Trajectories of the socioeconomic gradient of mental health: Results from the CLSA COVID-19 Questionnaire Study.

As the coronavirus disease (COVID-19) pandemic prolongs, documenting trajectories of the socioeconomic gradient of mental health is important. We describe changes in the prevalence and absolute and relative income-related inequalities of mental health between April and December 2020 in Canada. We used data from the Canadian Longitudinal Study on Aging (CLSA) COVID-19 Questionnaire Study and the pre-pandemic CLSA Follow-up 1. We estimated the prevalence proportion, the concentration index (relative inequality), and the generalized concentration index (absolute inequality) for anxiety and self-reported feeling generally unwell at multiple points in April-December 2020, overall, by sex and age group, by region, and among those who reported poor or fair overall health and mental health pre-pandemic. Overall, the prevalence of anxiety remained unchanged (22.45 to 22.10%, p = 0.231), but self-reported feeling generally unwell decreased (9.83 to 5.94%, p = 0.004). Relative and absolute income-related inequalities were unchanged for both anxiety and self-reported feeling generally unwell, with exceptions of an increased concentration of self-reported feeling generally unwell among the poor, measured by the concentration index, overall (-0.054 to -0.115, p = 0.004) and in Ontario (-0.035 to -0.123, p = 0.047) and British Columbia (-0.055 to -0.141, p = 0.044). The COVID-19 pandemic appeared to neither exacerbate nor ameliorate existing income-related inequalities in mental health among older adults in Canada between April and December 2020. Continued monitoring of inequalities is necessary.

When the technical is also normative: a critical assessment of measuring health inequalities using the concentration index-based indices.

BACKGROUND: Concentration index-based measures are one of the most popular tools for estimating socioeconomic-status-related health inequalities. In recent years, several variants of the concentration index have been developed that are designed to correct for deficiencies of the standard concentration index and which are increasingly being used. These variants, which include the Wagstaff index and the Erreygers index, have important technical and normative differences. MAIN BODY: In this study, we provide a non-technical review and critical assessment of these indices. We (i) discuss the difficulties that arise when measurement tools intended for income are applied in a health context, (ii) describe and illustrate the interrelationship between the technical and normative properties of these indices, (iii) discuss challenges that arise when determining whether index estimates are large or of policy significance, and (iv) evaluate the alignment of research practice with the properties of the indices used. Issues discussed in parts (i) and (ii) include the different conceptions of inequality that underpin the indices, the types of changes to a distribution which leave inequality unchanged and the importance of the measurement scale and range of the outcome variable. These concepts are illustrated using hypothetical examples. For parts (iii) and (iv), we reviewed 44 empirical studies published between 2015 and 2017 and find that researchers often fail to provide meaningful interpretations of the index estimates. CONCLUSION: We propose a series of questions to facilitate further sensitivity analyses and provide a better understanding of the index estimates. We also provide a guide for researchers and policy analysts to facilitate the critical assessment of studies using these indices, while helping applied researchers to choose inequality measures that have the normative properties they seek.

Economic Evaluation of Early Psychosis Interventions From A Canadian Perspective.

BACKGROUND: Compared to treatment as usual (TAU), early psychosis intervention programs (EPI) have been shown to reduce mortality, hospitalizations and days of assisted living while improving employment status. AIMS: The study aim was to conduct a cost-benefit analysis (CBA) and a cost-effectiveness analysis (CEA) to compare EPI and TAU in Canada. METHODS: A decision-analytic model was used to estimate the 5-year costs and benefits of treating patients with a first episode of psychosis with EPI or TAU. EPI benefits were derived from randomized controlled trials (RCTs) and Canadian administrative data. The cost of EPI was based on a published survey of 52 EPI centers in Canada while hospitalizations, employment and days of assisted living were valued using Canadian unit costs. The outcomes of the CBA and CEA were expressed in terms of net benefit (NB) and incremental cost per life year gained (LYG), respectively. Scenario analyses were conducted to examine the impact of key assumptions. Costs are reported in 2019 Canadian dollars. RESULTS: Base case results indicated that EPI had a NB of $85,441 (95% CI: $41,140; $126,386) compared to TAU while the incremental cost per LYG was $26,366 (95% CI: EPI dominates TAU (less costs, more life years); $102,269). In all sensitivity analyses the NB of EPI remained positive and the incremental cost per LYG was less than $50,000. CONCLUSIONS: In addition to EPI demonstrated clinical benefits, our results suggest that large-scale implementation of EPI in Canada would be desirable from an economic point of view .

Cautionary tails of grip strength in health inequality studies: An analysis from the Canadian longitudinal study on aging.

Self-rated health is widely used in studies of the socioeconomic gradient of health in community-based populations. Its subjectivity may lead to under- or over-estimation of a true underlying socioeconomic gradient and has increased interest in searching for alternative, objective measures of health. Grip strength has emerged as one such alternative for community-based older populations, yet no study has directly assessed the relationship between these two measures and compared their associations with socioeconomic status and health behaviours. Using 26,754 participants aged 45-85 years in the baseline data of the Canadian Longitudinal Study on Aging Comprehensive Cohort, we estimated adjusted-grip strength through indirect standardization using age, sex, height, weight, and their square terms and used ANOVA to assess the variance of adjusted-grip strength within and between each self-rated health category. We ran four separate logistic regression models, examining unhealthy tails (those reporting poor health vs. not and those at the bottom 8th percentile of adjusted-grip strength vs. above) and healthy tails (those reporting excellent health vs. not and those at the top 20th percentile of adjusted-grip strength vs. below). Stronger adjusted-grip strength correlated with better self-rated health, but only 2% of the total variance of adjusted-grip strength was explained by variance between the self-rated health categories. While self-rated health largely showed the expected socioeconomic gradients and positive relationships with health enhancing behaviours, adjusted-grip strength showed no clear, consistent associations with either socioeconomic or health behaviour variables. The results give caution about using grip strength as an objective alternative to self-rated health in studies of social inequalities in health. Empirical approaches demand careful considerations as to which dimensions of health and corresponding measures of health are most relevant to the context being studied.

Does moral reasoning influence public values for health care priority setting?: A population-based randomized stated preference survey.

OBJECTIVE: Preferences of members of the public are recognized as important inputs into health care priority-setting, though knowledge of such preferences is scant. We sought to generate evidence of public preferences related to healthcare resource allocation among adults and children. METHODS: We conducted an experimental stated preference survey in a national sample of Canadian adults. Preferences were elicited across a range of scenarios and scored on a visual analogue scale. Intervention group participants were randomized to a moral reasoning exercise prior to each choice task. The main outcomes were the differences in mean preference scores by group, scenario, and demographics. RESULTS: Our results demonstrate a consistent preference by participants to allocate scarce health system resources to children. Exposure to the moral reasoning exercise weakened but did not eliminate this preference. Younger respondent age and parenthood were associated with greater preference for children. The top principles guiding participants' allocative decisions were treat equally, relieve suffering, and rescue those at risk of dying. CONCLUSIONS: Our study affirms the relevance of age in public preferences for the allocation of scarce health care resources, demonstrating a significant preference by participants to allocate healthcare resources to children. However, this preference diminishes when challenged by exposure to a range of moral principles, revealing a strong public endorsement of equality of access. Definitions of value in healthcare based on clinical benefit and cost-effectiveness may exclude moral considerations that the public values, such as equality and humanitarianism, highlighting opportunities to enrich healthcare priority-setting through public engagement.

Inequality aversion in income, health, and income-related health.

Based on a survey of a sample of the general public, we estimate inequality aversion across income, health, and bivariate income-health. Inequality aversion is domain specific: mean inequality aversion is greater for income than for health, but the underlying distributions of aversion attitudes differ, with a highly bi-modal distribution of inequality-aversion values for health in which nearly half the participants display very low aversion and nearly half display very high aversion. Aversion to income-related health inequality is greater than that to income or health alone. Consistent with previous literature, we find only weak associations between aversion attitudes and individual characteristics. The magnitude of the estimates implies potentially large gains in welfare from reducing inequality in these domains.

Here comes the SUN: Self-assessed unmet need, worsening health outcomes, and health care inequity.

Utilization-based approaches have predominated the measurement of socioeconomic-related inequity in health care. This approach, however, can be misleading when preferences over health and health care are correlated with socioeconomic status, especially when the underlying focus is on equity of access. We examine the potential usefulness of an alternative approach to assessing inequity of access using a direct measure of possible barriers to access-self-reported unmet need (SUN)-which is documented to vary with socioeconomic status and is commonly asked in health surveys. Specifically, as part of an assessment of its external validity, we use Canadian longitudinal health data to test whether self-reported unmet need in one period is associated with a subsequent deterioration in health status in a future period, and find that it is. This suggests that SUN does reflect in part reduced access to needed health care, and therefore may have a role in assessing health system equity as a complement to utilization-based approaches.

Health inequalities and inequities by age: Stability for the Health Utilities Index and divergence for the Frailty Index.

Successful aging is an important policy goal in an aging society. A key indicator of successful aging of a population is whether health inequalities (differences) and inequities (unfair differences) in the population increase or decrease with age. This study investigates how health inequalities and inequities differ across age groups in the Canadian population within the equity framework of equal opportunity for health, using two popular measures of health, the Health Utilities Index Mark 3 (HUI) and the Frailty Index (FI). We use the 2009-10 Canadian Health Measures Survey. We first quantify the degree of health inequality by calculating the Gini coefficient for the distributions of the HUI and the FI within three age groups (20-44, 45-64, and 65-79 years). We then identify sources of health inequality by using regression models and decomposing inequality into ethically acceptable and unacceptable components. We finally quantify the degree of health inequity by calculating the Gini coefficient for each health measure and each age group after standardizing for fairness. We find that the magnitudes of inequality and inequity in the HUI and the FI in each of the three age groups are policy relevant. The magnitude and age-related dynamics of health inequality and inequity depend on the choice of the health measures. In all three age groups, inequality and inequity in health measured by the HUI are larger than those measured by the FI. Across the three age groups, inequality and inequity are stable in the HUI but divergent in the FI. This study contributes to the methodological development to support policies for successful aging. Examination of alternative notions of health captured by the HUI and the FI contributes to the exploration of how the fair distribution of each aspect of health may characterize a successfully aging population.

Effect of incentive payments on chronic disease management and health services use in British Columbia, Canada: Interrupted time series analysis.

We studied the effects of incentive payments to primary care physicians for the care of patients with diabetes, hypertension, and Chronic Obstructive Pulmonary Disease (COPD) in British Columbia, Canada. We used linked administrative health data to examine monthly primary care visits, continuity of care, laboratory testing, pharmaceutical dispensing, hospitalizations, and total h ealth care spending. We examined periods two years before and two years after each incentive was introduced, and used segmented regression to assess whether there were changes in level or trend of outcome measures across all eligible patients following incentive introduction, relative to pre-intervention periods. We observed no increases in primary care visits or continuity of care after incentives were introduced. Rates of ACR testing and antihypertensive dispensing increased among patients with hypertension, but none of the other modest increases in laboratory testing or prescriptions dispensed reached statistical significance. Rates of hospitalizations for stroke and heart failure among patients with hypertension fell relative to pre-intervention patterns, while hospitalizations for COPD increased. Total hospitalizations and hospitalizations via the emergency department did not change. Health care spending increased for patients with hypertension. This large-scale incentive scheme for primary care physicians showed some positive effects for patients with hypertension, but we observe no similar changes in patient management, reductions in hospitalizations, or changes in spending for patients with diabetes and COPD.

A population-based analysis of incentive payments to primary care physicians for the care of patients with complex disease.

BACKGROUND: In 2007, the province of British Columbia implemented incentive payments to primary care physicians for the provision of comprehensive, continuous, guideline-informed care for patients with 2 or more chronic conditions. We examined the impact of this program on primary care access and continuity, rates of hospital admission and costs. METHODS: We analyzed all BC patients who qualified for the incentive based on their diagnostic profile. We tracked primary care contacts and continuity, hospital admissions (total, via the emergency department and for targeted conditions), and cost of physician services, hospital care and pharmaceuticals, for 24 months before and 24 months after the intervention. RESULTS: Of 155 754 eligible patients, 63.7% had at least 1 incentive payment billed. Incentive payments had no impact on primary care contacts (change in contacts per patient per month: 0.016, 95% confidence interval [CI] -0.047 to 0.078) or continuity of care (mean monthly change: 0.012, 95% CI -0.001 to 0.024) and were associated with increased total rates of hospital admission (change in hospital admissions per 1000 patients per month: 1.46, 95% CI 0.04 to 2.89), relative to preintervention trends. Annual costs per patient did not decline (mean change: $455.81, 95% CI -$2.44 to $914.08). INTERPRETATION: British Columbia's $240-million investment in this program improved compensation for physicians doing the important work of caring for complex patients, but did not appear to improve primary care access or continuity, or constrain resource use elsewhere in the health care system. Policymakers should consider other strategies to improve care for this patient population.

Mandatory universal drug plan, access to health care and health: Evidence from Canada.

This paper examines the impacts of a mandatory, universal prescription drug insurance program on health care utilization and health outcomes in a public health care system with free physician and hospital services. Using the Canadian National Population Health Survey from 1994 to 2003 and implementing a difference-in-differences estimation strategy, we find that the mandatory program substantially increased drug coverage among the general population. The program also increased medication use and general practitioner visits but had little effect on specialist visits and hospitalization. Findings from quantile regressions suggest that there was a large improvement in the health status of less healthy individuals. Further analysis by pre-policy drug insurance status and the presence of chronic conditions reveals a marked increase in the probability of taking medication and visiting a general practitioner among the previously uninsured and those with a chronic condition.

Unexplained health inequality--is it unfair?

INTRODUCTION: Accurate measurement of health inequities is indispensable to track progress or to identify needs for health equity policy interventions. A key empirical task is to measure the extent to which observed inequality in health - a difference in health - is inequitable. Empirically operationalizing definitions of health inequity has generated an important question not considered in the conceptual literature on health inequity. Empirical analysis can explain only a portion of observed health inequality. This paper demonstrates that the treatment of unexplained inequality is not only a methodological but ethical question and that the answer to the ethical question - whether unexplained health inequality is unfair - determines the appropriate standardization method for health inequity analysis and can lead to potentially divergent estimates of health inequity. METHODS: We use the American sample of the 2002-03 Joint Canada/United States Survey of Health and measure health by the Health Utilities Index (HUI). We model variation in the observed HUI by demographic, socioeconomic, health behaviour, and health care variables using Ordinary Least Squares. We estimate unfair HUI by standardizing fairness, removing the fair component from the observed HUI. We consider health inequality due to factors amenable to policy intervention as unfair. We contrast estimates of inequity using two fairness-standardization methods: direct (considering unexplained inequality as ethically acceptable) and indirect (considering unexplained inequality as unfair). We use the Gini coefficient to quantify inequity. RESULTS: Our analysis shows that about 75% of the variation in the observed HUI is unexplained by the model. The direct standardization results in a smaller inequity estimate (about 60% of health inequality is inequitable) than the indirect standardization (almost all inequality is inequitable). CONCLUSIONS: The choice of the fairness-standardization method is ethical and influences the empirical health inequity results considerably. More debate and analysis is necessary regarding which treatment of the unexplained inequality has the stronger foundation in equity considerations.

A three-stage approach to measuring health inequalities and inequities.

INTRODUCTION: Measurement of health inequities is fundamental to all health equity initiatives. It is complex because it requires considerations of ethics, methods, and policy. Drawing upon the recent developments in related specialized fields, in this paper we incorporate alternative definitions of health inequity explicitly and transparently in its measurement. We propose a three-stage approach to measuring health inequities that assembles univariate health inequality, univariate health inequity, and bivariate health inequities in a systematic and comparative manner. METHODS: We illustrate the application of the three-stage approach using the Joint Canada/United States Survey of Health, measuring health by the Health Utilities Index (HUI). Univariate health inequality is the distribution of the observed HUI across individuals. Univariate health inequity is the distribution of unfair HUI--components of HUI associated with ethically unacceptable factors--across individuals. To estimate the unfair HUI, we apply two popular definitions of inequity: "equal opportunity for health" (health outcomes due to factors beyond individual control are unfair), and "policy amenability" (health outcomes due to factors amenable to policy interventions are unfair). We quantify univariate health inequality and inequity using the Gini coefficient. We assess bivariate inequities using a regression-based decomposition method. RESULTS: Our analysis reveals that, empirically, different definitions of health inequity do not yield statistically significant differences in the estimated amount of univariate inequity. This derives from the relatively small explanatory power common in regression models describing variations in health. As is typical, our model explains about 20% of the variation in the observed HUI. With regard to bivariate inequities, income and health care show strong associations with the unfair HUI. CONCLUSIONS: The measurement of health inequities is an excitingly multidisciplinary endeavour. Its development requires interdisciplinary integration of advances from relevant disciplines. The proposed three-stage approach is one such effort and stimulates cross-disciplinary dialogues, specifically, about conceptual and empirical significance of definitions of health inequities.

Fair reckoning: a qualitative investigation of responses to an economic health resource allocation survey.

OBJECTIVE: To investigate how participants in an economic resource allocation survey construct notions of fairness. DESIGN: Qualitative interview study guided by interpretive grounded theory methods. SETTING AND PARTICIPANTS: Qualitative interviews were conducted with volunteer university- (n=39) and community-based (n =7) economic survey participants. INTERVENTION OR MAIN VARIABLES STUDIED: We explored how participants constructed meanings to guide or explain fair survey choices, focusing on rationales, imagery and additional desired information not provided in the survey scenarios. MAIN OUTCOME MEASURES: Data were transcribed and coded into qualitative categories. Analysis iterated with data collection iterated through three waves of interviews. RESULTS: Participants compared the survey dilemmas to domains outside the health system. Most compared them with other micro-level, inter-personal sharing tasks. Participants raised several fairness-relevant factors beyond need or capacity to benefit. These included age, weight, poverty, access to other options and personal responsibility for illness; illness duration, curability or seriousness; life expectancy; possibilities for sharing; awareness of other's needs; and ability to explain allocations to those affected. They also articulated a fairness principle little considered by equity theories: that everybody must get something and nobody should get nothing. DISCUSSION AND CONCLUSIONS: Lay criteria for judging fairness are myriad. Simple scenarios may be used to investigate lay commitments to abstract principles. Although principles are the focus of analysis and inference, participants may solve simplified dilemmas by imputing extraneous features to the problem or applying unanticipated principles. These possibilities should be taken into account in the design of resource allocation surveys eliciting the views of the public.

Physician response to pay-for-performance: evidence from a natural experiment.

This study exploits a natural experiment in the province of Ontario, Canada, to identify the impact of pay-for-performance (P4P) incentives on the provision of targeted primary care services and whether physicians' responses differ by age, size of patient population, and baseline compliance level. We use administrative data that cover the full population of Ontario and nearly all the services provided by primary care physicians. We employ a difference-in-differences approach that controls for selection on observables and selection on unobservables that may cause estimation bias. We implement a set of robustness checks to control for confounding from other contemporaneous interventions of the primary care reform in Ontario. The results indicate that responses were modest and that physicians responded to the financial incentives for some services but not others. The results provide a cautionary message regarding the effectiveness of employing P4P to increase the quality of health care.

Health-related externalities: evidence from a choice experiment.

Health-related external benefits are of potentially large importance for public policy. This paper investigates health-related external benefits using a stated-preference discrete-choice experiment framed in a health care context and including choice scenarios defined by six attributes related to a recipient and the recipient's condition: communicability, severity, medical necessity, relationship to respondent, location, and amount of contribution requested. Subjects also completed a set of own-treatment scenarios and a values-orientation instrument. We find evidence of substantial health-related external benefits that vary as expected with the scenario attributes and subjects' value orientations. The results are consistent with a number of hypotheses offered by the general theoretical analysis of health-related externalities and the analysis of externalities specific to health care.

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.