Long-term trends in the work hours of physicians in Canada.

BACKGROUND: Physician work hours directly influence patient access to health care services and play a vital role in physician human resource planning. We sought to evaluate long-term trends in hours worked by physicians in Canada, overall and by subgroup. METHODS: We used Statistics Canada's Labour Force Survey to identify physicians via occupation and industry coding information. We estimated descriptive statistics and performed graphical analysis of the average weekly hours worked by physicians over the 1987-2021 period. RESULTS: Overall, weekly physician work hours remained stable from 1987 until 1997, after which they declined. Average weekly hours decreased by 6.9 hours (p < 0.001), from 52.8 in 1987-1991 to 45.9 in 2017-2021. Among male physicians, work hours declined notably after 1997, while those of female physicians remained relatively stable at around 45 per week. Hours worked by married physicians declined significantly, amounting to 7.4 fewer hours per week (p = 0.001). In contrast, unmarried physicians displayed a statistically insignificant decline of 2.2 hours (p = 0.3). The COVID-19 pandemic was associated with a sharp but brief disruption in weekly hours; by the end of 2020, physicians' work hours had returned to prepandemic levels. INTERPRETATION: These findings may indicate a long-term shift in work preferences among Canadian physicians; male physicians may be seeking a better work-life balance, which, in turn, has narrowed the gap in hours worked by sex, with potential implications for pay equity. Policymakers and planners should carefully consider changes in hours worked, rather than just the total number of physicians, to ensure an accurate evaluation of the physician workforce.

Multiple jobholding and part-time work among nurses in long-term care homes compared to other healthcare sectors: Evidence from Ontario.

About two-thirds of Canadian COVID-19 related deaths occurred in long-term care homes (LTCHs). Multiple jobholding and excessive part-time work among staff have been discussed as vectors of transmission. Using an administrative census of registered nurses (RNs) and registered practical nurses (RPNs) in the Canadian province of Ontario, this paper contrasts the prevalence of multiple jobholding, part-time/casual work, and other job and worker characteristics across health sectors in 2019 and 2020 to establish whether the LTCH sector deviates from the norms in Ontario healthcare. Prior to COVID-19, about 19% of RNs and 21% of RPNs in LTCHs held multiple jobs. For RPNs, this was almost identical to the RPN provincial average, while for RNs this was 2.5 percentage points above the RN provincial average. In 2020, multiple jobholding fell significantly in LTCHs after the province passed a single site order to reduce COVD-19 transmission. Although there are many similarities across sectors, nurses, especially RNs, in LTCHs differ on some dimensions. They are more likely to be internationally educated and, together with nurses in hospitals, those who work part- time/casual are more likely to prefer full-time hours (involuntary part-time/casual). Overall, while multiple jobholding and part-time work among nurses are problematic for infection prevention and control, these employment practices in LTCHs did not substantially deviate from the norms in the rest of healthcare in Ontario.

The gender earnings gap in medicine: Evidence from Canada.

Despite the gender gap in physician earnings being of concern to many in Canada, its existence is far from universally accepted and there are no studies covering all physicians/regions or addressing earnings rather than billings. This may explain the lack of serious consideration or remedial action by medical associations and governments in negotiations, or tariff and compensation processes. Our study employs 2016 Canadian Census data linked to Canada Revenue Agency taxation records. Rather than focusing on gross billings, we model physician net earnings (after overhead expenses and controlling for hours/weeks of work) including dividends from corporations. Using OLS, and unconditional quantile regression to document the gap across the earnings distribution, we observe that Canadian female physicians, on average, earn 9.3% less than their male counterparts. The average adjusted gap is slightly smaller for family physicians (8.5%) than other specialists (10.2%). Beyond averages, at the top of the income distribution the gap is double that at the median for both family physicians and other specialists. The gap also varies across provinces, from 6.6% in Quebec to 19.8% in Manitoba. Although our results yield somewhat smaller estimates than those from studies using billings/self-reported income, the magnitudes remain appreciable. The findings substantiate the claim that the gender pay gap in Canadian medicine is pervasive.

Drug survival of biologic therapies for the treatment of psoriasis: Results of Slovenian national registry.

The study was designed as observational retrospective analysis of the data from Slovenian Registry of patients with moderate and severe psoriasis treated with adalimumab, etanercept, infliximab or ustekinumab from 2005 to 2015. The survival rates of biologics were compared using survival analysis, and predictors of discontinuation were evaluated using a Cox regression model. All biologics have been prescribed as a first line therapy for moderate or severe psoriasis; 650 (94.9%) adalimumab, 254 (72.0%) ustekinumab, 76 (69.7%) infliximab, 68 (67.3%) etanercept. The overall biologics survival rate was 83.2% in the first line and 79.1% in the second line treatment. Drug survival for the first and second line of therapy was significantly longer for ustekinumab than for anti-TNFα agents (p < 0.001 and p = 0.014, respectively). Loss of efficacy accounted for 63% of all treatment discontinuations. Multivariate regression analysis showed that younger patients, being on etanercept, systemic conventional co-therapy, lower BSA and higher DLQI were independent predictors for treatment discontinuation. Our data showed the real-life situation in the treatment of moderate to severe psoriasis with biologics. Since longevity of drug survival is considered as a measure of treatment success, this data represents an important information when selecting a biologic treatment for individual patient.

Physician Payment Contracts in the Presence of Moral Hazard and Adverse Selection: The Theory and Its Application in Ontario.

We develop a stylized principal-agent model with moral hazard and adverse selection to provide a unified framework for understanding some of the most salient features of the recent physician payment reform in Ontario and its impact on physician behavior. These features include the following: (i) physicians can choose a payment contract from a menu that includes an enhanced fee-for-service contract and a blended capitation contract; (ii) the capitation rate is higher, and the cost-reimbursement rate is lower in the blended capitation contract; (iii) physicians sort selectively into the contracts based on their preferences; and (iv) physicians in the blended capitation model provide fewer services than physicians in the enhanced fee-for-service model. Copyright © 2015 John Wiley & Sons, Ltd.

Risk selection and cost shifting in a prospective physician payment system: evidence from Ontario.

We study the risk-selection and cost-shifting behavior of physicians in a unique capitation payment model in Ontario, using the incentive to enroll and care for complex and vulnerable patients as a case study. This incentive, which is incremental to the regular capitation payment, ceases after the first year of patient enrollment and may therefore impact on the physician's decision to continue to enroll the patient. Furthermore, because the enrolled patients in Ontario can seek care from any provider, the enrolling physician may shift some treatment costs to other providers. Using longitudinal administrative data and a control group of physicians in the fee-for-service model who were eligible for the same incentive, we find no evidence of either patient 'dumping' or cost shifting. These results highlight the need to re-examine the conventional wisdom about risk selection for physician payment models that significantly deviate from the stylized capitation model.

Link between pay for performance incentives and physician payment mechanisms: evidence from the diabetes management incentive in Ontario.

Pay for performance (P4P) incentives for physicians are generally designed as additional payments that can be paired with any existing payment mechanism such as a salary, fee-for-services and capitation. However, the link between the physician response to performance incentives and the existing payment mechanisms is still not well understood. In this article, we study this link using the recent primary care physician payment reform in Ontario as a natural experiment and the Diabetes Management Incentive as a case study. Using a comprehensive administrative data strategy and a difference-in-differences matching strategy, we find that physicians in a blended capitation model are more responsive to the Diabetes Management Incentive than physicians in an enhanced fee-for-service model. We show that this result implies that the optimal size of P4P incentives vary negatively with the degree of supply-side cost-sharing. These results have important implications for the design of P4P programs and the cost of their implementation.

Enhanced fee-for-service model and physician productivity: evidence from Family Health Groups in Ontario.

We study an enhanced fee-for-service model for primary care physicians in the Family Health Groups (FHG) in Ontario, Canada. In contrast to the traditional fee-for-service (FFS) model, the FHG model includes targeted fee increases, extended hours, performance-based initiatives, and patient enrolment. Using a long panel of claims data, we find that the FHG model significantly increases physician productivity relative to the FFS model, as measured by the number of services, patient visits, and distinct patients seen. We also find that the FHG physicians have lower referral rates and treat slightly more complex patients than the comparable FFS physicians. These results suggest that the FHG model offers a promising alternative to the FFS model for increasing physician productivity.

Modeling the risk of an emerging pathogen entering the Canadian blood supply.

BACKGROUND: As part of its risk management process, Canadian Blood Services (CBS) constructed mathematical models of how newly emerging pathogens might affect blood transfusion recipients. STUDY DESIGN AND METHODS: CBS convened an expert panel including medical, health economics, analytical, risk management, and insurance professionals to examine multiple data sources. The model for emerging pathogen risk included separate modules to calculate the frequency and severity of infections from transfusion-transmitted agents that could cause either acute transient or chronic persistent infection. Important model input variables were annual number of components transfused, the presumed incidence and prevalence of a new agent, the time interval of recipient risk, recipient age and sex, projected recipient survival, rate of secondary infection, pathogen-induced morbidity, and the associated medical costs of such morbidity. RESULTS: In the 5-year time frame considered in the model, it was estimated that approximately 3500 recipient infections (two-SD range of 0 to 11,370 infections) could occur from an emerging pathogen that establishes a chronic infection in donors, with 60% of these due to red blood cell transfusion. The medical costs associated with recipient outcomes due to a catastrophic emerging pathogen could be lowered by 20% if an effective pathogen reduction method for either platelets or plasma were in place. CONCLUSION: This modeling exercise offers a framework for other blood services to construct similar models. It also provides a useful way to model the implementation of new blood safety interventions (e.g., pathogen reduction) on emerging pathogen risk.

The physician perspective.

In their paper, Hurley et al. document the development of strategies used by workers' compensation boards (WCBs) to provide enhanced access and medical care to injured workers. They discuss the implications of these strategies for physicians, patients, government and the provincial public insurance plans. My comments on their paper focus primarily on Ontario and the physician sector.

The impact of a quit smoking contest on smoking behaviour in Ontario.

Community-based smoking cessation initiatives target large numbers of people, are highly visible and have the potential for great impact. Ontario's Quit Smoking (2002) Contest was evaluated one year after its implementation to measure behaviour change among adult smokers participating in the contest. The registration database of 15,521 contest participants provided the basis for a random sample of 700 participants throughout Ontario who were contacted for a follow-up telephone survey. A total of 347 surveys were completed, of which 60 percent were women. Almost one third (31.4 percent) of the survey respondents reported that they had not smoked since the start of the contest. Participation in the contest also may have delayed relapse by as much as fi ve months for 31.3 percent of respondents who resumed smoking. Older respondents, men, those who had previously attempted to quit and people who said their cessation "buddy" was helpful were more likely to stop smoking.

The impact of computerized clinical reminders on physician prescribing behavior: evidence from community oncology practice.

The objective of this study is to examine the impact of a clinical reminder generated by an electronic medical record (EMR) system on physician prescribing behavior in community oncology practice setting. A case-control trial assessing the prescribing rates of erythropoietin by physicians is used. The participants and setting involves a total of 11,644 physician-patient encounters in 2 community oncology practices in the United States during a 21-month period. The intervention is a clinical reminder generated in real time during a physician-patient encounter by an EMR identifying cancer patients with low hemoglobin (Hgb) levels (ie, anemic), that is, patients with Hgb less then 12 g/dL. The main outcome measure is to determine the frequency of erythropoietin prescription by physicians to cancer patients with low Hgb levels. Implementation of a clinical reminder generated by way of an EMR significantly improved the likelihood of low-Hgb patients receiving treatment with erythropoietin. Low-Hgb patients in the experimental clinic during the time that the clinical reminder system was in place were almost twice as likely (ie, adjusted odds ratio = 1.92, P = .008) to have been treated with erythropoietin. The data support the effectiveness of clinical reminders as a way to influence physician prescribing behaviors and potentially improve the quality of patient care. However, we feel that there is a need to investigate the use of reminders in other aspects of cancer care that may be undertreated or when new drugs may be available but are underused.

Antidepressant prescribing in community cancer care.

GOALS: To describe patterns of antidepressant (ADs) prescribing in community oncology practice. PATIENTS AND METHODS: Data were collected using an electronic medical record on all staged breast, colon, and lung cancer patients in three community-based oncology practices. The data were analyzed retrospectively, using descriptive and bivariate analyses and multivariate logistic regression modeling. There were 850 breast, 299 colon, and 473 lung cancer patients identified in this analysis. MAIN RESULTS: Overall, 19.2% of breast, 11% of colon, and 13.7% of lung cancer patients had been prescribed ADs during the 2-year period. The clinic in which cancer treatment was received predicted AD prescribing. The relationship between AD administration and age proved to be nonlinear; the pattern exhibited an "inverted U" shape. Patients with comorbidities and on pain medications were more likely to be administered ADs. Colon cancer patients on pain medications were five times more likely to be administered ADs than those not on pain medications. CONCLUSIONS: While some predictors of AD prescribing appear to be consistent with other studies, such as being on pain medication, there is still a great amount of variability in prescribing patterns across community practices, age groups, and cancer diagnoses. This study demonstrates that prescriptions of ADs seem to be influenced by parameters other than psychopathology. Given the importance of major depression in oncology care, diagnosis of psychiatric disorders and prescription patterns of psychotropics should be part of the routine monitoring and quality management in oncology patient care.

Physician Communication Skills: Results of a Survey of General/Family Practitioners in Newfoundland.

PURPOSE: To describe the attitudes related to communication skills, confidence in using communication skills, and use of communication skills during the physician-patient encounter among a population-based sample of family physicians. PROCEDURES: A mailed survey, distributed to all family physicians and general practitioners currently practicing in Newfoundland. The questionnaire was designed to collect data in five general areas-participant demographics, physician confidence in using specific communication strategies, perceived adequacy of time spent by physicians with their patients, physician use of specific communication strategies with the adult patients they saw in the prior week, and physician use of specific communication strategies during the closing minutes of the encounters they had with adult patients in the prior week. MAIN FINDINGS: A total of 160 completed surveys was received from practicing family physicians/ general practitioners in Newfoundland, yielding an adjusted response rate of 43.1%. Most of the respondents (83.8%) indicated their communication skills are as important as technical skills in terms of achieving positive patient outcomes. Between one-third and one-half of the respondents, depending on the educational level queried, rated their communications skills training as being inadequate. Fewer than 20% of the respondents rated the communications skills training they received as being excellent. Physicians indicated a need to improve their use of 8 of 13 specific communication strategies during patient encounters, and reported using few communication strategies during the closing minutes of the encounter. Interactions that occurred during a typical encounter tended to focus on biomedical versus psychosocial issues. CONCLUSIONS: Family physicians/general practitioners recognize a need to improve their communications skills. Well-designed communications skills training programs should be implemented at multi-levels of physician training in order to improve patient satisfaction with their encounters with family/general practitioners, and to increase the likelihood of positive patient outcomes.