Cost Impact of a Pharmacist-Driven Medication Reconciliation Program during Transitions to Long-Term Care and Retirement Homes.

The current provincial funding model in Ontario, Canada, does not offer dedicated funding to drive medication reconciliation (MedRec) programs during transitions into long-term care and retirement homes. This economic analysis aimed to estimate potential cost savings attributed to hospitalizations averted and decreases in polypharmacy by a MedRec program from a healthcare payer perspective. From a pool of 6,678 pharmacist recommendations, a limited sample of recommendations targeting specific medication-related adverse events showed potential savings of $622.35 per patient from hospital admissions avoided and of $1,414.52 per patient per year from medication discontinuations. Pharmacist-driven MedRec, conducted virtually, delivers substantial healthcare savings.

Negative association between BMI and depressive symptoms in middle aged and elderly Chinese: Results from a national household survey.

The association between body size and mental health has been the focus of many studies. Results, however, varies between studies. This study aimed to investigate the association between BMI and depressive symptoms among Chinese adults. We also further explored childhood starvation as a potential mediator of this association. The China Health and Retirement Longitudinal Study data, a representative national survey of adults age 45 and older was used in this study. Results showed that the prevalence of overweight and obesity were 28.8% and 11.6%. There was a negative association between BMI and depressive symptoms for males. Obese male adults had the lowest CES-D scores, followed by overweight male adults, and underweight male adults had the highest CES-D scores. These associations also exist but are not significant for females. Furthermore, these associations were significant among males who had been exposed to food shortage during their childhood. Our results suggested a significant positive association between BMI and depression in middle aged and elderly males in China, while this association is weak in females. Childhood food shortage experience was a potential causative factor accounting for this association.

Will the Needs-Based Planning of Health Human Resources Currently Undertaken in Several Countries Lead to Excess Supply and Inefficiency?

Recently, the emphasis on health human resources (HHR) planning has shifted away from a utilization-based approach toward a needs-based one in which planning is based on the projected health needs of the population. However, needs-based models that are currently in use rely on a definition of 'needs' that include only the medical circumstances of individuals and not personal preferences or other socio-economic factors. We examine whether planning based on such a narrow definition will maximize social welfare. We show that, in a publicly funded healthcare system, if the planner seeks to meet the aggregate need without taking utilization into consideration, then oversupply of HHR is likely because 'needs' do not necessarily translate into 'usage.' Our result suggests that HHR planning should track the healthcare system as access gradually improves because, even if health care is fully accessible, individuals may not fully utilize it to the degree prescribed by their medical circumstances.

A comparison of outpatient healthcare expenditures between public and private medical institutions in urban China: an instrumental variable approach.

The growth of healthcare expenditure provokes constant comments and discussions, as countries battle the issues on cost containment and cost effectiveness. Prior to 1978, medical institutions in China were either state-owned or were collective public hospitals. Since 1978, China has been trying to rebuild its healthcare system, which was destroyed during the 'cultural revolution', allowing private medical institutions to deliver healthcare services. As a result, private medical institutions have grown from 0% to 28.57% between 1978 and 2010. In this context, we compare outpatient healthcare expenditures between public and private medical institutions. The central problem of this comparison is that the choice of medical institution is endogenous. So we apply an instrumental variable (IV) framework utilizing geographic information (whether the closest medical institution is private) as the instrument while controlling for severity of health and other relevant confounding factors. Using China's Urban Resident Basic Medical Insurance Survey 2008-2010, we found that there is no difference in expenditure between public and private medical institutions when IV framework is used. Our econometric tests suggest that our IV model is specified appropriately. However, the ordinary least square model, which is inconsistent in the presence of endogenous regressor(s), reveals that public medical institutions are more expensive.

Working conditions of nurses and absenteeism: is there a relationship? An empirical analysis using National Survey of the Work and Health of Nurses.

OBJECTIVE: This paper investigates the relationship between the working conditions and illness- and injury-related absenteeism of full-time Registered Nurses (RNs) and Licensed Practical Nurses (LPNs). METHOD: We used 2005 National Survey of the Work and Health of Nurses, which was designed to be representative of nurses employed in nursing in Canada in the fall of 2005. We estimated Negative Binomial regression models separately for RNs and LPNs with health related absenteeism as the dependent variable. The regressors include working conditions, work settings, and shift type/length along with socio-demographic variables. RESULTS: Depression is a significant determinant of absenteeism for both RNs and LPNs. However, workload and lack of respect are significant determinant of absenteeism for LPNs but not for RNs. Both RNs and LPNs working in other setting (physician offices, private nursing educations, educational institutions, governments and associations) will have less absenteeism than those working in hospitals. For LPNs, those working in long-term facility will also have less absenteeism than those working in hospitals. The length and type of shift also has significant effect on absenteeism. DISCUSSION: Improving working conditions with a resulting reduction in absenteeism might be an economic way to increase the labour supply of nurses without increasing new admissions or new recruits.

Transitions in living arrangements of Canadian seniors: findings from the NPHS longitudinal data.

This paper examines transitions in living arrangement decisions of the seniors using the first six cycles of the Canadian longitudinal National Population Health Survey microdata. Transitions from independent to intergenerational and institutional living arrangements are uniquely analyzed using a discrete-time hazard rate multinomial logit modelling framework and accounted for unobserved individual heterogeneity in the data. Our results show: a) provision of publicly-provided homecare reduces the likelihood of institutionalization, but it has no effect on intergenerational living arrangements; b) access to social support services reduces the probability of both institutional and intergenerational living arrangements; c) higher levels of functional health status, measured by Health Utility Index, reduce the probability of transitions from independent to intergenerational and institutional living arrangements; d) a decline in self-reported health status increases the probability of institutionalization, but its effect on intergenerational living arrangements is statistically insignificant; e) higher levels of household income tend to decrease the probability of institutionalization; and f) the likelihood of transitioning to both intergenerational and institutional living arrangements increases with the duration of survival. Our findings suggest that access to and availability of publicly-provided homecare, social support services and other programs designed to foster better functional health status would contribute positively towards independent or intergenerational living arrangements and reduce the probability of institutionalization.

The modes of physician remuneration and their effect on direct patient contact.

Initiatives such as primary care reform have allocated millions of dollars towards the Canadian health care system. The way physicians are remunerated affects the supply of physician services and as such is essential to these initiatives to facilitate policy goals. However, there exists a gap in understanding how different modes of remuneration affect physician-patient contact. This paper examines if there is a significant difference between the average full-time-equivalent (FTE) of family physicians (FPs) remunerated through fee-for-service (FFS), salary, and blended arrangements. We used Nova Scotia physician billings dataset which tracks every services performed by both FFS and salaried physicians over the fiscal year 2003 to 2004. We estimated two semi-logarithmic models to examine the relationship between (1) modes of remuneration and FTE, and (2) modes of remuneration and total services, using ordinary least squares method. The National Physician Survey shows a significant difference between the current modes of remuneration and the preferred modes of remuneration; thus ruling out the possibility of selectivity bias. The results show that compared to the FFS FPs, the salaried FPs and blended FPs produce on average 40.46% and 23.13% less FTE respectively. It also indicates that compared to the FFS FPs, the salaried FPs and blended FPs deliver 53.54% and 31.49% fewer services on average.

Effect of population ageing on future demand for physicians: a case study of Nova Scotia, Canada, 2000-2025.

The health care system has been under pressure for some time to keep pace with its health human resource (HHR) requirements. Future demographic trends, however, are magnifying these pressures. Because of the lengthy training period for physicians, closing the physician supply and demand gap requires time. This paper attempts to explore the future utilization of physicians in terms of full-time equivalent (FTE) in Nova Scotia to the year 2025 by four general types of medical disciplines: General Physicians, Medical Specialties, Surgical Specialties, and Diagnostic Specialties. Further, it makes projections by most responsible diagnosis, in- and out-hospital status, age and sex of the patients. The study shows that for paediatric patients, the incidence of all diseases would decline and for patients between age 15 and 54, the incidence of disease would either decline or increase marginally. Consistent with the baby boom ageing wave, the prevalence of disease would increase significantly for those above 54 years. This would result in requirements for all categories of physicians to decline for patients below age 54, in contrast with those 55 years of age and over where the demand would substantially increase. It is found that the growth in the requirements would be highest for diagnostic specialists, followed by surgical specialists, medical specialists, and the general practitioners.

The influence of prescription drug insurance on psychotropic and non-psychotropic drug utilization in Canada.

Using 2002 Canadian Community Health Survey data, this paper examines the effect of public and private prescription drug insurance on the utilization of psychotropic and non-psychotropic drugs. It is found that prescription drug utilization is characterized by two stochastic regimes requiring use of latent class modelling framework. In many instances, results differ for the classes of high and low users of prescription drugs. After accounting for the unobserved individual heterogeneity and a number of socio-demographic factors, health status, and province fixed effects, we find that having prescription drug insurance (public or private) increases the expected number of non-psychotropic medications for both low and high users. Public insurance affects psychotropic drug utilization positively for the low-user group only. The statistical insignificance of insurance for the high-user psychotropic drugs or lower magnitude of insurance coefficients on high-user non-psychotropic drugs seems to stem from high inelastic demand for prescription drugs in the concerned groups. In addition, we find that age, self-reported health status, and long-term mental and physical health problem diagnosed by a health professional are important determinants of prescription drug utilization for both classes of users.

Interprovincial migration of physicians in Canada: where are they moving and why?

This paper analyzes the provincial characteristics contributing to physician's decision in his/her choice of province of residence. It (1) attempts to determine if, and the extent to which, expected income in a province plays a role in physician's decision; (2) predicts yearly probabilities of physician's choice of province of residence; (3) examines marginal effect of expected income in a province on response (choice of province of residence) probability for physicians residing in each province. We estimated McFadden's conditional logit discrete-choice model with yearly probability of choosing a province of residence as a dependent variable for physicians residing in each province separately. The results show: (1) the effect of expected income in a province on the choice of province of residence is positive and statistically significant for physicians residing in Ontario and Saskatchewan. There are other provincial characteristics besides income that affect physician's choice of province of residence; (2) most physicians choose the province they are currently residing. However, those who choose a province other than the current province of residence, the preference for a certain province varies across physicians residing in different provinces; (3) the marginal effect of expected income in a province on response probability varies across provinces for physicians residing in the same province. It also varies across physicians residing in different provinces for the same amount of change in income in the same province.

Interprovincial migration of physicians in Canada: What are the determinants?

This paper analyzes factors contributing to interprovincial migration of physicians in Canada. It (1) compares the migration patterns of the general practitioners and specialists (medical and surgical); (2) analyzes the changing patterns of out-migration over time via the interactions between the province of residence and time period; (3) analyzes the effect of language as a determinant of migration out of predominantly French speaking Quebec. A logistic formulation of discrete-time hazard model was employed to estimate the probability of moving from the current province of residence. Sets of physician's individual characteristics variables along with dummy variables to reflect the provincial characteristics and various time-periods were included in the model. The model was extended to allow for interaction effects between the province of residence and time-period, and also between language and Quebec (the only province in Canada which is predominantly French speaking) as province of residence. The results suggest that physician's age, specialty, province of residence have significant impact on interprovincial migration of physicians. The probability of moving differs significantly across province of residences in various time-periods.

[A physician demand and supply forecast model for Nova Scotia]. / Un modèle prévisionnel de l'offre et de la demande de médecins dans la province Canadienne de la Nouvelle-Ecosse.

RATIONALE: There is well-founded concern about the current and future availability of Health Human Resources (HHR). Demographic trends are magnifying this concern -- an ageing population will require more medical interventions at a time when the HHR workforce itself is ageing. The lengthy and costly training period for most health care workers, especially physicians, poses a real challenge that requires planning these activities well in advance. Hence, there is definite need for a good HHR forecasting model. OBJECTIVES: To present a physician forecasting model that projects the Full-Time Equivalent (FTE) demand for and supply of physicians in Nova Scotia to the year 2020 for three specialties: general practitioners, medical, and surgical. The model enables gap analysis and assessment of alternative policy options designed to close the gaps. METHODOLOGY: The methodology for estimating demand fo physician services involves three steps: (i) Establishing the FT for each physician. To this end we calculate the income of each physician using Physician Billings Data and then identify the 40th and 60th percentile income levels for each of the 40 specialties. The income levels are then used to calculate the FTE using a formula developed at Health Canada; (ii) Calculating the FTE for each service by distributing the FTE of each physician at the service level (i.e., by patient age, sex, most responsible diagnosis, and hospital status group); and (iii) Using Statistics Canada's population projections to project future demand for three broad medical disciplines: general practitioners, medical specialist, and surgical specialists. The supply side of the model employs a stock/flow approach and exploits time-series and other data for variables, such as emigration, international medical graduates (IMGs), medical school entrants, retirements, mortality, and so on, which in turn allow us to access a host of policy parameters. RESULTS: Under the status quo assumption, demand for physician services will outstrip the growth in supply for all three specialties. CONCLUSIONS: The model can simulate supply-side policy changes (e.g. more IMGs, delayed retirements) and can also reflect changes in demand (e.g. a cure for leukemia; different work intensities for physicians). The model is highly parameterized so that it can accommodate shocks that may influence the future requirements for physicians. Once a future requirement is determined, the supply model can identify the policy levers (new entrants, immigration, emigration, retirement) necessary to close the gap between demand and supply. The model is a user-friendly tool made for policy makers to formulate appropriate physician workforce planning.

The Barcelona International Symposium (21-23 April 2005). Synthesis reports.

The Symposium was held in Barcelona, Spain, with the Institut d'Estudis de la Salut acting as host. It gathered 51 participants working in 34 institutions based in 18 countries. The main objective of the Symposium was to create an opportunity for assessing the past trends and forecasting the future developments of health workforce within the various national health systems. The Symposium was composed of 5 sessions devoted to presentations of the papers freely contributed by the participants and 5 discussion sessions devoted to the following themes : (i) Supply of and demand for health workforce, (ii) Future trends and forecasting methods ; (iii) Strategies for managing and planning health workforce ; (iv) Health workforce in underserved areas; (v) International migration of health workers. Each discussion session was conducted by a discussion leader whose the synthesis report is displayed here below.

Drug coverage in Canada: who is at risk?

Drugs are playing an increasingly important role in health care. However, unlike physician care and hospital care, Canadians do not have universal coverage for drugs. Generally, many employers provide drug coverage as part of employment benefits. In addition, provincial governments provide coverage to some parts of the population, generally, seniors and families on social assistance. Two important recent reports on the state of health care in Canada--the Kirby and Romanow reports--focus on the need for relief to families for rising cost of drugs. Policy makers need good information not only on the likely costs of such a project but also the impact of increasing drug costs on individuals and families with significant drug expenses. One of the keys to assessing scenarios for such relief is knowledge about the extent and depth of existing drug insurance coverage. However, the needed information is scattered over a number of data sources. We have put together a comprehensive and cohesive micro database synthesizing data from these diverse sources. The resultant micro database contains individual/family drug coverage information arrayed by socio-economic characteristics. This paper uses the data set to conduct an extensive analysis of the extent of drug coverage under public and private drug plans in Canada. The paper then goes on to analyze the level of such coverage in terms of out-of-pocket drug expenses faced by Canadian families in an effort to identify gaps in coverage.