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Objective: This study examined differences in children's behavior and expenditures for health and social services used when their parents with dysthymia did or did not respond to antidepressant therapy. Method: Children ages 4 to 16 years of consenting parents enrolled in a treatment trial for dysthymia who did and did not respond to treatment were compared at baseline and 24 months. The responder was a parent with at least a 40% reduction in his or her baseline depressive symptoms using the Montgomery Asberg Depression Rating Scale. Children's behavior was measured using the Child Behavior Checklist, and expenditures for health and social services use was measured in Canadian dollars using the Health and Social Service Utilization Questionnaire. Results: Children of parents with dysthymia who responded to treatment had significantly greater reductions in emotional symptoms at 2-year follow-up than children of nonresponders, along with an economically important (not statistically significant) reduction in expenditures for health and social services use. Conclusions: Reductions in parental symptoms of dysthymia may be associated with reductions in childhood behavioral problems and in expenditures for the child's use of services. (Contains 4 tables.)

Background: Multimorbidity, the co-existence of 2+ (or 3+) chronic diseases in an individual, is an increasingly common global phenomenon leading to reduced quality of life and functional status, and higher healthcare service use and mortality. There is an urgent need to develop and test new models of care that incorporate the components of multimorbidity interventions recommended by international organizations, including care coordination, interdisciplinary teams, and care plans developed with patients that are tailored to their needs and preferences. Purpose: To determine the effectiveness of a 6-month, community-based, multimorbidity intervention compared to usual home care services for community-dwelling older adults (age 65+ years) with multimorbidity (3+ chronic conditions) that were newly referred to and receiving home care services. Methods: A pragmatic, parallel, two-arm randomized controlled trial evaluated the intervention, which included in-home visits by an interdisciplinary team, personal support worker visits, and monthly case conferences. The study took place in two sites in central Ontario, Canada. Eligible and consenting participants were randomly allocated to the intervention and control group using a 1:1 ratio. The participants, statistician/analyst, and research assistants collecting assessment data were blinded. The primary outcome was the Physical Component Summary (PCS) score of the 12-Item Short-Form health survey (SF-12). Secondary outcomes included the SF-12 Mental Component Summary (MCS) score, Center for Epidemiological Studies of Depression (CESD-10), Generalized Anxiety Disorder (GAD-7), Self-Efficacy for Managing Chronic Disease, and service use and costs. Analysis of covariance (ANCOVA) tested group differences using multiple imputation to address missing data, and non-parametric methods explored service use and cost differences. Results: 59 older adults were randomized into the intervention (n = 30) and control (n = 29) groups. At baseline, groups were similar for the primary outcome and number of chronic conditions (mean of 8.6), but the intervention group had lower mental health status. The intervention was cost neutral and no significant group differences were observed for the primary outcome of PCS from SF-12 (mean difference: −4.94; 95% CI: −12.53 to 2.66; p = 0.20) or secondary outcomes. Conclusion: We evaluated a 6-month, self-management intervention for older adults with multimorbidity. While the intervention was cost neutral in comparison to usual care, it was not found to improve the PCS from SF-12 or secondary health outcomes. Recruitment and retention challenges were significant obstacles limiting our ability to assess intervention effectiveness. Yet, the intervention was grounded in internationally-endorsed recommendations and implemented in a practice setting (home care) viewed as a key upstream resource fostering independence in older adults. These features collectively support the identification of ways to recruit/retain older adults and test alternative implementation strategies for interventions that are based on sound principles of multimorbidity management. [ABSTRACT FROM AUTHOR]

Background: Most studies that examine comorbidity and its impact on health service utilization focus on a single index-condition and are published in disease-specific journals, which limit opportunities to identify patterns across conditions/disciplines. These comparisons are further complicated by the impact of using different study designs, multimorbidity definitions and data sources. The aim of this paper is to share insights on multimorbidity and associated health services use and costs by reflecting on the common patterns across 3 parallel studies in distinct disease cohorts (diabetes, dementia, and stroke) that used the same study design and were conducted in the same health jurisdiction over the same time period.Methods: We present findings that lend to broader Insights regarding multimorbidity based on the relationship between comorbidity and health service use and costs seen across three distinct disease cohorts. These cohorts were originally created using multiple linked administrative databases to identify community-dwelling residents of Ontario, Canada with one of diabetes, dementia, or stroke in 2008 and each was followed for health service use and associated costs.Results: We identified 376,434 indviduals wtih diabetes, 95,399 wtih dementia, and 29,671 with stroke. Four broad insights were identified from considering the similarity in comorbidity, utilization and cost patterns across the three cohorts: 1) the most prevalent comorbidity types were hypertension and arthritis, which accounted for over 75% of comorbidity in each cohort; 2) overall utilization increased consistently with the number of comorbidities, with the vast majority of services attributed to comorbidity rather than the index conditions; 3) the biggest driver of costs for those with lower levels of comorbidity was community-based care, e.g., home care, GP visits, but at higher levels of comorbidity the driver was acute care services; 4) service-specific comorbidity and age patterns were consistent across the three cohorts.Conclusions: Despite the differences in population demographics and prevalence of the three index conditions, there are common patterns with respect to comorbidity, utilization, and costs. These common patterns may illustrate underlying needs of people with multimorbidity that are often obscured in literature that is still single disease-focused. [ABSTRACT FROM AUTHOR]

Active surveillance (AS) in the management of small, low risk papillary thyroid cancer (PTC) as an alternative option to thyroidectomy, is an area of active research. A national Canadian study is proposed to evaluate the long-term outcomes of patients with small, low risk PTC who choose AS or surgery. This letter describes the proceedings of a national investigator meeting to plan the study. [ABSTRACT FROM AUTHOR]

Objectives: To compare the effect of a 6‐month community‐based intervention with that of usual care on quality of life, depressive symptoms, anxiety, self‐efficacy, self‐management, and healthcare costs in older adults with type 2 diabetes mellitus (T2DM) and 2 or more comorbidities. Design: Multisite, single‐blind, parallel, pragmatic, randomized controlled trial. Setting: Four communities in Ontario, Canada. Participants: Community‐dwelling older adults (≥65) with T2DM and 2 or more comorbidities randomized into intervention (n = 80) and control (n = 79) groups (N = 159). Intervention: Client‐driven, customized self‐management program with up to 3 in‐home visits from a registered nurse or registered dietitian, a monthly group wellness program, monthly provider team case conferences, and care coordination and system navigation. Measurements: Quality‐of‐life measures included the Physical Component Summary (PCS, primary outcome) and Mental Component Summary (MCS, secondary outcome) scores of the Medical Outcomes Study 12‐item Short‐Form Health Survey (SF‐12). Other secondary outcome measures were the Generalized Anxiety Disorder Scale, Center for Epidemiologic Studies Depression Scale (CES‐D‐10), Summary of Diabetes Self‐Care Activities (SDSCA), Self‐Efficacy for Managing Chronic Disease, and healthcare costs. Results: Morbidity burden was high (average of eight comorbidities). Intention‐to‐treat analyses using analysis of covariance showed a group difference favoring the intervention for the MCS (mean difference = 2.68, 95% confidence interval (CI) = 0.28–5.09, P = .03), SDSCA (mean difference = 3.79, 95% CI = 1.02–6.56, P = .01), and CES‐D‐10 (mean difference = −1.45, 95% CI = −0.13 to −2.76, P = .03). No group differences were seen in PCS score, anxiety, self‐efficacy, or total healthcare costs. Conclusion: Participation in a 6‐month community‐based intervention improved quality of life and self‐management and reduced depressive symptoms in older adults with T2DM and comorbidity without increasing total healthcare costs. [ABSTRACT FROM AUTHOR]

Objectives: To measure preferences and willingness to pay (WTP) for a novel anaesthetic (dental gel) versus existing anaesthetic options for periodontal maintenance visits.Design: The study was conducted by developing and administering a survey, composed of a modified decision aid and a WTP instrument. The decision aid provided clinical information in layman's terms. Patients stated their anaesthetic preference; WTP elicited the hypothetical amount of money a subject would pay to have dental gel available for maintenance cleaning, should they require anaesthetic.Patients: Periodontal recall patients (n = 97; 'recall') and participants from the general population (n = 196; 'general') from southwestern Ontario, Canada.Results: The overwhelming majority of participants chose dental gel over injectable local anaesthetic or no anaesthetic as their first anaesthetic preference (general: 81.0%; recall: 82.5%). The median WTP for dental gel was 20.00 Canadian dollars (dollars Can) per visit for the general population and dollars Can10.00 for the recall population (1999 values). The majority of participants were willing to pay an insurance premium for dental gel, even if they did not personally prefer dental gel (general: 72.4%; recall: 73.2%). The median monthly premium to have dental gel available for any plan beneficiary requiring scaling and root planing (SRP) during maintenance was dollars Can2.00 per month for both groups.Conclusions: In this population, an alternative to traditional injectable local anaesthetic (i.e. dental gel) was overwhelmingly preferred by both general population participants and recall patients for maintenance cleaning procedures. Most participants were willing to pay to have dental gel available, either for themselves or for others. [ABSTRACT FROM AUTHOR]

The pan-Canadian Oncology Drug Review (pCODR) makes recommendations to Canada's provinces and territories (except Quebec) to guide their cancer drug funding decisions. The objective of this paper is to explore, using an economic perspective and the pCODR as an example, the challenges associated with striving to simultaneously achieve the goals of maximizing health benefits with available resources and improving access to a more consistent standard of care across Canada. The first challenge concerns how to interpret the goals in order to determine how resources should be allocated to achieve each goal. The second challenge relates to whether, if pursued simultaneously, both goals can be achieved to the same extent that each goal could have been achieved alone with the same available resources. Regarding the first challenge, we illustrate that, due to a lack of definitional clarity, it is difficult to determine exactly how resources should be allocated in order to achieve the goal of improving access to amore consistent standard of care across Canada. Regarding the second challenge, we illustrate that choosing to strive for both of the pCODR goals simultaneously will likely be associated with tradeoffs in the extent to which one or both goals can be achieved (relative to what could have been achieved for each goal alone with the same available resources). We suggest that, if the pCODR and the provincial drug plan decision-makers it supports want to strive for both goals simultaneously, they must prioritize the goals and explicitly identify the tradeoffs associated with the prioritization. This will ensure that the consequences of striving to simultaneously achieve both goals are explicit, transparent, and predictable for provincial drug plan decision-makers, physicians, patients, caregivers, and society as a whole. [ABSTRACT FROM AUTHOR]

In Canada, there are two separate review processes for the public reimbursement of drugs: one for cancer drugs (originally called the Joint Oncology Drug Review [JODR] and now called the pan-Canadian Oncology Drug Review [pCODR]) and one for drugs in all other disease areas (called the Common Drug Review). We explore whether a justification that is derived from an economic perspective has been provided, in Canada or elsewhere, for cancer drugs to have a separate reimbursement review process (i.e. to be 'treated separately') relative to drugs in all other disease areas. Literature reviews and internet searches were undertaken to identify, collect and analyze relevant documents that would provide information regarding whether an economic rationale has been provided for cancer drugs to be treated separately for resource allocation purposes. Although a number of reasons for cancer drugs to be treated separately were cited both by the JODR and pCODR and in the peer-reviewed literature, a rationale derived from an economic perspective did not appear to be documented. From an economic perspective, separating cancer drugs for resource allocation purposes is likely to impede drug plan decision makers' ability to allocate resources in a manner that maximizes the total aggregate health benefit for the population from available resources. While we acknowledge the challenges that cancer drugs pose to drug reimbursement decision makers, we suggest that separating the reimbursement review of cancer drugs requires further scrutiny. [ABSTRACT FROM AUTHOR]

This paper examines the sources of practice variations and definitions of unwarranted variation, as derived from the literature. The literature suggests variables/factors related to patient health needs, doctor 'practice style' and environmental constraints/opportunities as sources of practice variations. However, this list is likely to be incomplete because of significant unexplained variation in each study. Furthermore, it is unclear which factors are sources of unwarranted variation because the reviewed studies do not clearly discriminate between those variations that are unwarranted and those that are not. It is also unclear if context plays a role in determining if and when a factor is unwarranted. The literature contains few frameworks of what constitutes unwarranted variation. Among those offered, more information is needed regarding the scientific basis for including the selected factors, and how to operationalize the framework provided a particular one is chosen. A clear and consistent framework for unwarranted variation, and a clear indication how each component factor could be measured and integrated can help investigators determine which variables should be included in their studies, such that the sources of unwarranted variations may be identified. A better understanding of the role of patient preference as a potential source of practice variations is also required. [ABSTRACT FROM AUTHOR]

Background: Fractures have largely been assessed by their impact on quality of life or health care costs. We conducted this study to evaluate the relation between fractures and mortality. Methods: A total of 7753 randomly selected people (2187 men and 5566 women) aged 50 years and older from across Canada participated in a 5-year observational cohort study. Incident fractures were identified on the basis of validated self-report and were classified by type (vertebral, pelvic, forearm or wrist, rib, hip and "other"). We subdivided fracture groups by the year in which the fracture occurred during follow-up; those occurring in the fourth and fifth years were grouped together. We examined the relation between the time of the incident fracture and death. Results: Compared with participants who had no fracture during follow-up, those who had a vertebral fracture in the second year were at increased risk of death (adjusted hazard ratio [HR] 2.7, 95% confidence interval [CI] 1.1-6.6); also at risk were those who had a hip fracture during the first year (adjusted HR 3.2, 95% CI 1.4-7.4). Among women, the risk of death was increased for those with a vertebral fracture during the first year (adjusted HR 3.7, 95% CI 1.1-12.8) or the second year of follow-up (adjusted HR 3.2, 95% CI 1.2-8.1). The risk of death was also increased among women with hip fracture during the first year of follow-up (adjusted HR 3.0, 95% CI 1.0-8.7). Interpretation: Vertebral and hip fractures are associated with an increased risk of death. Interventions that reduce the incidence of these fractures need to be implemented to improve survival. [ABSTRACT FROM AUTHOR]

Family physicians' personal and practice characteristics may influence how osteoporosis is managed. Thus, we evaluated the impact of family physicians' personal and practice characteristics on the appropriate use of bone mineral density testing and osteoporosis therapy. The physician questionnaire assessed 13 personal and practice characteristics of the physicians. The patient questionnaire was used to collect data to ascertain how family physicians managed osteoporosis. A total of 225 family physicians from 7 provinces across Canada completed both the physician and patient questionnaires. The family physicians evaluated a total of 5601 patients. The generalized estimating equations technique was utilized to model the associations between family physicians' personal and practice characteristics and appropriate use of bone mineral density testing and osteoporosis therapy. Odds ratios (OR) and corresponding 95% confidence intervals (CI) are reported. Findings indicated that female family physicians have higher odds of administering appropriate bone density testing compared to male family physicians (OR: 1.28; 95% CI: 1.05, 1.55), and that physicians who have hospital privileges (OR: 0.77; 95% CI: 0.62, 0.97) and who graduated more recently from medical school (OR: 0.87; 95% CI: 0.77, 0.99) have lower odds of administering appropriate bone mineral density tests. Physicians who use electronic health records have higher odds of administering appropriate therapy (OR: 1.30; 95% CI: 1.06, 1.59) as compared to physicians who do not use them. Several family physicians' personal and practice characteristics are associated with appropriate utilization of bone mineral density testing and therapy. The education of both clinicians and policy makers regarding these new insights may translate to enhanced individual practices and an improved overall health care system to optimize the environment for managing osteoporosis. ( Population Health Management 2009;12:131–138) [ABSTRACT FROM AUTHOR]

Background: While the Osteoporosis Canada 2002 Canadian guidelines provided evidence based strategies in preventing, diagnosing, and managing this condition, publication and distribution of guidelines have not, in and of themselves, been shown to alter physicians clinical approaches. We hypothesize that primary care physicians enrolled in the Quality Circle project would change their patient management of osteoporosis in terms of awareness of osteoporosis risk factors and bone mineral density testing in accordance with the guidelines. Methods: The project consisted of five Quality Circle phases that included: 1) Training & Baseline Data Collection, 2) First Educational Intervention & First Follow-Up Data Collection 3) First Strategy Implementation Session, 4) Final Educational Intervention & Final Follow-up Data Collection, and 5) Final Strategy Implementation Session. A total of 340 circle members formed 34 quality circles and participated in the study. The generalized estimating equations approach was used to model physician awareness of risk factors for osteoporosis and appropriate utilization of bone mineral density testing pre and post educational intervention (first year of the study). Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated. Results: After the 1st year of the study, physicians' certainty of their patients' risk factor status increased. Certainty varied from an OR of 1.4 (95% CI: 1.1, 1.8) for prior vertebral fracture status to 6.3 (95% CI: 2.3, 17.9) for prior hip fracture status. Furthermore, bone mineral density testing increased in high risk as compared with low risk patients (OR: 1.4; 95% CI: 1.2, 1.7). Conclusion: Quality Circle methodology was successful in increasing both physicians' awareness of osteoporosis risk factors and appropriate bone mineral density testing in accordance with the 2002 Canadian guidelines. [ABSTRACT FROM AUTHOR]

Objective:To identify regional differences in recommendations for radioactive iodine remnant ablation (RRA) in early stage well-differentiated thyroid carcinoma (WDTC) within Canada and the United States. Design:A cross-sectional written survey of a sample of physicians in specialties potentially involved in thyroid cancer care was performed in 2006. Participants were asked if they recommended RRA for a hypothetical 38-year-old woman with a solitary, 1.6-cm papillary carcinoma resected by total thyroidectomy. Exploratory regional comparisons were performed using Student ttests or analysis of variance. The regions studied were western Canada, eastern Canada (Ontario, the Maritimes), Quebec, the northeastern United States, the western and midwestern United States, and the southern United States. In a secondary multivariable logistic regression analysis, we explored potential relationships between individual respondent characteristics RRA recommendations. Main outcome:Agreement with case-based RRA recommendations was measured on a Likert scale of 1 to 7 (7 strongest agreement). Results:The effective response rate was 56.3 (486/864). There were significant differences in RRA recommendations among the regions studied (F 11.99, 5 df, p< 0.001); national boundaries did not explain regional variations. For the sample case, the strongest support for RRA was in Quebec and the southern United States, intermediate support in eastern Canada and the northeastern United States, and the least support in western Canada and the western and midwestern United States. Academic affiliation and surgical specialty were independently inversely associated with strong RRA recommendations. Conclusions:There are significant regional differences in physician-based RRA recommendations in early stage WDTC within Canada and the United States. Physician specialty and practice characteristics may influence RRA recommendations. [ABSTRACT FROM AUTHOR]

Background: The two main treatment options for esophageal achalasia are laparoscopic distal esophageal myotomy (LM) and pneumatic dilatation (PD). Our objective was to compare the costs of these management strategies.Methods: We constructed a decision analytic model consisting of two treatment strategies for patients diagnosed with achalasia. Probabilities of events were systematically derived from a literature review, supplemented by expert opinion when necessary. Costs were estimated from the perspective of a third-party payer and society, including both direct and indirect costs. Future costs were discounted at a rate of 5.5% over a time horizon of 5 and 10 years. Uncertainty in the probability estimates was incorporated using probabilistic sensitivity analyses. We tested uncertainty in the model by modifying key assumptions and repeating the analysis.Results: From the societal perspective, the expected cost per patient was $10,789 (LM) compared with $5,315 (PD) five years following diagnosis, and $11,804 (LM) compared with $7,717 (PD) after 10 years. The 95% confidence interval of the incremental cost per patient treated with LM was ($5,280, $5,668) after five years, and ($3,863, $4,311) after 10 years. The incremental cost of LM was similar from the third-party payer perspective and in the secondary model analyzed.Conclusions: Initial LM is a more costly management strategy under all clinically plausible scenarios tested in this model. Further research is needed to determine patients' preferences for the two treatment modalities, and society's willingness to bear the incremental cost of LM for those who choose it. [ABSTRACT FROM AUTHOR]

Abstract: Routine bone mineral densitometry (BMD) screening has been recommended for women aged ≥65 yr (Osteoporosis Canada [OC], International Society for Clinical Densitometry [ISCD], Canadian and United States Task Forces on Preventative Healthcare, and National Osteoporosis Foundation) and for men ≥65 yr (OC) or ≥70 yr (ISCD). We estimated the number of older Canadians needed to screen (NNS) by BMD to detect an undiagnosed case of osteoporosis, using prospective, multicenter, population-based data from the Canadian Multicentre Osteoporosis Study (CaMos). We included participants aged ≥65 yr with baseline dual-energy X-ray absorptiometry (DXA) BMDs at the femoral neck and lumbar spine (L1–L4). Osteoporosis was defined by a T-score ≤2.5 at either site. Patients were questioned about a prior diagnosis of osteoporosis. We studied 2699 women and 1032 men aged ≥65 yr. The percentage prevalence and 95% confidence intervals were determined. In individuals aged ≥65 yr, the prevalence of osteoporosis was 25.6% in women (95% confidence interval, 24.0%, 27.3%) and 8.9% in men (7.3%, 10.8%). In 652 men aged ≥70 yr, the prevalence of osteoporosis was 11.3% (9.1%, 14.0%). Of the participants with BMD-defined osteoporosis, 76.6% of woman aged ≥65 yr (73.2%, 79.6%; 516 of 674 women), 93.4% of men aged ≥65 yr (86.4%, 96.9%; 85 of 91), and 93.2% of men ≥70 yr (84.9%, 97.0%; 68 of 73) were not aware of it. Thus, the minimum NNS by BMD testing to detect one previously undiagnosed case of osteoporosis in Canada is: 6 women aged ≥65 yr, 13 men aged ≥65 yr, and 10 men aged ≥70 yr. [Copyright &y& Elsevier]

Abstract Background Initiatives to improve end-of-life care are hampered by our nascent understanding of what quality care means to patients and their families. The primary purpose of this study was to describe what seriously ill patients in hospital and their family members consider to be the key elements of quality end-of-life care. Methods After deriving a list of 28 elements related to quality end-of-life care from existing literature, focus groups with experts and interviews with patients, we administered a face-to-face questionnaire to older patients with advanced cancer and chronic end-stage medical disease and their family members in 5 hospitals across Canada to assess their perspectives on the importance. We compared differences in ratings across various subgroups of patients and family members. Results Of 569 eligible patients and 176 family members, 440 patients (77%) and 160 relations (91%) agreed to participate. The elements rated as &ldquor;extremely important&rdquor; most frequently by the patients were &ldquor;To have trust and confidence in the doctors looking after you&rdquor; (55.8% of respondents), &ldquor;Not to be kept alive on life support when there is little hope for a meaningful recovery&rdquor; (55.7%), &ldquor;That information about your disease be communicated to you by your doctor in an honest manner&rdquor; (44.1%) and &ldquor;To complete things and prepare for life's end - life review, resolving conflicts, saying goodbye&rdquor; (43.9%). Significant differences in ratings of importance between patient groups and between patients and their family members were found for many elements of care. Interpretation Seriously ill patients and family members have defined the importance of various elements related to quality end-of-life care. The most important elements related to trust in the treating physician, avoidance of unwanted life support, effective communication, continuity of care and life completion. Variation in the perception of what matters the most indicates the need for customized or individualized approaches to providing end-of-life care. [ABSTRACT FROM AUTHOR]

The objective of this research was to determine the relative decrement in health-related quality of life, as measured by the health utilities index mark 3 (HUI3), in osteoporosis compared to other chronic medical conditions. The impact of chronic medical conditions other than osteoporosis on HUI3 measurements had been previously established in the 1996/1997 Canadian National Population Health Survey (NPHS). The Canadian Multicentre Osteoporosis Study (CaMos) is a national population-based study in which regional participants were randomly recruited, regardless of presence of osteoporosis. We analyzed data from participants aged ≥65 years who completed a baseline HUI3 questionnaire and provided information on their medical history ( n=3,750). We determined the age- and gender-adjusted mean decrement in HUI3 for several chronic medical conditions, including osteoporosis. The mean changes in HUI3 adjusted for age and gender (with 95% confidence intervals) were as follows: arthritis −0.10 (−0.11, −0.09), chronic obstructive pulmonary disease (COPD) −0.07 (−0.09, -0.05), diabetes mellitus −0.05 (−0.08, −0.03), heart disease −0.06 (-0.08, −0.04), hypertension −0.02 (-0.03, −0.01), and osteoporosis −0.08 (−0.11, −0.06), respectively (model r2=0.17; P<0.0001). These findings were comparable to those observed in the NPHS, with the exception of osteoporosis, which had not been previously studied in this fashion. The decrement in HUI3 score seen in participants with osteoporosis was comparable to that observed in other chronic medical conditions, such as arthritis, COPD, diabetes mellitus or heart disease. [ABSTRACT FROM AUTHOR]

Health care policy in Canada is based on providing public funding for medically necessary physician and hospital-based services free at the point of delivery ("first-dollar public funding"). Studies consistently show that the introduction of public funding to support the provision of health care services free at the point of delivery is associated with increases in the proportionate share of services used by the poor and in population distributions of services that are independent of income. Claims about the success of Canada's health care policy tend to be based on these findings, without reference to medical necessity. This article adopts a needs-based perspective to reviewing the distribution of health care services. Despite the removal of user prices, significant barriers remain to services being distributed in accordance with need--the objective of needs-based access to services remains elusive. The increased fiscal pressures imposed on health care in the 1990s, together with the failure of health care policy to encompass the changing nature of health care delivery, seem to represent further departures from policy objectives. In addition, there is evidence of increasing public dissatisfaction with the performance of the system. A return to modest increases in public funding in the new millennium has not been sufficient to arrest these trends. Widespread support for first-dollar public funding needs to be accompanied by greater attention to the scope of the legislation and the adoption of a needs-based focus among health care policymakers. [ABSTRACT FROM AUTHOR]

Context: The long-term results of randomized trials have demonstrated equivalent survival rates for mastectomy and breast-conserving therapy for the treatment of early stage breast cancer. Consequently, the choice of treatment should be based on a patient's preferences.Objective: To evaluate the impact of a decision aid regarding the different surgical treatment options on patient decision making.Design and Setting: A cluster randomized trial for which general surgeons in the communities of central-west, and eastern Ontario, Canada, were randomly assigned to use the decision aid or not in the surgical consultation. Patients received the decision aid or not based on the surgeon seen.Participants: Twenty surgeons participated in the study. Of the 208 eligible women with newly diagnosed clinical stage I or II breast cancer seen by study surgeons, 201 agreed to be evaluated: 94 were assigned to the decision board and 107 to usual practice. Patients were recruited from November 1999 to April 2002.Intervention: The decision board is a decision aid designed to help physicians inform their patients about different treatment options and to enable patients to express a preference for treatment.Main Outcome Measures: Patient knowledge about the surgical treatment of breast cancer; decisional conflict; satisfaction with decision making; and the treatment decision following the consultation.Results: Patients in the decision board group had higher knowledge scores about their treatment options (66.9 vs 58.7; P<.001), had less decisional conflict (1.40 vs 1.62, P =.02), and were more satisfied with decision making (4.50 vs 4.32, P =.05) following the consultation. Patients who used the decision board were more likely to choose BCT (94% vs 76%, P =.03).Conclusions: The decision board was helpful in improving communication and enabling women to make a choice regarding treatment. Such instruments should be considered by surgeons when communicating the different surgical options to women with breast cancer. [ABSTRACT FROM AUTHOR]

Abstract Rationale, aims and objectives This randomized controlled trial was designed to evaluate the 2-year costs and effects of a proactive, public health nursing case management approach compared with a self-directed approach for 129 single parents (98% were mothers) on social assistance in a Canadian setting. A total of 43% of these parents had a major depressive disorder and 38% had two or three other health conditions at baseline. Methods Study participants were recruited over a 12 month period and randomized into two groups: one receiving proactive public health nursing and one which did not. Results At 2 years, 69 single parents with 123 children receiving proactive public health nursing (compared with 60 parents with 91 children who did not receive public health nursing services) showed a slightly greater reduction in dysthymia and slightly higher social adjustment. There was no difference between the public health and control groups in total per parent annual cost of health and support services. However, costs were averted due to a 12% difference in non-use of social assistance in the previous 12 months for parents in the public health nursing group. This translates into an annual cost saving of $240 000 (Canadian) of costs averted within 1 year for every 100 parents. Conclusions In the context of a system of national health and social insurance, this study supports the fact that it is no more costly to proactively service this population of parents on social assistance. [ABSTRACT FROM AUTHOR]

Studies the effects of population change on requirements for physicians in Ontario. Age profiles of the utilization of physician services; Effect of aging on the distribution of requirements among categories of physicians; Tendency for utilization rates to rise with age; Age distribution of fee payments for male and female patients by category of physicians and for those physicians paid on a fee-for-service basis.

Interpretation: Given that patients who are accepted for CABG represent a selected population, our findings suggest that, with careful triage, CABG in octogenarians is as safe as, and no more costly than, CABG in septuagenarians. [ABSTRACT FROM AUTHOR]

Editorial. Highlights the topics discussed at the International Conference on Treatment Decision-Making in the Clinical Encounter held in Hamilton, Ontario. Type and amount of involvement that patients want in treatment decision-making; Different physician communication styles; Different approaches to treatment decision-making; Roles of patients and physicians in treatment decision-making.

A series of 12 studies (five historic cohort and seven randomized trials) examined clients in community settings in Southern Ontario suffering from a variety of chronic physical and mental health conditions. These studies are appraised using a framework for evaluating possible outcomes of economic evaluation. In the 12 studies, sample composition and size varied. Each study was designed to quantify the well-being outcomes and expenditures associated with different community-based approaches to care provided in the context of a system of national health insurance. As a collective, these studies represent increasing methodological rigour. Multiple-perspective client well-being outcome measures were used. In two studies, caregiver burden also was analysed. A common approach to quantification and evaluation of expenditures for service consumption was used in all 12 studies. The nature of community-based health services (health vs. disease care orientation) was found to have direct and measurable impact on total expenditures for health service utilization and client well-being outcomes. In most cases, a recurring pattern of equal or better client outcomes, yet lower expenditures for use of community based health services, was associated with well-integrated health oriented services. Integrated services aimed at factors which determine health are superior when compared to individual, fragmented, disease oriented, and focused approaches to care. The main lessons from the 12 studies are that it is as or more effective and as or less expensive to offer complete, proactive, community health services to persons living with chronic circumstance than to provide focused, on-demand, piecemeal services. Complete services would have a psychosocial and mental health focus included with the physical care approach. Furthermore, people with coexisting risk factors (age, living arrangements, mental distress and problem-solving ability) are the ones who most benefit at lower expense... [ABSTRACT FROM AUTHOR]

Presents a Canadian study to determine the cost effectiveness of providing needle exchange programs to prevent HIV transmission in intravenous drug users. Design of the study; Setting; Outcome measures; Results; Conclusion.

Presents research which studied the prevalence, correlates and health care expenditures associated with depression among sole-support parents receiving social assistance in Ontario. Coexistence of poverty and depression among single parents receiving social assistance; Methods; Results; High rates of depression and other psychiatric disorders; Higher expenditures for health care services; Impact on children.

Introduction: Stroke is the leading cause of death and adult disability in Canada. Up to 80% of older adults (>65 years) who have suffered a stroke will return to their homes, and 60% will require ongoing rehabilitation in the community. The transition between hospital and home is very challenging, particularly for those with comorbidities. Little is known about the core elements for successful care transitions specifically for older adults with stroke and comorbidities. New, integrated interventions are needed to provide quality transitional care from hospital-to-home to reduce hospital readmissions and optimize transition outcomes for this vulnerable population. Theory/Methods: This studyused a single-site one-group pre-test/post-test design. Participants were recruited from a hospital-based outpatient stroke rehabilitation centre in Ontario, Canada. Eligible participants were >55 years with a confirmed diagnosis of stroke in the past 12 months, had > 2 comorbidities, referred to a hospital-based outpatient stroke rehabilitation centre, and community-dwelling. The intervention was a 6-month transitional care intervention delivered by an interprofessional (IP) team (Occupational therapist, Physiotherapist, Speech Language Pathologist, Registered Nurse, Social Worker). It involved care coordination, self-management education and support, home visits, telephone contacts, interprofessional case conferences, and a web-based app. The primary focus of the study was the feasibility of the intervention, which was determined based on information from interviews with providers, managers, and patients. Effectiveness of the intervention was of secondary interest in our study and was based on the 6- month change in health outcomes (health-related quality of life, depression, anxiety, self-efficacy), provider experience, and cost. Results: In total, 30 (59%) of 51 eligible persons consented to participate. Of these, 25 (83%) completed the 6-month follow-up. Participants were an average of 71.3 years and had an average of 7 comorbid conditions. Providers and patients viewed implementation of the intervention as feasible and acceptable. Providers reported that the intervention improved communication and coordination among in- and outpatient teams, use of stroke best practices, and understanding of patients' needs, and built capacity in stroke rehabilitation and collaborative care. The results summary score at 6-months compared with baseline (Mean difference: -2.32, 95% CI: -6.83, 2.20). There were statistically-significant increases in the cost of use of outpatient services, physician specialists, and family physician visits. These increased costs were offset by a statisticallysignificant decrease in the cost of use of hospitalization and emergency room visits at 6-months compared with baseline. Discussion: This study provides initial evidence for the feasibility and preliminary effects of the intervention in reducing the use of hospitalization and emergency department visits and improving provider and patient experience. Conclusions: The results will inform knowledge users regarding the feasibility and preliminary effectiveness of a new and integrated intervention to optimize transitional care outcomes for older adults with stroke and multimorbidity. Suggestions for future research: Future research is needed to further test this intervention using a pragmatic randomized controlled trial, larger sample size, and a full economic evaluation. [ABSTRACT FROM AUTHOR]

Examines the inclusion of drugs in provincial drug benefit programs. Use of the cost-effectiveness approach by the Ontario Drug Quality and Therapeutics Committee (DQTC) and how it has lead to continuous and considerable increases in expenditures; Way in which the economics approach to health improvements differs from the way in which the DQTC uses information on the costs and effects of pharmaceuticals; How economics can help.

Deals with the highly active antiretroviral therapy (HAART) aspect of treating HIV-infected patients. Link between HAART and the rise in health care expenditures in Alberta; Positive health outcomes of HAART; Resource requirements of the HAART program in Alberta.

Aims: This study describes the comorbid conditions in Canadian, community-dwelling older adults with diabetes and the association between the number of comorbidities and health service use and costs.Methods: This retrospective cohort study used multiple linked administrative data to determine 5-year health service utilization in a population-based cohort of community-living individuals aged 66 and over with a diabetes diagnosis as of April 1, 2008 (baseline). Utilization included physician visits, emergency department visits, hospitalizations, and home care services.Results: There were 376,421 cohort members at baseline, almost all (95%) of which had at least one comorbidity and half (46%) had 3 or more. The most common comorbidities were hypertension (83%) and arthritis (61%). Service use and associated costs consistently increased as the number of comorbidities increased across all services and follow-up years. Conditions generally regarded as nondiabetes-related were the main driver of service use. Over time, use of most services declined for people with the highest level of comorbidity (3+). Hospitalizations and emergency department visits represented the largest share of costs for those with the highest level of comorbidity (3+), whereas physician visits were the main costs for those with fewer comorbidities.Conclusions: Comorbidities in community-living older adults with diabetes are common and associated with a high level of health service use and costs. Accordingly, it is important to use a multiple chronic conditions (not single-disease) framework to develop coordinated, comprehensive and patient-centred programs for older adults with diabetes so that all their needs are incorporated into care planning. [ABSTRACT FROM AUTHOR]

Background: The burden of comorbid dysthymia and other comorbid psychiatric illnesses in a Canadian primary care setting was measured. Two groups of primary care patients: those who scored positive for comorbid dysthymia versus those who scored negative for any psychiatric disorder were compared. Methods: This was a cross-sectional survey in a Health Service Organization (HSO) in Ontario, Canada. The subjects were patients of the HSO. The main outcome measures were: health status, mood, social adjustment, coping ability, children’s psychiatric disorders, child development, family function, and health and social service utilization. Results: Of the 6280 eligible adults who were patients at the HSO, 68.9% consented to be screened for psychiatric disorders; 5.1% screened positive for dysthymia, of which 90% had at least one comorbid psychiatric disorder. The following statistically significant differences were found between people with dysthymia and other comorbid psychiatric disorders versus people without any psychiatric disorder. People with dysthymia were more likely to have worse health status, worry more about their health, and report levels of pain that impaired their function; they had higher MADRS depression scores, lower social role function scores, lower social adjustment scores, and lower coping ability. More children of people with comorbid dysthymia met criteria for one or more childhood psychiatric disorders and there were more families with a parent with dysthymia that were dysfunctional. People with dysthymia used a greater proportion of health and social services, had higher per person annual health care costs (excluding hospital services), and had higher per person annual indirect costs (lost wages). Conclusion: This analysis demonstrated the burden of illness and costs that this disorder imposes on individuals, their families, and society as a whole. [Copyright &y& Elsevier]

Assesses the effects of provider-initiated interventions to the health and social services by sole-support parents on social assistance in Ontario. Use of interim analysis; Observation on the child competence levels; Production of short and long term financial gains and societal benefits.

Background: It is important to understand cancer survivors' perceptions about their treatment decisions and quality of life. Methods: We performed a prospective observational cohort study of Canadian patients with small (<2 cm) low-risk papillary thyroid cancer (PTC) who were offered the choice of active surveillance (AS) or surgery (Clinicaltrials.gov NCT03271892). Participants completed a questionnaire one year after their treatment decision. The primary intention-to-treat analysis compared the mean decision regret scale total score between patients who chose AS or surgery. A secondary analysis examined one-year decision regret score according to treatment status. Secondary outcomes included quality of life, mood, fear of disease progression, and body image perception. We adjusted for age, sex, and follow-up duration in linear regression analyses. Results: The overall questionnaire response rate was 95.5% (191/200). The initial treatment choices of respondents were AS 79.1% (151/191) and surgery 20.9% (40/191). The mean age was 53 years (standard deviation [SD] 15 years) and 77% (147/191) were females. In the AS group, 7.3% (11/151) of patients crossed over to definitive treatment (two for disease progression) before the time of questionnaire completion. The mean level of decision regret did not differ significantly between patients who chose AS (mean 22.4, SD 13.9) or surgery (mean 20.9, SD 12.2) in crude ( p  = 0.730) or adjusted ( p  = 0.29) analyses. However, the adjusted level of decision regret was significantly higher in patients who initially chose AS and crossed over to surgery (beta coefficient 10.1 [confidence interval; CI 1.3-18.9], p  = 0.02), compared with those remaining under AS. In secondary adjusted analyses, respondents who chose surgery reported that symptoms related to their cancer or its treatment interfered with life to a greater extent than those who chose AS ( p  = 0.02), but there were no significant group differences in the levels of depression, anxiety, fear of disease progression, or overall body image perception. Conclusions: In this study of patients with small, low-risk PTC, the mean level of decision regret pertaining to the initial disease management choice was relatively low after one year and it did not differ significantly for respondents who chose AS or surgery.

In developed countries, population aging due to advances in living standards and healthcare infrastructure means that the care associated with chronic and degenerative diseases is becoming more prevalent across all facets of society-including the labour market. Informal caregiving, that is, care provision performed by friends and family, is expected to increase in the near future in Canada, with implications for workplaces. Absenteeism, presenteeism, work satisfaction and retention are known to be worse in employees who juggle the dual role of caregiving and paid employment, representing losses to workplaces' bottom line. Recent discourse on addressing the needs of carer-employees (CEs) in the workplace have been centred around carer-friendly workplace policies. This paper aims to assess the potential cost implication of a carer-friendly workplace intervention implemented within a large-sized Canadian workplace. The goal of the intervention was to induce carer-friendly workplace culture change. A workplace-wide survey was circulated twice, prior to and after the intervention, capturing demographic variables, as well as absenteeism, presenteeism, turnover and impact on coworkers. Utilizing the pre-intervention timepoint as a baseline, we employed a cost implication analysis to quantify the immediate impact of the intervention from the employer's perspective. We found that the intervention overall was not cost-saving, although there were some mixed effects regarding some costs, such as absenteeism. Non-tangible benefits, such as changes to employee morale, satisfaction with supervisor, job satisfaction and work culture, were not monetarily quantified within this analysis; hence, we consider it to be a conservative analysis.

Background: The Continuous Glucose Monitoring in Women with Type 1 Diabetes in Pregnancy Trial (CONCEPTT) found improved health outcomes for mothers and their infants among those randomized to self-monitoring of blood glucose (SMBG) with continuous glucose monitoring (CGM) compared with SMBG alone. In this study, we evaluated whether CGM or standard SMBG was more or less costly from the perspective of a third-party payer., Methods: We conducted a posthoc analysis of data from the CONCEPTT trial (Mar. 25, 2013, to Mar. 22, 2016). Health care resource data from 215 pregnant women, randomized to CGM or SMBG, were collected from 31 hospitals in 7 countries. We determined resource costs posthoc based on prices from hospitals in 3 Canadian provinces (Ontario, British Columbia, Alberta). The primary outcome was the difference between groups in the mean total cost of care for mother and infant dyads, paid by each government (i.e., the third-party payer) from randomization to hospital discharge (time horizon). The secondary outcome included CGM and SMBG costs not paid by governments (e.g., glucose monitoring devices and supplies)., Results: The mean total cost of care was lower in the CGM group compared with the SMBG group in each province (Ontario: $13 270.25 v. $18 465.21, difference in mean total cost [DMT] -$5194.96, 95% confidence interval [CI] -$9841 to -$1395; BC: $13 480.57 v. $18 762.17, DMT -$5281.60, 95% CI -$9964 to -$1382; Alberta: $13 294.39 v. $18 674.45, DMT -$5380.06, 95% CI -$10 216 to -$1490). There was no difference in the secondary outcome., Interpretation: Government health care costs are lower when CGM is paid by the patient, driven by lower costs from reduced use of the neonatal intensive care unit in the CGM group; however, when governments pay for CGM equipment, there is no overall cost difference between CGM and SMBG. Governments should consider paying for CGM, as it results in improved maternal and neonatal outcomes with no added overall cost., Trial Registration: ClinicalTrials.gov, no. NCT01788527., Competing Interests: Competing interests: Rashid Ahmed received grant support from the Centre for Clinical Trial Support, Sunnybrook Research Institute, Toronto, Canada, from a grant funded by the Juvenile Diabetes Research Foundation (JDRF) and grants under the JDRF Canadian Clinical Trial Network. Helen Murphy reports personal fees from Medtronic, Novo Nordsik, Roche and Dexcom. She also reports acting as a board member of the Medtronic European Scientific Advisory Board, all outside the submitted work. Denice Feig reports receiving grant support from the JDRF Canadian Clinical Trials Network and advisory board and speaker fees from Medtronic, outside the submitted work. No other competing interests were declared., (© 2021 CMA Joule Inc. or its licensors.)

Background: Type II diabetes mellitus (T2DM) affects upwards of 25% of Canadian older adults and is associated with high comorbidity and burden. Studies show that lifestyle factors and self-management are associated with improved health outcomes, but many studies lack rigour or exclude older adults, particularly those with multimorbidity. More evidence is needed on the effectiveness of community-based self-management programs in older adults with T2DM and multimorbidity. The study purpose is to evaluate the effect of a community-based intervention versus usual care on physical functioning, mental health, depressive symptoms, anxiety, self-efficacy, self-management, and healthcare costs in older adults with T2DM and 2 or more comorbidities., Methods: Community-living older adults with T2DM and two or more chronic conditions were recruited from three Primary Care Networks (PCNs) in Alberta, Canada. Participants were randomly allocated to the intervention or control group in this pragmatic randomized controlled trial comparing the intervention to usual care. The intervention involved up to three in-home visits, a monthly group wellness program, monthly case conferencing, and care coordination. The primary outcome was physical functioning. Secondary outcomes included mental functioning, anxiety, depressive symptoms, self-efficacy, self-management, and the cost of healthcare service use. Intention-to-treat analysis was performed using ANCOVA modeling., Results: Of 132 enrolled participants (70-Intervention, 62-Control), 42% were 75 years or older, 55% were female, and over 75% had at least six chronic conditions (in addition to T2DM). No significant group differences were seen for the baseline to six-month change in physical functioning (mean difference: -0.74; 95% CI: - 3.22, 1.74; p-value: 0.56), mental functioning (mean difference: 1.24; 95% CI: - 1.12, 3.60; p-value: 0.30), or other secondary outcomes.., Conclusion: No significant group differences were seen for the primary outcome, physical functioning (PCS). Program implementation, baseline differences between study arms and chronic disease management services that are part of usual care may have contributed to the modest study results. Fruitful areas for future research include capturing clinical outcome measures and exploring the impact of varying the type and intensity of key intervention components such as exercise and diet., Trial Registration: NCT02158741 Date of registration: June 9, 2014.

Aims: The Heart Outcomes Prevention Evaluation-3 (HOPE-3) found that rosuvastatin alone or with candesartan and hydrochlorothiazide (HCT) (in a subgroup with hypertension) significantly lowered cardiovascular events compared with placebo in 12 705 individuals from 21 countries at intermediate risk and without cardiovascular disease. We assessed the costs implications of implementation in primary prevention in countries at different economic levels., Methods and Results: Hospitalizations, procedures, study and non-study medications were documented. We applied country-specific costs to the healthcare resources consumed for each patient. We calculated the average cost per patient in US dollars for the duration of the study (5.6 years). Sensitivity analyses were also performed with cheapest equivalent substitutes. The combination of rosuvastatin with candesartan/HCT reduced total costs and was a cost-saving strategy in United States, Canada, Europe, and Australia. In contrast, the treatments were more expensive in developing countries even when cheapest equivalent substitutes were used. After adjustment for gross domestic product (GDP), the costs of cheapest equivalent substitutes in proportion to the health care costs were higher in developing countries in comparison to developed countries., Conclusion: Rosuvastatin and candesartan/HCT in primary prevention is a cost-saving approach in developed countries, but not in developing countries as both drugs and their cheapest equivalent substitutes are relatively more expensive despite adjustment by GDP. Reductions in costs of these drugs in developing countries are essential to make statins and blood pressure lowering drugs affordable and ensure their use., Clinical Trial Registration: HOPE-3 ClinicalTrials.gov number, NCT00468923., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Background: WHO has targeted that medicines to prevent recurrent cardiovascular disease be available in 80% of communities and used by 50% of eligible individuals by 2025. We have previously reported that use of these medicines is very low, but now aim to assess how such low use relates to their lack of availability or poor affordability., Methods: We analysed information about availability and costs of cardiovascular disease medicines (aspirin, β blockers, angiotensin-converting enzyme inhibitors, and statins) in pharmacies gathered from 596 communities in 18 countries participating in the Prospective Urban Rural Epidemiology (PURE) study. Medicines were considered available if present at the pharmacy when surveyed, and affordable if their combined cost was less than 20% of household capacity-to-pay. We compared results from high-income, upper middle-income, lower middle-income, and low-income countries. Data from India were presented separately given its large, generic pharmaceutical industry., Findings: Communities were recruited between Jan 1, 2003, and Dec 31, 2013. All four cardiovascular disease medicines were available in 61 (95%) of 64 urban and 27 (90%) of 30 rural communities in high-income countries, 53 (80%) of 66 urban and 43 (73%) of 59 rural communities in upper middle-income countries, 69 (62%) of 111 urban and 42 (37%) of 114 rural communities in lower middle-income countries, eight (25%) of 32 urban and one (3%) of 30 rural communities in low-income countries (excluding India), and 34 (89%) of 38 urban and 42 (81%) of 52 rural communities in India. The four cardiovascular disease medicines were potentially unaffordable for 0·14% of households in high-income countries (14 of 9934 households), 25% of upper middle-income countries (6299 of 24,776), 33% of lower middle-income countries (13,253 of 40,023), 60% of low-income countries (excluding India; 1976 of 3312), and 59% households in India (9939 of 16,874). In low-income and middle-income countries, patients with previous cardiovascular disease were less likely to use all four medicines if fewer than four were available (odds ratio [OR] 0·16, 95% CI 0·04-0·57). In communities in which all four medicines were available, patients were less likely to use medicines if the household potentially could not afford them (0·16, 0·04-0·55)., Interpretation: Secondary prevention medicines are unavailable and unaffordable for a large proportion of communities and households in upper middle-income, lower middle-income, and low-income countries, which have very low use of these medicines. Improvements to the availability and affordability of key medicines is likely to enhance their use and help towards achieving WHO's targets of 50% use of key medicines by 2025., Funding: Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Patient decision aids (P-DAs) inform medical decision making, but longer term effects are unknown. This article describes extended follow-up from a thyroid cancer treatment P-DA trial., Methods: In this single-center, parallel-design randomized controlled trial conducted at a Canadian tertiary/quaternary care center, early-stage thyroid cancer patients from a P-DA trial were contacted 15 to 23 months after randomization/radioactive iodine (RAI) decision making to evaluate longer term outcomes. It was previously reported that the use of the computerized P-DA in thyroid cancer patients considering postsurgical RAI treatment significantly improved medical knowledge in comparison with usual care alone. The P-DA and control groups were compared for the following outcomes: feeling informed about the RAI treatment choice, decision satisfaction, decision regret, cancer-related worry, and physician trust. In a subgroup of 20 participants, in-depth interviews were conducted for a qualitative analysis., Results: Ninety-five percent (70 of 74) of the original population enrolled in follow-up at a mean of 17.1 months after randomization. P-DA users perceived themselves to be significantly more 1) informed about the treatment choice (P = .008), 2) aware of options (P = .009), 3) knowledgeable about treatment benefits (P = .020), and 4) knowledgeable about treatment risks/side effects (P = .001) in comparison with controls. There were no significant group differences in decision satisfaction (P = .142), decision regret (P = .199), cancer-related worry (P = .645), mood (P = .211), or physician trust (P = .764). In the qualitative analysis, the P-DA was perceived to have increased patient knowledge and confidence in decision making., Conclusions: The P-DA improved cancer survivors' actual and long-term perceived medical knowledge with no adverse effects. More research on the long-term outcomes of P-DA use is needed., (© 2015 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society.)

Purpose: Women with ovarian cancer (OC) must make treatment decisions. The first step in this process involves information giving about potential management choices. In this study, our objectives were to (1) describe the key issues that are reviewed by the oncologist when a woman presents with recurrent OC and (2) understand the extent to which physicians have different methods of giving information to patients., Methods: A descriptive qualitative study of 19 gynecologic and medical oncologists in Ontario, Canada was undertaken using a semi-structured interview guide., Results: Oncologists felt that the process of information giving was an important part of the medical encounter. The main themes that emerged from our data were (1) Oncologists varied in their approach to giving information about the disease and management; (2) oncologists felt that giving management choices to the patients helped engage patients in dealing with their disease and moving forward; (3) oncologists felt it was important to foster patient's hope; and (4) oncologists struggled with how much clinical outcome information to give to patients., Conclusions: Oncologists tried to achieve a difficult balance between providing patients with several management choices in order to help them keep hope alive and providing them with realistic clinical information suggesting poor patient outcomes. Areas for future research include exploring (1) how physicians can best walk this tightrope of information giving, (2) how to assess physician "success" in doing so, and (3) the meaning of fostering hope to patients and physicians in the context of treatment decision making.

Progress in the treatment of cancers in young people has resulted in an increasing success rate in curing the different forms of malignant diseases. The mission of the CPAC/C(17) Task Force on Adolescents and Young Adults (AYA) with cancer is to ensure prompt, equitable access to the best care; establish research priorities to optimize health outcomes and health-related quality of life; and mitigate current disparities of care through advances in treatment, education, and research. Although these goals are important, the mission statement seems to ignore an important factor: "affordability," or the ability to achieve these goals due to scarcity of resources. In this article, the role of economics in helping decision makers decide on resource allocation is discussed. Also described is the economic basis for the healthcare problem; the inability of the current methodology of cost-effectiveness to provide information that can help improve resource allocation in health; and how economics should be used to promote efficient use of healthcare resources. The author argued that "affordability" should be recognized in the mission statement. Recognizing "affordability" means recognizing the need to justify the transfer (or allocation) of additional resources to AYA cancer, which requires demonstration that the value of what is gained from the use of these resources in AYA cancer exceeds the value of what is forgone by using them elsewhere. This will also require making explicit the values or equity criteria to which society subscribes., (© 2011 American Cancer Society)

Against a background of poorly coordinated provision of holistic care to the adolescent and young adult (AYA) cancer population, the Canadian National Task Force on Adolescent and Young Adult Oncology, which is supported by the Canadian Partnership Against Cancer and the C17 network, convened a workshop to formulate the components of a systematic approach to care for this age group. Because such a program will deflect scarce resources, it must be validated and justified by reproducible metrics. A subgroup of experts was convened, comprising attendees at the AYA workshop, including AYA cancer survivors. A substantial number of key, feasible, and consistent metrics were identified and are systematized, justified, and presented in this article. Prioritization from within this range will be necessary., (© 2011 American Cancer Society)

Background: Concern has been growing in the academic literature and popular media about the licensing, introduction and adoption of surgical devices before full effectiveness and safety evidence is available to inform clinical practice. Our research will seek empirical survey evidence about the roles, responsibilities, and information and policy needs of the key stakeholders in the introduction into clinical practice of new surgical devices for pelvic floor surgery, in terms of the underlying ethical principals involved in the economic decision-making process, using the example of pelvic floor procedures., Methods/design: Our study involves three linked case studies using, as examples, selected pelvic floor surgery devices representing Health Canada device safety risk classes: low, medium and high risk. Data collection will focus on stakeholder roles and responsibilities, information and policy needs, and perceptions of those of other key stakeholders, in seeking and using evidence about new surgical devices when licensing and adopting them into practice. For each class of device, interviews will be used to seek the opinions of stakeholders. The following stakeholders and ethical and economic principles provide the theoretical framework for the study: Stakeholders--federal regulatory body, device manufacturers, clinicians, patients, health care institutions, provincial health departments, and professional societies. Clinical settings in two centres (in different provinces) will be included. Ethics--beneficence, non-maleficence, autonomy, justice. Economics--scarcity of resources, choices, opportunity costs.For each class of device, responses will be analysed to compare and contrast between stakeholders. Applied ethics and economic theory, analysis and critical interpretation will be used to further illuminate the case study material., Discussion: The significance of our research in this new area of ethics will lie in providing recommendations for regulatory bodies, device manufacturers, clinicians, health care institutions, policy makers and professional societies, to ensure surgical patients receive sufficient information before providing consent for pelvic floor surgery. In addition, we shall provide a wealth of information for future study in other areas of surgery and clinical management, and provide suggestions for changes to health policy.

This study examined the six-month prevalence, risk factors, and costs of falls in older people using home support services who are at risk of falling. Of the 109 participants, 70.6 per cent reported >or= one fall in the previous six months, and 27.5 per cent experienced multiple falls. Although there was no statistically significant difference in any fall-related risk factor between fallers (1+ falls) and non-fallers (0 falls), fallers had clinically important trends towards lower levels of physical, social, and psychological functioning. There was no statistically significant difference between fallers and non-fallers in the total per-person costs of use of health services in the previous six months; however, there were significant differences between groups in specific types of health services. The multivariate analysis revealed the presence of five risk factors for falls: neurological disorder (e.g., cognitive impairment, Parkinson's disease), age >or= 85 years, environmental hazards, previous slip or trip, and visual impairment.

Background: Drug formularies have been created by third party payers to control prescription drug usage and manage costs. Physicians try to provide the best care for their patients. This research examines family physicians' attitudes regarding prescription reimbursement criteria, prescribing and advocacy for patients experiencing reimbursement barriers., Methods: Focus groups were used to collect qualitative data on family physicians' prescribing decisions related to drug reimbursement guidelines. Forty-eight family physicians from four Ontario cities participated. Ethics approval for this study was received from the Hamilton Health Sciences/Faculty of Health Sciences Research Ethics Board at McMaster University. Four clinical scenarios were used to situate and initiate focus group discussions about prescribing decisions. Open-ended questions were used to probe physicians' experiences and attitudes and responses were audio recorded. NVivo software was used to assist in data analysis., Results: Most physicians reported that drug reimbursement guidelines complicated their prescribing process and can require lengthy interpretation and advocacy for patients who require medication that is subject to reimbursement restrictions., Conclusion: Physicians do not generally see their role as being cost-containment monitors and observed that cumbersome reimbursement guidelines influence medication choice beyond the clinical needs of the patient, and produce unequal access to medication. They observed that frustration, discouragement, fatigue, and lack of appreciation can often contribute to family physicians' failure to advocate more for patients. Physicians argue cumbersome reimbursement regulations contribute to lower quality care and misuse of physicians' time increasing overall health care costs by adding unnecessary visits to family physicians, specialists, and emergency rooms.

Background: Osteoporosis is a serious but treatable condition. However, appropriate therapy utilization of the disease remains suboptimal. Thus, the objective of the study was to change physicians' therapy administration behavior in accordance with the Osteoporosis Canada 2002 guidelines., Methods: The Project was a two year cohort study that consisted of five Quality Circle (QC) phases that included: 1) Training & Baseline Data Collection, 2) First Educational Intervention & First Follow-Up Data Collection 3) First Strategy Implementation Session, 4) Final Educational Intervention & Final Follow-up Data Collection, and 5) Final Strategy Implementation Session. A total of 340 family physicians formed 34 QCs and participated in the study. Physicians evaluated a total of 8376, 7354 and 3673 randomly selected patient charts at baseline, follow-up #1 and the final follow-up, respectively. Patients were divided into three groups; the high-risk, low-risk, and low-risk without fracture groups. The generalized estimating equations technique was utilized to model the change over time of whether physicians, Results: The odds of appropriate therapy was 1.29 (95% CI: 1.13, 1.46), and 1.41 (95% CI: 1.20, 1.66) in the high risk group, 1.15 (95% CI: 0.97, 1.36), and 1.16 (95% CI: 0.93, 1.44) in the low risk group, and 1.20 (95% CI: 1.01, 1.43), and 1.23 (95% CI: 0.97, 1.55) in the low risk group without fractures at follow-up #1 and the final follow-up, respectively., Conclusion: QCs methodology was successful in increasing physicians' appropriate use of osteoporosis medications in accordance with Osteoporosis Canada guidelines.

Background: The optimal treatment for displaced femoral neck fractures in elderly patients is controversial. Compared with hemiarthroplasty (HA), internal fixation (IF) is associated with less operative trauma, bleeding, and possibly lower mortality at the expense of a higher reoperation rate and possibly increased cost., Methods: We estimated the costs from a third party payer perspective after 1 year of 2 strategies (HA and IF) for the treatment of femoral neck fractures in patients over the age of 60 years. Using a decision board, we elicited patient preferences for the 2 operative approaches and calculated the net benefit using the willingness-to-pay technique., Results: The 1-year projected cost of 1 IF was $18,100, and that of 1 HA was $15,843 (incremental cost of $2257 for each IF). Of 108 participants, 61 (56.5%) chose IF as the preferred treatment option and were willing to pay an average of $3.33 per month to have this option available if needed. In Ontario, the total incremental cost of performing IF in patients that choose it was $64,714,103, and the total societal benefit was $289,263,600, yielding a net benefit of $224,549,497., Conclusion: The benefits of IF over HA outweigh the incremental costs from the perspective of a third-party payer. IF should be available to patients that choose it.

Objective: To explore physician recommendations regarding radioiodine remnant ablation (RRA) as adjuvant treatment in early-stage well-differentiated thyroid carcinoma (WDTC), their rationale for administration of RRA, and their willingness to involve patients' opinions in decision making about the use of RRA., Methods: We surveyed a representative sample of specialty physicians in Canada and the United States and asked survey participants whether they would recommend adjuvant RRA after thyroidectomy for a 1.6-cm papillary thyroid carcinoma (Likert scale of agreement responses from 1 to 7; strong agreement >or=6). Factor analysis was performed to explore the rationale for recommendations. We asked whether physicians accepted the role of patients' preferences in decision making about administration of RRA, and backward conditional logistic regression analysis was used to identify predictors of strong acceptance., Results: The effective response rate for the survey was 56.3% (486 of 864), with 62.8% (295 of 470 respondents) strongly recommending RRA. Strong RRA recommendations were founded in opinions that RRA (1) decreases WDTC-related mortality and recurrence and (2) facilitates WDTC follow-up at low risk of adverse effects. Approximately a third of the survey respondents (152 of 474) strongly agreed with incorporation of patients' preferences in decision making regarding the use of RRA. Physicians without firm convictions about the efficacy of RRA in decreasing disease-related outcomes and those practicing in the United States were most likely to indicate strong support for incorporating patients' preferences in decision making about RRA., Conclusion: The recommendations of physicians regarding use of adjuvant RRA are founded in beliefs in intervention efficacy and follow-up practices. Physicians in medical practice in the United States and those without strong convictions about RRA efficacy are most likely to incorporate patients' views in individualizing decisions about RRA therapy.