Primary care payment models and avoidable hospitalizations in Ontario, Canada: A multivalued treatment effects analysis.

Improving access to primary care physicians' services may help reduce hospitalizations due to Ambulatory Care Sensitive Conditions (ACSCs). Ontario, Canada's most populous province, introduced blended payment models for primary care physicians in the early- to mid-2000s to increase access to primary care, preventive care, and better chronic disease management. We study the impact of payment models on avoidable hospitalizations due to two incentivized ACSCs (diabetes and congestive heart failure) and two non-incentivized ACSCs (angina and asthma). The data for our study came from health administrative data on practicing primary care physicians in Ontario between 2006 and 2015. We employ a two-stage estimation strategy on a balanced panel of 3710 primary care physicians (1158 blended-fee-for-service (FFS), 1388 blended-capitation models, and 1164 interprofessional team-based practices). First, we account for the differences in physician practices using a generalized propensity score based on a multinomial logit regression model, corresponding to three primary care payment models. Second, we use fractional regression models to estimate the average treatment effects on the treated outcome (i.e., avoidable hospitalizations). The capitation-based model sometimes increases avoidable hospitalizations due to angina (by 7 per 100,000 patients) and congestive heart failure (40 per 100,000) relative to the blended-FFS-based model. Switching capitation physicians into interprofessional teams mitigates this effect, reducing avoidable hospitalizations from congestive heart failure by 30 per 100,000 patients and suggesting better access to primary care and chronic disease management in team-based practices.

Emergency department use following incentives to provide after-hours primary care: a retrospective cohort study.

BACKGROUND: Access to primary care outside of regular working hours is limited in many countries. This study investigates the relation between the after-hours premium, an incentive for primary care physicians to provide services after hours, and less-urgent visits to the emergency department in Ontario, Canada. METHODS: We analyzed a retrospective cohort of a random sample of Ontario residents from April 2002 to March 2006, and a subcohort of patients followed from April 2005 to March 2016. We linked patient and primary care physician data with emergency department visit data. We used fixed-effects regression models to analyze the association between the introduction of the after-hours premium, as well as subsequent increases in the value of the premium, and the number of monthly emergency department visits. RESULTS: The sample consisted of 586 534 patients between 2002 and 2006, and 201 594 patients from 2005 to 2016. After controlling for patient and physician characteristics, seasonality and time-invariant patient confounding factors, introduction of the after-hours premium was associated with a reduction of 1.26 less-urgent visits to the emergency department per 1000 patients per month (95% confidence interval -1.48 to -1.04). Most of this reduction was observed in after-hours visits. Sensitivity analysis showed that the monthly reduction in less-urgent visits to the emergency department was in the range of -1.24 to -1.16 per 1000 patients. Subsequent increases in the after-hours premium were associated with a small reduction in less-urgent visits to the emergency department. INTERPRETATION: Ontario's experience suggests that incentivizing physicians to improve access to after-hours primary care reduces some less-urgent visits to the emergency department. Other jurisdictions may consider incentives to limit less-urgent visits to the emergency department.

Is it worth it? Cost-effectiveness analysis of a commercial physical activity app.

BACKGROUND: Government interest in investing in commercial physical activity apps has increased with little evidence of their cost-effectiveness. This is the first study to our knowledge to examine the cost-effectiveness of a commercial physical activity app (Carrot Rewards) despite there being over 100,000 in the major app stores. METHODS: A cost-effectiveness analysis was performed to calculate the incremental cost-effectiveness ratio (ICER) of the app compared to a no-intervention reference scenario using a five-year time horizon. Primary data was collected between 2016 and 2017. Data synthesis, model creation, and statistical analyses were conducted between 2019 and 2020. An age-, sex-, and geography-dependent Markov model was developed assuming a public healthcare payer perspective. A closed cohort (n = 38,452) representing the population reached by Carrot Rewards in two Canadian provinces (British Columbia, Newfoundland & Labrador) at the time of a 12-month prospective study was used. Costs and effects were both discounted at 1.5% and expressed in 2015 Canadian dollars. Subgroup analyses were conducted to compare ICERs between provinces, sexes, age groups, and engagement levels. RESULTS: Carrot Rewards had an ICER of $11,113 CAD per quality adjusted life year (QALY), well below a $50,000 CAD per QALY willingness-to-pay (WTP) threshold. Subgroup analyses revealed that the app had lower ICERs for British Columbians, females, highly engaged users, and adults aged 35-64 yrs., and was dominant for older adults (65 + yrs). Deterministic sensitivity analyses revealed that the ICER was most influenced by the relative risk of diabetes. Probabilistic sensitivity analyses revealed varying parameter estimates predominantly resulted in ICERs below the WTP threshold. CONCLUSIONS: The Carrot Rewards app was cost-effective, and dominant for older adults. These results provide, for the first time, rigorous health economic evidence for a commercial physical activity app as part of public health programming.

Mental Health Services Provision in Primary Care and Emergency Department Settings: Analysis of Blended Fee-for-Service and Blended Capitation Models in Ontario, Canada.

Treating mental illnesses in primary care is increasingly emphasized to improve access to mental health services. Although family physicians (FPs) or general practitioners are in an ideal position to provide the bulk of mental health care, it is unclear how best to remunerate FPs for the adequate provision of mental health services. We examined the quantity of mental health services provided in Ontario's blended fee-for-service and blended capitation models. We evaluated the impact of FPs switching from blended fee-for-service to blended capitation on the provision of mental health services in primary care and emergency department using longitudinal health administrative data from 2007 to 2016. We accounted for the differences between those who switched to blended capitation and non-switchers in the baseline using propensity score weighted fixed-effects regressions to compare remuneration models. We found that switching from blended fee-for-service to blended capitation was associated with a 14% decrease (95% CI 12-14%) in the number of mental health services and an 18% decrease (95% CI 15-20%) in the corresponding value of services. This result was driven by the decrease in services during regular-hours. During after-hours, the number of services increased by 20% (95% CI 10-32%) and the corresponding value increased by 35% (95% CI 17-54%). Switching was associated with a 4% (95% CI 1-8%) decrease in emergency department visits for mental health reasons. Blended capitation reduced provision of mental health services without increasing emergency department visits, suggesting potential efficiency gain in the blended capitation model in Ontario.

Evaluating multiple living kidney donor candidates simultaneously is more cost-effective than sequentially.

When multiple living donor candidates come forward to donate a kidney to the same recipient, some living donor programs evaluate one candidate at a time to avoid unnecessary evaluations. Evaluating multiple candidates concurrently rather than sequentially may be cost-effective from a societal perspective if it reduces the time recipients spend on dialysis. We used a simple decision tree to estimate the cost-effectiveness of evaluating two to four candidates simultaneously rather than sequentially as potential kidney donors for the same intended recipient. Evaluating two donor candidates simultaneously cost $1,266 (CAD) more than if they were evaluated sequentially, but living donation occurred one month earlier. This translated into $6,931 in averted dialysis costs and a total cost-savings of $5,665 per intended recipient. Simultaneous evaluations also resulted in one percent more living donor transplants and overall gains in quality-of-life as recipients spent less time on dialysis. If recipients were free from dialysis at the start of donor candidate evaluations, simultaneous evaluations also reduced the rate of dialysis initiation by two percent. Benefits were also observed in the three- and four-candidate scenarios. Thus, living donor programs should consider evaluating up to four living donor candidates simultaneously when they come forward for the same recipient as health care system costs incurred are more than offset by avoided dialysis costs.

Stirring the pot: Switching from blended fee-for-service to blended capitation models of physician remuneration.

In Canada's most populous province, Ontario, family physicians may choose between the blended fee-for-service (Family Health Group [FHG]) and blended capitation (Family Health Organization [FHO] payment models). Both models incentivize physicians to provide after-hours (AH) and comprehensive care, but FHO physicians receive a capitation payment per enrolled patient adjusted for age and sex, plus a reduced fee-for-service while FHG physicians are paid by fee-for-service. We develop a theoretical model of physician labor supply with multitasking to predict their behavior under FHG and FHO, and estimable equations are derived to test the predictions empirically. Using health administrative data from 2006 to 2014 and a two-stage estimation strategy, we study the impact of switching from FHG to FHO on the production of a capitated basket of services, after-hours services and nonincentivized services. Our results reveal that switching from the FHG to FHO reduces the production of capitated services to enrolled patients and services to nonenrolled patients by 15% and 5% per annum and increases the production of after-hours and nonincentivized services by 8% and 15% per annum.

Meaning-Centered Men's Groups: Initial Findings of an Intervention to Enhance Resiliency and Reduce Suicide Risk in Men Facing Retirement.

Objectives: To assess the preliminary effectiveness of Meaning-Centered Men's Groups (MCMG), a 12-session existentially-oriented, community-based, psychological group intervention designed to enhance psychological resiliency and prevent the onset or exacerbation of suicide ideation among men who are concerned about or struggling with the transition to retirement.Methods: We recruited 30 men (n= 10 per group), 55 years and older (M= 63.7, SD= 4.1) from community settings to participate in a course of MCMG to be delivered in a community center. Participants completed eligibility, pre-, mid-, and post-group assessments of suicide ideation and psychological risk and resiliency factors.Results: Participants experienced significant increases in attitudinal sources of meaning in life, psychological well-being, life satisfaction, retirement satisfaction, and general health, and decreases in depression, hopelessness, loneliness, and suicide ideation.Conclusions: Preliminary findings suggest that MCMG is a novel men's mental health intervention that may help to enhance psychological well-being and potentially reduce the severity or prevent the onset of symptoms of depression, hopelessness, and suicide ideation.Clinical Implications: Upstream psychological interventions may serve an important role in mental health promotion and suicide prevention with potentially vulnerable individuals facing challenging life transitions.

Production of physician services under fee-for-service and blended fee-for-service: Evidence from Ontario, Canada.

We examine family physicians' responses to financial incentives for medical services in Ontario, Canada. We use administrative data covering 2003-2008, a period during which family physicians could choose between the traditional fee for service (FFS) and blended FFS known as the Family Health Group (FHG) model. Under FHG, FFS physicians are incentivized to provide comprehensive care and after-hours services. A two-stage estimation strategy teases out the impact of switching from FFS to FHG on service production. We account for the selection into FHG using a propensity score matching model, and then we use panel-data regression models to account for observed and unobserved heterogeneity. Our results reveal that switching from FFS to FHG increases comprehensive care, after-hours, and nonincentivized services by 3%, 15%, and 4% per annum. We also find that blended FFS physicians provide more services by working additional total days as well as the number of days during holidays and weekends. Our results are robust to a variety of specifications and alternative matching methods. We conclude that switching from FFS to blended FFS improves patients' access to after-hours care, but the incentive to nudge service production at the intensive margin is somewhat limited.

Financial Costs Incurred by Living Kidney Donors: A Prospective Cohort Study.

BACKGROUND: Approximately 40% of the kidneys for transplant worldwide come from living donors. Despite advantages of living donor transplants, rates have stagnated in recent years. One possible barrier may be costs related to the transplant process that potential willing donors may incur for travel, parking, accommodation, and lost productivity. METHODS: To better understand and quantify the financial costs incurred by living kidney donors, we conducted a prospective cohort study, recruiting 912 living kidney donors from 12 transplant centers across Canada between 2009 and 2014; 821 of them completed all or a portion of the costing survey. We report microcosted total, out-of-pocket, and lost productivity costs (in 2016 Canadian dollars) for living kidney donors from donor evaluation start to 3 months after donation. We examined costs according to (1) the donor's relationship with their recipient, including spousal (donation to a partner), emotionally related nonspousal (friend, step-parent, in law), or genetically related; and (2) donation type (directed, paired kidney, or nondirected). RESULTS: Living kidney donors incurred a median (75th percentile) of $1254 ($2589) in out-of-pocket costs and $0 ($1908) in lost productivity costs. On average, total costs were $2226 higher in spousal compared with emotionally related nonspousal donors (P=0.02) and $1664 higher in directed donors compared with nondirected donors (P<0.001). Total costs (out-of-pocket and lost productivity) exceeded $5500 for 205 (25%) donors. CONCLUSIONS: Our results can be used to inform strategies to minimize the financial burden of living donation, which may help improve the donation experience and increase the number of living donor kidney transplants.

Potential implications of a more timely living kidney donor evaluation.

Living donor kidney transplantation is the most promising way to avoid or minimize the amount of time a recipient spends on dialysis before transplantation. We studied 887 living kidney donors at 5 transplant centers in Ontario, Canada, who started their evaluation and donated between April 2006 and March 2014. Using a series of hypothetical scenarios, we estimated the impact of an earlier living donor evaluation completion and donation on the number pre-emptive transplants, the time spent on dialysis, healthcare cost savings from averted dialysis costs (CAD $2016), and the number of additional transplants. During the study period, if the donor transplants occurred 3 months earlier, the healthcare system would save on average $12 055 (standard deviation [SD] $13 594) per recipient; 21 recipients could have avoided dialysis altogether, and 57 additional transplants (a 26% increase) could have occurred each year. For the 220 living kidney donor transplants performed in Ontario, Canada, each year, this translates to a total annual cost savings of $2.7M. In conclusion, a more timely evaluation of living donor candidates and their intended recipients may increase the supply of kidneys for transplantation. Improved evaluation efficiency may also yield more pre-emptive transplants and substantial healthcare cost savings through averted dialysis costs.

Duration of Living Kidney Transplant Donor Evaluations: Findings From 2 Multicenter Cohort Studies.

BACKGROUND: A prolonged living kidney donor evaluation may result in worse outcomes for transplant recipients. Better knowledge of the duration of this process may help inform future donors and identify opportunities for improvement. STUDY DESIGN: 1 prospective and 1 retrospective cohort study. SETTING & PARTICIPANTS: At 16 Canadian and Australian transplantation centers (prospective cohort) and 5 Ontario transplantation centers (retrospective cohort), we assessed the duration of living kidney donor evaluation and explored donor, recipient, and transplantation factors associated with longer evaluation times. Data were obtained from 2 sources: donor medical records using chart abstraction and health care administrative databases. PREDICTORS: Donor and recipient demographics, direct versus paired donation, center-level variables. OUTCOMES: Duration of living donor evaluation. RESULTS: The median total duration of transplantation evaluation (time from when the candidate started the evaluation until donation) was 10.3 (IQR, 6.5-16.7) months. The median duration from evaluation start until approval to donate was 7.9 (IQR, 4.6-14.1) months, and from approval until donation was 0.7 (IQR, 0.3-2.4) months, respectively. The median time between the first and last consultation among donors who completed a nephrology, surgery, and psychosocial assessment in the prospective cohort was 3.0 (IQR, 1.0-6.3) months, and between computed tomography angiography and donation was 4.8 (IQR, 2.6-9.2) months. After adjustment, the total duration of transplantation evaluation was longer if the donor participated in paired donation (6.6 [95% CI, 1.6-9.7] months) and if the recipient was referred later relative to the donor's evaluation start date (0.9 [95% CI, 0.8-1.0] months [per month of delayed referral]). Results depended on whether the recipient was receiving dialysis. LIMITATIONS: Living donor candidates who did not donate were not included and proxy measures were used for some dates in the donor evaluation process. CONCLUSIONS: The duration of kidney transplant donor evaluation is variable and can be lengthy. Better understanding of the reasons for a prolonged evaluation may inform quality improvement initiatives to reduce unnecessary delays.

Trends in obesity and multimorbidity in Canada.

Very few studies have examined trends in multimorbidity over time and even fewer have examined trends over time across different body mass index (BMI) groups. Given a general decline in death rates but increased cardiovascular risk factors among individuals with obesity, the trend in the association between obesity and multimorbidity is hypothesized to be increasing over time. The data for our study came from the 1996-97 National Population Health Survey and the 2005 and 2012-13 Canadian Community Health Surveys (N = 277,366 across all 3 surveys). We examined trends in the association between BMI groups and multimorbidity using a logistic regression model. We also investigated trends in the prevalence of specific chronic conditions, pairs of chronic conditions and different levels of multimorbidity across BMI groups. We found significantly greater levels of multimorbidity in 2005 (OR = 1.42; p < 0.001) and 2012-13 (OR = 1.58; p < 0.001) relative to 1996-97. Changes in multimorbidity levels were much greater among individuals with class II/III (OR = 1.48; p = 0.005) and class I obesity (OR = 1.38; p = 0.001) in 2012-13 relative to 1996-97. Much of the increase in multimorbidity among individuals living with obesity was due to increases in 3+ chronic conditions and conditions in combination with hypertension, and the greatest increase was found among seniors living with obesity. Our results highlight the need for interventions aimed at preventing obesity and the prevention of chronic conditions among individuals with obesity, especially among seniors.

Cost-Effectiveness of First-Line Sevelamer and Lanthanum versus Calcium-Based Binders for Hyperphosphatemia of Chronic Kidney Disease.

BACKGROUND: Phosphate binders are used to treat hyperphosphatemia among patients with chronic kidney disease (CKD). OBJECTIVES: To conduct an economic evaluation comparing calcium-free binders sevelamer and lanthanum with calcium-based binders for patients with CKD. METHODS: Effectiveness data were obtained from a recent meta-analysis of randomized trials. Effectiveness was measured as life-years gained and translated to quality-adjusted life-years (QALYs) using utility weights from the literature. A Markov model consisting of non-dialysis-dependent (NDD)-CKD, dialysis-dependent (DD)-CKD, and death was developed to estimate the incremental costs and effects of sevelamer and lanthanum versus those of calcium-based binders. A lifetime horizon was used and both costs and effects were discounted at 1.5%. All costs are presented in 2015 Canadian dollars from the Canadian public payer perspective. Results of probabilistic sensitivity analysis were presented using cost-effectiveness acceptability curves. Sensitivity analyses were conducted for risk pooling methods, omission of dialysis costs, and persistence of drug effects on mortality. RESULTS: Sevelamer resulted in an incremental cost-effectiveness ratio of $106,522/QALY for NDD-CKD and $133,847/QALY for DD-CKD cohorts. Excluding dialysis costs, sevelamer was cost-effective in the NDD-CKD cohort ($5,847/QALY) and the DD-CKD cohort ($11,178/QALY). Lanthanum was dominated regardless of whether dialysis costs were included. CONCLUSIONS: Existing evidence does not clearly support the cost-effectiveness of non-calcium-containing phosphate binders (sevelamer and lanthanum) relative to calcium-containing phosphate binders in DD-CKD patients. Our study suggests that sevelamer may be cost-effective before dialysis onset. Because of the remaining uncertainty in several clinically relevant outcomes over time in DD-CKD and NDD-CKD patients, further research is encouraged.

Family physician remuneration schemes and specialist referrals: Quasi-experimental evidence from Ontario, Canada.

Understanding how family physicians respond to incentives from remuneration schemes is a central theme in the literature. One understudied aspect is referrals to specialists. Although the theoretical literature has suggested that capitation increases referrals to specialists, the empirical evidence is mixed. We push forward the empirical research on this question by studying family physicians who switched from blended fee-for-service to blended capitation in Ontario, Canada. Using several health administrative databases from 2005 to 2013, we rely on inverse probability weighting with fixed-effects regression models to account for observed and unobserved differences between the switchers and nonswitchers. Switching from blended fee-for-service to blended capitation increases referrals to specialists by about 5% to 7% per annum. The cost of specialist referrals is about 7 to 9% higher in the blended capitation model relative to the blended fee-for-service. These results are generally robust to a variety of alternative model specifications and matching techniques, suggesting that they are driven partly by the incentive effect of remuneration. Policy makers need to consider the benefits of capitation payment scheme against the unintended consequences of higher referrals to specialists.

The efficacy and safety of sevelamer and lanthanum versus calcium-containing and iron-based binders in treating hyperphosphatemia in patients with chronic kidney disease: a systematic review and meta-analysis.

Background: It remains unclear which phosphate binders should be preferred for hyperphosphatemia management in chronic kidney disease (CKD). Methods: We performed a systematic review and meta-analysis of randomized trials comparing sevelamer or lanthanum with other phosphate binders in CKD. Results: Fifty-one trials (8829 patients) were reviewed. Compared with calcium-based binders, all-cause mortality was nonsignificantly lower with sevelamer {risk ratio [RR] 0.62 [95% confidence interval (CI) 0.35-1.08]} and lanthanum [RR 0.73 (95% CI 0.18-3.00)], but risk of bias was concerning. Compared with calcium-based binders, sevelamer reduced the risk of hypercalcemia [RR 0.27 (95% CI 0.17-0.42)], as did lanthanum [RR 0.12 (95% CI 0.05-0.32)]. Sevelamer reduced hospitalizations [RR 0.50 (95% CI 0.31-0.81)], but not lanthanum [RR 0.80 (95% CI 0.34-1.93)]. The presence/absence of other clinically relevant outcomes was infrequently reported. Compared with calcium-based binders, sevelamer reduced serum calcium, low-density lipoprotein and coronary artery calcification, but increased intact parathyroid hormone. The clinical relevance of these changes is unknown since corresponding clinical outcomes were not reported. Lanthanum had less favorable impact on biochemical parameters. Sevelamer hydrochloride and sevelamer carbonate were similar in three studies. Sevelamer was similar to lanthanum (three studies) and iron-based binders (three studies). Conclusion: Sevelamer was associated with a nonsignificant reduction in mortality and significantly lower hospitalization rates and hypercalcemia compared with calcium-based binders. However, differences in important outcomes, such as cardiac events, fractures, calciphylaxis, hyperchloremic acidosis and health-related quality of life remain understudied. Lanthanum and iron-based binders did not show superiority for any clinically relevant outcomes. Future studies that fail to measure clinically important outcomes (the reason why phosphate binders are prescribed in the first place) will be wasteful.

Identification and survival outcomes of a cohort of patients with cancer of unknown primary in Ontario, Canada.

BACKGROUND: Cancer of unknown primary origin (CUP) is defined by the presence of pathologically identified metastatic disease without clinical or radiological evidence of a primary tumour. Our objective was to identify incident cases of CUP in Ontario, Canada, and determine the influence of histology and sites of metastases on overall survival (OS). MATERIAL AND METHODS: We used the Ontario Cancer Registry (OCR) and the Same-Day Surgery and Discharge Abstract Database (SDS/DAD) to identify patients diagnosed with CUP in Ontario between 1 January 2000, and 31 December 2005. Patient diagnostic information, including histology and survival data, was obtained from the OCR. We cross-validated CUP diagnosis and obtained additional information about metastasis through data linkage with the SDS/DAD database. OS was assessed using Cox regression models adjusting for histology and sites of metastases. RESULTS: We identified 3564 patients diagnosed with CUP. Patients without histologically confirmed disease (n = 1821) had a one-year OS of 10.9%, whereas patients with confirmed histology (n = 1743) had a one-year OS of 15.6%. The most common metastatic sites were in the respiratory or digestive systems (n = 1603), and the most common histology was adenocarcinoma (n = 939). Three-year survival rates were 3.5%, 5.3%, 41.6% and 3.6% among adenocarcinoma, unspecified carcinoma, squamous cell carcinoma and undifferentiated histology, respectively. Three-year survival rates were 40%, 2.4%, 8.0% and 4.6% among patients with metastases localised to lymph nodes, the respiratory or digestive systems, other specified sites, and unspecified sites, respectively. CONCLUSION: CUP patients in Ontario have a poor prognosis. Some subgroups may have better survival rates, such as patients with metastases localised to lymph nodes and patients with squamous cell histology.

The Effect of Leisure-Time Physical Activity on Obesity, Diabetes, High BP and Heart Disease Among Canadians: Evidence from 2000/2001 to 2005/2006.

Although studies have looked at the effect of physical activity on obesity and other health outcomes, the causal nature of this relationship remains unclear. We fill this gap by investigating the impact of leisure-time physical activity (LTPA) and work-related physical activity (WRPA) on obesity and chronic conditions in Canadians aged 18-75 using instrumental variable and recursive bivariate probit approaches. Average local temperatures surrounding the respondents' interview month are used as a novel instrument to help identify the causal relationship between LTPA and health outcomes. We find that an active level of LTPA (i.e., walking ≥1 h/day) reduces the probability of obesity by five percentage points, which increases to 11 percentage points if also combined with some WRPA. WRPA exhibits a negative effect on the probability of obesity and chronic conditions.

The relationship between diet quality and adult obesity: evidence from Canada.

OBJECTIVE: To assess the relationship between diet quality and body mass index (BMI) in Canadian adults. METHODS: We used confidential, individual-level data on 6325 adult men and 7211 nonpregnant adult women from the 2004 Canadian Community Health Survey to construct 2 diet quality indices (the Diet Quality Index [DQI] and and the Healthy Eating Index [HEI]) and BMI. After adjusting for known observable confounders, a latent class modeling analysis was conducted to account for unobservable confounders. RESULTS: We found that there were 2 latent classes (low-BMI and high-BMI components), and that DQI and HEI indices were negatively associated with BMI in the high-BMI component. In the high-BMI component, a one-unit increase in DQI score is associated with a 0.053 kg/m(2) decrease in BMI, whereas a one-unit increase in HEI score is associated with a 0.095 kg/m(2) decrease in BMI. Subgroup analyses revealed that the association between diet quality and obesity was stronger in women. CONCLUSIONS: Diet quality is associated with lower BMI in high-BMI individuals in Canada. Diet quality exhibits a distinct association in each latent class; this association is stronger in women. Latent class analysis offers a superior methodological framework in understanding the modifiable risk factors for obesity.

Primary care services and emergency department visits in blended fee-for-service and blended capitation models: evidence from Ontario, Canada.

INTRODUCTION: It is well-known that the way physicians are remunerated can affect delivery of health care services to the population. Fee-for-service (FFS) generally leads to oversupply of services, while capitation leads to undersupply of services. However, little evidence exists on the link between remuneration and emergency department (ED) visits. We fill this gap using two popular blended models introduced in Ontario, Canada: the Family Health Group (FHG), an enhanced/blended FFS model, and Family Health Organization (FHO), a blended capitation model. We compare primary care services and rates of emergency department ED visits between these two models. We also evaluate whether these outcomes vary by regular- and after-hours, and patient morbidity status. METHODS: Physicians practicing in an FHG or FHO between April 2012 and March 2017 and their enrolled adult patients were included for analyses. The covariate-balancing propensity score weighting method was used to remove the influence of observable confounding and negative-binomial and linear regression models were used to evaluate the rates of primary care services, ED visits, and the dollar value of primary care services delivered between FHGs and FHOs. Visits were stratified as regular- and after-hours. Patients were stratified into three morbidity groups: non-morbid, single-morbid, and multimorbid (two or more chronic conditions). RESULTS: 6184 physicians and their patients were available for analysis. Compared to FHG physicians, FHO physicians delivered 14% (95% CI 13%, 15%) fewer primary care services per patient per year, with 27% fewer services during after-hours (95% CI 25%, 29%). Patients enrolled to FHO physicians made 27% more less-urgent (95% CI 23%, 31%) and 10% more urgent (95% CI 7%, 13%) ED visits per patient per year, with no difference in very-urgent ED visits. Differences in the pattern of ED visits were similar during regular- and after-hours. Although FHO physicians provided fewer services, multimorbid patients in FHOs made fewer very-urgent and urgent ED visits, with no difference in less-urgent ED visits. CONCLUSION: Primary care physicians practicing in Ontario's blended capitation model provide fewer primary care services compared to those practicing in a blended FFS model. Although the overall rate of ED visits was higher among patients enrolled to FHO physicians, multimorbid patients of FHO physicians make fewer urgent and very-urgent ED visits.

Cost-Effectiveness Analysis of Pharmacogenomics (PGx)-Based Warfarin, Apixaban, and Rivaroxaban Versus Standard Warfarin for the Management of Atrial Fibrillation in Ontario, Canada.

OBJECTIVE: To assess the cost-effectiveness of pharmacogenomics (PGx)-based warfarin (i.e., warfarin dosing following genetic testing), apixaban, and rivaroxaban oral anticoagulation versus standard warfarin for the treatment of newly diagnosed patients with nonvalvular atrial fibrillation (AF) aged ≥ 65 years. METHODS: We developed a Markov decision-analytic model to compare costs [2017 Canadian dollars (C$)] and quality-adjusted life years (QALYs) from the Ontario health care payer perspective over a life-time horizon. The parameters used in the model were derived from the published literature, the Ontario health care administrative database, and expert opinion. To account for the uncertainty of model parameters, we conducted extensive deterministic and probabilistic sensitivity analyses. The results were summarized using incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves. RESULTS: We found that PGx-based warfarin had an ICER of C$17,584/QALY compared with standard warfarin, and apixaban had an ICER of C$64,590/QALY compared with PGx-based warfarin in our base-case analysis. Rivaroxaban was extendedly dominated by PGx-based warfarin and apixaban. The probabilistic sensitivity analysis showed that apixaban, rivaroxaban, PGx-based warfarin, and standard warfarin were cost-effective at some willingness-to-pay (WTP) thresholds. PGx-based warfarin had a higher probability of being cost-effective than apixaban (51.3% versus 14.3%) at a WTP threshold of C$50,000/QALY. At a WTP threshold of C$100,000/QALY, apixaban had a higher probability of being cost-effective than PGx-based warfarin (54.6% versus 22.6%). CONCLUSION: We found that PGx-based warfarin for patients with AF is cost-effective at a WTP threshold of C$50,000/QALY. Apixaban had a higher probability of being cost-effective (> 50%) at a WTP threshold of C$93,000/QALY.