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PubMed2006

Pay-for-performance in publicly financed healthcare: some international experience and considerations for Canada.

Recent reports in the United States and Canada provide evidence that healthcare systems routinely fail to deliver safe and high-quality healthcare services. Governments and other healthcare payers have begun to experiment with pay-for-performance programs that offer healthcare providers and organizations financial incentives for quality. The purpose of this paper is (1) to provide an overview of the design of major pay-for-performance programs in the United States, the United Kingdom, and Australia, with specific focus on government-sponsored programs, and (2) to articulate some considerations for potential implementation of pay-for-performance in Canada.

Australia↗
PubMed2003

Looking back, looking ahead: primary healthcare renewal in Canada.

This year's Health Care in Canada report prepared by the Canadian Institute for Health Information profiles what is changing, and what is not, in Canada's healthcare system, including a selection of findings related to this year's focus topic: primary healthcare.

Canada↗
PubMed2006

Canada's Compassionate Care Benefit: views of family caregivers in chronic illness.

AIM: Based on a pilot evaluation of Canada's recently introduced Compassionate Care Benefit (CCB), the purpose of this paper is to highlight the experiences of family caregivers caring for people with non-malignant advanced chronic illness. DESIGN: Using Patton's (1997) utilization-focused evaluation approach, 25 telephone interviews were conducted with three groups of family caregivers: those who had successfully applied for the CCB; those who were unsuccessful in their applications; those who had never applied for the benefit. FINDINGS: The CCB has a number of limitations, particularly for caregivers of patients diagnosed with non-malignant advanced chronic illness. The central limitations are: difficulties associated with accurate prognostication; limited definition of "family member"; insufficient length of the funding period. CONCLUSION: By modelling similar programmes internationally, such as those in Sweden, Norway, and the Netherlands, Canada would likely find the CCB to have greater relevance and accessibility to Canadian caregivers, particularly those caring for people with non-malignant advanced chronic illness.

Canada↗
PubMed2001

Long-term care funding in Canada: a policy mosaic.

When Canada was founded, health care was delegated as a provincial responsibility. Although the federal government shares a portion of health care costs, it is not directly responsible for the planning, delivery, and governance of health services. The 1984 Canada Health Act set national standards for the provision of physician and hospital services, but it does not apply to home care and long-term care facilities. Consequently, each province has established a unique approach to long-term care, resulting in a health policy mosaic. This paper examines different approaches to funding long-term care with a particular emphasis on the impacts of regionalization and of the implementation of case-mix-based funding systems.

Aged↗
PubMed2006

The impact of deinstitutionalization of psychiatric hospitals on psychological distress of the community in Canada.

OBJECTIVE: There has been a plethora of studies that evaluate the impact of deinstitutionalization of psychiatric services, but they have not examined whether this policy has had an impact on the broader community. The present study addresses this gap by evaluating the impact of the deinstitutionalization of psychiatric hospitals on the mental health of the general population in Canada. METHOD: This research builds on an empirical analysis of 40 years of the process of deinstitutionalization of psychiatric services in Canada (Sealy and Whitehead 2004). An experimental design is simulated through the use of a derived construct, earlier vs. later deinstitutionalization, in order to test whether the policy of deinstitutionalization has achieved the goal of decreasing levels of psychological distress for people in the community. This study attempts to rectify some of the methodological limitations of past evaluations by standardizing the rates of deinstitutionalization among the provinces and taking into consideration the impact of the interaction among levels of perceived social support and the various social correlates of psychological distress. Cross sectional data from the 1994/95 (n = 16,989) and the 1998/99 waves of the National Population Health Survey (n = 14,682) are used to measure levels of psychological distress. RESULTS: Provinces that implemented this policy earlier have levels of psychological distress that are significantly lower than the provinces that implemented deinstitutionalization later. All high risk groups (people with lower levels of income and education, younger people, people living in urban areas) have significantly lower levels of psychological distress in 1998/99 (as compared to 1994/95) with the exception of single parents in the provinces that implemented deinstitutionalization earlier. CONCLUSION: Based on the NPHS, the earlier implementation of deinstitutionalization is associated with lower levels of psychological distress of the community as compared to the provinces that implemented deinstitutionalization later.

Adolescent↗
PubMed2003

Number and distribution of gay bathhouses in the United States and Canada.

Although gay bathhouses have been the subject of debate and some public health policy for decades, the relative number and geographic distribution of these establishments has not been described. As a result, it is easy to miss or ignore them in making public policy in response to discase prevention. No straightforward methodology for such a description is available, so we used a series of gay travel books, first published in 1965 by the Damron Company, to estimate this distribution in the United States and Canada. Each of the annual guides published from 1968 to 1999 were reviewed for listings of bathhouses and sex clubs. The results suggest that bathhouses and other similar establishments exist in most states and provinces and in most large and many moderate-sized cities. Furthermore, the largest numbers of listings for bathhouses were in the same six cities across the decades, three in the U.S. and three in Canada. The greatest change in the number of listings was seen in the three U.S. cities where a public policy of closure was attempted. Nevertheless, the numbers of venues in these three cities have been increasing again since the early 1990s, although nothing near the numbers of listings in the late 1970s and early 1980s.

Canada↗
PubMed2004

Operational characteristics of tractors driven by children on farms in the United States and Canada.

Farm tractors are an important source of traumatic injury for children on farms. There is, however, no documentation about the age and size of tractors that children are operating and little information about the frequency with which rollover protective structures (ROPS) are used. This study described tractors that children on farms in the U.S. and Canada were operating by age, horsepower, and the presence of ROPS, according to the age and gender of the farm children involved. As a sub-analysis of data compiled during a randomized controlled trial, a descriptive analysis was completed on work exposure data collected by telephone interview. Of the 1,113 children involved in the trial, 522 (47%) were reported to perform at least one job that involved the operation of a farm tractor, and 408 (36.7%) were operating tractors of at least 20 horsepower. The majority of these children were male. There was a wide range of ages and sizes of tractors operated. However, the majority of tractors were between 20 and 70 horsepower and manufactured after 1970. Nearly one-half of the tractors were equipped with ROPS, and these tended to be newer and larger tractors. This analysis provides new data about the broad range of tractors driven by farm children in the U.S. and Canada. The findings point to a need to re-examine the reliance on a single voluntary standard to mitigate the hazard of tractor rollovers and the need for an enhanced safety policy requiring all tractors operated by children be equipped with ROPS.

Accidents, Occupational↗
PubMed2006

Evidence-based practice and setting basic standards for stroke rehabilitation in Canada.

It is a concern that the consistency of care in stroke rehabilitation appears to vary significantly among practice settings within Canada. Based upon an evidence-based review of stroke rehabilitation, a group of physiatrists from across Canada agreed to some basic standards for stroke rehabilitation. The following standards were deemed to be critical to providing effective stroke rehabilitation care: early assessment and quick access to specialized interdisciplinary rehabilitation, appropriate intensity of therapies, availability of outpatient therapy, appropriate community supports, and careful attention to secondary prevention of stroke. Providing stroke rehabilitation care consistently within these standards remains a challenge, particularly given the potential initial costs, despite significant improvements in patient outcomes and quality of life. Nevertheless, these standards should be the expectation of stroke patients, essentially forming a stroke rehabilitation "bill of rights."

Canada↗
PubMed2002

Increased use of antidepressants in Canada: 1981-2000.

OBJECTIVE: To provide a descriptive analysis of Canadian utilization (prescriptions, cost, cost per prescription) of antidepressants (ATC-code: N06A). METHODS: IMS Canada provided prescription volumes and costs from 1981 to 2000. We analyzed time trends for antidepressants in general and 4 subclasses (tricyclic antidepressants [TCAs], selective serotonin-reuptake inhibitors [SSRIs], dual action antidepressants [DAAs], and monoamine oxidase inhibitors [MAOIs]). Costs were discounted using the consumer price index, adjusting for population growth using data from Statistics Canada. RESULTS: Between 1981 and 2000, total prescriptions increased from 3.2 to 14.5 million. Market share of TCAs (23.7%) and MAOIs (2.1%) remained constant, despite the introduction of the first SSRI, fluoxetine, in 1989. SSRI prescriptions increased to 6.7 million (market share 46.3%). DAA use increased gradually after 1994 to 3.5 million prescriptions (23.9% market share) in 2000. The number of prescriptions expanded (possibly due to SSRIs) by 238%, with an increased cost of 2.7 billion dollars. Total expenditures for antidepressants increased exponentially, from 31.4 million dollars in 1981 to 543.4 million dollars in 2000 (y = 4E - 130e(0.1556x) [R(2) = 0.99]). Cost per prescription increased linearly from 9.85 dollars in 1981 to 37.44 dollars in 2000 (y = 1.72x + 7.92 [R(2) = 0.96]). CONCLUSIONS: Utilization and costs of pharmacotherapy for depression have increased above the inflation rate and are expected to exceed 1.2 billion dollars (50 dollars per prescription) in 2005. Increased costs may be due to increased availability of new products with increased safety, efficacy, and acquisition cost; increased number of users; and increasing costs.

Antidepressive Agents↗
PubMed2005

Pharmaceutical care in community pharmacies: practice and research in Canada.

OBJECTIVE: To discuss the provision of pharmaceutical care in community pharmacies in Canada including the following topics: organization and delivery of health services, health service policy, methods of payment, types of pharmacy services provided, types of cognitive pharmacy services, research in community pharmacy, and future plans for community pharmacy services. DATA SYNTHESIS: The implementation of pharmaceutical care in Canadian community pharmacies continues to become more widespread. However, barriers to the provision of pharmaceutical care still exist, including the current shortage of pharmacists and lack of reimbursement systems for cognitive services. Evidence of the value of pharmaceutical care in Canadian community pharmacies has been supported by several pharmacy practice research projects. The pharmacist's role in patient care is expected to continue to expand. CONCLUSIONS: Although Canadian pharmacists' capabilities are not yet universally recognized and applied to their full potential, there is reason to be optimistic about the future of pharmaceutical care in the community setting in Canada.

Canada↗
PubMed2000

Community services landscape in Canada: survey of developmental disability agencies.

A survey of support services for adults with development disabilities living in community settings in Canada was conducted. Information gathered on services and changes occurring in the community services landscape is discussed. Along with a diminution of government's role in funding and guiding service provision, Canada has witnessed the emergence of private-for-profit services, a relatively recent phenomenon in human services. Differences between the private-for-profit and nonprofit sectors are discussed, including a greater propensity in the nonprofit agencies to engage in advocacy and community education. Overall, evidence indicates that some services are beginning to incorporate individualized approaches to funding and support. Implications for government and for services of emergent patterns of support are noted.

Adult↗
PubMed2004

Averting disaster: the Hudson's Bay Company and smallpox in western Canada during the late eighteenth and early nineteenth centuries.

During the late eighteenth and early nineteenth centuries the Hudson's Bay Company served as a de facto public health agency across western Canada. Among its biggest challenges was combating the smallpox epidemics that periodically threatened the Aboriginal people of the region. Initially, the Company's employees turned to quarantine over variolation in order to prevent the spread of the disease to Hudson Bay in the summer of 1782. Although well thought-out, ultimately this policy proved unsuccessful. Within thirty years the HBC had turned to the newly discovered vaccination, a strategy that was to prove far more effective in fighting the disease. By the late 1830s the Company was able to mount an effective vaccination campaign that covered much of western Canada.

Canada↗
PubMed2001

A model of destination-language acquisition: application to male immigrants in Canada.

We develop a model using human capital theory and an immigrant adjustment process to generate hypotheses on the acquisition of destination-language skills among immigrants. The model is tested for adult male immigrants in the 1991 Census of Canada. Use of English or French is greater, the younger the age at migration, the longer the duration of residence, the higher the educational attainment, the farther the country of origin from Canada, and the linguistically closer the mother tongue to English or French, and among those who are not refugees, those from a former British, French, or American colony, and those who live in an area where fewer people speak the respondent's mother tongue. The explanatory variables based on birthplace have behavioral interpretations and possess almost as much explanatory power as the birthplace dummy variables.

Adult↗
PubMed2000

Cystic fibrosis. End-stage care in Canada.

OBJECTIVES: To determine the circumstances in which individuals with cystic fibrosis (CF) die, the role of different caregivers, and the extent of palliative care for CF patients. DESIGN: Mailed survey of CF physicians. SETTING: CF centers in Canada. PATIENTS: All CF deaths in 1996 known to centers in Canada. RESULTS: The mean age (+/- SD) at death of the 45 individuals included in the study was 25.8 +/- 13.5 years. The major cause of death was respiratory (34 patients; 75.5%). Nutritional concerns were common. Lung transplantation was considered in 42 patients (93.2%), with 7 patients (17.1%) being entered on a list, but it was carried out in only 2 patients (4.4%). Autopsies were performed on only 10 patients (22.2%). Most patients died in hospital (37 patients; 82.2%), and 7 patients (15.6%) died in ICUs while receiving intermittent positive-pressure ventilation. Palliative care was never discussed in 10 patients (25%). In a further 16 patients (40%), it was not discussed until the last month before death. CONCLUSIONS: Respiratory disease remains the most common cause of death in CF patients. Lung transplantation is frequently considered, but most patients die without having had a transplant. Discussions on end-of-life care could be considered sooner.

Adult↗
PubMed2002

Use of specific inhalation challenge in the evaluation of workers at risk for occupational asthma: a survey of pulmonary, allergy, and occupational medicine residency training programs in the United States and Canada.

STUDY OBJECTIVES: To document the current practice of occupational asthma (OA) diagnosis and use of specific inhalation challenge (SIC). DESIGN, SETTING, AND PARTICIPANTS: A survey evaluating the current practice of SIC was mailed to 259 residency training programs in adult pulmonary diseases, allergy and immunology, and occupational medicine accredited in the United States and Canada during the year 2000. RESULTS: Forty-six percent (123 of 259 programs) participated. Ninety-two programs reported that patients with OA were seen during the previous year, 15 programs reported that SIC had been performed, and 10 programs reported that patients had been referred to other sites for SIC. A total of 259 patients underwent SIC. No unexpected adverse reactions were reported. Forty-one programs reported that they had been willing to undertake SIC but were unable to do so. The most common barriers cited were lack of availability of SIC within the evaluating institution, inability to locate a site for referral, concerns about reimbursement, and lack of an appropriate diagnostic reagent for use in SIC. Seventy-four programs indicated that SIC was useful, and 34 programs included training in the use of SIC was part of the residency curriculum. CONCLUSION: Although SIC is considered the "gold standard" for objective documentation of OA, the test is performed in only a few institutions in the United States and Canada. Many institutions indicate that SIC is not available, even when desired for patient management. Only a minority of participating residency training programs include SIC as a formal part of the training curriculum.

Asthma↗
PubMed2004

Geographic and gender variability in the prevalence of bronchial responsiveness in Canada.

OBJECTIVES: Geographic variability in reported prevalences of asthma worldwide could in part relate to interpretation of symptoms and diagnostic biases. Bronchial responsiveness measurements provide objective evidence of a common physiologic characteristic of asthma. We measured bronchial responsiveness using the standardized protocol of the European Community Respiratory Health Survey (ECRHS) in six sites in Canada, and compared prevalences across Canada with international sites. DESIGN: Samples of 3,000 to 4,000 adults aged 20 to 44 years were randomly selected in Vancouver, Winnipeg, Hamilton, Montreal, Halifax, and Prince Edward Island, and a mail questionnaire was completed by 18,616 individuals (86.5%). Preselected random subsamples (n = 2,962) attended a research laboratory for examination including more detailed questionnaires, lung function testing including methacholine challenge, and skin testing with 14 allergens. RESULTS: Prevalences of bronchial hyperresponsiveness, measured as cumulative dose of methacholine required to produce a 20% fall from the post-saline solution FEV1 < or = 1 mg, ranged from 4.9% (95% confidence interval [CI], 1.6 to 8.5) in Halifax to 22.0% (95% CI, 18.1 to 26.0) in Hamilton (median, 10.7%). In all Canadian sites, bronchial hyperresponsiveness was more prevalent in women than in men. Neither the geographic nor gender differences were accounted for by differences in age, smoking, skin test reactivity, or baseline FEV1. Geographic- and gender-related variability changed little when only bronchial hyperresponsiveness associated with asthma-like symptoms was considered. CONCLUSIONS: A wide variability in bronchial responsiveness can occur within one country, almost as wide as the range found across all international sites participating in the ECRHS study and not explained by differences in gender, smoking, skin test reactivity, and FEV1. While gender variability in the prevalence of bronchial responsiveness is likely due to hormonal and immunologic factors, geographic variability is likely to result from environmental factors.

Adult↗
PubMed2005

Severe maternal morbidity in Canada, 1991-2001.

BACKGROUND: Although death rates are often used to monitor the quality of health care, in industrialized countries maternal deaths have become rare. Severe maternal morbidity has therefore been proposed as a supplementary indicator for surveillance of the quality of maternity care. Our purpose in this study was to describe severe maternal morbidity in Canada over a 10-year period, among women with or without major pre-existing conditions. METHODS: We carried out a retrospective cohort study of severe maternal morbidity involving 2,548,824 women who gave birth in Canadian hospitals between 1991 and 2000. Thirteen conditions that may threaten the life of the mother (e.g., eclampsia) and 11 major pre-existing chronic conditions (e.g., diabetes) that could be identified from diagnostic codes were noted. RESULTS: The overall rate of severe maternal morbidity was 4.38 per 1000 deliveries. The fatality rate among these women was 158 times that of the entire sample. Rates of venous thromboembolism, uterine rupture, adult respiratory distress syndrome, pulmonary edema, myocardial infarction, severe postpartum hemorrhage requiring hysterectomy, and assisted ventilation increased substantially from 1991 to 2000. The presence of major pre-existing conditions increased the risk of severe maternal morbidity to 6-fold. INTERPRETATION: Severe maternal morbidity occurs in about 1 of 250 deliveries in Canada, with marked recent increases in certain morbid conditions such as pulmonary edema, myocardial infarction, hemorrhage requiring hysterectomy, and the use of assisted ventilation.

Adult↗