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Conspicuous consumption: characterizing high users of physician services in one Canadian province

Objectives: To examine medical care use and costs, patterns of morbidity and co-morbidity, and other patient characteristics of high users of physician services in British Columbia. Methods: This population-based study uses physician claims, hospital discharge summaries and vital statistics data linked at the level of the individual to compare characteristics of high users, other users and non-users of physician services in the Province of British Columbia, Canada. The study included all enrolled adults in the universal health care plan during fiscal year 1996/97. High users were defined as the most costly 5% of users of fee-reimbursed services. Key variables included age, sex, an ecological socio-economic status indicator and a comprehensive set of morbidity indicators, derived from the diagnoses recorded on the utilization records. Results: The top 5% of users consumed a disproportionate 30% of spending on physician services. High users were overwhelmingly characterized by a significant burden of morbidity. Over 80% had at least six different types of morbidity during the study year compared with fewer than 20% of other users. High users were also much more likely to have major diagnoses that were both acute and chronic in nature. Co-morbidity involving psychosocial and chronic medical conditions was also very common. Conclusions: High users of physician services are overwhelmingly characterized by multiple and complex health problems. Policy tools based on a philosophy of deterrence such as cost-sharing are unlikely to have much impact on their costs and will likely do considerable harm.

Social and environmental determinants of Aedes aegypti infestation in Central Havana: results of a case–control study nested in an integrated dengue surveillance programme in Cuba

Objective  To characterize the social and environmental risk factors associated with the presence of Aedes aegypti in order to improve community dengue control.

Network analysis as a tool to assess the intersectoral management of health determinants at the local level: A report from an exploratory study of two Cuban municipalities

Intersectoral action on health determinants has long been recognized as an important factor in achieving better population health. Nevertheless, there is no process that provides empirical evidence to policy-makers on the extent of intersectoral collaboration. We aimed to fill this gap by conducting case studies in two municipalities in Cuba, a country well known for its intersectoral practice and good health outcomes. We surveyed an intentional sample of key members of Health Councils - virtual intersectoral spaces in Cuba - about links and related actions they had with other sectors on eleven health determinants. Using network analysis we were able to produce measures to evaluate and characterize the network of sectors. Findings show that the two municipalities were similar in reported importance of health determinants, extent of long-term engagement in intra-sectors actions and level of collaboration with other sectors for virtually all determinants. Municipalities also showed similar overall levels of collaboration for most determinants when considered as a network of different sectors (network density). However municipalities showed differences in the central role played by some sectors (centrality index). We further used the network analysis blockmodeling technique to typify the municipal Health Councils. We found that while one Health Council can be typified by a single well connected network structure, the other has two distinct structures with more sparse connections. We conclude that intersectoral collaboration can be assessed by the use of network analysis measurements. This approach is novel and provides evidence to decision-makers about their role and their effort towards collaboration in achieving better health outcomes.

Intersectoral action for health at a municipal level in Cuba

ObjectiveTo consider how Cuba’s acknowledged achievement of excellent health outcomes may relate to how health determinants are addressed intersectorally.MethodsOur team of Canadian and Cuban researchers and health policy practitioners undertook a study to consider the organization and practices involved in addressing health determinants in 2 municipalities (1 urban and 1 rural). The study included a questionnaire of municipal Health Council members and others involved in health and non-health sectors, key informant interviews of policy makers, focus groups in each municipality and examination of three common case scenarios.ResultsRegular engagement of different sectors and other agencies in addressing health determinants was quite systematic and comparable in both municipalities. Specific policies and organizational structures in support of intersectoral actions were frequently cited and illustrated in case scenarios that demonstrate how maintenance of regular linkages facilitates regular pursuit of intersectoral approaches.ConclusionsThe study demonstrates the feasibility of examining processes of intersectoral action for health processes and suggests that further examination in evaluating factors such as training, particular practices, etc., can be a fruitful direction to pursue comparatively and with analytical designs.

Chronic Pesticide Poisoning from Persistent Low-dose Exposures in Ecuadorean Floriculture Workers: Toward Validating a Low-cost Test Battery

Abstract Chronic pesticide poisoning is difficult to detect. We sought to develop a low-cost test battery for settings such as Ecuador’s floriculture industry. First we had to develop a case definition; as with all occupational diseases a case had to have both sufficient effective dose and associated health effects. For the former, using canonical discriminant analysis, we found that adding measures of protection and overall environmental stressors to occupational category and duration of exposure was useful. For the latter, factor analysis suggested three distinct manifestations of pesticide poisoning. We then determined sensitivity and specificity of various combinations of symptoms and simple neurotoxicity tests from the Pentox questionnaire, and found that doing so increased sensitivity and specificity compared to use of acethylcholinesterase alone – the current screening standard. While sensitivity and specificity varied with different case definitions, our results support the development of a low-cost test battery for screening in such settings.

The impact of professional and personal satisfaction on perceptions of rural and urban: Some analytic evidence

Studies of rural-urban location decisions traditionally used ana priori definition of rural/urban based on population size. A group of 29 physicians (study group) practising in communities of less than 10 000, that were part of a larger sample, perceived their communities as ‘urban’. A matched group of physicians (control group) in the same communities, who perceived the communities as ‘rural’, was selected. The research question raised was: Are there personal and professional factors that could reliably predict the perception of rural and urban? A logistic regression analysis was done using professional and personal satisfaction items as predictors of the two groups. The analysis gives some evidence that, once the effect of community size is removed, the perception of rural urban can be explained by satisfaction with the following: (i) access to specialist expertise, (ii) quality of education for children, (iii) quality of life for children and (iv) quality of housing; satisfaction with size of community was not a significant predictor of rural/urban perception.

A profile of academic physicians in British Columbia.

Abstract —To determine the extent of involvement of British Columbias physician community in the operation of the provinces only medical school, the authors sent questionnaires to all physicians who had any affiliation with the University of British Columbia (UBC). About 20 percent of the provinces physicians were involved in some capacity with the UBC Faculty of Medicine, which accepts about 120 students into the first year annually. Most faculty held “clinical” appointments, meaning that they pursued largely non‐academic careers. Full‐time academic appointees worked more than 20 percent more hours annually than did their “clinical” counterparts, and average hours for men exceeded those for women. As many as two‐thirds of the full‐time faculty were also engaged in sufficient clinical practice activity to be classified as fulltime practicing physicians by a definition adopted by a provincial Joint Medical Manpower Committee. Acad. Med. 64(1989):524–532.

Identifying the population of health managers in one Canadian province: A two-stage approach

Abstract This paper describes a two-stage approach suitable for identifying, and taking inventory of a population of interest which does not have a regulatory body complete with a central registry of personnel employed in the field. The paper discusses the process of developing a conceptual and an operational definition of the population of interest as part of the overall methodology. Our population of interest was health managers and our definition included “those who manage the system” as well as “those who administer facilities”. A two-stage mail survey was then designed first, to identify the individuals, and second, to survey at a later date the individuals thus identified. The second stage, in turn, was done at two levels. The first was a census survey to provide a sociodemographic profile of health managers; and the second more in-depth level was a random sample survey to provide additional information on management roles and competency requirements. The methodology is quite simple and can be generalized to other settings where the population frame for conducting a survey is necessary but not available. Recommendations on how and where to improve this methodology are discussed.

Health care managers in British Columbia, Part I: Who manages our system?

Part I of this article provides, for the first time, the supply side overview of middle- and high-level managers in the B.C. health care system. It presents findings from two province-wide surveys and describes the sociodemographic characteristics and the employment experiences of the population of interest. Part II presents a detailed analysis of management tasks and management roles, and of competency requirements for future managerial roles.

Health care managers in British Columbia, Part II: Exploring future directions.

his is the second part of the analysis from our 1989 multi-stage study to describe the socioT demographic and employment characteristics of health managers in British Columbia, as well as to examine their current and future roles and functions. This paper discusses future directions in health management, as perceived by a random sample of the respondents to the survey, expressed in terms of skills and knowledge required to fulfil management roles of the future. The design and methodology of the study have been described elsewhere? There were 230 usable responses to this section of the survey, administered to a randomly selected sample (n = 468) of the population of interest.