Annual relative increased in inpatient mortality from antimicrobial resistant nosocomial infections in Thailand.

Antimicrobial resistance is a major health threat worldwide as it brings about poorer treatment outcome and places economic burden to the society. This study aims to estimate the annual relative increased in inpatient mortality from antimicrobial resistant (AMR) nosocomial infections (NI) in Thailand. A retrospective cohort study was conducted at Ramathibodi Hospital, Bangkok, Thailand, over 2008-2012. Survival model was used to estimate the hazard ratio of mortality of AMR relative to those patients without resistance (non-AMR) after controlling for nine potential confounders. The majority of NI (73.80%) were caused by AMR bacteria over the study period. Patients in the AMR and non-AMR groups had similar baseline clinical characteristics. Relative to patients in the non-AMR group, the expected hazard ratios of mortality for patients in the AMR group with Acinetobacter baumannii, Escherichia coli, Pseudomonas aeruginosa and Staphylococcus aureus were 1.92 (95% CI 0.10-35.52), 1.25 (95% CI 0.08-20.29), 1.60 (95% CI 0.13-19.10) and 1.84 (95% CI 0.04-95.58), respectively. In the complete absence of AMR bacteria, this study estimated that annually, in Thailand, there would be 111 295 fewer AMR cases and 48 258 fewer deaths.

A cost-utility analysis of atezolizumab in the second-line treatment of patients with metastatic bladder cancer.

Background: Despite initial promising results, the IMvigor211 clinical trial failed to demonstrate an overall survival (os) benefit for atezolizumab compared with chemotherapy as second-line treatment for metastatic bladder cancer (mbc). However, given lessened adverse events (aes) and preserved quality of life (qol) with atezolizumab, there might still be investment value. To evaluate that potential value, we conducted a cost-utility analysis (cua) of atezolizumab compared with chemotherapy from the perspective of the Canadian health care payer. Methods: A partitioned survival model was used to evaluate atezolizumab compared with chemotherapy over a lifetime horizon (5 years). The base-case analysis was conducted for the intention-to-treat (itt) population, with additional scenario analyses for subgroups by IMvigor-defined PD-L1 status. Health outcomes were evaluated through life-year gains and quality-adjusted life-years (qalys). Cost estimates in 2018 Canadian dollars for systemic treatment, aes, and end-of-life care were incorporated. The incremental cost-effectiveness ratio (icer) was used to compare treatment strategies. Parameter and model uncertainty were assessed through sensitivity and scenario analyses. Per Canadian guidelines, cost and effectiveness were discounted at 1.5%. Results: For the itt population, the expected qalys for atezolizumab and chemotherapy were 0.75 and 0.56, with expected costs of $90,290 and $8,466 respectively. The resultant icer for atezolizumab compared with chemotherapy was $430,652 per qaly. Scenario analysis of patients with PD-L1 expression levels of 5% or greater led to a lower icer ($334,387 per qaly). Scenario analysis of observed compared with expected benefits demonstrated a higher icer, with a shorter time horizon ($928,950 per qaly). Conclusions: Despite lessened aes and preserved qol, atezolizumab is not considered cost-effective for the second-line treatment of mbc.

Economic evaluation of a publicly funded hepatitis A travel vaccination program in Ontario, Canada.

BACKGROUND: Hepatitis A virus (HAV) causes acute liver infection and is spread through the fecal-oral route. Travel to countries in HAV-endemic regions (e.g., Asia and Latin America) is a well-described risk factor for infection. Currently, Ontario publicly funds hepatitis A vaccination for some populations at high risk of HAV infection but not for all travellers to endemic countries. The objective of this study was to determine the cost-effectiveness of expanding publicly funded HAV vaccination to people planning travel to HAV-endemic regions, from the Ontario healthcare payer perspective. METHODS: We conducted a cost-utility analysis comparing an expanded high-risk publicly-funded hepatitis A vaccination program including funded vaccine for travellers to endemic regions to the current high risk program in Ontario. A Markov state transition model was developed, including six possible health states. Model parameters were informed through targeted literature searches and included hepatitis A disease probabilities, utilities associated with health states, health system expenditures, and vaccine costs. Future costs and health outcomes were discounted at 1.5%. Primary outcomes included cost, incremental cost-effectiveness ratio (ICER) and quality adjusted life years (QALYs) over a lifetime time horizon. We conducted one-way, two-way, and probabilistic sensitivity analysis. RESULTS: The expanded high risk HAV vaccine program provided few incremental health gains in the travel population (mean 0.000037 QALYs/person), at an incremental cost of $124.31. The ICER of the expanded program compared to status quo is $3,391,504/QALY gained. The conclusion of the model was robust to changes in key parameters across reasonable ranges. CONCLUSIONS: The expanded vaccination program substantially exceeds commonly accepted cost-effectiveness thresholds. Further research concerning possible cost-effective implementation of high-risk travel hepatitis A vaccination should focus on a more integrated understanding of the risk of acquiring hepatitis A during travel to endemic regions (e.g., purpose, length of stay).

Health services utilization reporting in respiratory patients. Pharmacy Medication Monitoring Program Advisory Board.

Health services utilization information is important for outcomes research. This study assessed the reliability of self-reports of health services utilization in respiratory patients. Patients reported health services use and other information during three telephone interviews over 6 months. Reports of visits to general practitioners (GPs), specialists, emergency room (ER)/clinics, and hospital admissions were compared with corresponding fee service claims in the Ontario Health Insurance Plan administrative database in 83 subjects. Agreement between the two sources was calculated using observed agreement and estimated kappa. Substantial agreement was found for hospital admissions and visits to respiratory specialists. Agreement was moderate for GP visits and slight for ER/clinic visits. Patient self-report of ER use appeared unreliable and may be related to imprecise questionnaire wording and inadequately defined fee service codes. The findings emphasize the importance of the methods used to assess the reliability of patient self-reports used in outcomes research.

Changing rates of cancer. The hazards of using a single definition.

Changing cancer rates, abstracted from tumor registries, are used to make inferences about the effect of carcinogens and cancer treatments on a population-wide basis. We compared the annual age-standardized incidence rates of extremity soft tissue sarcomas from two large tumor registries using different case definitions. We identified all limb soft tissue sarcoma cases diagnosed 1973-1993 in the Ontario Cancer Registry (OCR) and the Surveillance, Epidemiology, and End Results (SEER) databases. Two case definitions for limb soft tissue sarcoma were used based on missing data, incomplete diagnostic methods and ICD-9 codes; an upper limit estimate of the rates which included all possible cases of limb soft tissue sarcoma and a lower limit estimate of the rates which included all definite cases of limb soft tissue sarcoma (with the true rates lying in between). The upper limit OCR rates showed a statistically significant decreasing linear trend (slope = -0.021, P < 0.01). Whereas the slope of the OCR lower limit regression line showed a statistically significant increase in rates (slope = 0.01, P = 0.04). Neither the upper or lower limit SEER rates had a statistically significant linear trend (slope = 0.002, P = 0.60 and slope = 0.001, P = 0.18, respectively). Case definition affects incidence rates and changing rates of cancer. Thus the use of a single case definition along with changing coding practices may alone explain changing cancer rates.

Accuracy of administrative data for assessing outcomes after knee replacement surgery.

OBJECTIVE: To assess the accuracy of information in an administrative database (Canadian Institute for Health Information; CIHI) compared with the hospital record for patients undergoing knee replacement (KR). METHODS: A stratified random sample of 185 KR recipients from 5 Ontario hospitals were chosen. Their hospital records and corresponding CIHI files were compared to assess percent complete agreement, false negative (FN) and false positive (FP) rates for demographic data, procedures, and diagnoses. RESULTS: Of 185 records, 175 (95%) were reviewed. Percent complete agreement was greater than 94% for each of patient demographics and procedures (mean FN rates: 0%; mean FP rates: 0-5%). For comorbidities and complications, although mean percent complete agreement was high, and FP rates were low, mean FN rates were 63% for specific comorbid conditions and 70% for organ systems. CONCLUSIONS: High FN rates have been found in documentation of comorbidities and in-hospital complications for CIHI data compared with the hospital record. Under-coding of comorbidities and in-hospital complications has potential implications for researchers using administrative databases.

The economic cost of musculoskeletal disorders in Canada.

OBJECTIVE: This study estimated the total cost of musculoskeletal disorders for Canadians in 1994 and assessed the sensitivity of these cost estimates to variations in the definition of musculoskeletal disorders. METHODS: Disease-related costs, from a societal perspective, were measured using a prevalence-based analysis. First, direct treatment costs, including expenditures on hospitals and other institutions, physicians and other health professionals, drugs, research, and other items were assessed. Second, indirect costs associated with lost (or foregone) productivity due to disability and premature mortality were evaluated using the human capital approach. RESULTS: The total cost of musculoskeletal disorders in Canada was $25.6 billion (in 1994 Canadian dollars, $1.00 CDN approximately $0.75 US) or 3.4% of the gross domestic product. Direct and indirect costs were estimated at $7.5 billion and $18.1 billion, respectively. Lower and upper bound estimates of the total cost of musculoskeletal disorders, derived from the sensitivity analysis, were $19.9 billion and $30.8 billion, respectively. Wide variations were reported in the total cost of various musculoskeletal disorder subcategories, with the highest costs reported for injuries ($10.7 billion), back and spine disorders ($8.1 billion), and arthritis and rheumatism ($5.9 billion). CONCLUSIONS: The economic cost of musculoskeletal disorders was substantial and was sensitive to the definition of musculoskeletal disorders and other underlying assumptions. The hallmark of this study was the variation between subcategories in their cost, pattern of health resource use, and sequelae. The cost estimates may provide guidance in setting priorities for research and prevention activities.

Ambulatory care or home-based treatment? An economic evaluation of two physiotherapy delivery options for people with rheumatoid arthritis.

OBJECTIVE: To assess the difference in costs of home-based versus clinic-based physiotherapy (PT) for patients with rheumatoid arthritis (RA) from a societal perspective. METHODS: A cost analysis was performed using statistical and financial information provided by The Arthritis Society, Ontario Division, from April 1, 1997 to March 30, 1998. Cost estimates included treatment costs and costs borne by patients. A sensitivity analysis was conducted to examine the effect of altering the valuation of treatment time and patient employment status. RESULTS: Total costs per case were $210.87 for the home setting, and $183.87 for the clinic setting when patients were employed. Sensitivity analysis did not change the trend of the results. The estimated start-up costs for an arthritis clinic were between $302.90 and $652.40. From the perspective of the health care system, these costs would be recovered after serving 4 to 8 RA patients at a clinic. CONCLUSION: The findings suggest that ambulatory PT care is less costly than home-based services for people with RA based on The Arthritis Society model. Further studies should be conducted to examine the effectiveness and the possible adverse consequences of alternative settings for service delivery.

Costs and outcomes associated with alternative discharge strategies following joint replacement surgery: analysis of an observational study using a propensity score.

We estimated the impact of alternative discharge strategies, following joint replacement (JR) surgery, on acute care readmission rates and the total cost of a continuum of care. Following surgery, patients were discharged to one of four destinations. Propensity scores were used to adjust costs and outcomes for potential bias in the assignment of discharge destinations. We demonstrated that the use of rehabilitation hospitals may lower readmission rates, but at a prohibitive incremental cost of each saved readmission, that patients discharged with home care had longer acute care stays than other patients, that the provision of home care services increased health system costs, and that acute care readmission rates were greatest among patients discharged with home care. Our study should be seen as one important stepping stone towards a full economic evaluation of the continuum of care for patients.

Canadian medical malpractice liability: an empirical analysis of recent trends.

The determinants of the frequency of Canadian malpractice claims, the proportion of claims that result in payment, and the severity of these claims are examined. Inter-specialty variation in the frequency of malpractice claims is almost entirely related to the differential performance of major surgery. Various legal doctrines concerning both compensation and liability appear responsible for approximately half of the upward trend in the propensity to initiate malpractice litigation. We believe that the remaining explanations for growth in claims frequency are changes in social attitudes toward risk-bearing, increasing social distance between patients and physicians, and innovations in medical technology.

The effects of fee bundling on dental utilization.

OBJECTIVE: To examine dental utilization following an adjustment to the provincial fee schedule in which preventive maintenance (recall) services were bundled at lower fees. DATA SOURCES/STUDY SETTING: Blue Cross dental insurance claims for claimants associated with four major Ontario employers using a common insurance plan over the period 1987-1990. STUDY DESIGN: This before-and-after design analyzes the dental claims experience over a four-year period for 4,455 individuals 18 years of age and older one year prior to the bundling of services, one year concurrent with the change, and two years after the introduction of bundling. The dependent variable is the annual adjusted payment per user. DATA COLLECTION/EXTRACTION METHODS: The analysis was based on all claims submitted by adult users for services received at recall visits and who reported at least one visit of this type between 1987 and 1990. In these data, 26,177 services were provided by 1,214 dentists and represent 41 percent of all adult service claims submitted over the four years of observation. PRINCIPAL FINDINGS: Real per capita payment for adult recall services decreased by 0.3 percent in the year bundling was implemented (1988), but by the end of the study period such payments had increased 4.8 percent relative to pre-bundling levels. Multiple regression analysis assessed the role of patient and provider variables in the upward trend of per capita payments. The following variables were significant in explaining 37 percent of the variation in utilization over the period of observation: subscriber employment location; ever having received periodontal scaling or ever having received restorative services; regular user; dentist's school of graduation; and interactions involving year, service type, and regular user status. CONCLUSIONS: The volume and intensity of services received by adult patients increased when fee constraints were imposed on dentists. Future efforts to contain dental expenditures through fee schedule design will need to take this into consideration. Issues for future dental services research include provider billing practices, utilization among frequent attenders, and outcomes evaluation particularly with regard to periodontal care and replacement of restorations.

Prospective study of the patient-level cost of asthma care in children.

Our objective was to assess the cost of asthma care at the patient level in children from the perspectives of society, the Ontario Ministry of Health, and the patient. In this longitudinal evaluation, health service use data and costs were collected during telephone interviews at 1, 3, and 6 months with parents of 339 Ontario children with asthma. Direct costs were respiratory-related visits to healthcare providers, emergency rooms, hospital admissions, pulmonary function tests, prescription medications, devices, and out-of-pocket expenses. Indirect costs were parents' absences from work/usual activities and travel and waiting time. Hospital admissions accounted for 43%, medications for 31%, and parent productivity losses for 12% of total costs from a societal perspective. Statistically significant predictors of higher total costs were worse symptoms, younger age group, and season of participation. Adjusted annual societal costs per patient in 1995 Canadian dollars varied from $1,122 in children aged 4-14 years to $1,386 in children under 4 years of age. From the Ministry of Health perspective, adjusted annual costs per patient were $663 in children over 4 years and $904 in younger children. Adjusted annual costs from the patient perspective were $132 in children over 4 years and $129 in children under 4 years. The rising incidence of pediatric asthma demands that greater attention be paid to the delivery of optimal care to this segment of the population. Appropriate methods must be used to analyze healthcare costs and the use of services in the midst of widespread healthcare reform. The quality of clinical and health policy decision-making may be enhanced by cost-of-illness estimates that are comprehensive, precise, and expressed from multiple perspectives.

Incremental cost analysis of ambulatory clinic and home-based intravenous therapy for patients with multiple myeloma.

BACKGROUND: Patients with multiple myeloma and other forms of cancer receiving pamidronate via intravenous (IV) infusion at the Hamilton Regional Cancer Centre in Hamilton, Ontario, Canada face 2 treatment options: they can have their entire treatment completed at the clinic using traditional IV therapy (e.g. IV bag and pole) or they can have the treatment initiated at the clinic and then return home to complete the treatment utilising a portable and disposable IV therapy device. OBJECTIVE: To perform a cost analysis of these 2 treatment options. PERSPECTIVE: Societal. METHODS AND PATIENTS: Data on all patients with multiple myeloma who attended the Hamilton Regional Cancer Centre for pamidronate therapy from November 1, 1997 to October 31, 1998 were collected from clinic records. As almost all of these patients with multiple myeloma completed their IV therapy at home, comparison to clinic-based therapy was based on derived cost estimates. Cost data, where possible, were acquired from the Hamilton Regional Cancer Centre's records. A sensitivity analysis was also conducted. RESULTS: In the base-case scenario for the study period, the incremental cost of the infusion device and training in Canadian dollars ($Can; 1998 values) for the 48 patients (299 cycles) who had their infusion initiated at the clinic but completed at home was $Can 5.50/cycle ($Can 4,636 for the 299 cycles). If these 48 patients had had their entire infusion at the clinic, the incremental costs of overtime treatment, parking, clinic overheads and lost work or leisure time would have been $Can 68.49/cycle ($Can 20,477 for the 299 cycles). Therefore, shifting treatment from the clinic to the home resulted in net cost savings to society of $Can 52.98/cycle ($Can 15,841 for the 299 cycles). Sensitivity analysis of best- and worst-cost scenarios did not alter the substantive findings although the relative difference between treatment options varied. In the best-case scenario, home treatment was $Can 95.97/cycle ($Can 28,696 for the 299 cycles) less costly than clinic treatment, while in the worst-case scenario, home treatment was $Can 17.19/cycle ($Can 5,141 for the 299 cycles) less costly than clinic treatment. The results also demonstrated that clinic overheads, the cost of a portable and disposable infusion device and the cost of lost work and leisure time had the greatest impact on incremental costs for each treatment option. CONCLUSION: Subject to study limitations, a significant cost advantage was demonstrated through the home-based treatment option for patients with multiple myeloma. Key issues that must be addressed in future evaluations include the precise determination of clinic overheads, the valuation of lost work and/or leisure time and the direct cost of portable and disposable infusion devices.

Socio-economic status and the utilisation of physicians' services: results from the Canadian National Population Health Survey.

This paper assesses the extent to which Canada's universal health care system has eliminated socio-economic barriers in the use of physician services by examining the role of socio-economic status in the differential use of specific, publicly-insured, primary and specialist care services. Data from the 1994 National Population Health Survey, a nationally representative survey, were analysed using multiple logistic regression. In order to control for the association between primary and specialist utilisation, a two-staged least squares method was used for models explaining specialist utilisation. Health need, as measured by perceived health status and number of health problems, was found to be consistently associated with increased physician utilisation, for both primary and specialist visits. Whereas the likelihood of an individual making at least one visit to a primary care physician was found to be independent of income, those with lower incomes were more likely to be frequent users of primary care, that is, make at least six visits to a primary care physician. Even after adjusting for the greater utilisation of primary care services by those in lower socio-economic groups, and, therefore, their higher exposure to the risk of referral, the utilisation of specialist visits was greater for those in higher socio-economic groups. Canadians lacking a regular medical doctor were less likely to receive primary and specialist care, even after adjustments for socio-economic variables such as income and education. Although financial barriers may not directly impede access to health care services in Canada, differential use of physician services with respect to socio-economic status persists. After adjusting for differences in health need, Canadians with lower incomes and fewer years of schooling visit specialists at a lower rate than those with moderate or high incomes and higher levels of education attained despite the existence of universal health care.

Current trends in Canadian health care: myths and misconceptions in health economics.

This paper is concerned with the economic aspects of the trends in Canadian health care. Various myths and misconceptions abound regarding the applicability of economics to behaviour in the health care industry as well as to the interpretation of recent trends. Both issues are examined in this paper. While most discussions regarding health care trends begin with the share of health expenditures in Gross National Product, I propose an alternative share that adjusts for cyclical variations in both unemployment and labour force participation. Using this measure, I show that the "real" growth of resources devoted to the health care industry is much larger than that obtained with conventional measures, and that the difference in growth rates between Canada and the U.S. is narrowed considerably. The paper outlines and disputes the validity of three public health policy propositions. First, it is not empirically valid to say that the introduction of universal medical insurance in Canada successfully contained the growth in the share of society's resources devoted to the health care industry. Second, it is not correct to argue that the change in the federal funding for hospital and medical care in 1977 was a "fiscal non-event". And finally, the proposed "equity" funding formula for Ontario hospitals is unlikely to contain costs and will potentially skew hospitals towards the provision of complex forms of care instead of cost-effective community-based alternatives.

Rates of revision knee replacement in Ontario, Canada.

BACKGROUND: The present study was designed to measure the longevity of knee replacements and to assess the determinants of revision knee replacements in order to enhance the potential for informed decision-making. METHODS: Data on all hospitalizations for knee replacement that occurred in Ontario, Canada, between April 1, 1984, and March 31, 1991, were acquired. To calculate the rates of revision knee replacement, two algorithms were developed: one distinguished primary knee replacements from revision knee replacements, and the second linked revision knee replacements to primary knee replacements. The Kaplan-Meier method was used to assess survivorship (absence of a revision) for primary knee replacement. A proportional-hazards regression model was estimated to assess the role of independent variables on the survival of primary knee replacements. RESULTS: During the period of the study, 7.0 percent (1301) of 18,530 knee replacements were classified as revisions. Significant differences were identified between hospitalizations for primary and revision knee replacements in terms of the patient and hospital characteristics. Patients who were more than fifty-five years old, lived in a rural area, or had a diagnosis of rheumatoid arthritis had a significantly (p < 0.05) longer duration before revision than did other patients. Primary knee replacements performed in a teaching or specialty hospital had a significantly (p < 0.05) shorter duration before revision than did those performed in a non-teaching hospital. The long-term rates of revision were uniformly low. Estimates of the proportion of knee replacements that would need to be revised within seven years ranged from a low of 4.3 percent, with use of the algorithm for the longest time to revision, to a high of 8.0 percent, with use of the algorithm for the shortest time to revision. CONCLUSIONS: Revision of a primary knee replacement was a rare event that depended on a patient's age, gender, and place of residence as well as on the hospital where the primary knee replacement was performed. Estimates of the rates of revision knee replacement after almost seven years ranged from a low of 4.3 percent to a high of 8.0 percent.

Cost analysis of methylprednisolone treatment of multiple sclerosis patients.

BACKGROUND: Intravenous methylprednisolone (IVMP) is the treatment of choice for multiple sclerosis (MS) patients undergoing acute exacerbation of disease symptoms and yet its cost has not been accurately determined. Determination of this cost in different settings is also pertinent to consideration of cost-saving alternatives to in-patient treatment. METHODS: Cost analysis from the point of view of the health care system of IVMP treatment of MS patients receiving treatment in association with a selected Toronto teaching hospital in fiscal year 1994/95 was carried out. Costs of any concurrent treatments were excluded. RESULTS: Total cost for 92 patients, based on a 4 dose regime, was estimated to be $78,527. The the cost per patient was $1,1181.84 for in-patients (IP), $714.64 for out-patients of the MS Clinic (OP) and $774.21 for patients whose treatment was initiated in the Clinic, but completed in the home (HC). Sensitivity analyses indicated: 1) IP treatment was in all cases more expensive than that of OP or HC; 2) the cost savings of OP vs. HC was sensitive to assumptions made regarding Clinic overhead, Clinic nursing costs and Home Care Program overhead. CONCLUSION: Alternatives to in-patient care must be considered carefully. In this study, both out-patient and in-home treatment were cost-saving alternatives to in-patient treatment, but large differences in the cost of hospital out-patient vs. in-home care could not be demonstrated.

The patient level cost of asthma in adults in south central Ontario. Pharmacy Medication Monitoring Program Advisory Board.

OBJECTIVE: To assess the annual cost of asthma per adult patient from the perspectives of society, the Ontario Ministry of Health and the patient. DESIGN: Prospective cost of illness evaluation. SETTING: Ambulatory out-patients residing in southern central Ontario. POPULATION STUDIED: Nine hundred and forty patients with asthma over 15 years of age studied between May 1995 and April 1996. OUTCOME MEASURES: Direct costs, such as respiratory-related visits to general/family practitioners, respiratory specialists, emergency rooms, hospital admissions, laboratory tests, prescription medications, dispensing fees, devices and out-of-pocket expenses, were calculated. Indirect costs, such as absences from work or usual activities, and travel and waiting time, were studied. MAIN RESULTS: Unadjusted annual costs were $2,550 per patient. Hospitalizations and medications each accounted for 22% of the total cost and indirect costs 50% of the total costs. More severe disease, older age, smoking, drug plan availability and retirement were significant predictors of costs. Annual costs per patient varied from $1,255 (95% CI $1,061 to $1,485) in young nonsmokers with no drug plan and mild disease to $5,032 (95% CI $4,347 to $5,825) in older smokers with drug plans and severe disease. Clinically important reductions in the quality of life occurred with increasing severity. CONCLUSIONS: Interventions aimed at reducing productivity losses, admissions to hospital and medication costs may result in savings to society, the provincial government and the patient. The quality of policy and allocation decisions may be enhanced by cost of illness estimates that are comprehensive, precise and incorporate multiple perspectives.

The economic cost of otitis media in Canada.

The purpose of this study was to estimate the total costs of otitis media (OM) from a societal perspective using a prevalence-based approach to estimate disease related costs for Canadians with OM in 1994. Direct expenditures attributable to OM associated with hospitals, other institutions, physicians, other health professionals, drugs, research and other components of care were assessed, along with estimates of lost productivity due to illness and the workloss of caregivers. The total costs of OM for Canadians were $611.0 million in 1994, with direct and indirect cost components at $470.7 million and $140.3 million, respectively. Over 70% of total OM costs were attributed to children aged 14 years and under ($428.4 million), with direct and indirect costs being $334.1 million and $94.3 million, respectively. This study highlights the scope and magnitude of the economic consequences of OM. The costs calculated may be used to provide guidance in the setting of priorities for research and prevention activities.

Home care in Canada: passing the buck.

This paper provides an overview of Canadian home-care utilization, highlights the health-policy assumptions that have resulted in an increasing reliance on in-home services, and assesses the current roles of the private and public sectors in the financing of home care. Significant interprovincial variations in per capita home-care expenditures and potential inequalities in access to home care call for resolution by federal and provincial governments. There is a need for consensus with respect to medically and socially necessary services that are subject to national standards, irrespective of the setting in which services are sought, received, and delivered. The development and enforcement of national home-care standards that complement the principles of the Canada Health Act would be a useful first step in ensuring that the Canadian health-care system is ready to confront the challenges of the new millennium.