Federal and Provincial Governments Need To Be Transparent about Trade-Offs When They Buy Healthcare.

Spending on healthcare is carefully scrutinized by the public, the media and academics because the amounts are so large and represent a very significant proportion of provincial budgets. Some quarters are calling for increases in spending, whereas others are focused on restraint owing to perceived inefficiencies and ineffectiveness. The debate over healthcare spending has continued for decades and is likely to heat up as new provincial labour agreements have locked in annual healthcare spending increases of at least five percent for 2023 (BC Nurses' Union 2023; ONA 2023).

A Problem of Money and Health: The Need for Value in Healthcare.

Almost ten years ago, on june 5, 2013, jeffrey simpson of the globe and mail wrote that more money was not the answer to reducing wait times for elective surgery (Simpson 2013). The editorial's text described the billions that had been spent by provinces through the federal Wait Times Reduction Fund to supply more surgeries and that meaningful progress on surgical wait times was still lacking.

Factors associated with frequent high-cost individuals with cystic fibrosis and their healthcare utilization and cost patterns.

Cystic fibrosis (CF) is a progressive multi-organ disease with significant morbidity placing extensive demands on the healthcare system. Little is known about those individuals with CF who continually incur high costs over multiple years. Understanding their characteristics may help inform opportunities to improve management and care, and potentially reduce costs. The purpose of this study was to identify and understand the clinical and demographic attributes of frequent high-costing CF individuals and characterize their healthcare utilization and costs over time. A longitudinal study of retrospective data was completed in British Columbia, Canada by linking the Canadian CF Registry with provincial healthcare administrative databases for the period between 2009 and 2017. Multivariable Cox regression models were employed to identify baseline factors associated with becoming a frequent high-cost CF user (vs. not a frequent high-cost CF user) in the follow-up period. We found that severe lung impairment (Hazard Ratio [HR]: 3.71, 95% confidence interval [CI], 1.49-9.21), lung transplantation (HR: 4.23, 95% CI, 1.68-10.69), liver cirrhosis with portal hypertension (HR: 10.96, 95% CI: 3.85-31.20) and female sex (HR: 1.97, 95% CI: 1.13-3.44) were associated with becoming a frequent high-cost CF user. Fifty-nine (17% of cohort) frequent high-cost CF users accounted for more than one-third of the overall total healthcare costs, largely due to inpatient hospitalization and outpatient medication costs.

Case mix-based changes in health status: A prospective study of elective surgery patients in Vancouver, Canada.

INTRODUCTION: Hospital activity is often measured using diagnosis-related groups, or case mix groups, but this information does not represent important aspects of patients' health outcomes. This study reports on case mix-based changes in health status of elective (planned) surgery patients in Vancouver, Canada. DATA AND METHODS: We used a prospectively recruited cohort of consecutive patients scheduled for planned inpatient or outpatient surgery in six acute care hospitals in Vancouver. All participants completed the EQ-5D(5L) preoperatively and 6 months postoperatively, collected from October 2015 to September 2020 and linked with hospital discharge data. The main outcome was whether patients' self-reported health status improved among different inpatient and outpatient case mix groups. RESULTS: The study included 1665 participants with completed EQ-5D(5L) preoperatively and postoperatively, representing a 44.8% participation rate across eight inpatient and outpatient surgical case mix categories. All case mix categories were associated with a statistically significant gain in health status (p < .01 or lower) as measured by the utility value and visual analogue scale score. Foot and ankle surgery patients had the lowest preoperative health status (mean utility value: 0.6103), while bariatric surgery patients reported the largest improvements in health status (mean gain in utility value: 0.1515). CONCLUSIONS: This study provides evidence that it was feasible to compare patient-reported outcomes across case mix categories of surgical patients in a consistent manner across a system of hospitals in one province in Canada. Reporting changes in health status of operative case mix categories identifies characteristics of patients more likely to experience significant gains in health.

Associations between perceptions of shared decision making and health among hysterectomy patients: A prospective observational study.

OBJECTIVE: To investigate patient and clinical factors that are associated with perceptions of shared decision making between hysterectomy patients and surgeons and to evaluate associations between shared decision making and postoperative health. METHODS: This study is based on a prospective cohort scheduled for hysterectomy for benign conditions in Vancouver, Canada. Validated patient-reported outcomes assessed shared decision making, pelvic health, depression, and pain. Regression analyses measured the association between perceptions of shared decision making with patient and clinical factors. Then, associations between shared decision making with postoperative pelvic health, pain and depression were evaluated using regression analysis and adjusted for patient and clinical factors. RESULTS: In this study, 308 participants completed preoperative measures, and a subset of 146 participants also completed the postoperative measures. More than 50% of participants reported less than optimal shared decision making scores. No significant associations were identified between patients' perceptions of shared decision making with patients' age, comorbidities, socioeconomic factors, indication for surgery, or preoperative depression and pain. Regression analyses found that higher/better self-reported shared decision making scores were associated with fewer postoperative pelvic organ symptoms (P = 0.01). CONCLUSION: Many patients' reporting lower than optimal scores on the shared decision making instrument highlight the opportunity to improve surgeon-patient communication in this surgical cohort. Strengthening shared decision making between surgeons and their patients may be associated with improved self-reported postoperative health.

Associations between clinical pathway concordance, cost, and survival outcomes for stage II colon cancer: a population-based study.

This study measures patient's concordance between clinical reference pathways with survival or cost among a population-based cohort of colon cancer patients applying a continuous measure of concordance. The primary hypothesis is that a higher concordance score with the clinical pathway is significantly associated with longer survival or lower cost. The study informs whether patient's adherence to a defined clinical pathway is beneficial to patients' outcomes or health system. An externally determined clinical pathway for colon cancer was used to identify treatment nodes in colon cancer care. Using observational data up to 2019, the study generated a continuous measure of pathway concordance. The study measured whether incremental improvements in pathway concordance were associated with survival and treatment costs. Concordance between patients' reference pathways and their observed trajectories of care was highly statistically associated with survivorship [hazard ratio: 0.95 (95% confidence interval, CI, 0.95-0.96)], showing that adherence to the clinical pathway was associated with a lower mortality rate. An increase in concordance was statistically significantly associated with a decrease in health system cost. When patients' care followed the clinical pathway, survival outcomes were better and total health system costs were lower in this cohort. This finding creates a compelling case for further research into understanding the barriers to pathway concordance and developing interventions to improve outcomes and help providers implement best practice care where appropriate.

Provinces and Territories Are Overdue for an Update in Healthcare Funding Policies.

Even before the recent funding announcement, the provinces had money earmarked for spending on health services, therapies and devices. Canadians expect that this money will be put to work to improve access to scheduled services and emergency care, to increase capacity of primary care to manage complex conditions and to begin the assembly of patients' health information. This does not represent an exhaustive list as most provinces also have other pressing needs, including access to and quality of long-term care and mental healthcare services.

Physician Financial Incentives for Use of Outpatient Intravenous Antimicrobial Therapy: An Interrupted Time Series Analysis.

BACKGROUND: In 2011, policymakers in British Columbia introduced a fee-for-service payment to incentivize infectious diseases physicians to supervise outpatient parenteral antimicrobial therapy (OPAT). Whether this policy increased use of OPAT remains uncertain. METHODS: We conducted a retrospective cohort study using population-based administrative data over a 14-year period (2004-2018). We focused on infections that required intravenous antimicrobials for ≥10 days (eg, osteomyelitis, joint infection, endocarditis) and used the monthly proportion of index hospitalizations with a length of stay shorter than the guideline-recommended "usual duration of intravenous antimicrobials" (LOS < UDIVA) as a surrogate for population-level OPAT use. We used interrupted time series analysis to determine whether policy introduction increased the proportion of hospitalizations with LOS < UDIVA. RESULTS: We identified 18 513 eligible hospitalizations. In the pre-policy period, 82.3% of hospitalizations exhibited LOS < UDIVA. Introduction of the incentive was not associated with a change in the proportion of hospitalizations with LOS < UDIVA, suggesting that the policy intervention did not increase OPAT use (step change, -0.06%; 95% confidence interval [CI], -2.69% to 2.58%; P = .97 and slope change, -0.001% per month; 95% CI, -.056% to .055%; P = .98). CONCLUSIONS: The introduction of a financial incentive for physicians did not appear to increase OPAT use. Policymakers should consider modifying the incentive design or addressing organizational barriers to expanded OPAT use.

Provincial Health Systems: Are They Imploding?

Recently, we have all seen myriad articles in the national newspapers announcing that provinces' healthcare systems are imploding, with authors describing systems in states of "crisis" (Laverly 2022), "visibly coming apart" (Tumilty 2022), "broken" (Urback 2022) and "a travesty" (Picard 2022). Without minimizing the hardships or frustrations that some patients and their families have been experiencing at the hands of provincial health systems, are the harsh descriptors apt or fair?

New Spending Programs and Old Frustrations: Where Is the Vision?

The spring has ushered in an unexpected number of major health policy announcements compared with the last 10 years. They are led by the federal government's outlines of a national pharmacare program, an unexpected dental care program (Prime Minister of Canada Justin Trudeau 2022), plus "top-up" funding for clearing provincial surgical and imaging backlogs. These announcements are on top of the voices expressing concerns about COVID-19-related healthcare expenditure trends (Bailey 2022). Without a doubt, taxpayer money is flowing freely into healthcare (Labby 2020).

Outpatient Versus Inpatient Intravenous Antimicrobial Therapy: A Population-Based Observational Cohort Study of Adverse Events and Costs.

BACKGROUND: Bacterial infections such as osteomyelitis and endocarditis routinely require several weeks of treatment with intravenous (IV) antimicrobials. Outpatient parenteral antimicrobial therapy (OPAT) programs allow patients to receive IV antimicrobials in an outpatient clinic or at home. The outcomes and costs of such treatments remain uncertain. METHODS: We conducted a retrospective observational cohort study over a 5-year study interval (1 June 2012 to 31 March 2018) using population-based linked administrative data from British Columbia, Canada. Patients receiving OPAT following a hospitalization for bacterial infection were matched based on infection type and implied duration of IV antimicrobials to patients receiving inpatient parenteral antimicrobial therapy (IPAT). Cumulative adverse events and direct healthcare costs were estimated over a 90-day outcome interval. RESULTS: In a matched cohort of 1842 patients, adverse events occurred in 35.6% of OPAT patients and 39.0% of IPAT patients (adjusted odds ratio, 1.04 [95% confidence interval {CI}, .83-1.30; P = .61). Relative to IPAT patients, OPAT patients were significantly more likely to experience hospital readmission (30.5% vs 23.0%) but significantly less likely to experience Clostridioides difficile diarrhea (1.2% vs 3.1%) or death (2.0% vs 8.8%). Estimated mean direct healthcare costs were $30 166 for OPAT patients and $50 038 for IPAT patients (cost ratio, 0.60; average cost savings with OPAT, $17 579 [95% CI, $14 131-$21 027]; P < .001). CONCLUSIONS: Outpatient IV antimicrobial therapy is associated with a similar overall prevalence of adverse events and with substantial cost savings relative to patients remaining in hospital to complete IV antimicrobials. These findings should inform efforts to expand OPAT use.

Physician Financial Incentives to Reduce Unplanned Hospital Readmissions: an Interrupted Time Series Analysis.

BACKGROUND: In 2012, the Ministry of Health in British Columbia, Canada, introduced a $75 incentive payment that could be claimed by hospital physicians each time they produced a written post-discharge care plan for a complex patient at the time of hospital discharge. OBJECTIVE: To examine whether physician financial payments incentivizing enhanced discharge planning reduce subsequent unplanned hospital readmissions. DESIGN: Interrupted time series analysis of population-based hospitalization data. PARTICIPANTS: Individuals with one or more eligible hospitalizations occurring in British Columbia between 2007 and 2017. MAIN MEASURES: The proportion of index hospital discharges with subsequent unplanned hospital readmission within 30 days, as measured each month of the 11-year study interval. We used interrupted time series analysis to determine if readmission risk changed after introduction of the incentive payment policy. KEY RESULTS: A total of 40,588 unplanned hospital readmissions occurred among 409,289 eligible index hospitalizations (crude 30-day readmission risk, 9.92%). Policy introduction was not associated with a significant step change (0.393%; 95CI, - 0.190 to 0.975%; p = 0.182) or change-in-trend (p = 0.317) in monthly readmission risk. Policy introduction was associated with significantly fewer prescription fills for potentially inappropriate medications among older patients, but no improvement in prescription fills for beta-blockers after cardiovascular hospitalization and no change in 30-day mortality. Incentive payment uptake was incomplete, rising from 6.4 to 23.5% of eligible hospitalizations between the first and last year of the post-policy interval. CONCLUSION: The introduction of a physician incentive payment was not associated with meaningful changes in hospital readmission rate, perhaps in part because of incomplete uptake by physicians. Policymakers should consider these results when designing similar interventions elsewhere. TRIAL REGISTRATION: ClinicalTrials.gov ID, NCT03256734.

The Mounting Opportunity Cost of Pivoting to COVID-19-Related Health Systems and Services Research.

In 2020, the COVID-19 pandemic unexpectedly upended everyone's life, from sudden mass unemployment to family separations. In spite of this upheaval, health systems and services research carried on. Often, these efforts supported public health efforts to slow the spread of the virus.

Comparing patient-reported outcomes across countries: An assessment of methodological challenges.

OBJECTIVES: There is little published literature on the comparison of patient-reported outcomes between countries. This study aimed to assess pre- and postoperative health among samples of patients undergoing elective groin hernia repair procedures in the National Health Service (NHS), England, and groin hernia patients in Vancouver, Canada. METHODS: We used datasets from two different sources. For the English NHS we used published anonymized patient-level data files which include the EQ-5D(3L) patient-reported outcome measure and a number of demographic and clinical characteristics. For Vancouver, we used data from a sample of Vancouver patients who completed the same instrument during a similar time frame. English patients were matched with Vancouver participant's characteristics using propensity score methods. A linear regression model was used to measure differences in postoperative visual analogue scale values between countries, adjusting for patient characteristics. RESULTS: Our study revealed a range of methodological issues concerning the comparability of patient-reported outcomes following hernia repair surgery in the two health systems. These related to differences in approaches to collecting patient-reported outcome measures and the nature of explanatory variables (self-report vs. administrative data), among other challenges. As a consequence, there were differences between the matched samples and the NHS data, indicating a healthy participant bias. Unadjusted results found that Vancouver patients (N = 280) reported more problems in domains of mobility, self care, usual activities and anxiety/depression than the matched cohort of NHS patients (N = 840). Interpreting differences is challenging given different sampling designs. CONCLUSIONS: There are significant hurdles facing comparisons of surgical patients' outcomes between countries, including adjusting for patient differences, health system factors and approaches to survey administration. While between-country comparisons of surgical outcomes using patient-reported outcomes shows significant promise, much work on standardizing sampling design, variables and analytic methods is needed.

Measuring the impact of delayed access to elective cholecystectomy through patient's cost-utility: an observational cohort study.

BACKGROUND: Deferral of surgeries due to COVID-19 has negatively affected access to elective surgery and may have deleterious consequences for patient's health. Delays in access to elective surgery are not uniform in their impact on patients with different attributes. The objective of this study is to measure the change in patient's cost utility due to delayed elective cholecystectomy. METHODS: This study is based on retrospective analysis of a longitudinal sample of participants who have had elective cholecystectomy and completed the EQ-5D(3L) measuring health status preoperatively and postoperatively. Emergent cases were excluded. Patients younger than 19 years of age, unable to communicate in English or residing in a long-term care facility were ineligible. Quality-adjusted life years attributable to cholecystectomy were calculated by comparing health state utility values between the pre- and postoperative time points. The loss in quality-adjusted life years due to delayed access was calculated under four assumed scenarios regarding the length of the delay. The mean cost per quality-adjusted life years are shown for the overall sample and by sex and age categories. RESULTS: Among the 646 eligible patients, 30.1% of participants (N = 195) completed their preoperative and postoperative EQ-5D(3L). A delay of 12 months resulted in a mean loss of 6.4%, or 0.117, of the quality-adjusted life years expected without the delay. Among patients older than 70 years of age, a 12-month delay in their surgery corresponded with a 25.1% increase in the cost per quality-adjusted life years, from $10 758 to $13 463. CONCLUSIONS: There is a need to focus on minimizing loss of quality of life for patients affected by delayed surgeries. Faced with equal delayed access to elective surgery, triage may need to prioritize older patients to maximize their health over their remaining life years.

Pattern discovery of health curves using an ordered probit model with Bayesian smoothing and functional principal component analysis.

This article is motivated by the need for discovering patterns of patients' health based on their daily settings of care to aid the health policy-makers to improve the effectiveness of distributing funding for health services. The hidden process of one's health status is assumed to be a continuous smooth function, called the health curve, ranging from perfectly healthy to dead. The health curves are linked to the categorical setting of care using an ordered probit model and are inferred through Bayesian smoothing. The challenges include the nontrivial constraints on the lower bound of the health status (death) and on the model parameters to ensure model identifiability. We use the Markov chain Monte Carlo method to estimate the parameters and health curves. The functional principal component analysis is applied to the patients' estimated health curves to discover common health patterns. The proposed method is demonstrated through an application to patients hospitalized from strokes in Ontario. Whilst this paper focuses on the method's application to a health care problem, the proposed model and its implementation have the potential to be applied to many application domains in which the response variable is ordinal and there is a hidden process. Our implementation is available at https://github.com/liangliangwangsfu/healthCurveCode.

Health Services Research and Government's Spending on Healthcare Programs: A Welcome Misalignment?

Excluding capital projects, spending on hospitals, physicians and drugs makes up more than two thirds of provincial and territorial governments' healthcare spending (CIHI 2019). One expects that health services and policy research would be aligned with where the money flows and yet, there is a misalignment. For example, research as published by Healthcare Policy, is not so neatly aligned with provincial and territorial governments' healthcare spending patterns. In this issue, for instance, there are only two such articles - one related to medication adherence and cost, and another related to payment policy associated with a hospital's alternative level of care utilization. The previous issue of Healthcare Policy was similarly focused, with only two articles the study settings of which were primary care.

Reallocating Cancer Surgery Payments for Alternate Level of Care in Ontario: What Are the Options?

This article examines how alternate-level-of-care (ALC) days are funded through the cancer surgery funding model in Ontario and evaluates policy options to better address ALC days. The contribution of ALC days to hospital funding and the impact of removing or reallocating this funding from cancer surgery is measured. Though costs associated with ALC days in cancer surgery are low, this article highlights the need for policy options that would realign funding across the healthcare system in Ontario to better meet the needs of patients waiting for ALC, reduce pressure on inpatient bed capacity and improve value for money.

Moving from Volume to Value with Hospital Funding Policies in Canada.

Canada's two most populous provinces are moving toward activity-based funding (ABF) of hospitals. Although ABF may encourage greater value by improving cost-efficiency, it may decrease value in other respects. To address this trade-off, many jurisdictions have implemented value-based payment programs that modify ABF payments based on hospital performance on other aspects of value, such as outcomes and patient experience. In this article, the design and implementation of two value-based programs are reviewed: Australia's Pricing for Safety and Quality Program and Medicare's Hospital Value-Based Purchasing Program. The contrasts of these programs highlight key questions facing provincial payers in Canada to increase value from hospital spending.

How the design and implementation of centralized waiting lists influence their use and effect on access to healthcare - A realist review.

CONTEXT: Many health systems have centralized waiting lists (CWLs), but there is limited evidence on CWL effectiveness and how to design and implement them. AIM: To understand how CWLs' design and implementation influence their use and effect on access to healthcare. METHODS: We conducted a realist review (n = 21 articles), extracting context-intervention-mechanism-outcome configurations to identify demi-regularities (i.e., recurring patterns of how CWLs work). RESULTS: In implementing non-mandatory CWLs, acceptability to providers influences their uptake of the CWL. CWL eligibility criteria that are unclear or conflict with providers' role or judgement may result in inequities in patient registration. In CWLs that prioritize patients, providers must perceive the criteria as clear and appropriate to assess patients' level of need; otherwise, prioritization may be inconsistent. During patients' assignment to service providers, providers may select less-complex patients to obtain CWLs rewards or avoid penalties; or may select patients for other policies with stronger incentives, disregarding the established patient order and leading to inequities and limited effectiveness. CONCLUSION: These findings highlight the need to consider provider behaviours in the four sequential CWL design components: CWL implementation, patient registration, patient prioritization and patient assignment to providers. Otherwise, CWLs may result in limited effects on access or lead to inequities in access to services.