Publications by authors named "Audrey Laporte"

102 Publications

The effect of mental health on social capital: An instrumental variable analysis.

Soc Sci Med 2021 Mar 9;272:113693. Epub 2021 Jan 9.

IHPME, University of Toronto, Centre for Health Economics and Hull York Medical School, University of York, UK. Electronic address:

Although a large body of literature has examined the effect of social capital on health and theoretical models suggest a reciprocal relationship between the two variables, there are relatively few studies that have investigated the effect of mental health on social capital. This paper evaluates the impact of mental health on the stock of social capital using data from the cross-sectional 2012 (N = 21,844) and 2002 (N = 31,089) Canadian Community Health Survey - Mental Health editions. Mental health was measured retrospectively as self-rated mental health, past year mental health conditions, and past 30-day psychological distress. Given the reciprocal relationship, we used an instrumental variable approach with family history of mental health problems as the instrument and examined forms of social capital - sense of belonging and workplace social support - that are largely measures of social capital provided by non-family members in the community and workplace. The analysis suggests there are large and significant associations between measures of mental health and both outcomes, which persist in the instrumental variable analyses. These findings highlight the urgent need for policy makers to implement greater prevention and treatment of poor mental health, and provide greater support for individuals with poor mental health so they can build and maintain their social capital.
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http://dx.doi.org/10.1016/j.socscimed.2021.113693DOI Listing
March 2021

Smoking patterns based on birth-cohort-specific histories from 1965 to 2013, with projections to 2041.

Health Rep 2020 11;31(11):16-31

Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut.

Background: Characterizing smoking patterns over time is essential for evaluating the impact of tobacco control interventions and predicting smoking-related mortality. Beginning with a 1920s birth cohort, smoking histories (i.e., estimates of smoking initiation and cessation, and prevalence of current and former smokers) were generated.

Data: The Ontario sample (n = 238,411) of the 2003 to 2013 cycles of the Canadian Community Health Survey, which is conducted biennially, was used to obtain cross-sectional information on current smoking behaviour.

Methods: Age at smoking initiation and age at smoking cessation were used to construct smoking histories for each respondent, up to the survey date. An age-period-cohort model was generated and used to examine survival differences by smoking status. Using the model, and adjusting for survival differences in smoking status, the prevalence of current, former and never smokers was estimated in cohorts from 1920 to 1985. Smoking initiation, cessation and intensity were then estimated for age-specific distributions of each birth cohort. These rates were projected forward through to 2041. Smoking patterns by highest level of education were generated using education-stratified models.

Results: Smoking histories show clear trends over time by sex, cohort and age. If current patterns persist, smoking prevalence is projected to decline to single digits (below 10%) by 2023 for women and 2040 for men.

Discussion: Birth-cohort-specific smoking histories can be generated using cross-sectional health surveys. These cohort histories can describe smoking patterns over time and into the future. In turn, these histories can be used in micro-simulation models to evaluate historic or planned tobacco control interventions, and to project smoking prevalence.
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http://dx.doi.org/10.25318/82-003-x202001100002-engDOI Listing
November 2020

Evaluation of a Heart Failure Telemonitoring Program Through a Microsimulation Model: Cost-Utility Analysis.

J Med Internet Res 2020 10 6;22(10):e18917. Epub 2020 Oct 6.

Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.

Background: Heart failure (HF) is a major public health issue in Canada that is associated with high prevalence, morbidity, and mortality rates and high financial and social burdens. Telemonitoring (TM) has been shown to improve all-cause mortality and hospitalization rates in patients with HF. The Medly program is a TM intervention integrated as standard of care at a large Canadian academic hospital for ambulatory patients with HF that has been found to improve patient outcomes. However, the cost-effectiveness of the Medly program is yet to be determined.

Objective: This study aims to conduct a cost-utility analysis of the Medly program compared with the standard of care for HF in Ontario, Canada, from the perspective of the public health care payer.

Methods: Using a microsimulation model, individual patient data were simulated over a 25-year time horizon to compare the costs and quality-adjusted life years (QALYs) between the Medly program and standard care for patients with HF treated in the ambulatory care setting. Data were sourced from a Medly Program Evaluation study and literature to inform model parameters, such as Medly's effectiveness in reducing mortality and hospitalizations, health care and intervention costs, and model transition probabilities. Scenario analyses were conducted in relation to HF severity and TM deployment models. One-way deterministic effectiveness analysis and probabilistic sensitivity analysis were performed to explore the impact on the results of uncertainty in model parameters.

Results: The Medly program was associated with an average total cost of Can $102,508 (US $77,626) per patient and total QALYs of 5.51 per patient compared with the average cost of Can $97,497 (US $73,831) and QALYs of 4.95 per patient in the Standard Care Group. This led to an incremental cost of Can $5011 (US $3794) and incremental QALY of 0.566, resulting in an incremental cost-effectiveness ratio of Can $8850 (US $6701)/QALY. Cost-effectiveness improved in relation to patients with advanced HF and with deployment models in which patients used their own equipment. Baseline and alternative scenarios consistently showed probabilities of cost-effectiveness greater than 85% at a willingness-to-pay threshold of Can $50,000 (US $37,718). Although the results showed some sensitivity to assumptions about effectiveness parameters, the intervention was found to remain cost-effective.

Conclusions: The Medly program for patients with HF is cost-effective compared with standard care using commonly reported willingness-to-pay thresholds. This study provides evidence for decision makers on the use of TM for HF, supports the use of a nurse-led model of TM that embeds clinically validated algorithms, and informs the use of economic modeling for future evaluations of early-stage health informatics technology.
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http://dx.doi.org/10.2196/18917DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7576467PMC
October 2020

Impacts of Absolute and Relative Income on Self-Rated Health in Urban and Rural China.

Int J Health Serv 2020 May 3:20731420922689. Epub 2020 May 3.

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.

This study aims to assess the impacts of absolute and relative income on self-rated health (SRH) of residents in rural and urban China. Data were derived from the China Health and Nutrition Survey. Three distinct measures of relative income were considered (Gini coefficient, Yitzhaki index, and Deaton index) and computed for 3 geographic units (nation, province, and community). Nonlinear dynamic models for panel data were employed to test the absolute and relative income hypotheses. Absolute income was significantly associated with SRH among urban and rural populations. Relative income, as measured by the Gini coefficient, the Yitzhaki index, and the Deaton index, had statistically significant and negative impacts on SRH among the rural population, regardless of the reference group. For the urban population, the Gini coefficient was associated with SRH regardless of the reference group. In contrast, only the Yitzhaki index and the Deaton index at the provincial level were associated with SRH among the urban population. Our findings may provide a reference for policymakers to implement health policies designed to improve population health.
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http://dx.doi.org/10.1177/0020731420922689DOI Listing
May 2020

Towards a Community-Based Dementia Care Strategy: How do We Get There from Here?

World Health Popul 2019 12;18(1):6-29

Associate Professor of Health Economics, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.

As recent policy reports in Ontario and elsewhere have emphasized, most older persons would prefer to age at home. This desire does not diminish for the growing numbers of persons living with dementia (PLWD). Nevertheless, many PLWD end up in residential long-term care (LTC) or in hospital beds. While LTC is valuable for PLWD with highly progressed cognitive and functional impairment requiring high-intensity care, it can be a costly and avoidable option for those who could remain at home if given early access to a coordinated mix of community-based supports. In this lead paper, we begin by exploring the "state of the art" in community-based care for PLWD, highlighting the importance of early and ongoing intervention. We then offer a brief history of dementia care policy in Ontario as an illustrative case study of the challenges faced by policy makers in all jurisdictions as they aim to re-direct healthcare systems focused on "after-the-fact" curative care towards "before-the-fact" prevention and maintenance in the community. Drawing on results from a "balance of care" study, which we conducted in South West Ontario, we examine how, in the absence of viable community-based care options, PLWD can quickly "default" to institutional care. In the final section, we draw from national and international experience to identify the following three key strategic pillars to guide action towards a community-based dementia care strategy: engage PLWD to the extent possible in decisions around their own care; acknowledge and support informal caregivers in their pivotal roles supporting PLWD and consequently the formal care; and enable "ground-up" change through policies and funding mechanisms designed to ensure early intervention across a continuum of care with the aim of maintaining PLWD and their caregivers as independently as possible, for as long as possible, "closer to home."
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http://dx.doi.org/10.12927/whp.2019.26062DOI Listing
December 2019

User-Centered Adaptation of an Existing Heart Failure Telemonitoring Program to Ensure Sustainability and Scalability: Qualitative Study.

JMIR Cardio 2018 Dec 6;2(2):e11466. Epub 2018 Dec 6.

Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.

Background: Telemonitoring interventions for the management of heart failure have seen limited adoption in Canadian health systems, but isolated examples of telemonitoring programs do exist. An example of such a program was launched in a specialty heart failure clinic in Toronto, Canada, and a recent implementation evaluation concluded that reducing the cost of delivering the program is necessary to ensure its sustainability and scalability.

Objective: The objectives of this study were to (1) understand which components of the telemonitoring program could be modified to reduce costs and adapted to other contexts while maintaining program fidelity and (2) describe the changes made to the telemonitoring program to enable its sustainability within the initial implementation site and scalability to other health organizations.

Methods: Semistructured interviews probed the experiences of patients (n=23) and clinicians (n=8) involved in the telemonitoring program to identify opportunities for cost reduction and resource optimization. Ideas for adapting the program were informed by the interview results and prioritized based on (1) potential impact for sustainability and scalability, (2) feasibility, and (3) perceived risks to negatively impacting the program's ability to yield desired health outcomes.

Results: A total of 5 themes representing opportunities for cost reduction were discussed, including (1) Bring Your Own Device (BYOD), (2) technical support, (3) clinician role, (4) duration of enrollment, and (5) intensity of monitoring. The hardware used for the telemonitoring system and the modalities of providing technical support were found to be highly adaptable, which supported the decision to implement a BYOD model, whereby patients used their own smartphone, weight scale, and blood pressure cuff. Changes also included the development of a website aimed at reducing the burden on a technical support telehealth analyst. In addition, the interviews suggested that although it is important to have a clinician who is part of a patient's circle of care monitoring telemonitoring alerts, the skill level and experience were moderately adaptable. Thus, a registered nurse was determined to be more cost-effective and was hired to replace the existing nurse practitioners in the frontline management of telemonitoring alerts and take over the technical support role from a telehealth analyst.

Conclusions: This study provides a user-centered example of how necessary cost-reduction actions can be taken to ensure the sustainability and scalability of telemonitoring programs. In addition, the findings offer insights into what components of a telemonitoring program can be safely adapted to ensure its integration in various clinical settings.
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http://dx.doi.org/10.2196/11466DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6857927PMC
December 2018

Burden of health behaviours and socioeconomic position on health care expenditure in Ontario.

F1000Res 2019 18;8:303. Epub 2019 Mar 18.

ICES, Toronto and Ottawa, Canada.

Smoking, unhealthy alcohol consumption, poor diet and physical inactivity are leading risk factors for morbidity and mortality, and contribute substantially to overall healthcare costs. The availability of health surveys linked to health care provides population-based estimates of direct healthcare costs. We estimated health behaviour and socioeconomic-attribute healthcare costs, and how these have changed during a period when government policies have aimed to reduce their burden.  The Ontario samples of the Canadian Community Health Surveys (conducted in 2003, 2005, and 2007-2008) were linked at the individual level to all records of health care use of publicly funded healthcare. Generalized linear models were estimated with a negative binomial distribution to ascertain the relationship of health behaviours and socioeconomic risk factors on health care costs. The multivariable cost model was applied to unlinked, Ontario CCHS samples for each year from 2004 to 2013 to examine the evolution of health behaviour and socioeconomic-attributable direct health care expenditures over a 10-year period. We included 80,749 respondents, aged 25 years and older, and 312,952 person-years of follow-up. The cost model was applied to 200,324 respondents aged 25 years and older (CCHS 2004 to 2013). During the 10-year period from 2004 to 2013, smoking, unhealthy alcohol consumption, poor diet and physical inactivity attributed to 22% of Ontario's direct health care costs. Ontarians in the most disadvantaged socioeconomic position contributed to 15% of the province's direct health care costs. Combined, these health behaviour and socioeconomic risk factors were associated with 34% ($134 billion) of direct health care costs (2004 to 2013). Over this time period, we estimated a 1.9% reduction in health care expenditure ($5.0 billion) attributable to improvements in some health behaviours, most importantly reduced rates of smoking. Adverse health behaviours and socioeconomic position cause a large direct health care system cost burden.
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http://dx.doi.org/10.12688/f1000research.18205.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6844135PMC
June 2020

The Association between Stroke, Integrated Stroke Systems, and the Employability and Productivity of Canadian Stroke Survivors.

Neuroepidemiology 2019 17;53(3-4):209-219. Epub 2019 Sep 17.

Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.

Background: Integrated stroke systems have been associated with reduced disability in stroke survivors, but their impact on employability and productivity (hours worked/week and hourly wages) of stroke survivors is unclear.

Methods: We used Canadian Community Health Surveys (2000-2014) to conduct a quasi-experimental study with the aim of determining the impact of stroke on employability and productivity, and whether the implementation of integrated stroke systems was associated with improvements in the employability and productivity of adult Canadian stroke survivors. Multivariable generalized Poisson regression models were used to determine the effect of stroke on employability; multivariable Heckman models were used to estimate the effect of stroke on productivity. A difference in differences analysis was used to determine the impact of stroke systems on the primary outcomes.

Results: The study sample included 400,797 respondents, of whom 5,786 (1.4%) were stroke survivors. Compared to the general population, stroke survivors were less likely to be employed (adjusted incidence rate ratio 0.62, 95% CI 0.59-0.66) and earned an hourly wage that was 5.3% lower (95% CI 1.1-9.3) and worked an average of 1.9 fewer hours per week (95% CI 0.9-2.9). Over the study period, the employability of stroke survivors improved but not productivity. After accounting for temporal changes in overall employment, there was no association between the implementation of integrated stroke systems and either employability or productivity.

Conclusion: Employability of stroke survivors improved over the study period but remained lower than the general population, with no differences in provinces with and without integrated stroke systems.
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http://dx.doi.org/10.1159/000502010DOI Listing
June 2020

Cost-effectiveness analysis of infant feeding modalities for virally suppressed mothers in Canada living with HIV.

Medicine (Baltimore) 2019 Jun;98(23):e15841

Women's College Research Institute, Women's College Hospital, Toronto.

Objective: The aim of the study was to determine whether exclusive breastfeeding or exclusive formula feeding is more cost-effective when a Canadian mother with HIV is adherent to antiretroviral therapy and has full virologic suppression.

Design: Current Canadian guidelines recommend that mothers with HIV practice exclusive formula feeding. This contradicts the updated World Health Organization (WHO) guidelines which recommend that mothers with HIV should breastfeed for ≥12 months while receiving support for antiretroviral therapy adherence. Due to the economic and health risks and benefits associated with each modality, there remains expert disagreement on whether the WHO recommendations should be adopted in high-income countries.

Methods: A microsimulation model was developed to estimate lifetime costs and effectiveness (i.e., infant's quality-adjusted life years) of a hypothetical group of 1,000,000 initially healthy, HIV-negative infants, if the mother with HIV was on antiretroviral therapy with full virologic suppression and either exclusive breastfeeding or exclusive formula feeding. The model was developed from the economic perspective of the Ontario Ministry of Health, taking into account direct costs associated with infant feeding modality as well as related indirect costs born out of the child's lifetime health outcomes. Uncertainties related to model parameters were evaluated using one-way and probabilistic sensitivity analyses.

Results: In comparison to exclusive formula feeding, exclusive breastfeeding was the dominant feeding modality (i.e., less costly and more effective) yielding cost-savings of $13,812 per additional quality-adjusted life year gained. Neither one-way nor probabilistic sensitivity analyses altered the conclusions.

Conclusions: Despite the risk of HIV transmission, exclusive breastfeeding was more cost-effective than exclusive formula feeding. These findings merit review of current infant feeding guidelines for mothers with HIV living in high-income countries.
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http://dx.doi.org/10.1097/MD.0000000000015841DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6571366PMC
June 2019

Patient Adherence to a Mobile Phone-Based Heart Failure Telemonitoring Program: A Longitudinal Mixed-Methods Study.

JMIR Mhealth Uhealth 2019 02 26;7(2):e13259. Epub 2019 Feb 26.

Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, Toronto, ON, Canada.

Background: Telemonitoring (TM) can improve heart failure (HF) outcomes by facilitating patient self-care and clinical decision support. However, these outcomes are only possible if patients consistently adhere to taking prescribed home readings.

Objective: The objectives of this study were to (1) quantify the degree to which patients adhered to taking prescribed home readings in the context of a mobile phone-based TM program and (2) explain longitudinal adherence rates based on the duration of program enrollment, patient characteristics, and patient perceptions of the TM program.

Methods: A mixed-methods explanatory sequential design was used to meet the 2 research objectives, and all explanatory methods were guided by the unified theory of acceptance and use of technology 2 (UTAUT2). Overall adherence rates were calculated as the proportion of days patients took weight, blood pressure, heart rate, and symptom readings over the total number of days they were enrolled in the program up to 1 year. Monthly adherence rates were also calculated as the proportion of days patients took the same 4 readings over each 30-day period following program enrollment. Next, simple and multivariate regressions were performed to determine the influence of time, age, sex, and disease severity on adherence rates. Additional explanatory methods included questionnaires at 6 and 12 months probing patients on the perceived benefits and ease of use of the TM program, an analysis of reasons for patients leaving the program, and semistructured interviews conducted with a purposeful sampling of patients (n=24) with a range of adherence rates and demographics.

Results: Overall average adherence was 73.6% (SD 25.0) with average adherence rates declining over time at a rate of 1.4% per month (P<.001). The multivariate regressions found no significant effect of sex and disease severity on adherence rates. When grouping patients' ages by decade, age was a significant predictor (P=.04) whereby older patients had higher adherence rates over time. Adherence rates were further explained by patients' perceptions with regard to the themes of (1) performance expectancy (improvements in HF management and peace of mind), (2) effort expectancy (ease of use and technical issues), (3) facilitating conditions (availability of technical support and automated adherence calls), (4) social influence (support from family, friends, and trusted clinicians), and (5) habit (degree to which taking readings became automatic).

Conclusions: The decline in adherence rates over time is consistent with findings from other studies. However, this study also found adherence to be the highest and most consistent over time in older age groups and progressively lower over time for younger age groups. These findings can inform the design and implementation of TM interventions that maximize patient adherence, which will enable a more accurate evaluation of impact and optimization of resources.

International Registered Report Identifier (irrid): RR2-10.2196/resprot.9911.
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http://dx.doi.org/10.2196/13259DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6412156PMC
February 2019

Exploring Chiropractic Services in the Canadian Forces Health Services - Perceptions of Facilitators and Barriers Among Key Informants.

Mil Med 2019 05;184(5-6):e344-e351

University of Toronto, Institute of Health Policy, Management and Evaluation, 155 College Street, 4th Floor, Toronto, Ontario, Canada.

Introduction: Musculoskeletal (MSK) conditions have a significant impact on the health and operational readiness of military members. The Canadian Forces Health Services (CFHS) provides a spectrum of health services in managing Canadian Armed Forces (CAF) personnel health care needs with on-base and off-base services provided by civilian and uniformed health care professionals, including chiropractors. Although chiropractic services are available in US DoD and VA systems, little is known about the facilitators and barriers to integrating on-base chiropractic services within the CFHS. This study explored key informants' perceptions of facilitators and barriers to the integration of on-base chiropractic services within the CFHS.

Methods: We conducted a qualitative study to describe and understand how an integrated chiropractic service could be designed, implemented, and evaluated within the current interdisciplinary CFHS. Telephone interviews were conducted, using a semi-structured interview guide, to explore key informants' perceptions and experiences of chiropractic care within the CFHS. In total, we invited 27 individuals across Canada to participate; 15 were identified through purposeful sampling, 12 through a snowball sampling technique, and 2 declined. The 25 participants included military personnel (52%), public servants and contractors employed by the Department of Defense (24%), as well as civilian health care providers (24%). All participants were health care providers [physicians (MD) (7), physiotherapists (PT) (13), chiropractors (DC) (5)]. Interviews were audio-recorded and transcribed verbatim. Transcripts were prepared and analyzed using an interpretivist approach that explored key informants' perceptions and experiences.

Results: Qualitative analysis revealed numerous facilitators and barriers to chiropractic services in the CFHS. These were categorized under three broad themes: base-to-base variations, variable gatekeeper roles, and referral processes. Barriers to integrating chiropractic services included: lack of clarity about a chiropractor's clinical knowledge and skills; CFHS team members' negative prior experiences with chiropractors (e.g., inappropriate patient-focused communication, clinical management that was not evidence-based, ignorance of military culture); suboptimal bi-directional communication between CAF personnel and DCs across bases; and wide-ranging perspectives pertaining to duplication of services offered by PTs and DCs in managing MSK conditions. Facilitators associated with the integration of chiropractic services within a collaborative and interdisciplinary CAF environment included: patient benefits associated with multiple approaches utilized by different providers; adoption of up-to-date, high-quality evidence and guidelines to standardize care and curtail "dependency" between patient and providers; and co-location of providers to strengthen existing interprofessional communication and relationships. Key informants called for patient care that is collaborative, integrated and patient-centered, rather than "patient-driven" care; civilian providers understanding and respecting military culture rather than assuming transferability of patient management processes from the public civilian sector; standardization of communication protocols and measures to evaluate outcomes of care; and the need to move slowly and respectfully within the current CAF health care system if planning the on-base implementation of chiropractic services.

Conclusion: This study illuminated many opportunities and barriers, in complex and diverse domains, related to introducing collaborative chiropractic services in the CFHS. The findings are relevant to increasing understanding and strengthening interprofessional collaborative care within the unique CAF health care delivery system.
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http://dx.doi.org/10.1093/milmed/usy319DOI Listing
May 2019

Physician Service Costs: Is There Blame to Share Around?

Authors:
Audrey Laporte

Healthc Pap 2018 04;17(4):28-31

Professor of Health Economics, Director, Canadian Centre for Health Economics, Director, MSc/PhD Research Program, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Adjunct Senior Scientist, Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON.

The rising portion of national income devoted to healthcare in general and the portion allocated to physician services have been a focus of the health policy literature for some time. Greater recognition should be given to the fact that the observed trends in physician service expenditures are the product of the interaction between physicians and provincial governments. Improving the productivity of healthcare systems in the delivery of high-quality primary care will require moving beyond simple oversight to deeper engagement with physicians as partners in system improvement.
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http://dx.doi.org/10.12927/hcpap.2018.25579DOI Listing
April 2018

Pediatric-onset multiple sclerosis is associated with reduced parental health-related quality of life and family functioning.

Mult Scler 2019 10 30;25(12):1661-1672. Epub 2018 Aug 30.

Division of Child Neurology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Background: Diagnosis of multiple sclerosis (MS) during childhood has the potential to impact the affected child's self-perception and the health-related quality of life (HRQoL) of the family.

Objective: To evaluate the impact of chronic disease, in children ascertained as having MS and their families, when compared to those with monophasic acquired demyelinating syndrome (monoADS).

Methods: In a national prospective cohort study of pediatric acquired demyelinating syndromes (ADS), the HRQoL of children and their families was captured using the Pediatric Quality of Life Inventory (PedsQL) Modules.

Results: Participants (58 MS; 178 monoADS) provided cross-sectional HRQoL data a median (interquartile range (IQR)) of 4.1 (2.0-6.0) years after disease onset. The HRQoL of parents of children with MS and their family functioning was lower when compared to that of parents and families of children with monoADS (both  < 0.001); parents of children with MS reported greater emotional dysfunction, worry, worse communication, and lower family functioning irrespective of clinical disease activity. Self-reports of the MS and monoADS participants did not suggest a difference in overall HRQoL or fatigue after adjusting for age of the child at the time of assessment.

Conclusion: While children with MS did not self-report lower HRQoL compared to children who experienced monoADS, the diagnosis of MS during childhood was negatively associated with parental HRQoL and family functioning.
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http://dx.doi.org/10.1177/1352458518796676DOI Listing
October 2019

Evaluating the Implementation of a Mobile Phone-Based Telemonitoring Program: Longitudinal Study Guided by the Consolidated Framework for Implementation Research.

JMIR Mhealth Uhealth 2018 Jul 31;6(7):e10768. Epub 2018 Jul 31.

Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.

Background: Telemonitoring has shown promise for alleviating the burden of heart failure on individuals and health systems. However, real-world implementation of sustained programs is rare.

Objective: The objective of this study was to evaluate the implementation of a mobile phone-based telemonitoring program, which has been implemented as part of standard care in a specialty heart function clinic by answering two research questions: (1) To what extent was the telemonitoring program successfully implemented? (2) What were the barriers and facilitators to implementing the telemonitoring program?

Methods: We conducted a longitudinal single case study. The implementation success was evaluated using the following four implementation outcomes: adoption, penetration, feasibility, and fidelity. Semistructured interviews based on the Consolidated Framework for Implementation Research (CFIR) were conducted at 0, 4, and 12 months with 12 program staff members to identify the barriers and facilitators of the implementation.

Results: One year after the implementation, 98 patients and 8 clinicians were enrolled in the program. Despite minor technical issues, the intervention was used as intended. We obtained qualitative data from clinicians (n=8) and implementation staff members (n=4) for 24 CFIR constructs. A total of 12 constructs were facilitators clustered in the CFIR domains of inner setting (culture, tension for change, compatibility, relative priority, learning climate, leadership engagement, and available resources), characteristics of individuals (knowledge and beliefs about the intervention and self-efficacy), and process (engaging and reflecting and evaluating). In addition, we identified other notable facilitators from the characteristics of the intervention domain (relative advantage and adaptability) and the outer setting (patient needs and resources). Four constructs were perceived as minor barriers- the complexity of the intervention, cost, inadequate communication among high-level stakeholders, and the absence of a formal implementation plan. The remaining CFIR constructs had a neutral impact on the overall implementation.

Conclusions: This is the first comprehensive evaluation of the implementation of a mobile phone-based telemonitoring program. Although the acceptability of the telemonitoring system was high, the strongest facilitators to the implementation success were related to the implementation context. By identifying what works and what does not in a real-world clinical context using a framework-guided approach, this work will inform the design of telemonitoring services and implementation strategies of similar telemonitoring interventions.
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http://dx.doi.org/10.2196/10768DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6092591PMC
July 2018

Implementation and Evaluation of a Smartphone-Based Telemonitoring Program for Patients With Heart Failure: Mixed-Methods Study Protocol.

JMIR Res Protoc 2018 May 3;7(5):e121. Epub 2018 May 3.

Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.

Background: Meta-analyses of telemonitoring for patients with heart failure conclude that it can lower the utilization of health services and improve health outcomes compared with the standard of care. A smartphone-based telemonitoring program is being implemented as part of the standard of care at a specialty care clinic for patients with heart failure in Toronto, Canada.

Objective: The objectives of this study are to (1) evaluate the impact of the telemonitoring program on health service utilization, patient health outcomes, and their ability to self-care; (2) identify the contextual barriers and facilitators of implementation at the physician, clinic, and institutional level; (3) describe patient usage patterns to determine adherence and other behaviors in the telemonitoring program; and (4) evaluate the costs associated with implementation of the telemonitoring program from the perspective of the health care system (ie, public payer), hospital, and patient.

Methods: The evaluation will use a mixed-methods approach. The quantitative component will include a pragmatic pre- and posttest study design for the impact and cost analyses, which will make use of clinical data and questionnaires administered to at least 108 patients at baseline and 6 months. Furthermore, outcome data will be collected at 1, 12, and 24 months to explore the longitudinal impact of the program. In addition, quantitative data related to implementation outcomes and patient usage patterns of the telemonitoring system will be reported. The qualitative component involves an embedded single case study design to identify the contextual factors that influenced the implementation. The implementation evaluation will be completed using semistructured interviews with clinicians, and other program staff at baseline, 4 months, and 12 months after the program start date. Interviews conducted with patients will be triangulated with usage data to explain usage patterns and adherence to the system.

Results: The telemonitoring program was launched in August 2016 and patient enrollment is ongoing.

Conclusions: The methods described provide an example for conducting comprehensive evaluations of telemonitoring programs. The combination of impact, implementation, and cost evaluations will inform the quality improvement of the existing program and will yield insights into the sustainability of smartphone-based telemonitoring programs for patients with heart failure within a specialty care setting.
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http://dx.doi.org/10.2196/resprot.9911DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5958281PMC
May 2018

Relationships between work outcomes, work attitudes and work environments of health support workers in Ontario long-term care and home and community care settings.

Hum Resour Health 2018 03 22;16(1):15. Epub 2018 Mar 22.

Regional Geriatric Program of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.

Background: Our overarching study objective is to further our understanding of the work psychology of Health Support Workers (HSWs) in long-term care and home and community care settings in Ontario, Canada. Specifically, we seek novel insights about the relationships among aspects of these workers' work environments, their work attitudes, and work outcomes in the interests of informing the development of human resource programs to enhance elder care.

Methods: We conducted a path analysis of data collected via a survey administered to a convenience sample of Ontario HSWs engaged in the delivery of elder care over July-August 2015.

Results: HSWs' work outcomes, including intent to stay, organizational citizenship behaviors, and performance, are directly and significantly related to their work attitudes, including job satisfaction, work engagement, and affective organizational commitment. These in turn are related to how HSWs perceive their work environments including their quality of work life (QWL), their perceptions of supervisor support, and their perceptions of workplace safety.

Conclusions: HSWs' work environments are within the power of managers to modify. Our analysis suggests that QWL, perceptions of supervisor support, and perceptions of workplace safety present particularly promising means by which to influence HSWs' work attitudes and work outcomes. Furthermore, even modest changes to some aspects of the work environment stand to precipitate a cascade of positive effects on work outcomes through work attitudes.
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http://dx.doi.org/10.1186/s12960-018-0277-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5863810PMC
March 2018

A Canadian Population-Based Cohort to the Study Cost and Burden of Surgically Resected Hidradenitis Suppurativa.

J Cutan Med Surg 2018 May/Jun;22(3):312-317. Epub 2018 Mar 11.

1 Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.

Background: Hidradenitis suppurativa (HS) is a chronic debilitating disease with long-lasting comorbidities that impose direct and indirect costs on the health care system. However, limited studies have estimated the burden of this disease in Canada, and no population-based studies have previously addressed this condition.

Objectives: This work describes the characteristics of a population-based HS cohort to address the existing knowledge gap on the burden of HS for the Canadian health care system. This cohort will provide a foundation for further studies about clinical outcomes and risk factors of HS by providing opportunities for merging additional databases.

Methods: Data on demographic information, morbidities, relative resource use, and the cost of sectorial services were obtained from the Institute for Clinical Evaluative Sciences (ICES). All residents of Ontario covered by the Ontario Health Insurance Plan (OHIP) between April 1, 2002, and March 31, 2013, who underwent surgery for HS, defined by OHIP billing codes, were included.

Results: A total of 6244 cases were included in the analysis, following quality control procedures. Twice as many females were treated surgically relative to males. The majority of individuals treated were under the age of 64, with more than half having a moderate level of morbidity (according to Resource Utilization Bands defined by the Johns Hopkins Adjusted Clinical Group Classification System).

Conclusions: This cohort study is the first population-based resource about HS in Canada. Administrative population-based databases provide essential information to assess the burden of chronic diseases and identify factors associated with higher cost.
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http://dx.doi.org/10.1177/1203475418763536DOI Listing
December 2018

Shining a Light: Examining Similarities and Differences in the Work Psychology of Health Support Workers Employed in Long-Term Care and Home and Community Care Settings.

J Appl Gerontol 2019 11 6;38(11):1595-1614. Epub 2017 Nov 6.

Ryerson University, Toronto, ON, Canada.

Health Support Workers (HSWs) provide up to 80% of care to residents and clients in the long-term care (LTC) and home and community care (HCC) sectors but have received little research attention compared with the regulated professions. The authors explore similarities and differences in the work psychology of HSWs employed in LTC and HCC settings. Data were collected via survey from 276 LTC and 184 HCC HSWs. Descriptive statistics and path analyses were conducted. HSWs in LTC and HCC settings have significant, positive associations between organizational citizenship behaviors directed toward the organization (OCB-Os) and psychological empowerment, as well as intention to stay (ITS) and job satisfaction. For LTC sector HSWs, there are significant relationships between OCB-Os and quality of work life (QWL), ITS and work engagement, and individual performance and both job satisfaction and QWL. For the HCC sector, OCB-Os and ITS are significantly and directly related to organizational commitment. This study has implications for organizations interested in developing targeted interventions to improve the retention of HSWs.
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http://dx.doi.org/10.1177/0733464817737622DOI Listing
November 2019

Costs of health care across primary care models in Ontario.

BMC Health Serv Res 2017 08 1;17(1):511. Epub 2017 Aug 1.

Canadian Centre for Health Economics, Toronto, Canada.

Background: The purpose of this study is to analyze the relationship between newly introduced primary care models in Ontario, Canada, and patients' primary care and total health care costs. A specific focus is on the payment mechanisms for primary care physicians, i.e. fee-for-service (FFS), enhanced-FFS, and blended capitation, and whether providers practiced as part of a multidisciplinary team.

Methods: Utilization data for a one year period was measured using administrative databases for a 10% sample selected at random from the Ontario adult population. Primary care and total health care costs were calculated at the individual level and included costs from physician services, hospital visits and admissions, long term care, drugs, home care, lab tests, and visits to non-medical health care providers. Generalized linear model regressions were conducted to assess the differences in costs between primary care models.

Results: Patients not enrolled with a primary care physicians were younger, more likely to be males and of lower socio-economic status. Patients in blended capitation models were healthier and wealthier than FFS and enhanced-FFS patients. Primary care and total health care costs were significantly different across Ontario primary care models. Using the traditional FFS as the reference, we found that patients in the enhanced-FFS models had the lowest total health care costs, and also the lowest primary care costs. Patients in the blended capitation models had higher primary care costs but lower total health care costs. Patients that were in multidisciplinary teams (FHT), where physicians are also paid on a blended capitation basis, had higher total health care costs than non-FHT patients but still lower than the FFS reference group. Primary care and total health care costs increased with patients' age, morbidity, and lower income quintile across all primary care payment types.

Conclusions: The new primary care models were associated with lower total health care costs for patients compared to the traditional FFS model, despite higher primary care costs in some models.
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http://dx.doi.org/10.1186/s12913-017-2455-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5540455PMC
August 2017

Factors Associated with Residential Long-Term Care Wait-List Placement in North West Ontario.

Can J Aging 2017 Sep 6;36(3):286-305. Epub 2017 Jul 6.

Institute of Health Policy,Management, and Evaluation,University of Toronto.

This article is based on a study that investigated factors associated with long-term care wait list placement in Ontario, Canada. We based the study's analysis on Resident Assessment Instrument for Home Care (RAI-HC) data for 2014 in the North West Local Health Integration Network (LHIN). Our analysis quantified the contribution of three factors on the likelihood of wait list placement: (1) care recipient, (2) informal caregiver, and (3) formal system. We find that all three factors are significantly related to wait list placement. The results of this analysis could have implications for policies aimed at reducing the number of wait-listed individuals in the community.
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http://dx.doi.org/10.1017/S071498081700023XDOI Listing
September 2017

Hospitalizations for ambulatory care sensitive conditions across primary care models in Ontario, Canada.

Soc Sci Med 2017 05 22;181:24-33. Epub 2017 Mar 22.

Canadian Centre for Health Economics; Institute of Health Policy, Management and Evaluation, University of Toronto. Electronic address:

The study analyzes the relationship between the risk of a hospitalization for an ambulatory care sensitive condition (ACSC), and the primary care payment and the organizational model used by the patient (fee-for-service, enhanced fee-for-service, blended capitation, blended capitation with interdisciplinary teams). The study used linked patient-level health administrative databases and census data housed at the Institute for Clinical Evaluative Sciences in Ontario. Since the province provides universal health care, the data capture all patients in Ontario, Canada's most populous province, with about 13 million inhabitants. All Ontario patients diagnosed with an ACSC prior to April 1, 2012, who had at least one visit with a physician between April 1, 2012, and March 31, 2013, were included in the study (n = 1,710,310). Each patient was assigned to the primary care model of his/her physician. The different models were categorized as Fee-for-Service (FFS), enhanced-FFS, blended capitation, and interdisciplinary team. A logistic regression was used to model the risk of having an ACSC hospitalization during the one-year observation period. Adjustments were made for patient characteristics (age, sex, health status, and socio-economic status) and for the geographic location of the practice. Using patients belonging to FFS models as the reference group, the risk of an ACSC hospitalization was higher for patients belonging to the blended-capitation model using interdisciplinary teams (Adjusted Odds Ratio [AOR] = 1.06, 95% confidence interval [CI] = 1.00-1.12) and lower for enhanced-FFS (AOR = 0.78, CI = 0.74-0.82) and blended capitation patients (AOR = 0.91, CI = 0.86-0.96). Using patients with hypertension as the reference group, the odds of an ACSC hospitalization were much higher for patients with any other ACSC and increased with patients' morbidity. The risk was lower for patients of higher socio-economic status (AOR = 0.63, CI = 0.60-0.67) in the highest neighborhood income quintile.
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http://dx.doi.org/10.1016/j.socscimed.2017.03.040DOI Listing
May 2017

Is the Rational Addiction model inherently impossible to estimate?

J Health Econ 2017 07 28;54:161-175. Epub 2016 Dec 28.

Canadian Centre for Health Economics, Health Sciences Building, University of Toronto, 155 College Street, suite 440, Toronto, Ontario, M5T 3M6, Canada; Department of Economics, University of Guelph, 50 Stone Rd E, Guelph, Ontario, N1G 2W1, Canada.

The Rational Addiction (RA) model is increasingly often estimated using individual level panel data with mixed results; in particular, with regard to the implied rate of time discount. This paper suggests that the odd values of the rate of discount frequently found in the literature may in fact be a consequence of the saddle-point dynamics associated with individual level inter-temporal optimization problems. We report the results of Monte Carlo experiments estimating RA-type difference equations that seem to suggest the possibility that the presence of both a stable and an unstable root in the dynamic process may create serious problems for the estimation of RA equations.
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http://dx.doi.org/10.1016/j.jhealeco.2016.12.005DOI Listing
July 2017

Utilisation of home-based physician, nurse and personal support worker services within a palliative care programme in Ontario, Canada: trends over 2005-2015.

Health Soc Care Community 2017 05 26;25(3):1127-1138. Epub 2016 Dec 26.

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.

With health system restructuring in Canada and a general preference by care recipients and their families to receive palliative care at home, attention to home-based palliative care continues to increase. A multidisciplinary team of health professionals is the most common delivery model for home-based palliative care in Canada. However, little is known about the changing temporal trends in the propensity and intensity of home-based palliative care. The purpose of this study was to assess the propensity to use home-based palliative care services, and once used, the intensity of that use for three main service categories: physician visits, nurse visits and care by personal support workers (PSWs) over the last decade. Three prospective cohort data sets were used to track changes in service use over the period 2005 to 2015. Service use for each category was assessed using a two-part model, and a Heckit regression was performed to assess the presence of selectivity bias. Service propensity was modelled using multivariate logistic regression analysis and service intensity was modelled using log-transformed ordinary least squares regression analysis. Both the propensity and intensity to use home-based physician visits and PSWs increased over the last decade, while service propensity and the intensity of nurse visits decreased. Meanwhile, there was a general tendency for service propensity and intensity to increase as the end of life approached. These findings demonstrate temporal changes towards increased use of home-based palliative care, and a shift to substitute care away from nursing to less expensive forms of care, specifically PSWs. These findings may provide a general idea of the types of services that are used more intensely and require more resources from multidisciplinary teams, as increased use of home-based palliative care has placed dramatic pressures on the budgets of local home and community care organisations.
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http://dx.doi.org/10.1111/hsc.12413DOI Listing
May 2017

Lost Productivity in Stroke Survivors: An Econometrics Analysis.

Neuroepidemiology 2016 20;47(3-4):164-170. Epub 2016 Dec 20.

Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada.

Background: Stroke leads to a substantial societal economic burden. Loss of productivity among stroke survivors is a significant contributor to the indirect costs associated with stroke. We aimed to characterize productivity and factors associated with employability in stroke survivors.

Methods: We used the Canadian Community Health Survey 2011-2012 to identify stroke survivors and employment status. We used multivariable logistic models to determine the impact of stroke on employment and on factors associated with employability, and used Heckman models to estimate the effect of stroke on productivity (number of hours worked/week and hourly wages).

Results: We included data from 91,633 respondents between 18 and 70 years and identified 923 (1%) stroke survivors. Stroke survivors were less likely to be employed (adjusted OR 0.39, 95% CI 0.33-0.46) and had hourly wages 17.5% (95% CI 7.7-23.7) lower compared to the general population, although there was no association between work hours and being a stroke survivor. We found that factors like older age, not being married, and having medical comorbidities were associated with lower odds of employment in stroke survivors in our sample.

Conclusions: Stroke survivors are less likely to be employed and they earn a lower hourly wage than the general population. Interventions such as dedicated vocational rehabilitation and policies targeting return to work could be considered to address this lost productivity among stroke survivors.
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http://dx.doi.org/10.1159/000454730DOI Listing
December 2017

Achalasia-Specific Quality of Life After Pneumatic Dilation or Laparoscopic Heller Myotomy With Partial Fundoplication: A Multicenter, Randomized Clinical Trial.

Am J Gastroenterol 2016 Nov 13;111(11):1536-1545. Epub 2016 Sep 13.

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.

Objectives: Achalasia is a chronic, progressive, and incurable esophageal motility disease. There is clinical uncertainty about which treatment should be recommended as first-line therapy. Our objective was to evaluate the effectiveness of pneumatic dilation compared with laparoscopic Heller myotomy with partial fundoplication in improving achalasia-specific quality of life.

Methods: This was a prospective, multicenter, randomized trial at five academic hospitals in Canada. Fifty previously untreated adults with a clinical diagnosis of primary achalasia, confirmed by manometric testing, were enrolled between November 2005 and March 2010, and followed for 5 years after treatment. Randomization was stratified by site, in random blocks of size four and with balanced allocation. Patients were treated with pneumatic dilation or laparoscopic Heller myotomy with partial fundoplication. The primary outcome was the difference between the treatments in the mean improvement of the achalasia severity questionnaire (ASQ) score at 1 year from baseline. Prespecified secondary outcomes included general and gastrointestinal quality of life, symptoms, esophageal physiology measures (lower esophageal sphincter relaxation and pressure, esophageal emptying, abnormal esophageal acid exposure), complications, and incidence of retreatment. Functional and imaging studies were performed blinded and all outcome assessors were blinded.

Results: There were no significant differences between treatments in the improvement of ASQ score at 1 year from baseline (27.5 points in the Heller myotomy arm vs. 20.2 points in the pneumatic dilation arm; difference 7.3 points, 95% confidence interval -4.7 to 19.3; P=0.23). There were no differences between treatments in improvement of symptoms, general and gastrointestinal quality of life, or measures of esophageal physiology. Improvements in ASQ score diminished over time for both interventions. At 5 years, there were no differences between treatments in improvement of ASQ score, symptoms, and general or gastrointestinal quality of life. There were no serious adverse events. No patient who received Heller myotomy required retreatment, whereas five patients treated initially with pneumatic dilation required retreatment.

Conclusions: Treatment with pneumatic dilation or laparoscopic Heller myotomy similarly improves achalasia-specific disease severity at 1 year. Either of the therapeutic approaches can be used as first-line therapy for previously untreated adults with achalasia.
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http://dx.doi.org/10.1038/ajg.2016.402DOI Listing
November 2016

The Impact of Receiving Predictive Genetic Information about Lynch Syndrome on Individual Colonoscopy and Smoking Behaviors.

Cancer Epidemiol Biomarkers Prev 2016 11 15;25(11):1524-1533. Epub 2016 Aug 15.

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.

Background: This study investigated whether receiving the results of predictive genetic testing for Lynch syndrome, indicating the presence or absence of an inherited predisposition to various cancers, including colorectal cancer, was associated with change in individual colonoscopy and smoking behaviors, which could prevent colorectal cancer.

Methods: The study population included individuals with no previous diagnosis of colorectal cancer, whose families had already identified deleterious mutations in the mismatch repair or EPCAM genes. Hypotheses were generated from a simple health economics model and tested against individual-level panel data from the Australasian Colorectal Cancer Family Registry.

Results: The empirical analysis revealed evidence consistent with some of the hypotheses, with a higher likelihood of undergoing colonoscopy in those who discovered their genetic predisposition to colorectal cancer and a lower likelihood of quitting smoking in those who discovered their lack thereof.

Conclusions: Predictive genetic information about Lynch syndrome was associated with change in individual colonoscopy and smoking behaviors but not necessarily in ways to improve population health.

Impact: The study findings suggest that the impact of personalized medicine on disease prevention is intricate, warranting further analyses to determine the net benefits and costs. Cancer Epidemiol Biomarkers Prev; 25(11); 1524-33. ©2016 AACR.
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http://dx.doi.org/10.1158/1055-9965.EPI-16-0346DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5274544PMC
November 2016

Does Increased Medication Use among Seniors Increase Risk of Hospitalization and Emergency Department Visits?

Health Serv Res 2017 08 27;52(4):1550-1569. Epub 2016 Sep 27.

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.

Objective: To examine the extent of the health risks of consuming multiple medications among the older population.

Data Sources/study Setting: Secondary data from the period 2004-2006. The study setting was the province of Ontario, Canada, and the sample consisted of individuals aged 65 years or older who responded to a national health survey.

Study Design: We estimated a system of equations for inpatient and emergency department (ED) services to test the marginal effect of medication use on hospital services. We controlled for endogeneity in medication use with a two-stage residual inclusion approach appropriate for nonlinear models.

Principal Findings: Increased prescription drug use has the effect of increasing the likelihood of both being admitted into hospital and visiting a hospital ED. Each additional medication is associated with a 2-3 percent increase in the likelihood of hospitalization and a 3-4 percent increase in the likelihood of an ED visit, after controlling for past utilization, health status, the endogeneity of medication use, and the unobserved factors that may affect the use of both services.

Conclusions: Multiple medications appear to increase the risk of hospitalization among seniors covered by a universal prescription drug plan. These results raise questions about the appropriateness of medication use and the need for increased oversight of current prescribing practices.
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http://dx.doi.org/10.1111/1475-6773.12560DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5517678PMC
August 2017

Efficiency of Ontario primary care physicians across payment models: a stochastic frontier analysis.

Health Econ Rev 2016 Dec 6;6(1):22. Epub 2016 Jun 6.

Canadian Centre for Health Economics, Toronto, Canada.

Objective: The study examines the relationship between the primary care model that a physician belongs to and the efficiency of the primary care physician in Ontario, Canada.

Methods: Survey data were collected from 183 self-selected physicians and linked to administrative databases to capture the provision of services to the patients served for the 12 month period ending June 30, 2013, and the characteristics of the patients at the beginning of the study period. Two stochastic frontier regression models were used to estimate efficiency scores and parameters for two separate outputs: the number of distinct patients seen and the number of visits.

Results: Because of missing data, only 165 physicians were included in the analyses. The average efficiency was 0.72 for both outputs with scores varying from 4 % to 93 % for the visits and 5 % to 94 % for the number of patients seen. We observed that there were both very low and very high efficiency scores within each model. These variations were larger than variations in average scores across models.
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http://dx.doi.org/10.1186/s13561-016-0101-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4894855PMC
December 2016

Funding Long-Term Care in Canada: Who Is Responsible for What?

Healthc Pap 2016 ;15(4):36-40

Associate Professor of Health Economics, Institute for Health Policy, Management and Evaluation, University of Toronto, Director, Canadian Centre for Health Economics, Toronto, ON.

As Adams and Vanin (2016) have noted, different ways of funding long-term care (LTC) have different implications. Because health is not just healthcare, and LTC is not homogeneous, determining the appropriate public-private mix is complex. We suggest that how issues are framed helps influence policy choices, including who should pay for what, and how things should be financed. In addition, the distribution of expenditures for some services can be highly skewed, affecting the extent to which average cost data are useful in extrapolating their costs. We note that health expenditures fall into multiple categories, each presenting different policy issues. For example, framing LTC as health, as basic costs associated with living or as forced savings (like pensions) affects which funding approaches might be used, and the extent to which changes in the population distribution will affect cost structures. Underlying these discussions are questions of solidarity, and how much we believe that we are our brother's - or grandmother's - keeper.
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http://dx.doi.org/10.12927/hcpap.2016.24587DOI Listing
June 2019

Staffing in Ontario's Long-Term Care Homes: Differences by Profit Status and Chain Ownership.

Can J Aging 2016 06;35(2):175-89

Institute of Health Policy,Management and Evaluation (IHPME),University of Toronto.

Ontario has the highest proportion of for-profit nursing homes in Canada. These facilities, which are known in Ontario as long-term care (LTC) homes, offer 24-hour custodial as well as nursing care to individuals who cannot live independently. Increasingly, they are also operating as members of multi-facility chains. Using longitudinal data (1996-2011) from the Residential Care Facilities Survey (n = 627), our analysis revealed discernible differences in staffing levels by profit status and chain affiliation. We found for-profit LTC homes - especially those owned by a chain organization - provided significantly fewer hours of care, after adjusting for variation in the residents' care needs. Findings from this study offer new information on the impact of organizational structure on staffing levels in Ontario's LTC homes and have implications for other jurisdictions where a growing presence of private, chain-affiliated operators has been observed.
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http://dx.doi.org/10.1017/S0714980816000192DOI Listing
June 2016