Cost-Effectiveness of Cryoballoon Ablation Versus Radiofrequency Ablation for Paroxysmal Atrial Fibrillation in China: Results Based on Real-World Data.

BACKGROUND: Paroxysmal atrial fibrillation (AF) presents a significant economic burden to the healthcare system. Catheter ablations is a commonly adopted treatment for paroxysmal AF. OBJECTIVES: To evaluate the cost effectiveness of cryoballoon ablation versus radiofrequency ablation in patients with drug-refractory paroxysmal AF in a tertiary hospital in China. METHODS: A Markov model was developed to study the effects and costs. Cost and probability input data were obtained mainly from a retrospective real-world study conducted in a tertiary hospital. Propensity score matching was used to overcome retrospective bias. Input data gaps were remedied by means of literature review and advice from experts. A simulation was performed for the post-procedure lifetime years. Univariate and probabilistic sensitivity analyses were conducted. RESULTS: In the base-case analysis of a lifetime time horizon, a patient treated with cryoballoon ablation was associated with 7.85 quality-adjusted life-years (QALYs) and ¥132 222 ($19 913) total costs, whereas a radiofrequency ablation treated patient was associated with 7.71 QALYs and ¥147 304 ($22 184) total costs. The cryoballoon group had slightly better health outcomes (with a difference of 0.14 QALY) and lower total costs (with a difference of ¥15 082) (USD $2 271), and it may be considered as cost-effective or cost-saving strategy (incremental cost-effectiveness ratio -¥110 158 [$16 590] per QALY) for the management of paroxysmal AF. Different scenarios were tested with sensitivity analyses, but still, the outcomes remained cost-effective or cost-saving for cryoballoon ablation. CONCLUSIONS: An economic evaluation based on real-world data suggests that, relative to radiofrequency ablation, cryoballoon ablation may be considered as a more cost-effective or cost-saving long-term strategy for drug-refractory paroxysmal AF in this tertiary hospital in China. However, further evidence is needed using data from large-scale studies in order to reflect a national perspective.

Cost-Effectiveness Analysis of Non-invasive Prenatal Testing for Down Syndrome in China.

OBJECTIVES: There is little evidence in China regarding the cost-effectiveness of non-invasive prenatal testing (NIPT) for Down syndrome (DS). This study aims to evaluate the cost-effectiveness of NIPT and provide evidence to inform decision-making. METHODS: To determine the cost-effectiveness of NIPT for DS, a decision-analytic model was developed using the TreeAge Pro software from a societal perspective in a simulated cohort of 10 000 pregnant women. Main indicators were based on field surveys from sampled hospitals in four locations in China and a literature review. RESULTS: The conventional maternal serum screening (CMSS) strategy, contingent screening strategy (NIPT delivered to high risk pregnant women after CMSS), and universal screening strategy could prevent 3.02, 7.53, and 9.97 DS births, respectively. NIPT would decrease unnecessary invasive procedures, resulting in fewer procedure-related miscarriages. The cost-effectiveness ratio of the contingent screening strategy was the lowest. When compared with the CMSS strategy, the incremental cost per DS birth averted by the contingent screening strategy and universal screening strategy were USD 20,160 and 352,388, respectively. One-way sensitivity analysis showed that, if the cost of NIPT could be decreased to USD 76.92, the cost-effectiveness ratio of the universal screening strategy would be lower than the CMSS strategy. CONCLUSIONS: Although NIPT has the merits of greater effectiveness and safety, CMSS is unlikely to be replaced by NIPT at this time because of NIPT's higher cost. Contingent screening may be an appropriate strategy to balance the effectiveness and cost factors of the new genetic testing technology.

Determinants of knowledge translation from health technology assessment to policy-making in China: From the perspective of researchers.

BACKGROUND: For health technology assessment (HTA) to be more policy relevant and for health technology-related decision-making to be truly evidence-based, promoting knowledge translation (KT) is of vital importance. Although some research has focused on KT of HTA, there is a dearth of literature on KT determinants and the situation in developing countries and transitional societies remains largely unknown. OBJECTIVE: To investigate the determinants of HTA KT from research to health policy-making from the perspective of researchers in China. DESIGN: Cross-sectional study. METHODS: A structured questionnaire which focused on KT was distributed to HTA researchers in China. KT activity levels in various fields of HTA research were compared, using one-way ANOVA. Principal component analysis was performed to provide a basis to combine similar variables. To investigate the determinants of KT level, multiple linear regression analysis was performed. RESULTS: Based on a survey of 382 HTA researchers, it was found that HTA KT wasn't widespread in China. Furthermore, results showed that no significant differences existed between the various HTA research fields. Factors, such as attitudes of researchers toward HTA and evidence utilization, academic ranks and linkages between researchers and policy-makers, had significant impact on HTA KT (p-values<0.05). Additionally, collaboration between HTA researchers and policy-makers, policy-relevance of HTA research, practicality of HTA outcomes and making HTA reports easier to understand also contributed to predicting KT level. However, academic nature of HTA research was negatively associated with KT level. CONCLUSION: KT from HTA to policy-making was influenced by many factors. Of particular importance were collaborations between researchers and policy-makers, ensuring policy relevance of HTA and making HTA evidence easier to understand by potential users.

A "Simple" Evidence-Based Intervention to Improve Care Transitions for Frail Patients with Complex Health Conditions: Why Didn't It Work as Expected?

The transition from hospital to home is a vulnerable period for patients with complex conditions, who are often frail, at risk for adverse events and unable to navigate a system of poorly coordinated care in the post-discharge period. Care transition interventions are seen as effective care coordinating mechanisms for reducing avoidable adverse events associated with the transition of the patient from the hospital to the home. A study was undertaken to evaluate the effectiveness of a care transition intervention involving a hand-off between a hospital-based care transitions nurse and a community-based rapid response nurse. Two focus groups were held, one involving rapid response nurses and the other involving care transition nurses. Individual interviews were conducted with the managers (n = 2) and executives (n = 2) to identify the factors that facilitated or were barriers to its implementation. Using thematic content analysis, it was found that the effectiveness of transitional coordination efforts was thwarted by ineffective communication, which affected the quality of the underlying relationships between the two teams. Other barriers to achieving the desired outcomes included the following: issues of role clarity, role awareness and acceptance, the adequacy and reinforcement of coordinating mechanisms, the effectiveness of the information exchange protocols and the absence of shared measures of accountability. Clinical integration initiatives have fewer human resource and financial implementation barriers compared with organizational integration efforts but are complex undertakings requiring clear alignment between organizations, shared accountability measures, effective communication processes and relationships of trust and respect between interprofessional teams.

Different Models of Hospital-Community Health Centre Collaboration in Selected Cities in China: A Cross-Sectional Comparative Study.

OBJECTIVE: In recent years, in order to provide patients with seamless and integrated healthcare services, some models of collaboration between public hospitals and community health centres have been piloted in some cities in China. The main goals of this study were to assess the nature and characteristics of these collaboration models. METHODS: Three cases of three different collaboration models in three Chinese cities were selected to analyse using descriptive statistics, Pearson χ (2) and ordinal logistic regression. RESULTS: Results showed that the Direct Management Model in Wuhan exhibited better structure indicators than the other two models. Staff in the Direct Management Model had the highest satisfaction level (77.6%) with respect to patient referral. Communications between hospitals and community health centres and among care providers were generally inadequate. Publicity about hospital-community health centre collaboration was inadequate, resulting in low awareness among patients and even among health professionals. CONCLUSION: Results can inform health service delivery integration efforts in China and provide crucial information for the assessment of similar collaborations in other countries.

How patients think about social responsibility of public hospitals in China?

BACKGROUND: Hospital social responsibility is receiving increasing attention, especially in China where major changes to the healthcare system have taken place. This study examines how patients viewed hospital social responsibility in China and explore the factors that influenced patients' perception of hospital social responsibility. METHODS: A cross-sectional survey was conducted, using a structured questionnaire, on a sample of 5385 patients from 48 public hospitals in three regions of China: Shanghai, Hainan, and Shaanxi. A multilevel regression model was employed to examine factors influencing patients' assessments of hospital social responsibility. Intra-class correlation coefficients (ICCs) were calculated to estimate the proportion of variance in the dependent variables determined at the hospital level. RESULTS: The scores for service quality, appropriateness, accessibility and professional ethics were positively associated with patients' assessments of hospital social responsibility. Older outpatients tended to give lower assessments, while inpatients in larger hospitals scored higher. After adjusted for the independent variables, the ICC rose from 0.182 to 0.313 for inpatients and from 0.162 to 0.263 for outpatients. The variance at the patient level was reduced by 51.5 and 48.6 %, respectively, for inpatients and outpatients. And the variance at the hospital level was reduced by 16.7 % for both groups. CONCLUSIONS: Some hospital and patient characteristics and their perceptions of service quality, appropriateness, accessibility and professional ethics were associated with their assessments of public hospital social responsibility. The differences were mainly determined at the patient level. More attention to law-abiding behaviors, cost-effective health services, and charitable works could improve perceptions of hospitals' adherence to social responsibility.

Milestones on the social accountability journey: Family medicine practice locations of Northern Ontario School of Medicine graduates.

OBJECTIVE: To assess the effect of different levels of exposure to the Northern Ontario School of Medicine's (NOSM's) distributed medical education programs in northern Ontario on FPs' practice locations. DESIGN: Cross-sectional design using longitudinal survey and administrative data. SETTING: Canada. PARTICIPANTS: All 131 Canadian medical graduates who completed FP training in 2011 to 2013 and who completed their undergraduate (UG) medical degree or postgraduate (PG) residency training or both at NOSM. INTERVENTION: Exposure to NOSM's medical education program at the UG (n = 49) or PG (n = 31) level or both (n = 51). MAIN OUTCOME MEASURES: Primary practice location in September of 2014. RESULTS: Approximately 16% (21 of 129) of FPs were practising in rural northern Ontario, 45% (58 of 129) in urban northern Ontario, and 5% (7 of 129) in rural southern Ontario. Logistic regression found that more rural Canadian background years predicted rural practice in northern Ontario or Ontario, with odds ratios of 1.16 and 1.12, respectively. Northern Canadian background, sex, marital status, and having children did not predict practice location. Completing both UG and PG training at NOSM predicted practising in rural and northern Ontario locations with odds ratios of 4.06 to 48.62. CONCLUSION: Approximately 61% (79 of 129) of Canadian medical graduate FPs who complete at least some of their training at NOSM practise in northern Ontario. Slightly more than a quarter (21 of 79) of these FPs practise in rural northern Ontario. The FPs with more years of rural background or those with greater exposure to NOSM's medical education programs had higher odds of practising in rural northern Ontario. This study shows that NOSM is on the road to reaching one of its social accountability milestones.

Outcomes of the Northern Ontario School of Medicine's distributed medical education programmes: protocol for a longitudinal comparative multicohort study.

INTRODUCTION: The Northern Ontario School of Medicine (NOSM) has a social accountability mandate to serve the healthcare needs of the people of Northern Ontario, Canada. A multiyear, multimethod tracking study of medical students and postgraduate residents is being conducted by the Centre for Rural and Northern Health Research (CRaNHR) in conjunction with NOSM starting in 2005 when NOSM first enrolled students. The objective is to understand how NOSM's selection criteria and medical education programmes set in rural and northern communities affect early career decision-making by physicians with respect to their choice of medical discipline, practice location, medical services and procedures, inclusion of medically underserved patient populations and practice structure. METHODS AND ANALYSIS: This prospective comparative longitudinal study follows multiple cohorts from entry into medical education programmes at the undergraduate (UG) level (56-64 students per year at NOSM) or postgraduate (PG) level (40-60 residents per year at NOSM, including UGs from other medical schools and 30-40 NOSM UGs who go to other schools for their residency training) and continues at least 5 years into independent practice. The study compares learners who experience NOSM UG and NOSM PG education with those who experience NOSM UG education alone or NOSM PG education alone. Within these groups, the study also compares learners in family medicine with those in other specialties. Data will be analysed using descriptive statistics, χ(2) tests, logistic regression, and hierarchical log-linear models. ETHICS AND DISSEMINATION: Ethical approval was granted by the Research Ethics Boards of Laurentian University (REB #2010-08-03 and #2012-01-09) and Lakehead University (REB #031 11-12 Romeo File #1462056). Results will be published in peer-reviewed scientific journals, presented at one or more scientific conferences, and shared with policymakers and decision-makers and the public through 4-page research summaries and social media such as Twitter (@CRaNHR, @NOSM) or Facebook.

The economic contribution of the Northern Ontario School of Medicine to communities participating in distributed medical education.

INTRODUCTION: The economic contribution of medical schools to major urban centres can be substantial, but there is little information on the contribution to the economy of participating communities made by schools that provide education and training away from major cities and academic health science centres. We sought to assess the economic contribution of the Northern Ontario School of Medicine (NOSM) to northern Ontario communities participating in NOSM's distributed medical education programs. METHODS: We developed a local economic model and used actual expenditures from 2007/08 to assess the economic contribution of NOSM to communities in northern Ontario. We also estimated the economic contribution of medical students or residents participating in different programs in communities away from the university campuses. To explore broader economic effects, we conducted semistructured interviews with leaders in education, health care and politics in northern Ontario. RESULTS: The total economic contribution to northern Ontario was $67.1 million based on $36.3 million in spending by NOSM and $1.0 million spent by students. Economic contributions were greatest in the university campus cities of Thunder Bay ($26.7 million) and Sudbury ($30.4 million), and $0.8-$1.2 million accrued to the next 3 largest population centres. Communities might realize an economic contribution of $7300-$103 900 per pair of medical learners per placement. Several of the 59 interviewees remarked that the dollar amount could be small to moderate but had broader economic implications. CONCLUSION: Distributed medical education at the NOSM resulted in a substantial economic contribution to participating communities.

INTRODUCTION: Les écoles de médecine peuvent apporter des avantages économiques importants aux grands centres urbains. On n'en sait guère toutefois sur l'apport économique, pour les communautés participantes, des écoles qui offrent des cours et de la formation hors des grandes villes et loin des centres universitaires des sciences de la santé. Nous avons voulu évaluer la contribution économique de l'École de médecine du Nord de l'Ontario (EMNO) aux communautés qui participent à ses programmes d'apprentissage distribué. MÉTHODES: Nous avons créé un modèle économique local et utilisé les dépenses réelles de 2007/08 pour évaluer l'apport économique de l'EMNO aux communautés du Nord de l'Ontario. Nous avons aussi estimé l'apport économique des étudiants en médecine ou des médecins résidents qui participent aux divers programmes offerts dans les communautés éloignées des campus de l'université. Enfin, pour explorer les répercussions économiques plus vastes, nous avons effectué des entrevues semi-structurées auprès de chefs de file des milieux de l'éducation, des soins de santé et de la politique dans le Nord de l'Ontario. RÉSULTATS: L'apport économique total de l'EMNO s'est chiffré à 67,1 millions de dollars (dépenses de l'École, 36,3 millions; dépenses des étudiants, 1,0 million). L'apport économique a été le plus important pour les villes qui hébergent un campus de l'université, soit Thunder Bay (26,7 millions) et Sudbury (30,4 millions), les 3 centres suivants en importance bénéficiant d'un apport de 0,8 à 1,2 million de dollars. Les communautés peuvent réaliser des bénéfices économiques de 7 300 $ à 103 900 $ par paire d'apprenants en médecine par placement. Plusieurs des 59 personnes interviewées ont souligné que le montant des contributions, en argent, peut être assez petit ou moyen, mais que les répercussions économiques se font sentir à plus grande échelle. CONCLUSION: L'éducation médicale distribuée à l'EMNO a apporté une contribution économique substantielle aux communautés participantes.

Factors influencing prenatal screening for Down's syndrome: evidence from Zhejiang (China).

This article attempts to identify the factors that influence prenatal screening uptake. About 1400 postdelivery, still-hospitalized women in 15 hospitals in Zhejiang Province were surveyed from November to December 2007. Univariate analysis was used to describe screening uptake and compare respondents with different characteristics. Stepwise logistic regression (forward) was then used to assess the relative strength of those influencing factors. It was found that 49.7% of the respondents received maternal serum prenatal screening. The factors that influenced prenatal screening service utilization included place of residence (urban vs countryside), migrant versus nonmigrant status, attitudes toward screening, frequency of routine prenatal checkups, and doctor's advice. Migrants had a lower probability of getting screened than permanent residents (odds ratio = 0.456; 95% confidence interval [CI] = 0.31, 0.68). The screening uptake probability of women with doctor's advice was 12 times as great as that of women without doctor's advice (95% CI = 7.91, 18.69).

Differences in evaluating health technology assessment knowledge translation by researchers and policy makers in China.

OBJECTIVES: The aim of this study was to examine the gaps between researchers and policy makers in perceptions and influencing factors of knowledge translation (KT) of health technology assessment (HTA) in China. METHODS: A sample of 382 HTA researchers and 112 policy makers in China were surveyed using structured questionnaires. The questionnaires contained two sections: perceptions of HTA research and assessments of six-stage KT activities. Wilcoxon rank sum test was applied to compare the differences in these two sections between HTA researchers and policy makers. Multivariate linear regression was performed to explore KT determinants of HTA for researchers and policy makers separately. RESULTS: Policy makers and researchers differed in their perceptions of HTA research in all items except collaboration in research development and presentation of evidence in easy-to-understand language. Significant differences in KT activities existed in all the six stages except academic translation. Regarding KT determinants, close contact between research unit and policy-making department, relevance of HTA to policy making, and importance of HTA on policy making were considered facilitators by both groups. For researchers, practicality of HTA report and presentation of evidence in easy-to-understand language can facilitate KT. Policy makers, on the other hand, considered an overly pedantic nature of HTA research as an obstacle to effective KT. CONCLUSIONS: Substantial gaps existed between HTA researchers and policy makers regarding the perceptions of HTA research and KT activities. There are also some differences in KT determinants by these two groups. Enhancing collaboration, promoting practicality and policy relevance of HTA research, and making HTA findings easily understood are likely to further the KT of HTA evidence.

Does better access to FPs decrease the likelihood of emergency department use? Results from the Primary Care Access Survey.

OBJECTIVE: To determine whether better access to FP services decreases the likelihood of emergency department (ED) use among the Ontario population. DESIGN: Population-based telephone survey. SETTING: Ontario. PARTICIPANTS: A total of 8502 Ontario residents aged 16 years and older. MAIN OUTCOME MEASURES: Emergency department use in the 12 months before the survey. RESULTS: Among the general population, having a regular FP was associated with having better access to FPs for immediate care (P < .001) but was not associated with a decreased likelihood of ED visits (odds ratio [OR] = 1.49, P = .03). Better actual access to FP services for immediate care was associated with a decreased likelihood of ED use (OR = 0.62, P < .001) among the general population. Among those with chronic diseases, having a regular FP was associated with a decreased likelihood of ED use (OR = 0.47, P = .01). Of the Ontario population, 39.3% wanted to see FPs for immediate care at least once a year; 63.1% of them had seen FPs without difficulties and were significantly less likely to use EDs than those who did not see FPs or had difficulties accessing physicians when needed (OR = 0.62, P < .001). Having a chronic health condition, recent immigrant status, residence in rural and northern parts of Ontario, and lower educational and income levels were significant predictors of a higher likelihood of ED use, independent of access to FPs (P < .05). CONCLUSION: A decreased likelihood of ED use is strongly associated with having a regular FP among those with chronic diseases and with having access to FPs for immediate care among the general population. Further research is needed to understand what accounts for a higher likelihood of ED use among those with regular FPs, new immigrants, residents of northern and rural areas of Ontario, and people with low socioeconomic status when actual access and sociodemographic characteristics have been taken into consideration. More important, this study demonstrates a need of distinguishing between potential and actual access to care, as having a regular FP and having timely and effective access to FP care might mean different things and have different effects on ED use.

Differences in occupational, transportation, domestic, and leisure-time physical activities: do geographical location and socio-cultural status matter?

BACKGROUND: Researchers have recently expressed their concern for the health of Francophones and rural dwellers in Canada. Their levels of physical activity may explain part of the observed differences. However, little is known about the physical activity levels of these 2 groups. The purpose of this study was to assess levels of physical activity among a sample of Francophones and rural dwellers. The study also assessed the associations of various types of physical activity to measures of health status. METHODS: A quota-based convenience sample of 256 adults from Northern Ontario was surveyed using the IPAQ and the SF-12. RESULTS: There were no significant differences in activity levels between language groups (P = .06) or geographical groups (P = .22) on the combined dependent variables based on MANOVA. Leisure-time physical activity scores were consistently associated to better physical component summary scores of the SF-12. CONCLUSIONS: Implications for practice include that leisure-time physical activities have been at the forefront of public health promotion, and our findings support this approach. Further, population specific interventions are indeed important, however, within this Canadian context when identifying target groups one must look beyond sociocultural status or geographical location.

A closer look at Ontario's northern and southern rural physician demographics.

INTRODUCTION: In Ontario, Canada, there is a tendency to conflate rural and northern issues and although much of northern Ontario is rural, this is not exclusively the case. In this study, data were utilized from the licensing and regulatory body of physicians in Ontario to provide a more nuanced understanding of the distribution of the physician population across varying degrees of rurality in northern and southern regions. METHODS: This is a report on the geographic distribution of the 22 688 GPs, and specialists certified by the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada who had their primary practice address in Ontario. Descriptive statistics were produced to determine differences in distribution of physician numbers, age, sex, international medical graduates (IMGs), and certification for physicians with primary practices coded as northern versus southern across varying degrees of rurality. RESULTS: Differences were found in the Ontario physician population with regard to age, sex and IMG status between rural and urban areas and also from the northern versus southern perspective. There were more younger and male physicians in northern and rural areas. Female physicians were more frequently found in the south with decreasing proportions of females with increasing rurality. In the northern areas of the province, although the proportion of female physicians was lower than in the south, there was a slight increase in the proportion of female physicians as rurality increased. The largest proportions of IMGs were found in urban areas and the proportions of IMGs decreased with increasing rurality. However, northern rural regions did tend to have a higher proportion of IMG physicians than in corresponding rural areas in the south. CONCLUSIONS: The results indicate that although there are similarities in physician demographics in rural and urban areas, there are clear differences between the rural north and the rural south. Likewise, although some patterns distinguish the south from the north, these areas are not homogeneous regions where the urban north is clearly different from the rural north.

Postgraduate specialty training in northeastern Ontario and subsequent practice location.

INTRODUCTION: Physician specialists are under-represented in communities in northern Ontario, even in larger communities of approximately 100 000 population. The positive association between postgraduate training in northern or rural areas and eventual practice in these locations has been well documented in the literature, but only for family medicine/general practice. Few, if any, studies have explored the association for other specialties. The objective of this study was to determine if there was an association between northern training and northern practice location for physicians who were enrolled in the Northeastern Ontario Postgraduate Specialty (NOPS) program, which offers placements in northeastern Ontario in specialties such as anesthesiology, internal medicine and surgery. METHODS; A national medical human resources database provided the 31 December 2006 practice location of all 50 participants in the NOPS program since its inception in 2000 until 2006. Program records provided data on participants' specialty rotations in northeastern Ontario, including number, location, and duration of rotations. Non-NOPS participants (n=50) were randomly selected for comparison, matched one for one to the NOPS group on sex, year of birth, language, medical school, year of graduation from medical school, age at the time of graduation, and specialty. Hierarchical log-linear models and 2 tests were used to assess differences between NOPS and non-NOPS participants in geographic location and population size of practice community. Chi-square tests were used to analyze the relationship between the duration of northeastern rotations and practice location of NOPS participants. RESULTS: NOPS and the matched non-NOPS groups did not differ significantly for age or age at graduation from medical school (paired t-tests, p>0.80) and matched exactly for sex, medical school location and specialty group. Forty-six percent of NOPS participants were female and 80% came from Ontario residency programs. Seventy-two percent of the program participants were enrolled in medical specialties (the remainder were in surgical specialties) and this differed significantly by sex: 83% of females vs 63% of males (Χ (2)=4.76, df=1, p=0.03). A majority completed residency training at 31-35 years of age. Fifty percent of NOPS participants obtained medical degrees from Ontario universities, 34% from other Canadian universities and 16% from other universities. Significantly more NOPS participants than non-participants were located in northeastern Ontario (9 vs 0), significantly fewer were in other provinces (13 vs 22) and identical numbers were located in southern Ontario (28 vs 28) (=11.61, df=2, p<0.01). Significantly more NOPS participants than non-participants were practicing in communities of 10 000-99 999 people (15 vs 4), approximately equal numbers in communities of 100 000-499 999 (9 vs11) and non-significantly fewer were practicing in areas of 500 000 or more (26 vs 35) (Χ (2)=7.90, df=2, p=0.02), though this interaction was not significant in the hierarchical log-linear model. The NOPS participants located in northeastern Ontario were more likely to have longer northeastern rotations (>4 weeks) than those located in southern Ontario (Χ (2)=7.81, df=2, p=0.02). However, a longer northeastern rotation was no guarantee of a northeastern practice location because roughly equal numbers of participants with longer rotations were spread throughout the 3 geographic practice locations. Conversely, a shorter rotation was strongly associated with a southern Ontario practice location (18/25). The NOPS participants located in communities of ≥ 500 000 people were more likely to have shorter rotations than longer rotations, but this difference was only marginally statistically significant Χ (2)=5.13, df=2, p=0.08). CONCLUSIONS: The study found that specialists who participated in NOPS postgraduate specialty training in northeastern Ontario were more likely to practice in northeastern Ontario than non-participants. There was also a strong association between the duration of training in the northeast and northeastern practice and avoidance of practice in metropolitan areas. It is not clear yet whether longer northeastern rotations encourage northeastern practice or whether this reflects an existing disposition; it is clear, however, that specialists with longest specialty training rotations in the northeast were more likely to practice in the northeast. The results from this study provide the first empirical evidence of positive association between postgraduate specialty training in the northeast and eventual practice in northeastern Ontario and smaller cities.

Socio-spatial patterns of home care use in Ontario, Canada: a case study.

Home care is the fastest growing segment of Canada's health care system. Since the mid-1990 s, the management and delivery of home care has changed dramatically in the province of Ontario. The objective of this paper is to examine the socio-spatial characteristics of home care use (both formal and informal) in Ontario among residents aged 20 and over. Data are drawn from two cycles of the Canadian Community Health Survey (CCHS Cycle 3.1 2005 and Cycle 4.1 2007) and are analyzed at a number of geographical scales and across the urban to rural continuum. The study found that rural residents were more likely than their urban counterparts to receive government-funded home care, particularly nursing care services. However, rural residents were less likely to receive nursing care that was self-financed through for-profit agencies and were more reliant on informal care provided by a family member. The study also revealed that women and seniors were far more dependent on services that they paid for as compared to informal services. People with lower incomes and poorer health status, as well as rural residents, were also more likely to use informal services. The paper postulates that the introduction of managed competition in Ontario's home care sector may be effective in more populated parts of the province, including large cities, but at the same time may have left a void in access to for-profit formal services in rural and remote regions.

Determinants of health care demand in poor, rural China: the case of Gansu Province.

This paper examines the determinants that influence health care demand decisions in rural areas of Gansu province, China. This represents the first effort to identify and quantify the effect of price of care on choice of provider in China, and is the first quantitative examination of this topic focusing on poor rural areas in China. In the three-tier health care system in rural China, we further distinguish the public village clinics and private village clinics using a mixed multinomial logit model. The results show that price and distance play significant roles in choice of health care provider. The price elasticity of demand for outpatients is higher for low-income groups than for high-income groups. When outpatients have particular concerns about provider quality or reputation, or when their health status is poor, distance tends to matter less, i.e. they are willing to travel further in order to obtain better treatment for their illness. Insurance status has a significant impact on the choice of public village clinics relative to self-treatment. Furthermore, age and the attributes of illness are also statistically significant factors. We discuss the policy implications of the results for meeting the health care needs of the poor in rural China.

Rural-urban disparities in health: how does Canada fare and how does Canada compare with Australia?

OBJECTIVE: To analyse rural-urban and intra-rural disparities in health status in Canada and to compare Canada with Australia with respect to such disparities. DESIGN: Four indicators were used to show rural-urban and intra-rural differences in health status: (i) mortality due to circulatory diseases, (ii) mortality due to cancer, (iii) injury-related mortality; and (iv) all-cause mortality. Rural was disaggregated into finer categories based on degree of remoteness, using the Metropolitan Influence Zone classification in Canada and the Accessibility/Remoteness Index of Australia. Comparisons were made using age-standardised mortality rates and standardised mortality ratios. PARTICIPANTS: Rural and urban populations of Canada and Australia. RESULTS: The study confirmed previous findings that rural Canadians tended to have poorer health status than their urban counterparts. However, when rural was disaggregated into finer categories, different health status patterns emerged. Although the most rural areas tended to have the worst health status, the least rural areas generally enjoyed good health. The Canada-Australia comparisons revealed convergence and divergence. CONCLUSIONS: The similarities between Canada and Australia show that rural-urban disparities in health status are not limited to a particular country. For several causes of death, whereas the mortality risks in Rural 1 areas in Canada are significantly lower than in urban areas, the opposite is true in Australia, suggesting that although there are some common patterns across the two countries in relation to rural-urban health status disparities, nation-specific uniqueness is to be expected.

Strategies to overcome physician shortages in northern Ontario: a study of policy implementation over 35 years.

BACKGROUND: Shortages and maldistribution of physicians in northern Ontario, Canada, have been a long-standing issue. This study seeks to document, in a chronological manner, the introduction of programmes intended to help solve the problem by the provincial government over a 35-year period and to examine several aspects of policy implementation, using these programmes as a case study. METHODS: A programme analysis approach was adopted to examine each of a broad range of programmes to determine its year of introduction, strategic category, complexity, time frame, and expected outcome. A chronology of programme initiation was constructed, on the basis of which an analysis was done to examine changes in strategies used by the provincial government from 1969 to 2004. RESULTS: Many programmes were introduced during the study period, which could be grouped into nine strategic categories. The range of policy instruments used became broader in later years. But conspicuous by their absence were programmes of a directive nature. Programmes introduced in more recent years tended to be more complex and were more likely to have a longer time perspective and pay more attention to physician retention. The study also discusses the choice of policy instruments and use of multiple strategies. CONCLUSION: The findings suggest that an examination of a policy is incomplete if implementation has not been taken into consideration. The study has revealed a process of trial-and-error experimentation and an accumulation of past experience. The study sheds light on the intricate relationships between policy, policy implementation and use of policy instruments and programmes.