Integrating health geography and behavioral economic principles to strengthen context-specific behavior change interventions.

The long-term economic viability of modern health care systems is uncertain, in part due to costs of health care at the end of life and increasing health care utilization associated with an increasing population prevalence of multiple chronic diseases. Control of health care spending and sustaining delivery of health care services will require strategic investments in prevention to reduce the risk of disease and its complications over an individual's life course. Behavior change interventions aimed at reducing a range of harmful and risky health-related behaviors including smoking, physical inactivity, excess alcohol consumption, and excess weight, are one approach that has proven effective at reducing risk and preventing chronic disease. However, large-scale efforts to reduce population-level chronic diseases are challenging and have not been very successful at reducing the burden of chronic diseases. A new approach is required to identify when, where, and how to intervene to disrupt patterns of behavior associated with high-risk factors using context-specific interventions that can be scaled. This paper introduces the need to integrate theoretical and methodological principles of health geography and behavioral economics as opportunities to strengthen behavior change interventions for the prevention of chronic diseases. We discuss how health geography and behavioral economics can be applied to expand existing behavior change frameworks and how behavior change interventions can be strengthened by characterizing contexts of time and activity space.

Behavior change interventions are challenged by lack of information about the contexts influencing decisions patients make as part of their daily routine such as when, where, and how health behaviors occur. A new approach is required to strengthen behavior change interventions by integrating contexts of time and activity space so that strategies can be scaled across populations to influence how individuals make decisions about improving their health behaviors. Incorporating ideas from health geography and behavioral economics into the design of behavior change interventions provides an opportunity to collect and investigate individual-level health information characterizing contexts of individuals' activities across space, connections to place, time management, and patterns in behavior over time. By visualizing and characterizing key spatiotemporal contexts about an individual's day-to-day routine, insight can be gained about where and for how long activities occur and what opportunities exist for adapting day-to-day routines. This paper will discuss how theory from health geography could be applied to understand contexts influencing behaviors and how spatiotemporal information could be applied for the purpose of tailoring behavioral economic strategies to strengthen the design of behavior change interventions.

Disparities in access to primary care are growing wider in Canada.

Canadian provinces and territories have undertaken varied reforms to how primary care is funded, organized, and delivered, but equity impacts of reforms are unclear. We explore disparities in access to primary care by income, educational attainment, dwelling ownership, immigration, racialization, place of residence (metropolitan/non-metropolitan), and sex/gender, and how these have changed over time, using data from the Canadian Community Health Survey (2007/08 and 2015/16 or 2017/18). We observe disparities by income, educational attainment, dwelling ownership, recent immigration, immigration (regular place of care), racialization (regular place of care), and sex/gender. Disparities are persistent over time or increasing in the case of income and racialization (regular medical provider and consulted with a medical professional). Primary care policy decisions that do not explicitly consider existing inequities may continue to entrench them. Careful study of equity impacts of ongoing policy reforms is needed.

The Team Assessment of Self-Management Support (TASMS): A new approach to uncovering how teams support people with chronic conditions.

Canadian and other healthcare systems are adopting primary care models founded on multidisciplinary, team-based care. This paper describes the development and use of a new tool, the Team Assessment of Self-Management Support (TASMS), designed to understand and improve the self-management support teams provide to patients with chronic conditions. Team Assessment of Self-Management Support captures the time providers spend supporting seven different types of self-management support (process strategies, resources strategies, disease controlling strategies, activities strategies, internal strategies, social interactions strategies, and healthy behaviours strategies), their referral patterns and perceived gaps in care. Four unique features make TASMS user-friendly: it is patient-centred, it uses provider-level data to create a team profile, it has the ability to be tailored to needs (diagnosis and visit type), and visual presentation of results are quickly and intuitively understood by both providers and planners. Currently being used by providers and planners in Nova Scotia, scaling up will allow more widespread use.

Transitioning to Full Field Digital Mammography in Nova Scotia: Using Interrupted Time Series Methods to Study the Impact of Technology Change on Mammography Volumes.

BACKGROUND: Over the past decade, mammography has transitioned from film to digital media with promises of increased productivity and time savings. Between 2007 and 2010 in Nova Scotia, 10 mammography sites transitioned from analog to digital, providing a natural experiment to evaluate the transition (full-field digital mammography) on mammography with respect to changes in throughput volumes in a "real-world" setting. METHODS: Study data consisted of aggregate, monthly, site-specific counts of screening and diagnostic mammograms for the period 2006 to 2014, which were obtained from an information system that supports central booking, clinical reporting, and patient management for all breast imaging in Nova Scotia. A multigroup interrupted time series design using segmented regression with site-month data assessed pre-to post-transition changes in screening throughput volumes and the proportion of diagnostic mammograms performed. RESULTS: The overall mean monthly number of mammograms per machine per full-time equivalent increased by 17% from 192.9 (95% confidence interval: 182.7-203.1) to 225.7 (95% CI 218.3-233.0); however, there was marked heterogeneity across these sites. A pooled analysis for all sites revealed that there was no statistically significantly change in the proportion of diagnostic mammograms performed after transition. CONCLUSIONS: Increases in throughput volumes were observed only in some sites, suggesting unmeasured site-specific factors may have limited the potential for improvement. Interrupted time series methods are an appropriate and meaningful approach for evaluating technology and procedure changes in diagnostic imaging.

The Taxonomy of Everyday Self-management Strategies (TEDSS): A framework derived from the literature and refined using empirical data.

OBJECTIVE: To extend our understanding of self-management by using original data and a recent concept analysis to propose a unifying framework for self-management strategies. METHODS: Longitudinal interview data with 117 people with neurological conditions were used to test a preliminary framework derived from the literature. Statements from the interviews were sorted according to the predefined categories of the preliminary framework to investigate the fit between the framework and the qualitative data. Data on frequencies of strategies complemented the qualitative analysis. RESULTS: The Taxonomy of Every Day Self-management Strategies (TEDSS) Framework includes five Goal-oriented Domains (Internal, Social Interaction, Activities, Health Behaviour and Disease Controlling), and two additional Support-oriented Domains (Process and Resource). The Support-oriented Domain strategies (such as information seeking and health navigation) are not, in and of themselves, goal focused. Instead, they underlie and support the Goal-oriented Domain strategies. Together, the seven domains create a comprehensive and unified framework for understanding how people with neurological conditions self-manage all aspects of everyday life. CONCLUSIONS: The resulting TEDSS Framework provides a taxonomy that has potential to resolve conceptual confusion within the field of self-management science. PRACTICE IMPLICATIONS: The TEDSS Framework may help to guide health service delivery and research.

What we know about the purpose, theoretical foundation, scope and dimensionality of existing self-management measurement tools: A scoping review.

OBJECTIVES: To identify self-report, self-management measures for adults with chronic conditions, and describe their purpose, theoretical foundation, dimensionality (multi versus uni), and scope (generic versus condition specific). METHODS: A search of four databases (8479 articles) resulted in a scoping review of 28 self-management measures. RESULTS: Although authors identified tools as measures of self-management, wide variation in constructs measured, purpose, and theoretical foundations existed. Subscales on 13 multidimensional tools collectively measure domains of self-management relevant to clients, however no one tool's subscales cover all domains. CONCLUSIONS: Viewing self-management as a complex, multidimensional whole, demonstrated that existing measures assess different, related aspects of self-management. Activities and social roles, though important to patients, are rarely measured. Measures with capacity to quantify and distinguish aspects of self-management may promote tailored patient care. PRACTICE IMPLICATIONS: In selecting tools for research or assessment, the reason for development, definitions, and theories underpinning the measure should be scrutinized. Our ability to measure self-management must be rigorously mapped to provide comprehensive and system-wide care for clients with chronic conditions. Viewing self-management as a complex whole will help practitioners to understand the patient perspective and their contribution in supporting each individual patient.

Understanding the Effects of Competition for Constrained Colonoscopy Services with the Introduction of Population-level Colorectal Cancer Screening.

BACKGROUND: Median wait times for gastroenterology services in Canada exceed consensus-recommended targets and have worsened substantially over the past decade. Meanwhile, efforts to control colorectal cancer have shifted their focus to screening asymptomatic, average-risk individuals. Along with increasing prevalence of colorectal cancer due to an aging population, screening programs are expected to add substantially to the existing burden on colonoscopy services, and create competition for limited services among individuals of varying risk. Failure to understand the effects of operational programmatic screening decisions may cause unintended harm to both screening participants and higher-risk patients, make inefficient use of limited health care resources, and ultimately hinder a program's success. METHODS: We present a new simulation model (Simulation of Cancer Outcomes for Planning Exercises, or SCOPE) for colorectal cancer screening which, unlike many other colorectal cancer screening models, reflects the effects of competition for limited colonoscopy services between patient groups and can be used to guide planning to ensure adequate resource allocation. We include verification and validation results for the SCOPE model. RESULTS: A discrete event simulation model was developed based on an epidemiological representation of colorectal cancer in a sample population. Colonoscopy service and screening modules were added to allow observation of screening scenarios and resource considerations. The model reproduces population-based data on prevalence of colorectal cancer by stage, and mortality by cause of death, age, and sex, and attendant demand and wait times for colonoscopy services. CONCLUSIONS: The study model differs from existing screening models in that it explicitly considers the colonoscopy resource implications of screening activities and the impact of constrained resources on screening effectiveness.

A prediction model to estimate completeness of electronic physician claims databases.

OBJECTIVES: Electronic physician claims databases are widely used for chronic disease research and surveillance, but quality of the data may vary with a number of physician characteristics, including payment method. The objectives were to develop a prediction model for the number of prevalent diabetes cases in fee-for-service (FFS) electronic physician claims databases and apply it to estimate cases among non-FFS (NFFS) physicians, for whom claims data are often incomplete. DESIGN: A retrospective observational cohort design was adopted. SETTING: Data from the Canadian province of Newfoundland and Labrador were used to construct the prediction model and data from the province of Manitoba were used to externally validate the model. PARTICIPANTS: A cohort of diagnosed diabetes cases was ascertained from physician claims, insured resident registry and hospitalisation records. A cohort of FFS physicians who were responsible for the diagnosis was ascertained from physician claims and registry data. PRIMARY AND SECONDARY OUTCOME MEASURES: A generalised linear model with a γ distribution was used to model the number of diabetes cases per FFS physician as a function of physician characteristics. The expected number of diabetes cases per NFFS physician was estimated. RESULTS: The diabetes case cohort consisted of 31,714 individuals; the mean cases per FFS physician was 75.5 (median = 49.0). Sex and years since specialty licensure were significantly associated (p < 0.05) with the number of cases per physician. Applying the prediction model to NFFS physician registry data resulted in an estimate of 18,546 cases; only 411 were observed in claims data. The model demonstrated face validity in an independent data set. CONCLUSIONS: Comparing observed and predicted disease cases is a useful and generalisable approach to assess the quality of electronic databases for population-based research and surveillance.

The role of proximity to death in need-based approaches to health care.

OBJECTIVES: This study examines the role of proximity to death (PTD) in need-based approaches to health care by: (1) investigating whether PTD is a statistically significant, independent predictor of health-care use; and (2) estimating PTD's marginal impact on need-based allocation of health-care resources. METHODS: The primary data source is the Canadian National Population Health Survey (NPHS), a longitudinal survey that uses vital statistics to confirm deaths of the respondents. We use two-part models separately for general practitioner, specialist, and short stay inpatient hospital services. We calculate per-capita allocation, with and without PTD, from the Canadian federal government to its ten provinces and by income groups. RESULTS: PTD is a robust and important predictor of health-care resource use for each service even after adjustment for other need and non-need factors. PTD's marginal impact on allocation is relatively small in the contexts we examined, but failure to include PTD could introduce inequity in allocation by disadvantaging populations with greater need. CONCLUSIONS: PTD is an important need indicator when modeling health-care resource requirements. It deserves greater attention in need-based approaches to health-care planning and resource allocation.

Examining variations in health within rural Canada.

INTRODUCTION: Differences in health between urban and rural areas of Canada are well documented. Canadian rural communities are remarkably heterogeneous in terms of social, economic, and geographic characteristics. There is reason to believe that there is also considerable heterogeneity in health within rural Canada but existing literature has not given this adequate consideration. This article describes heterogeneity in health along the urban-rural continuum, both between and within categories of rural areas. Factors that may explain observed variations are then examined. METHODS: The study population included all adult (>18 years) respondents on the Canadian Community Health Survey Cycle 1.1, linked to census subdivision-level data from the corresponding Canadian Census. Study areas were classified according to Metropolitan Influenced Zones (MIZ), which group rural areas based on their degree of connectivity with nearby urban areas. Dichotomized Health Utilities Index (HUI) scores were the outcome variable. Random-intercept logistic regression models investigated the associations of HUI with individual and area characteristics. To describe between-area variation in health, the proportion of the total variation accounted for by the area random effect (the intra-class correlation coefficient [ICC]) was estimated. To aid interpretation of the magnitude of the effect of area relative to other variables in the models, the ICC was also expressed as a median odds ratio (MOR), or the median amount by which the probability of disability will change for an individual who moves from one area to another. RESULTS: On a descriptive level, poorer health was observed in more remote rural areas, but the size of estimated effects for categories of rural areas was generally small compared with effects of other individual and area variables, and with the degree of heterogeneity between areas. The composition of rural areas is important in order to understand patterns in health. Individual income, education, and employment, and area characteristics such as Francophone or Aboriginal populations, and migration patterns help explain the gradient in health by MIZ, but considerable heterogeneity in health within categories of MIZ remains. In models stratified by MIZ, significant between-area heterogeneity was observed in all models, with MORs ranging from 1.18 to 1.53. CONCLUSION: It was observed that heterogeneity in health among rural areas is substantial, and generally larger than the effect of rurality, itself, on health. More attention is needed to understand the characteristics of Canada's heterogeneous rural communities, and the different processes by which disparities in health emerge and persist. The findings suggest that a focus on rurality alone, emphasizing urban versus rural disparities, or even continuum-based approaches like MIZ, may be less informative than finding ways to classify and examine different types of rural areas according to factors relevant to health.

Understanding different methodological approaches to measuring inequity in health care.

The objectives of this study were to classify different methodological approaches to measuring inequity in health care, identify the strengths and weaknesses of each approach, and suggest directions for future improvement of each approach. The authors classified three approaches to measuring inequity in health care according to: (1) collective expert judgments (clinical standard approach), (2) average health care use based on need (population standard approach), and (3) assessment of health care users or providers (direct approach). The clinical standard approach has strong face validity and immediate policy implication, while lacking global policy implications. The population standard approach offers a global picture of inequity but has weak face validity. The direct approach can reveal private information of health care users and offer opportunity for managing public expectation. Strengths and limitations of these approaches are complementary, suggesting directions for future improvements of each approach. This study will help researchers make a well-informed choice of measurement approach and assist policymakers in resolving some of the problems caused by the diverse findings of studies, partly due to the measurement approaches taken.

Health human resources planning and the production of health: development of an extended analytical framework for needs-based health human resources planning.

Health human resources planning is generally based on estimating the effects of demographic change on the supply of and requirements for healthcare services. In this article, we develop and apply an extended analytical framework that incorporates explicitly population health needs, levels of service to respond to health needs, and provider productivity as additional variables in determining the future requirements for the levels and mix of healthcare providers. Because the model derives requirements for providers directly from the requirements for services, it can be applied to a wide range of different provider types and practice structures including the public health workforce. By identifying the separate determinants of provider requirements, the analytical framework avoids the "illusions of necessity" that have generated continuous increases in provider requirements. Moreover, the framework enables policy makers to evaluate the basis of, and justification for, increases in the numbers of provider and increases in education and training programs as a method of increasing supply. A broad range of policy instruments is identified for responding to gaps between estimated future requirements for care and the estimated future capacity of the healthcare workforce.

Need-based resource allocation: different need indicators, different results?

BACKGROUND: A key policy objective in most publicly financed health care systems is to allocate resources according to need. Many jurisdictions implement this policy objective through need-based allocation models. To date, no gold standard exists for selecting need indicators. In the absence of a gold standard, sensitivity of the choice of need indicators is of concern. The primary objective of this study was to assess the consistency and plausibility of estimates of per capita relative need for health services across Canadian provinces based on different need indicators. METHODS: Using the 2000/2001 Canadian Community Health Survey, we estimated relative per capita need for general practitioner, specialist, and hospital services by province using two approaches that incorporated a different set of need indicators: (1) demographics (age and sex), and (2) demographics, socioeconomic status, and health status. For both approaches, we first fitted regression models to estimate standard utilization of each of three types of health services by indicators of need. We defined the standard as average levels of utilization by needs indicators in the national sample. Subsequently, we estimated expected per capita utilization of each type of health services in each province. We compared these estimates of per capita relative need with premature mortality in each province to check their face validity. RESULTS: Both approaches suggested that expected relative per capita need for three services vary across provinces. Different approaches, however, yielded different and inconsistent results. Moreover, provincial per capita relative need for the three health services did not always indicate the same direction of need suggested by premature mortality in each province. In particular, the two approaches suggested Newfoundland had less need than the Canadian average for all three services, but it had the highest premature mortality in Canada. CONCLUSION: Substantial differences in need for health care may exist across Canadian provinces, but the direction and magnitude of differences depend on the need indicators used. Allocations from models using survey data lacked face validity for some provinces. These results call for the need to better understand the biases that may result from the use of survey data for resource allocation.

Planning for what? Challenging the assumptions of health human resources planning.

OBJECTIVES: Health human resource planning has traditionally been based on simple models of demographic changes applied to observed levels of service utilization or provider supply. No consideration has been given to the implications of changing levels of need within populations over time. Recently, needs based resource planning models have been suggested that incorporate changes in needs for care explicitly as a determinant of health care needs. METHODS: In this paper, population indicators of morbidity, mortality and self-assessed health are analyzed to determine if health care needs have changed across birth cohorts in Canada from 1994 to 2005 among older age groups. Multivariate regression analysis was used to estimate the age pattern of health by birth year with interaction terms included to examine whether the association of age with health was conditional on the birth year. RESULTS: Results indicate that while the probability of mortality, mobility problems and pain rises with age, the rate of change is greater for those born earlier. The probability of self-assessed poor health increases with age but the rate of change with age is constant across birth years. CONCLUSIONS: Even in the short time period covered, our analysis shows that health care needs by age are changing over time in Canada.

An applied simulation model for estimating the supply of and requirements for registered nurses based on population health needs.

Aging populations, limited budgets, changing public expectations, new technologies, and the emergence of new diseases create challenges for health care systems as ways to meet needs and protect, promote, and restore health are considered. Traditional planning methods for the professionals required to provide these services have given little consideration to changes in the needs of the populations they serve or to changes in the amount/types of services offered and the way they are delivered. In the absence of dynamic planning models that simulate alternative policies and test policy mixes for their relative effectiveness, planners have tended to rely on projecting prevailing or arbitrarily determined target provider-population ratios. A simulation model has been developed that addresses each of these shortcomings by simultaneously estimating the supply of and requirements for registered nurses based on the identification and interaction of the determinants. The model's use is illustrated using data for Nova Scotia, Canada.

Use of wet nebulized inhaled respiratory medications under criteria-based reimbursement guidelines in a publicly funded Seniors' Pharmacare Program in Nova Scotia, Canada.

BACKGROUND: During the 1999/2000 fiscal year, approximately 19% of beneficiaries in the Nova Scotia Seniors' Pharmacare Program (NSSPP), a publicly funded drug insurance program in Nova Scotia, Canada, received inhaled respiratory medications by wet nebulization. The cost was estimated at more than Can $2 million annually. On August 1, 2000, the NSSPP initiated new criteria-based reimbursement guidelines for wet nebulized respiratory medications, requiring prior authorization. OBJECTIVE: Within the NSSPP, we examined approved reimbursement requests to determine demographic characteristics of those who accessed wet nebulized therapy through exception criteria, compare these factors between those who accessed wet nebulized therapy within the exception criteria and those who fell outside the criteria, identify indications for use of wet nebulization, and determine patterns of wet nebulization use. METHODS: Two hundred approved requests, received between August 1, 2000, and April 30, 2001, were randomly selected and reviewed for indications and patterns of use. RESULTS: Of 200 requests reviewed, 28 were excluded due to coverage in another Pharmacare program (Community Services). Of the 172 requests reviewed, 27% were for nursing home or other residential care facility residents. Indications and patterns of use differed only by place of residence (P<0.001). The majority of indications (72%) fell within outlined reimbursement criteria, with the most frequently cited indication (56%) being inability to use portable inhalers due to cognitive or physical disability. Almost one third (28%) of exception requests were approved for other reasons (31% of these were for short-term use [ie, <3 months] secondary to an acute respiratory infection or for palliative care; 69% continued to access wet nebulization because of a preference or a perception of greater effectiveness). Examination of patterns of use demonstrated that 36% of beneficiaries, primarily community dwelling (P < 0.001), were using wet nebulized therapy and portable inhalers concurrently. CONCLUSIONS: The majority of approved requests for wet nebulization criteria fell within the established reimbursement guidelines. Many approvals outside of guidelines were clinically valid. Approval of requests outside the criteria highlights the need for flexibility in the claims administrative and adjudication system to respond to unique circumstances not covered by established criteria. However, concurrent use of wet nebulization and portable inhalers by some beneficiaries suggests suboptimal use of portable inhalers, the need for portable inhalers for patients using wet nebulization when they leave their residence, and the need for more patient education.

Effect of copayments on drug use in the presence of annual payment limits.

OBJECTIVE: To test the hypothesis that deductibles (copayment combined with annual limits on out-of-pocket payments) may reduce the effect of copayments on drug use for patients who expect to reach the annual limit, using as a natural experiment the introduction of copayments with an annual maximum to the seniors' drug plan in Nova Scotia. STUDY DESIGN: An interrupted time-series design estimated effects of the introduction of and subsequent increase in drug copayments on the use (vs nonuse) of medications and on the mean daily quantity of use among users by patients' likelihood of exceeding the annual maximum copayment. Effects on the use of less essential medications (histamine(2)-receptor antagonists) and more essential medications (oral antihyperglycemic agents) were examined. methods: Data were drug claims for beneficiaries 65 years and older from April 1, 1989, through September 30, 1992. Regression models (applied to person-month data) estimated effects of the policies on the use and quantity of medication use. RESULTS: Copayments ($3 per prescription and 20% of the prescription cost) were associated with reductions in the quantity of medication use, ranging from 5% to 15%, but only when the annual maximum copayment was unlikely to be reached. Introducing a 20% copayment increased the percentage who reached the annual maximum, decreasing the proportion of patients who reduced their drug use. CONCLUSION: Although copayment policies are associated with reductions in the use of essential and less essential medications, annual limits on total copayments paid will limit copayment effects to patients who are unlikely to reach the annual maximum copayment.

Equity in health services use and intensity of use in Canada.

BACKGROUND: The Canadian health care system has striven to remove financial or other barriers to access to medically necessary health care services since the establishment of the Canada Health Act 20 years ago. Evidence has been conflicting as to what extent the Canadian health care system has met this goal of equitable access. The objective of this study was to examine whether and where socioeconomic inequities in health care utilization occur in Canada. METHODS: We used a nationally representative cross-sectional survey, the 2000/01 Canadian Community Health Survey, which provides a large sample size (about 110,000) and permits more comprehensive adjustment for need indicators than previous studies. We separately examined general practitioner, specialist, and hospital services using two-part hurdle models: use versus non-use by logistic regression, and the intensity of use among users by zero-truncated negative binomial regression. RESULTS: We found that lower income was associated with less contact with general practitioners, but among those who had contact, lower income and education were associated with greater intensity of use of general practitioners. Both lower income and education were associated with less contact with specialists, but there was no statistically significant relationship between these socioeconomic variables and intensity of specialist use among the users. Neither income nor education was statistically significantly associated with use or intensity of use of hospitals. CONCLUSION: Our study unveiled possible socioeconomic inequities in the use of health care services in Canada.

Impact of a criteria-based reimbursement policy on the use of respiratory drugs delivered by nebulizer and health care services utilization in Nova Scotia, Canada.

BACKGROUND: In February 2000, the Nova Scotia Seniors' Pharmacare Program announced a change in the reimbursement of respiratory drugs that added specific reimbursement criteria for wet nebulization therapy. Policy implementation coincided with multifaceted interventions to assist patients and providers with the change. OBJECTIVE: To assess the impact of the new policy and associated interventions on the use of wet nebulization and portable inhaler delivery systems of respiratory drugs and on the utilization of health services. METHODS: The administrative claims database identified all beneficiaries (age > or = 65 yrs) who received at least one respiratory drug prescription in the 12 months before the study. These patients were then grouped into the wet nebulization cohort or the control cohort receiving a metered-dose or a dry-powder inhaler. The study period was from April 1998-February 2002. Use of respiratory drugs, physician visits, and hospitalizations were compared between study cohorts using an interrupted time-series design. RESULTS: A sharp decrease was noted in use of wet nebulization after the policy announcement, along with an increase in use of short-acting beta2-agonists and anticholinergic agents delivered by metered-dose or drypowder inhaler. From December 1999 to December 2001, in the heavy wet nebulization cohort (a subset of the wet nebulization cohort), wet nebulization use dropped from 100% to 35%; in the wet nebulization cohort, wet nebulization use decreased from 67% to 20%. Rates of spacer device use were 42%, 31%, and 17% in the heavy wet nebulization, wet nebulization, and control cohorts, respectively, in December 2001. Rates of general practitioner visits and hospitalizations for respiratory conditions did not increase in the intervention cohorts after the policy announcement. In fact, relative to the control cohort, health services use in response to the policy and interventions in the wet nebulization cohort decreased. CONCLUSION: The reimbursement policy resulted in decreased use of respiratory drugs delivered by wet nebulization without a negative impact on general practitioner visits and hospitalizations for respiratory conditions.

Use of physician profiles to influence prescribing of topical corticosteroids.

BACKGROUND: Physician profiling is a tool used to attempt to affect changes in prescribing. The Drug Evaluation Alliance of Nova Scotia (DEANS) decided to implement a physician profiling project to determine if prescribing of topical corticosteroids could be altered. OBJECTIVES: To evaluate a DEANS initiative utilizing physician prescribing profiles to shift prescribing of topical corticosteroids from higher to lower potency agents in beneficiaries of the Nova Scotia Seniors' Pharmacare Program. METHODS: Administrative claims from the Nova Scotia Seniors' Pharmacare program were used to identify prescriptions for topical corticosteroids. Prescriptions were summarized at the individual physician level, and aggregated by Anatomical Therapeutic Classification into weak, moderately potent, potent and very potent products. The number of prescriptions for topical corticosteroids was compared for the twelve-month period before and after mailing of the profiles. Overall results were aggregated by utilization and expenditures. RESULTS: The number of prescriptions for topical corticosteroids per physician profiled was 44.0 in 2000/2001 and 42.8 in 2001/2002 (p = NS) and the expenditures per physician profiled were 838.94 dollars in 2000/2001 and 826.81 dollars in 2001/2002 (p = NS). There was a small decrease in prescriptions dispensed for potent topical products over the profiling period (52.4% of prescriptions in 2000/2001 versus 51.5% of prescriptions in 2001/2002, p=0.03). Otherwise, changes in utilization or expenditures for topical corticosteroids were not statistically different between the profiling periods. CONCLUSIONS: This project showed that mailing unsolicited individual-level profiles did not alter prescribing or expenditures for topical corticosteroids over a two-year period. Further work is needed to determine physician attitudes towards such projects.