusionOur study unveiled possible socioeconomic inequities in the use of health care services in Canada.

Human Resources Planning and the Production of Health: A Needs-Based Analytical Framework

Traditional approaches to health human resources planning emphasize the effects of demographic change on the needs for health human resources. Planning requirements are largely based on the size and demographic mix of the population applied to simple population-provider or population-utilization ratios. We develop an extended analytical framework based on the production of health-care services and the multiple determinants of health human resource requirements. The requirements for human resources are shown to depend on four separate elements: demography, epidemiology, standards of care, and provider productivity. The application of the framework is illustrated using hypothetical scenarios for the population of the combined provinces of Atlantic Canada.

Variation in pharmacy prescription refill adherence measures by type of oral antihyperglycaemic drug therapy in seniors in Nova Scotia, Canada

Objective: To examine the association between pharmacy prescription refill adherence by type of oral antihyperglycaemic medications used in seniors in Nova Scotia, Canada.

Coprescribing of nonsteroidal anti-inflammatory drugs and cytoprotective and antiulcer drugs in Nova Scotia's senior population

Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently prescribed for the elderly and are commonly prescribed with cytoprotective or antiulcer drugs to prevent or treat gastrointestinal side effects. The objective of this study was to examine the utilization and drug costs of NSAIDs, and to examine coprescription of cytoprotective and antiulcer drugs with NSAIDs in the Nova Scotia population aged 65 years and older. The study used data from the Nova Scotia Seniors Pharmacare program database, which contains data on claims for all filled prescriptions to persons 65 years of age and older. We examined claims for the period April 1, 1993, to March 31, 1994. Aspirin accounted for the largest percentage of the total days supply of NSAIDs (25.2%), followed by diclofenac (18.8%) and naproxen (12.9%). Diclofenac accounted for the largest share of expenditures for NSAIDs (27.6%). Overall, 17.1% of the total days supply of NSAIDs were coprescribed with a cytoprotective or antiulcer drug. Histamine2 blockers accounted for most coprescribed days supply (83.6%) followed by sucralfate (8.1%), misoprostol (4.5%), and omeprazole (2.3%). The appropriateness and cost-effectiveness of these coprescriptions must be examined.

Planning for what? Challenging the assumptions of health human resources planning

OBJECTIVES Health human resource planning has traditionally been based on simple models of demographic changes applied to observed levels of service utilization or provider supply. No consideration has been given to the implications of changing levels of need within populations over time. Recently, needs based resource planning models have been suggested that incorporate changes in needs for care explicitly as a determinant of health care needs. METHODS In this paper, population indicators of morbidity, mortality and self-assessed health are analyzed to determine if health care needs have changed across birth cohorts in Canada from 1994 to 2005 among older age groups. Multivariate regression analysis was used to estimate the age pattern of health by birth year with interaction terms included to examine whether the association of age with health was conditional on the birth year. RESULTS Results indicate that while the probability of mortality, mobility problems and pain rises with age, the rate of change is greater for those born earlier. The probability of self-assessed poor health increases with age but the rate of change with age is constant across birth years. CONCLUSIONS Even in the short time period covered, our analysis shows that health care needs by age are changing over time in Canada.

The Use of the World Health Organisation Anatomical Therapeutic Chemical/Defined Daily Dose Methodology in Canada*:

Drug utilization studies can provide useful information to improve the appropriate and effective use of pharmaceuticals in populations. Using common drug utilization evaluation systems can facilitate national and international comparisons of drug use, examine trends in use over time, and compare drug use to best practice. Limited work has been done in Canada to compare drug use across jurisdictions (provinces, regions) or with other countries. In order to make such comparisons, a common framework is needed. The World Health Organisation (WHO) Anatomical Therapeutic Chemical classification and Defined Daily Dose measure for studying drug utilization in Canada is explained, high-lighting advantages of and considerations with use of this methodology. Examples of Canadian studies using this methodology are provided. In linking the Anatomical Therapeutic Chemical/Defined Daily Dose with each marketed drugs unique identifier (the Canadian Drug Identification Number), researchers in Canada have a tool for measuring drug utilization among regions, countries, and time periods.

An Applied Simulation Model for Estimating the Supply of and Requirements for Registered Nurses Based on Population Health Needs

Aging populations, limited budgets, changing public expectations, new technologies, and the emergence of new diseases create challenges for health care systems as ways to meet needs and protect, promote, and restore health are considered. Traditional planning methods for the professionals required to provide these services have given little consideration to changes in the needs of the populations they serve or to changes in the amount/types of services offered and the way they are delivered. In the absence of dynamic planning models that simulate alternative policies and test policy mixes for their relative effectiveness, planners have tended to rely on projecting prevailing or arbitrarily determined target provider—population ratios. A simulation model has been developed that addresses each of these shortcomings by simultaneously estimating the supply of and requirements for registered nurses based on the identification and interaction of the determinants. The model’s use is illustrated using data for Nova Scotia, Canada.

Need-based resource allocation: different need indicators, different results?

BackgroundA key policy objective in most publicly financed health care systems is to allocate resources according to need. Many jurisdictions implement this policy objective through need-based allocation models. To date, no gold standard exists for selecting need indicators. In the absence of a gold standard, sensitivity of the choice of need indicators is of concern. The primary objective of this study was to assess the consistency and plausibility of estimates of per capita relative need for health services across Canadian provinces based on different need indicators.MethodsUsing the 2000/2001 Canadian Community Health Survey, we estimated relative per capita need for general practitioner, specialist, and hospital services by province using two approaches that incorporated a different set of need indicators: (1) demographics (age and sex), and (2) demographics, socioeconomic status, and health status. For both approaches, we first fitted regression models to estimate standard utilization of each of three types of health services by indicators of need. We defined the standard as average levels of utilization by needs indicators in the national sample. Subsequently, we estimated expected per capita utilization of each type of health services in each province. We compared these estimates of per capita relative need with premature mortality in each province to check their face validity.ResultsBoth approaches suggested that expected relative per capita need for three services vary across provinces. Different approaches, however, yielded different and inconsistent results. Moreover, provincial per capita relative need for the three health services did not always indicate the same direction of need suggested by premature mortality in each province. In particular, the two approaches suggested Newfoundland had less need than the Canadian average for all three services, but it had the highest premature mortality in Canada.ConclusionSubstantial differences in need for health care may exist across Canadian provinces, but the direction and magnitude of differences depend on the need indicators used. Allocations from models using survey data lacked face validity for some provinces. These results call for the need to better understand the biases that may result from the use of survey data for resource allocation.

Estimation of hospital costs for colorectal cancer care in Nova Scotia

BACKGROUND Colorectal cancer (CRC) is the second most common invasive cancer in Canada. Estimates of the costs of care allow estimation of the cost effectiveness of screening for premalignant and early disease. OBJECTIVE To estimate, from administrative data, the hospital costs incurred by a population-based cohort of CRC cases over three years from diagnosis. DESIGN All Nova Scotia residents with CRC who were diagnosed in 1990 were identified from the Nova Scotia Cancer Registry. These cases were linked to the administrative files of the Nova Scotia Department of Health, which contain information on diagnosis, procedures and length of stay for all admissions and day surgery visits to Nova Scotia hospitals. MEASUREMENTS The lengths of stay and hospital-specific per diem rates were used as the measures of resource use. The costs were analyzed in terms of the extent of spread at diagnosis; the time period after diagnosis; the time period before death; and, for typical cases, the age and presence of comorbidity identified during the initial surgical admission. RESULTS The estimated three-year hospital cost for the complete cohort of 593 cases was

Chronic disease risk factors associated with health service use in the elderly

9.8 million. This cost was significantly less for cases with local spread, highest in the six months around, and after diagnosis and in the final six months of life, and highest in the typical cases (patients who were older and had significant comorbid conditions). CONCLUSIONS Hospital-specific per diem rates and lengths of stay are an approximate measure of hospital resource use.