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.

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.

Does prescribing apixaban or rivaroxaban versus warfarin for patients diagnosed with atrial fibrillation save health system costs? A multivalued treatment effects analysis.

BACKGROUND: Non-valvular atrial fibrillation (AF) is a common heart arrhythmia in the elderly population. AF patients are at high-risk of ischemic strokes, but oral anticoagulant (OAC) therapy reduces such risks. Warfarin had been the standard OAC for AF patients, however its effectiveness is highly variable and dependent on close monitoring of the anticoagulant response. Newer OACs such as rivaroxaban and apixaban address these drawbacks but are more costly. It is uncertain which OAC therapy for AF is cost-saving from the healthcare system perspective. METHODS: We followed a cohort of patients in Ontario, Canada, aged ≥ 66 who were newly diagnosed with AF and prescribed OACs between 2012 and 2017. We used a two-stage estimation procedure. First, we account for the patient selection into OACs using a multinomial logit regression model and estimated propensity scores. Second, we used an inverse probability weighted regression adjustment approach to determine cost-saving OAC options. We also examined component-specific costs (i.e., drug, hospitalization, emergency department and physician) to understand the drivers of cost-saving OACs. RESULTS: We found that compared to warfarin, rivaroxaban and apixaban treatments were cost-saving options, with per-patient 1-year healthcare cost savings at $2436 and $1764, respectively. These savings were driven by cost-savings in hospitalization, emergency department visits, and physician visits, outweighing higher drug costs. These results were robust to alternative model specifications and estimation procedures. CONCLUSIONS: Treating AF patients with rivaroxaban and apixaban than warfarin reduces healthcare costs. OAC reimbursement policies for AF patients should consider rivaroxaban or apixaban over warfarin as the first-line treatment.

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.

School nutrition policy and diet quality of children and youth: a quasi-experimental study from Canada.

OBJECTIVE: We investigated the impact of mandatory school nutrition policy on diet quality of Canadian school children using a quasi-experimental study design. METHODS: Using 24-h dietary recall data from the 2004 Canadian Community Health Survey (CCHS) Cycle 2.2 and 2015 CCHS - Nutrition, we constructed the Diet Quality Index (DQI). We used multivariable difference-in-differences regressions to quantify the DQI scores associated with school nutrition policy. We conducted stratified analyses by sex, school grade, household income, and food security status to gain additional insights into the impact of nutrition policy. RESULTS: We found that mandatory school nutrition policy was associated with an increased DQI score by 3.44 points (95% CI: 1.1, 5.8) during school-hours in intervention provinces relative to control provinces. DQI score was higher among males (3.8 points, 95% CI: 0.6, 7.1) than among females (2.9 points, 95% CI: -0.5, 6.3), and the score among students in elementary schools was higher (5.1 points, 95% CI: 2.3, 8.0) than that among high school students (0.4 points, 95% CI: -3.6, 4.5). We also found that DQI scores were higher for middle-high income and food secure households. CONCLUSION: Provincial mandatory school nutrition policy was associated with better diet quality among children and youth in Canada. Our findings suggest that other jurisdictions may consider implementing mandatory school nutrition policy.

RéSUMé: OBJECTIF: Nous avons étudié l'effet des politiques nutritionnelles en milieu scolaire sur la qualité du régime des enfants canadiens d'âge scolaire à l'aide d'un protocole d'étude quasi expérimental. MéTHODE: En utilisant les données des rappels alimentaires de 24 heures du cycle 2.2 de l'Enquête sur la santé dans les collectivités canadiennes (ESCC) de 2004 et de l'ESCC ­ Nutrition de 2015, nous avons construit un « indice de qualité du régime ¼ (IQR). Au moyen de régressions multivariées de la différence dans les différences, nous avons chiffré les valeurs de l'IQR associées aux politiques nutritionnelles en milieu scolaire. Nous avons mené des analyses stratifiées selon le sexe, le niveau scolaire, le revenu du ménage et l'état de sécurité alimentaire pour en savoir plus sur l'effet des politiques nutritionnelles. RéSULTATS: Nous avons constaté que les politiques nutritionnelles obligatoires en milieu scolaire étaient associées à des valeurs d'IQR de 3,44 points plus élevées (IC de 95 % : 1,1, 5,8) pendant les heures de classe dans les provinces ayant de telles politiques par rapport aux provinces témoins. La valeur d'IQR était plus élevée chez les garçons (3,8 points, IC de 95 % : 0,6, 7,1) que chez les filles (2,9 points, IC de 95 % : -0,5, 6,3), et la valeur chez les élèves des écoles primaires était plus élevée (5,1 points, IC de 95 % : 2,3, 8,0) que celle chez les élèves des écoles secondaires (0,4 points, IC de 95 % : -3,6, 4,5). Nous avons aussi constaté que les valeurs d'IQR étaient supérieures pour les ménages de revenu moyen à élevé et pour les ménages à l'abri de l'insécurité alimentaire. CONCLUSION: Les politiques nutritionnelles provinciales obligatoires en milieu scolaire étaient associées à un régime de meilleure qualité chez les enfants et les jeunes au Canada. Nos constatations indiquent que d'autres provinces et territoires pourraient envisager la mise en œuvre de politiques nutritionnelles en milieu scolaire.

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.

Risk of Hospital Encounters With Kidney Stones in Autosomal Dominant Polycystic Kidney Disease: A Cohort Study.

BACKGROUND: There is a perception that patients with autosomal dominant polycystic kidney disease (ADPKD) are more likely to develop kidney stones than the general population. OBJECTIVE: To compare the rate of hospital encounter with kidney stones and the rate of stone interventions between patients with and without ADPKD. DESIGN: Retrospective cohort study. SETTING: Ontario, Canada. PATIENTS: Patients with and without ADPKD who had a prior hospital encounter between 2002 and 2016. MEASUREMENTS: Rate of hospital encounter with kidney stones and rate of stone intervention. METHODS: We used inverse probability exposure weighting based on propensity scores to balance baseline indicators of health between patients with and without ADPKD. We followed each patient until death, emigration, outcomes, or March 31, 2017. We used a Cox proportional hazards model to compare event rates between the two groups. RESULTS: Patients with ADPKD were at higher risk of hospital encounter with stones compared with patients without ADPKD (81 patients of 2094 with ADPKD [3.8%] vs 60 patients of 1902 without ADPKD [3.2%]; 8.9 vs 5.1 events per 1000 person-years; hazard ratio 1.6 [95% CI, 1.3-2.1]). ADPKD was not associated with a higher risk of stone intervention (49 of 2094 [2.3%] vs 47 of 1902 [2.4%]; 5.3 vs 3.9 events per 1000 person-years; hazard ratio 1.2 [95% CI = 0.9-1.3]). LIMITATIONS: We did not have information on kidney stone events outside of the hospital. There is a possibility of residual confounding. CONCLUSION: ADPKD was a significant risk factor for hospital encounters with kidney stones.

CONTEXTE: Il existe une perception selon laquelle les patients atteints de polykystose rénale autosomique dominante (ADPKD) seraient plus susceptibles de développer des calculs rénaux que la population générale. OBJECTIF: Comparer les taux d'hospitalisations et d'interventions pour calculs rénaux entre des patients atteints ou non d'ADPKD. TYPE D'ÉTUDE: Étude de cohorte rétrospective. CADRE: Ontario, Canada. SUJETS: Des patients atteints ou non d'ADPKD qui avaient déjà été hospitalisés entre 2002 et 2016. MESURES: Les taux d'hospitalisations et d'interventions pour calculs rénaux. MÉTHODOLOGIE: Nous avons utilisé une pondération d'exposition à probabilité inverse fondée sur les scores de propension afin d'équilibrer les indicateurs de santé de base entre les patients atteints ou non d'ADPKD. Nous avons suivi chaque patient jusqu'à son décès, jusqu'à son émigration, jusqu'au résultat ou jusqu'au 31 mars 2017. Nous avons utilisé un modèle de risques proportionnels de Cox pour comparer les taux d'événements entre les deux groupes. RÉSULTATS: Les patients atteints d'ADPKD présentaient un risque plus élevé d'être hospitalisés pour calculs rénaux que les patients non atteints d'ADPKD (81 patients sur 2094 atteints d'ADPKD [3,8 %] contre 60 patients sur 1902 sans ADPKD [3,2 %]; 8,9 contre 5,1 événements pour 1 000 années-personnes; risque relatif: 1,6 [IC 95 %: 1,3 à 2,1]). L'ADPKD n'a pas été associée à un risque plus élevé d'interventions pour retirer des calculs rénaux (49 patients sur 2094 atteints d'ADPKD [2,3 %] contre 47 patients sur 1902 sans ADPKD [2,4 %]; 5,3 contre 3,9 événements pour 1 000 années-personnes; risque relatif: 1,2 [IC 95 %: 0,9 à 1,3]). LIMITES: Nous n'avions pas d'information sur les événements liés aux calculs rénaux à l'extérieur de l'hôpital. Il existe une possibilité de facteurs de confusion résiduels. CONCLUSION: L'ADPKD s'est avéré un facteur de risque important d'être hospitalisé pour des calculs rénaux.

Impact of pretreatment dihydropyrimidine dehydrogenase genotype-guided fluoropyrimidine dosing on chemotherapy associated adverse events.

Consensus guidelines exist for genotype-guided fluoropyrimidine dosing based on variation in the gene dihydropyrimidine dehydrogenase (DPYD). However, these guidelines have not been widely implemented in North America and most studies of pretreatment DPYD screening have been conducted in Europe. Given regional differences in treatment practices and rates of adverse events (AEs), we investigated the impact of pretreatment DPYD genotyping on AEs in a Canadian context. Patients referred for DPYD genotyping prior to fluoropyrimidine treatment were enrolled from December 2013 through November 2019 and followed until completion of fluoropyrimidine treatment. Patients were genotyped for DPYD c.1905+1G>A, c.2846A>T, c.1679T>G, and c.1236G>A. Genotype-guided dosing recommendations were informed by Clinical Pharmacogenetics Implementation Consortium guidelines. The primary outcome was the proportion of patients who experienced a severe fluoropyrimidine-related AE (grade ≥3, Common Terminology Criteria for Adverse Events version 5.0). Secondary outcomes included early severe AEs, severe AEs by toxicity category, discontinuation of fluoropyrimidine treatment due to AEs, and fluoropyrimidine-related death. Among 1394 patients, mean (SD) age was 64 (12) years, 764 (54.8%) were men, and 47 (3.4%) were DPYD variant carriers treated with dose reduction. Eleven variant carriers (23%) and 418 (31.0%) noncarriers experienced a severe fluoropyrimidine-related AE (p = 0.265). Six carriers (15%) and 284 noncarriers (21.1%) experienced early severe fluoropyrimidine-related AEs (p = 0.167). DPYD variant carriers treated with genotype-guided dosing did not experience an increased risk for severe AEs. Our data support a role for DPYD genotyping in the use of fluoropyrimidines in North America.

Diagnostic accuracy of administrative codes for autosomal dominant polycystic kidney disease in clinic patients with cystic kidney disease.

BACKGROUND: The ability to identify patients with autosomal dominant polycystic kidney disease (ADPKD) and distinguish them from patients with similar conditions in healthcare administrative databases is uncertain. We aimed to measure the sensitivity and specificity of different ADPKD administrative coding algorithms in a clinic population with non-ADPKD and ADPKD kidney cystic disease. METHODS: We used a dataset of all patients who attended a hereditary kidney disease clinic in Toronto, Ontario, Canada between 1 January 2010 and 23 December 2014. This dataset included patients who met our reference standard definition of ADPKD or other cystic kidney disease. We linked this dataset to healthcare databases in Ontario. We developed eight algorithms to identify ADPKD using the International Classification of Diseases, 10th Revision (ICD-10) codes and provincial diagnostic billing codes. A patient was considered algorithm positive if any one of the codes in the algorithm appeared at least once between 1 April 2002 and 31 March 2015. RESULTS: The ICD-10 coding algorithm had a sensitivity of 33.7% [95% confidence interval (CI) 30.0-37.7] and a specificity of 86.2% (95% CI 75.7-92.5) for the identification of ADPKD. The provincial diagnostic billing code had a sensitivity of 91.1% (95% CI 88.5-93.1) and a specificity of 10.8% (95% CI 5.3-20.6). CONCLUSIONS: ICD-10 coding may be useful to identify patients with a high chance of having ADPKD but fail to identify many patients with ADPKD. Provincial diagnosis billing codes identified most patients with ADPKD and also with other types of cystic kidney disease.

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.

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.

Quality of Diabetes Care in Blended Fee-for-Service and Blended Capitation Payment Systems.

OBJECTIVES: In the middle to late 2000s, many family physicians switched from a Family Health Group (FHG; a blended fee-for-service model) to a Family Health Organization (FHO; a blended capitation model) in Ontario, Canada. The evidence on the link between physician remuneration schemes and quality of diabetes care is mixed in the literature. We examined whether physicians who switched from the FHG to FHO model provided better care for individuals living with diabetes relative to those who remained in the FHG model. METHODS: Using longitudinal health administrative data from 2006 to 2016, we investigated the impact of physicians switching from FHG to FHO on 8 quality indicators related to diabetes care. Because FHO physicians are likely to be systematically different from FHGs, we employed propensity-score-based inverse probability-weighted fixed-effects regression models. All analyses were conducted at the physician level. RESULTS: We found that FHO physicians were more likely to provide glycated hemoglobin testing by 2.75% (95% confidence interval [CI], 1.89% to 3.60%), lipid assessment by 2.76% (CI, 1.95% to 3.57%), nephropathy screening by 1.08% (95% CI, 0.51% to 1.66%) and statin prescription by 1.08% (95% CI, 0.51% to 1.66%). Patients under FHOs had a lower estimated risk of mortality by 0.0124% (95% CI, 0.0123% to 0.0126%) per physician per year. However, FHG and FHO physicians were similar for annual eye examination, prescription of angiotensin-converting enzyme inhibitors (or angiotensin II receptor blockers) and patients' risk of avoidable diabetes-related hospitalizations. CONCLUSIONS: Compared with blended fee-for-service, blended capitation payment is associated with a small, but statistically significant, improvement in some aspects of diabetes care.

Physician remuneration schemes, psychiatric hospitalizations and follow-up care: Evidence from blended fee-for-service and capitation models.

Psychiatric hospitalizations could be reduced if mental illnesses were detected and treated earlier in the primary care setting, leading to the World Health Organization recommendation that mental health services be integrated into primary care. The mental health services provided in primary care settings may vary based on how physicians are incentivized. Little is known about the link between physician remuneration and psychiatric hospitalizations. We contribute to this literature by studying the relationship between physician remuneration and psychiatric hospitalizations in Canada's most populous province, Ontario. Specifically, we study family physicians (FPs) who switched from blended fee-for-service (FFS) to blended capitation remuneration model, relative to those who remained in the blended FFS model, on psychiatric hospitalizations. Outcomes included psychiatric hospitalizations by enrolled patients and the proportion of hospitalized patients who had a follow-up visit with the FP within 14 days of discharge. We used longitudinal health administrative data from a cohort of practicing physicians from 2006 through 2016. Because physicians practicing in these two models are likely to be different, we employed inverse probability weighting based on estimated propensity scores to ensure that switchers and non-switchers were comparable at the baseline. Using inverse probability weighted fixed-effects regressions controlling for relevant confounders, we found that switching from blended FFS to blended capitation was associated with a 6.2% decrease in the number of psychiatric hospitalizations and a 4.7% decrease in the number of patients with a psychiatric hospitalization. No significant effect of remuneration on follow-up visits within 14 days of discharge was observed. Our results suggest that the blended capitation model is associated with fewer psychiatric hospitalizations relative to blended FFS.

Complications in Patients With Autosomal Dominant Polycystic Kidney Disease Undergoing Ureteroscopy: A Cohort Study.

BACKGROUND: Ureteroscopy is a minimally invasive treatment option for upper tract stones. The distorted kidney anatomy in patients with autosomal dominant polycystic kidney disease (ADPKD) may place them at higher risk for ureteroscopic complications. OBJECTIVE: To compare the 30-day risk of ureteroscopic complications between patients with and without ADPKD. DESIGN: Retrospective cohort study. SETTING: Ontario, Canada. PATIENTS: Seventy three patients with ADPKD and 81 445 patients without ADPKD who underwent ureteroscopy for upper urinary tract stones between April 1, 2002, and March 1, 2018. MEASUREMENTS: A 30-day risk of (1) hospital presentation with ureteroscopic complications (which was a composite outcome of either emergency department visit or hospital admission with acute kidney injury, urinary tract infection, or sepsis); (2) all-cause hospital presentation; (3) all-cause hospital admission; and (4) all-cause emergency department visit. METHODS: We regressed outcomes on demographic variables, health care use in the prior 1-year, various procedures and comorbidities related to the outcome in the prior 5 years, and prescribed medications filled in the past 120 days using modified Poisson regression to compare the risk ratio (RR) of each outcome between patients with and without ADPKD. RESULTS: The median (interquartile, IQR) age was 44 (38-60 years) in the ADPKD group and 53 (42-64) in the control group. About 40% were women in both groups. The risk of ureteroscopic complications was not significantly different in patients with versus without ADPKD (8.2% vs 4.3%; adjusted RR = 1.5, 95% confidence interval [CI] = 0.7-3.2). Patients with versus without ADPKD were more likely to present to hospital after their procedure (35.6% vs. 20.0%; adjusted RR = 1.6, 95% CI = 1.2-2.2), which included a statistically significant increase in the risk of presenting to the emergency department (32.9% vs. 19.0%; adjusted RR = 1.6, 95% CI = 1.1-2.2) but not hospital admissions (10.9% vs. 5.0%; adjusted RR = 1.8, 95% CI = 0.9-3.4). LIMITATIONS: The low numbers of events led to imprecision around the estimates. CONCLUSION: Patients with ADPKD have a higher risk of return to the hospital within 30 days of ureteroscopy for stone disease. TRIAL REGISTRATION: We did not register this study.

CONTEXTE: L'urétéroscopie est une option minimalement invasive pour traiter les calculs des voies urinaires hautes. Cependant, les distorsions anatomiques des reins présentes chez les patients atteints de polykystose rénale autosomique dominante (ADPKD) exposent ces derniers à un risque accru de complications liées à la procédure. OBJECTIF: Comparer le risque de complications liées à l'urétéroscopie chez des patients atteints ou non d'ADPKD dans les 30 jours suivant la procédure. TYPE D'ÉTUDE: Étude de cohorte rétrospective. CADRE: Ontario, Canada. SUJETS: L'étude porte sur 73 patients atteints d'ADPKD et 81 445 patients témoins ayant subi une urétéroscopie entre le 1er avril 2002 et le 1er mars 2018 pour le traitement de calculs des voies urinaires hautes. MESURES: Le risque dans les 30 jours de: 1) visite à l'hôpital pour des complications liées à l'urétéroscopie (résultat composite d'une visite aux urgences ou d'une admission en raison d'une insuffisance rénale aiguë, d'une infection urinaire ou d'un sepsis); 2) toute autre cause de visite à l'hôpital; 3) toute autre cause d'admission; et 4) toute autre cause de visite aux urgences. MÉTHODOLOGIE: Une régression de Poisson modifiée a été employée pour l'analyze des résultats sur les variables démographiques, l'utilization des soins de santé au cours de l'année précédente, les différentes procédures et maladies concomitantes liées au résultat au cours des cinq années précédentes et les médicaments prescrits au cours des 120 derniers jours afin de comparer le rapport de risque (RR) de chaque résultat entre les patients atteints ou non d'ADPKD. RÉSULTATS: L'âge médian des sujets (écart interquartile) s'établissait à 44 ans (38-60 ans) dans le groupe de patients ADPKD et à 53 ans (42-64 ans) dans le groupe témoin; les femmes représentaient environ 40 % des sujets dans les deux groupes. Le risque de complications liées à l'urétéroscopie n'était pas significativement différent entre le groupe ADPKD et le groupe témoin (8,2 % vs 4,2 %; RR corrigé: 1,5; IC 95 %: 0,7 à 3,2). Tous les patients, avec ou sans ADPKD, étaient plus susceptibles de se présenter à l'hôpital après l'intervention (36,6 % vs 20,0 %; RR corrigé: 1,6; IC 95 %: 1,2 à 2,2). Ce résultat incluait un risque significativement plus élevé de se présenter aux urgences (32,9 % vs 19,0 %; RR corrigé: 1,6; IC 95 %: 1,1 à 2,2), mais pas d'être hospitalisé (11 % vs 5 %; RR corrigé: 1,8; IC 95 %: 0,9 à 3,4). LIMITES: Le faible nombre d'événements a mené à l'imprécision des estimations. CONCLUSION: Les patients atteints d'ADPKD présentent un risque accru de retourner à l'hôpital dans les 30 jours suivant une urétéroscopie pour traiter des calculs urinaires. ENREGISTREMENT DE L'ESSAI: L'étude n'a pas été enregistrée.

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.

Efficacy and Safety of Surgical Kidney Stone Interventions in Autosomal Dominant Polycystic Kidney Disease: A Systematic Review.

BACKGROUND: Reduced kidney function and distorted kidney anatomy in patients with autosomal dominant polycystic kidney disease (ADPKD) may complicate stone interventions more compared with the general population. OBJECTIVES: To review studies describing the safety and efficacy of the 3 main stone interventions in adults with ADPKD: shock wave lithotripsy (SWL), ureteroscopy, and percutaneous nephrolithotomy (PCNL). DESIGN: Systematic review. SETTING: Any country of origin. PATIENTS: Adults with ADPKD who underwent SWL, ureteroscopy, or PCNL. MEASUREMENTS: Being stone free after the intervention and postoperative complications as reported by each study, which included pain, bleeding, and fever. METHODS: Relevant studies published until February 2019 were identified through a comprehensive search of MEDLINE, EMBASE, Web of Science, BIOSIS PREVIEW, and CINAHL. Studies were eligible for review if they reported at least one outcome following SWL, ureteroscopy, and/or PCNL in adults with ADPKD. We then abstracted information on study characteristics, patient characteristics, intervention details, and postintervention outcomes and assessed the methodological quality of each study using a modified Downs and Black checklist. RESULTS: We screened 221 citations from which we identified 24 studies that met our review criteria. We identified an additional article when manually reviewing the reference list of an included article, yielding a total of 25 studies describing 311 patients (32 SWL, 42 ureteroscopy, and 237 PCNL). The percentage of patients who were stone free after 1 session ranged from 0% to 69% after SWL, 73% to 100% after ureteroscopy, and 45% to 100% after PCNL. The percentage of patients with ADPKD that experienced at least one postoperative complication ranged from 0% to 33% for SWL, 0% to 27% for ureteroscopy, and 0% to 100% for PCNL. LIMITATIONS: The number and quality of studies published to date are limited. CONCLUSIONS: The efficacy and safety of stone interventions in patients with ADPKD remains uncertain, with wide-ranging estimates reported in the literature. TRIAL REGISTRATION: We did not register the protocol of this systematic review.

CONTEXTE: Les interventions visant à traiter les calculs rénaux sont plus compliquées chez les patients atteints de polykystose rénale autosomique dominante (ADPKD) que dans la population générale en raison de la fonction rénale réduite et des distorsions anatomiques des reins présentes chez ces patients. OBJECTIF: Passer en revue les études portant sur l'innocuité et l'efficacité des trois principales interventions pour traiter les calculs rénaux chez des adultes atteints d'ADPKD: la lithotripsie par ondes de choc (LOC), l'urétéroscopie et la néphrolithotomie percutanée (NLPC). TYPE D'ÉTUDE: Revue systématique. CADRE: Les pays d'origine des études. SUJETS: Des adultes atteints d'ADPKD ayant subi une LOC, une urétéroscopie ou une NLPC. MESURES: Une intervention réussie (absence de calculs rénaux) et les complications postopératoires rapportées (douleur, hémorragie et fièvre). MÉTHODOLOGIE: Une recherche exhaustive sur MEDLINE, EMBASE, Web of Science, BIOSIS PREVIEW et CINAHL a permis de répertorier toutes les études pertinentes publiées jusqu'en février 2019. Les études devaient rapporter minimalement une des mesures d'intérêt à la suite d'une LOC, d'une urétéroscopie ou d'une NLPC chez des adultes atteints d'ADPKD. Les caractéristiques des études, les caractéristiques des patients, les détails de l'intervention et les résultats postopératoires ont été extraits des études retenues. La qualité méthodologique de chaque étude a été mesurée selon la grille d'évaluation de Downs et Black. RÉSULTATS: Des 221 citations répertoriées par la revue de la littérature, 24 études satisfaisaient nos critères d'inclusion. Une 25e étude s'est ajoutée en passant en revue manuellement les références d'un des essais déjà inclus. Notre revue systématique porte donc sur un total de 311 patients (32 LOC, 42 urétéroscopie et 237 NLPC). Le pourcentage de patients sans calculs rénaux après une seule intervention variait de 0 à 69 % après une LOC, de 73 à 100 % après une urétéroscopie et de 45 à 100 % après une NLPC. Le pourcentage de patients ayant souffert d'au moins une complication postopératoire variait de 0 à 33 % après une LOC, de 0 à 27 % pour une urétéroscopie et de 0 à 100 % pour une NLPC. LIMITES: Le nombre et la qualité des études publiées sur le sujet sont limités. CONCLUSION: L'efficacité et l'innocuité des interventions visant le retrait de calculs rénaux chez des patients atteints d'ADPKD demeurent incertaines; les estimations rapportées dans la littérature présentent une grande variété. ENREGISTREMENT DE L'ESSAI: Le protocole de cette revue systématique n'a pas été enregistré.

The impact of the diabetes management incentive on diabetes-related services: evidence from Ontario, Canada.

Financial incentives have been introduced in several countries to improve diabetes management. In Ontario, the most populous province in Canada, a Diabetes Management Incentive (DMI) was introduced to family physicians practicing in patient enrollment models in 2006. This paper examines the impact of the DMI on diabetes-related services provided to individuals with diabetes in Ontario. Longitudinal health administrative data were obtained for adults diagnosed with diabetes and their family physicians. The study population consisted of two groups: DMI group (patients enrolled with a family physician exposed to DMI for 3 years), and comparison group (patients affiliated with a family physician ineligible for DMI throughout the study period). Diabetes-related services was measured using the Diabetic Management Assessment (DMA) billing code claimed by patient's physician. The impact of DMI on diabetes-related services was assessed using difference-in-differences regression models. After adjusting for patient- and physician-level characteristics, patient fixed-effects and patient-specific time trend, we found that DMI increased the probability of having at least one DMA fee code claimed by patient's physician by 9.3% points, and the probability of having at least three DMA fee codes claimed by 2.1% points. Subgroup analyses revealed the impact of DMI was slightly larger in males compared to females. We found that Ontario's DMI was effective in increasing the diabetes-related services provided to patients diagnosed with diabetes in Ontario. Financial incentives for physicians help improve the provision of targeted diabetes-related services.

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.

The impact of improved access to after-hours primary care on emergency department and primary care utilization: A systematic review.

Access to after-hours primary care is problematic in many developed countries, leading patients to instead visit the emergency department for non-urgent conditions. However, emergency department utilization for conditions treatable in primary care settings may contribute to emergency department overcrowding and increased health system costs. This systematic review examines the impact of various initiatives by developed countries to improve access to after-hours primary care on emergency department and primary care utilization. We performed a systematic review on the impact of improved access to after-hours primary and searched CINAHL, EMBASE, MEDLINE, and Scopus. We identified 20 studies that examined the impact of improved access to after-hours primary care on ED utilization and 6 studies that examined the impact on primary care utilization. Improved access to after-hours primary care was associated with increased primary care utilization, but had a mixed effect on emergency department utilization, with limited evidence of a reduction in non-urgent and semi-urgent emergency department visits. Although our review suggests that improved access to after-hours primary care may limit emergency department utilization by shifting patient care from the emergency department back to primary care, rigorous research in a given institutional context is required before introducing any initiative to improve access to after-hours primary care.

Geographic variation in preventable hospitalisations across Canada: a cross-sectional study.

OBJECTIVE: The objective of this study is to examine the magnitude and pattern of small-area geographic variation in rates of preventable hospitalisations for ambulatory care-sensitive conditions (ACSC) across Canada (excluding Québec). DESIGN AND SETTING: A cross-sectional study conducted in Canada (excluding Québec) using data from the 2006 Canadian Census Health and Environment Cohort (CanCHEC) linked prospectively to hospitalisation records from the Discharge Abstract Database (DAD) for the three fiscal years: 2006-2007, 2007-2008 and 2008-2009. PRIMARY OUTCOME MEASURE: Preventable hospitalisations (ACSC). PARTICIPANTS: The 2006 CanCHEC represents a population of 22 562 120 individuals in Canada (excluding Québec). Of this number, 2 940 150 (13.03%) individuals were estimated to be hospitalised at least once during the 2006-2009 fiscal years. METHODS: Age-standardised annualised ACSC hospitalisation rates per 100 000 population were computed for each of the 190 Census Divisions. To assess the magnitude of Census Division-level geographic variation in rates of preventable hospitalisations, the global Moran's I statistic was computed. 'Hot spot' analysis was used to identify the pattern of geographic variation. RESULTS: Of all the hospitalisation events reported in Canada during the 2006-2009 fiscal years, 337 995 (7.10%) events were ACSC-related hospitalisations. The Moran's I statistic (Moran's I=0.355) suggests non-randomness in the spatial distribution of preventable hospitalisations. The findings from the 'hot spot' analysis indicate a cluster of Census Divisions located in predominantly rural and remote parts of Ontario, Manitoba and Saskatchewan and in eastern and northern parts of Nunavut with significantly higher than average rates of preventable hospitalisation. CONCLUSION: The knowledge generated on the small-area geographic variation in preventable hospitalisations can inform regional, provincial and national decision makers on planning, allocation of resources and monitoring performance of health service providers.