Michel Grignon

Subjective unmet need and utilization of health care services in Canada: what are the equity implications?

This study aimed to evaluate whether subjective assessments of unmet need may complement conventional methods of measuring socioeconomic inequity in health care utilization. This study draws on the 2003 Canadian Community Health Survey to develop a conceptual framework for understanding how unmet need arises, to empirically assess the association between utilization and the different types of unmet need (due to waiting times, barriers and personal reasons), and to investigate the effect of adjusting for unmet need on estimates of income-related inequity. The studys findings suggest that a disaggregated approach to analyzing unmet need is required, since the three different subgroups of unmet need that we identify in Canada have different associations with utilization, along with different equity implications. People who report unmet need due to waiting times use more health services than would be expected based on their observable characteristics. However, there is no consistent pattern of utilization among people who report unmet need due to access barriers, or for reasons related to personal choice. Estimates of inequity remain unchanged when we incorporate information on unmet need in the analysis. Subjective assessments of unmet need, namely those that relate to barriers to access, provide additional policy-relevant information that can be used to complement conventional methods of measuring inequity, to better understand inequity, and to guide policy action.

Access to psycho-social resources and health: exploratory findings from a survey of the French population

We study the psycho-social determinants of self-assessed health in order to explain social inequalities in health in France. We use a unique general population survey to assess the respective impact on self-assessed health status of subjective perceptions of social capital, social support, and sense of control, controlling for standard socio-demographic factors (SES, income, education, age, and gender). The survey is unique in that it provides a variety of measures of self-perceived psycho-social resources (trust and civic engagement, social support, sense of control, and self-esteem). We find empirical support for the link between the subjective perception of psycho-social resources and health. Sense of control at work is the most important correlate of health status after income. Other important ones are civic engagement and social support. To a lesser extent, sense of being lower in the social hierarchy is associated with poorer health status. On the contrary, relative deprivation does not affect health in our survey. Since access to psycho-social resources is not equally distributed in the population, these findings suggest that psycho-social factors can partially explain of social inequalities in health in France.

Hospitals in rural or remote areas: An exploratory review of policies in 8 high-income countries.

Our study reviewed policies in 8 high-income countries (Australia, Canada, United States, Italy, Spain, United Kingdom, Croatia and Estonia) in Europe, Australasia and North America with regard to hospitals in rural or remote areas. We explored whether any specific policies on hospitals in rural or remote areas are in place, and, if not, how countries made sure that the population in remote or rural areas has access to acute inpatient services. We found that only one of the eight countries (Italy) had drawn up a national policy on hospitals in rural or remote areas. In the United States, although there is no singular comprehensive national plan or vision, federal levers have been used to promote access in rural or remote areas and provide context for state and local policy decisions. In Australia and Canada, intermittent policies have been developed at the sub-national level of states and provinces respectively. In those countries where access to hospital services in rural or remote areas is a concern, common challenges can be identified, including the financial sustainability of services, the importance of medical education and telemedicine and the provision of quick transport to more specialized services.

The determinants of efficiency in the Canadian health care system.

In spite of the vast number of studies measuring economic efficiency in health care, there has been little take-up of this evidence by policy-makers to date. This study provides an illustration of how a system-level study drawing on best practice in empirical measurement of efficiency may be of practical use to health system decision makers and managers. We make use of the rich data available in Canada to undertake a robust two-stage data envelopment analysis to calculate efficiency at the regional (sub-provincial) level. Decisions about what the health system produces (the outcome to measure efficiency against) and what are the resources it has to produce that outcome were based on interviews and consultation with health system decision makers. Overall, we find large inefficiencies in the Canadian health care system, which could improve outcomes (here, measured as a reduction in treatable causes of death) by between 18 and 35% across our analyses. Also, we find that inefficiencies are the result of three main sets of factors that policy makers could pay attention to: management factors, such as hospital re-admissions; public health factors, such as obesity and smoking rates; and environmental factors such as the populations average income.

Understanding the full breadth of cancer-related patient costs in Ontario: a qualitative exploration

ObjectiveThis research informs existing work by examining the full scope of out-of-pocket costs and lost income, patients’ private insurance behaviors, and their overall management of finances during their cancer treatment. The intent was to gain a deeper understanding of patient circumstances and the related costs.MethodsParticipant qualitative interviews were conducted in person during outpatient clinic visits or by telephone and were recorded between June 2011 and July 2012. Interviews were transcribed verbatim and subjected to a descriptive qualitative analysis. The research team collaborated early in the process (after three subjects were enrolled) to develop a preliminary coding framework. The coding framework was modified to incorporate additional emerging content until saturation of data was evident. Transcripts were coded using the qualitative software NVivo version 9.0.ResultsFifteen patients agreed to participate in the study and 14 completed the interview (seven breast, three colorectal, two lung, and two prostate). Consistent with existing published work, participants expressed concerns regarding expenses related to medications, complementary/alternative medicines, devices, parking and travel. These concerns were exacerbated if patients did not have insurance or lost insurance coverage due to loss of work. Although many acknowledged in hindsight that additional insurance would have helped, they also recognized that at the time of their diagnoses, it was not a viable option. Previously unidentified categorical costs identified in this study included modifications to housing arrangements or renovations, special clothing, fitness costs and the impact of an altered diet.ConclusionWe confirmed the results of earlier Canadian quantitative work. Additionally, cost categories not previously explored were identified, which will facilitate the development of an improved and more comprehensive quantitative questionnaire for future research. Many patients indicated that supplemental health insurance would have made their cancer journey less stressful, highlighting existing gaps in the government funded health care system.

Transnational Wealth-Related Health Inequality Measurement

The study of international differences in wealth-related health inequalities has traditionally consisted of country-by-country comparisons using own-country relative measures of socioeconomic status, which effectively ignores absolute differences in both wealth and health that can differ between and within countries. To address these limitations, we propose an alternative approach: that of constructing a transnational measure of wealth-related health inequality. To illustrate the limitations of the country-by-country approach, we simulate the impact of changes in wealth and health inequalities both between and within countries on cross-country measures of health inequality and find at least five errors that may arise using country-by-country methods. We then empirically demonstrate the transnational approach to wealth-related health inequalities between and within Haiti and the Dominican Republic, the two constituent countries of the island of Hispaniola, using data from their respective Demographic and Health Surveys. Transnational socioeconomic rankings reveal a large and increasing divergence in wealth between the two countries, which would be ignored using the county-by-country approach. We find that wealth-related inequalities in long-term children’s health outcomes are larger than inequalities in short-term health outcomes, and decompositions of the influence of place-based variables on these inequalities reveal country of residence to be the most important factor for long-term outcomes, while urban/rural residence and subnational regions are more important for short-term health outcomes. The significance of this novel methodological approach in relation to conventional health inequality research, including hidden dimensions of wealth-related health inequalities, for example the urbanized “middle class” distribution of HIV and a hidden unequal burden of wasting among children uncovered by the transnational approach are discussed, and errors in gauging changes in inequality over time using a country-by-country approach are highlighted. Using the transnational approach can help to measure important trends in wealth-related health inequalities across countries that more commonly used methods traditionally overlook.

Health inequalities and inequities by age: Stability for the Health Utilities Index and divergence for the Frailty Index

Successful aging is an important policy goal in an aging society. A key indicator of successful aging of a population is whether health inequalities (differences) and inequities (unfair differences) in the population increase or decrease with age. This study investigates how health inequalities and inequities differ across age groups in the Canadian population within the equity framework of equal opportunity for health, using two popular measures of health, the Health Utilities Index Mark 3 (HUI) and the Frailty Index (FI). We use the 2009-10 Canadian Health Measures Survey. We first quantify the degree of health inequality by calculating the Gini coefficient for the distributions of the HUI and the FI within three age groups (20–44, 45–64, and 65–79 years). We then identify sources of health inequality by using regression models and decomposing inequality into ethically acceptable and unacceptable components. We finally quantify the degree of health inequity by calculating the Gini coefficient for each health measure and each age group after standardizing for fairness. We find that the magnitudes of inequality and inequity in the HUI and the FI in each of the three age groups are policy relevant. The magnitude and age-related dynamics of health inequality and inequity depend on the choice of the health measures. In all three age groups, inequality and inequity in health measured by the HUI are larger than those measured by the FI. Across the three age groups, inequality and inequity are stable in the HUI but divergent in the FI. This study contributes to the methodological development to support policies for successful aging. Examination of alternative notions of health captured by the HUI and the FI contributes to the exploration of how the fair distribution of each aspect of health may characterize a successfully aging population.

The Determinants of the Technical Efficiency of Acute Inpatient Care in Canada

OBJECTIVE To evaluate the technical efficiency of acute inpatient care at the pan-Canadian level and to explore the factors associated with inefficiency-why hospitals are not on their production frontier. DATA SOURCES/STUDY SETTING Canadian Management Information System (MIS) database (CMDB) and Discharge Abstract Database (DAD) for the fiscal year of 2012-2013. STUDY DESIGN We use a nonparametric approach (data envelopment analysis) applied to three peer groups (teaching, large, and medium hospitals, focusing on their acute inpatient care only). The double bootstrap procedure (Simar and Wilson 2007) is adopted in the regression. DATA COLLECTION/EXTRACTION METHODS Information on inpatient episodes of care (number and quality of outcomes) was extracted from the DAD. The cost of the inpatient care was extracted from the CMDB. PRINCIPAL FINDINGS On average, acute hospitals in Canada are operating at about 75 percent efficiency, and this could thus potentially increase their level of outcomes (quantity and quality) by addressing inefficiencies. In some cases, such as for teaching hospitals, the factors significantly correlated with efficiency scores were not related to management but to the social composition of the caseload. In contrast, for large and medium nonteaching hospitals, efficiency related more to the ability to discharge patients to postacute care facilities. The efficiency of medium hospitals is also positively related to treating more clinically noncomplex patients. CONCLUSIONS The main drivers of efficiency of acute inpatient care vary by hospital peer groups. Thus, the results provide different policy and managerial implications for teaching, large, and medium hospitals to achieve efficiency gains.

Non-market resource allocation and the public’s interpretation of need: an empirical investigation in the context of health care

The concept of need is central to the non-market allocation of many public resources, although the definition of need to serve as a basis for such resource allocation often remains contested. This study uses a discrete-choice experiment to investigate the general public’s interpretation of need in the context of health care resource allocation, focusing on three commonly cited definitions of need: need as a person’s baseline health status; need as a person’s ability-to-benefit; and need as the amount of resources required to exhaust a person’s ability-to-benefit. Analysis of participants’ need judgments using a latent-class, rank-ordered conditional logit model reveals that most individuals draw on all three definitions when assessing need, and that here is heterogeneity in interpretations of need among the public. Baseline health status is the most influential and consistent determinant of need, while ability-to-benefit and resources-required-to-exhaust-benefit are considered jointly. However, while some assign greater need to those who are worse off in the sense that they have little ability-to-benefit and require large amounts of resources to achieve that benefit, others assign greater need to those who have greater ability-to-benefit and whose benefit can be achieved with small amounts of resources. The public’s reasoning about need contrasts sharply in a number of ways with the types of arguments offered in the literature on needs-based resource allocation.

THE IMPACT OF TECHNOLOGICAL INTENSITY OF SERVICE PROVISION ON PHYSICIAN EXPENDITURES: AN EXPLORATORY INVESTIGATION

Advances in technology and subsequent changes in clinical practice can lead to increases in healthcare costs. Our objective is to assess the impact that changes in the technological intensity of physician-provided health services have had on the age pattern of both the volume of services provided and the average expenditures associated with them. We based our analysis on age-sex-specific patient-level administrative records of diagnoses and treatments. These records include virtually all physician services provided in the province of Ontario, Canada in a 10-year span ending in 2004 and their associated costs. An algorithm is developed to classify services and their costs into three levels of technological intensity. We find that while the overall age-standardized level and cost of services per capita have decreased, the volume and cost of high technologically intensive treatments have increased, especially among older patients.