Health Planning Regions Research Articles

Statewide Outbreak of Neisseria meningitidis Serogroup Y, Sequence Type 1466 - Virginia, 2022-2024.

Invasive meningococcal disease (IMD) is a severe illness that can have devastating effects; outbreaks are uncommon in the United States. Vaccination is the preferred control measure for IMD outbreaks when a defined population at risk (e.g., college students or persons experiencing homelessness) can be identified. In August 2022, the Virginia Department of Health (VDH) began investigating an IMD outbreak in Virginia's Eastern Health Planning Region, prompted by the detection of four confirmed cases within 8 weeks. Clinical isolates available from three cases were characterized as Neisseria meningitidis serogroup Y, sequence type 1466. A subsequent statewide investigation identified 36 genetically related cases, including seven deaths (case fatality rate=19.4%) as of March 1, 2024. A majority of patients (63.9%) were in an age group (30-60 years) not generally considered at increased risk for IMD; 78.0% were non-Hispanic Black or African American. No common exposures, affiliations, or risk factors were identified, and a defined population could not be identified for vaccination. VDH recommended quadrivalent (serogroups A, C, W, and Y) meningococcal conjugate vaccination of a subset of close contacts of patients based on IMD risk factors and age range similar to that of patients with identified cases. IMD outbreaks might affect populations without established IMD risk factors. Lack of a well-defined population at risk might prompt exploration of novel control strategies, such as selective vaccination of close contacts.

Androgen deprivation therapy for prostate cancer: Prescribing behaviors and preferences among urologists.

Several androgen deprivation therapy (ADT) medications are available for treating advanced prostate cancer with roughly equivalent oncological efficacy and tolerability. We investigated the proportion of physicians who predominantly prescribe one type of ADT drug ("mono-prescriber") and assessed characteristics associated with prescription behavior. Ontario men aged ≥65 years who were diagnosed with advanced prostate cancer (1997-2017) and initiated ADT thereafter for ≥3 consecutive months were identified using population-level administrative data. Their first prescription for injectable ADT was linked to a physician, and urologists with ≥10 prescriptions over the study period were included in the analysis (n=282). Urologists were classified as high mono-prescribers if ≥80% of their prescriptions were for one drug type. Multivariable logistic regression was used to examine the association of physician characteristics with the odds of being a high mono-prescriber. Overall, 67 (23.8%) of urologists were classified as high mono-prescribers but the frequency varied across health planning regions. The most commonly prescribed drugs and those used by mono-prescribers were goserelin (41.8% and 56.7%) and leuprolide (44.3% and 43.3%), respectively. In multivariable analysis, the odds of a physician being a high mono-prescriber were higher with more years in practice (odds ratio [OR] 1.06/year, 95% confidence interval [CI] 1.03-1.09, p<0.0001) and lower for higher patient volume (OR 0.33 for above vs. below median, 95% CI 0.17-0.63, p=0.0008). Overall, one in four urologists were classified as high mono-prescribers. Mono-prescribers had more years in practice and smaller volume practices, potentially suggesting habitual prescription behavior and/or the effect of external pressures.

Development of a Needs-Based Planning Model to Estimate Required Capacity of a Substance Use Treatment System.

Substance use services and supports have traditionally been funded without the benefit of a comprehensive, quantitative planning model closely aligned with population needs. This article describes the methodology used to develop and refine key features of such a model, gives an overview of the resulting Canadian prototype, and offers examples and lessons learned in pilot work. The need for treatment was defined according to five categories of problem severity derived from national survey data and anticipated levels of help-seeking estimated from a narrative synthesis of international literature. A pan-Canadian Delphi procedure was used to allocate this help-seeking population across an agreed-upon set of treatment service categories, which included three levels each of withdrawal management, community, and residential treatment services. Projections of need and required service capacity for Canadian health planning regions were derived using synthetic estimation by age and gender. The model and gap analyses were piloted in nine regions. National distribution of need was estimated as Tier 1: 80.7%; Tier 2: 10.4%; Tier 3: 6.1%; Tier 4: 2.6%; and Tier 5: 0.2%. Pilot work of the full estimation protocol, including gap analysis, showed the results triangulated with other indicators of need and were useful for local planning. Lessons learned from pilot testing were identified, including challenges with the model itself and those associated with its implementation. The process of estimation developed in this Canadian prototype, and the specifics of the model itself, can be adapted to other jurisdictions and contexts.

Senior high-cost healthcare users’ resource utilization and outcomes: a protocol of a retrospective matched cohort study in Canada

IntroductionSenior high-cost users (HCUs) are estimated to represent 60% of all HCUs in Ontario, Canada’s most populous province. To improve our understanding of individual and health system characteristics related to...

Structure and characteristics of community-based multidisciplinary wound care teams in Ontario: an environmental scan.

Multidisciplinary team approach is an essential component of evidence-based wound management in the community. The objective of this study was to identify and describe community-based multidisciplinary wound care teams in Ontario. For the study, a working definition of a multidisciplinary wound care team was developed, and a two-phase field evaluation was conducted. In phase I, a systematic survey with three search strategies (environmental scan) was conducted to identify all multidisciplinary wound care teams in Ontario. In phase II, the team leads were surveyed about the service models of the teams. We identified 49 wound care teams in Ontario. The highest ratio of Ontario seniors to wound team within each Ontario health planning region was 82,358:1; the lowest ratio was 14,151:1. Forty-four teams (90%) participated in the survey. The majority of teams existed for at least 5 years, were established as hospital outpatient clinics, and served patients with chronic wounds. Teams were heterogeneous in on-site capacity of specialized diagnostic testing and wound treatment, team size, and patient volume. Seventy-seven percent of teams had members from three or more disciplines. Several teams lacked essential disciplines. More research is needed to identify optimal service models leading to improved patient outcomes.

Economic burden of irritable bowel syndrome with constipation: a retrospective analysis of health care costs in a commercially insured population.

The prevalence of irritable bowel syndrome with constipation (IBS-C) is estimated to be between 4.3% and 5.2% among adults in the United States. Little is known about the health care resource utilization and costs associated with IBS-C. To (a) evaluate the annual total all-cause, gastrointestinal (GI)-related, and IBS-C-related health care costs among IBS-C patients seeking medical care in a commercially insured population and (b) estimate the incremental all-cause health care costs among IBS-C patients relative to matched controls. Patients aged ≥ 18 years with continuous medical and pharmacy benefit eligibility in 2010 were identified from the HealthCore Integrated Research Database, which consists of administrative claims from 14 geographically dispersed U.S. health plans representing 45 million lives. IBS-C patients were defined as those with ≥ 1 medical claim with an ICD-9-CM diagnosis code in any position for IBS (ICD-9-CM 564.1x) and either ≥ 2 medical claims for constipation (ICD-9-CM 564.0x) on different service dates or ≥ 1 medical claim for constipation plus ≥ 1 pharmacy claim for a constipation-related prescription on different dates of service during the study period. Controls were defined as patients without any medical claims for IBS, constipation, abdominal pain, or bloating or pharmacy claims for constipation-related prescriptions. Controls were randomly selected and matched with IBS-C patients in a 1:1 ratio based on age (± 4 years), gender, health plan region, and health plan type. Patients with diagnoses or prescriptions suggesting mixed IBS, IBS with diarrhea, chronic diarrhea, or drug-induced constipation were excluded. Total health care costs in 2010 U.S. dollars were defined as the sum of health plan and patient paid costs for prescriptions and medical services, including inpatient visits, emergency room (ER) visits, physician office visits, and other outpatient services. The total cost approach was used to assess total all-cause or disease-specific health care costs for patients with IBS-C, while the incremental cost approach was used to examine the excess all-cause costs of IBS-C by comparing IBS-C patients with matched controls. Generalized linear models with bootstrapping were used to assess the incremental all-cause costs attributable solely to IBS-C after adjusting for demographics, Elixhauser Comorbidity Index (ECI) score, and other general and GI-related comorbidities not included in the ECI score. A total of 7,652 patients (n = 3,826 each in the IBS-C and control cohorts) were included in the analysis. The mean (± SD) age was 48 (± 17) years, and 83.6% were female. The mean annual all-cause health care costs for IBS-C patients were $11,182, with over half (53.7%) of the costs attributable to outpatient services, including physician office visits and other outpatient services (13.1% and 40.6%, respectively). Remaining total all-cause costs were attributable to hospitalizations (21.8%), prescriptions (19.1%), and ER visits (5.4%). GI-related costs ($4,456) comprised 39.8% of total all-cause costs, while IBS-C-related costs ($1,335) accounted for 11.9% and were primarily driven by costs of other outpatient services (50.3%). After adjusting for demographics and comorbidities, the incremental annual all-cause health care costs associated with IBS-C were $3,856 ($8,621 for IBS-C patients vs. $4,765 for controls, P less than 0.01) per patient per year, of which 78.1% of the incremental costs were due to medical services, and 21.9% were due to prescription fills. IBS-C imposes a substantial economic burden in terms of direct health care costs in a commercially insured population. Compared with matched controls, IBS-C patients incurred significantly higher total annual all-cause health care costs even after controlling for general and GI-related comorbidities. Incremental all-cause costs associated with IBS-C were mainly driven by costs related to more frequent use of medical services as opposed to prescriptions.

Healthcare costs among patients with chronic constipation: a retrospective claims analysis in a commercially insured population

Objective:To evaluate total annual all-cause, gastrointestinal-related, and symptom-related healthcare costs among chronic constipation (CC) patients and estimate incremental all-cause healthcare costs of CC patients relative to matched controls.Methods:Patients aged ≥18 years with continuous medical and pharmacy benefit eligibility in 2010 were identified from the HealthCore Integrated Research Database. CC patients had ≥2 medical claims for constipation (ICD-9-CM code 564.0x) ≥90 days apart or ≥1 medical claim for constipation plus ≥1 constipation-related pharmacy claim ≥90 days apart, and no medical claims for irritable bowel syndrome (IBS). Sub-groups with and without abdominal symptoms were classified according to the presence/absence of abdominal pain (ICD-9-CM code 789.0x) and bloating (ICD-9-CM code 787.3x). Controls without claims for constipation, abdominal pain, bloating, or IBS or constipation-related prescriptions were randomly selected and matched 1:1 with CC patients on age, gender, health plan region, and plan type. Generalized linear models with bootstrapping evaluated incremental all-cause costs attributable to CC, adjusting for demographics and comorbidities.Results:Overall, 14,854 patients (n = 7427 each in CC and control groups) were identified (mean age = 59 years; 75.4% female). Mean annual all-cause costs for CC patients were $11,991 (2010 USD), with nearly half (44.8%) attributable to outpatient services, including physician office visits and other outpatient services (10.0% and 34.8%, respectively). GI-related costs comprised 33.7% of total all-cause costs. Symptom-related costs accounted for 10.5%, primarily driven by costs of other outpatient services (50.6%). Adjusted incremental all-cause costs associated with CC were $3508 per patient per year ($4446 for CC with abdominal symptoms; $2783 for CC without abdominal symptoms), of which 81.0% were from medical services. Incremental cost estimates may be over- or under-estimated due to classification based on claims.Conclusions:CC imposes a substantial burden in direct healthcare costs in a commercially insured population, mainly attributable to greater use of medical services.

Incremental Healthcare Costs Associated with Chronic Constipation: A Retrospective Claims Analysis

Purpose: The estimated prevalence of chronic constipation (CC) is approximately 12-19% in the US; however, healthcare costs associated with this condition are not well understood. The objective of this study is to evaluate incremental costs associated with CC in patients in a managed care population. Methods: Patients were identified from the HealthCore Integrated Research Database, which consists of approximately 45 million members from 14 geographically-dispersed health plans. Inclusion criteria for CC patients were: (1) age ≥18 years as of January 1, 2010; (2) continuously eligible in 2010; (3) >2 medical claims for constipation (ICD-9-CM code 564.0x) occurring ≥90 days apart or ≥1 medical claim for constipation plus ≥1 constipation-related pharmacy claim occurring ≥90 days apart. Patients with irritable bowel syndrome (ICD-9-CM code 564.1x) or diagnoses or prescriptions suggesting chronic diarrhea or drug induced constipation were excluded. A control group without irritable bowel syndrome, constipation, abdominal pain, or bloating was randomly selected using 1:1 matching on age, gender, health plan region, and plan type. All-cause medical services included inpatient visits, emergency room (ER) visits, physician office visits, and other outpatient services for any condition. Total healthcare costs included costs from medical services and pharmacy costs. Generalized linear models with bootstrapping were used to evaluate the incremental costs attributable to CC, after adjusting for a series of confounders including demographics, Elixhauser comorbidity index (ECI) score, and 15 general and gastrointestinal-related comorbidities not included in the ECI score (e.g., chronic pain, hyperlipidemia, gastro esophageal reflux disorder, hemorrhoids). Results: A total of 14,854 patients (n=7,427 for CC and matched controls, respectively) met the inclusion criteria. The mean age of CC patients and matched controls was 58.7 years; 75.4% were female. CC patients had higher unadjusted all-cause healthcare costs versus controls ($11,991 vs. $3,278, p<0.01). Nearly half of this difference (44.1%) was due to physician office visits and other outpatient services/diagnostics (8.9% and 35.2%, respectively). The remaining difference was attributable to hospitalizations (37.8%), prescriptions (14.3%), and ER visits (3.8%). After adjusting for demographics and comorbidities, the adjusted incremental all-cause costs for CC patients were $3,508 (in 2010 US dollars), of which 81.0% were for medical services (see Table).Table: Adjusteda mean all-cause costs for CC patients and controls in 2010Conclusion: CC imposes a significant economic burden even after controlling for demographic and clinical comorbidities. Incremental costs were mainly driven by medical services as opposed to prescription use. Disclosure: Qian Cai, Abhishek Kavati, Hiangkiat Tan, and Judith Stephenson: employees of Healthcore, Inc., which is a consultancy whose activities related to the project are funded by Forest Laboratories, Inc., and Ironwood Pharmaceuticals; Robyn Carson and Jessica Buono: employees of Forest Laboratories, Inc. and own stock and/or stock options in Forest Laboratories, Inc.; Phil Sarocco and William Spalding: employees of Ironwood Pharmaceuticals, Inc. and own stock and/or stock options in Ironwood Pharmaceuticals. This research was supported by an industry grant from Forest Laboratories, Inc., and Ironwood Pharmaceuticals, Inc., were involved in the study design; collection, analysis and data interpretation; and decision to submit these data for presentation. Study was sponsored by Forest Laboratories, Inc., and Ironwood Pharmaceuticals, Inc.

Economic Burden of Irritable Bowel Syndrome with Constipation: A Retrospective Cohort Study in a Large Managed Care Population

Purpose: The prevalence of irritable bowel syndrome with constipation (IBS-C) is approximately 5-10% in the U.S. However, the economic burden of IBS-C is not well understood. This study aimed to estimate the incremental costs of IBS-C in a managed care population. Methods: Patients aged ≥18 years continuously enrolled in 2010 were identified using claims from the HealthCore Integrated Research Database, which consists of 14 geographically-dispersed US health plans representing 45 million lives. IBS-C patients were defined as those with >1 medical claim of IBS (ICD-9-CM code 564.1x) and >2 medical claims for constipation (ICD-9-CM 564.0x) or >1 medical claim for constipation plus >1 pharmacy claim for a constipation-related prescription. Controls without IBS, constipation, abdominal pain, or bloating were randomly selected using 1:1 matching on age, gender, health plan region and insurance plan type. Patients with diagnoses or prescriptions suggesting mixed IBS, IBS with diarrhea, chronic diarrhea, or drug-induced constipation were excluded. All-cause medical services included inpatient visits, emergency room (ER) visits, physician office visits, and other outpatient services for any condition. Total healthcare costs consisted of costs from medical services and pharmacy costs. Generalized linear models with bootstrapping were used to assess the incremental costs attributable to IBS-C, after adjusting for a series of confounders including demographics, Elixhauser comorbidity index (ECI) score, and 15 general and gastrointestinal-related comorbidities not included in the ECI score (e.g., chronic pain, hyperlipidemia, gastro esophageal reflux disorder, hemorrhoids). Results: A total of 7,652 patients (n=3,826 for IBS-C) were identified. The mean (+SD) age was 48 (+17) years; 83.6% were female. IBS-C patients had significantly higher unadjusted all-cause healthcare costs compared to controls ($11,182 vs. $3,116, p<0.01). Over half (54.2%) of this difference was due to physician office visits and other outpatient services/diagnostics (13.2% and 41.0%, respectively). The remaining difference was attributable to hospitalizations (22.5%), prescriptions (16.9%) and ER visits (6.5%). After adjusting for demographic characteristics and comorbidities, the incremental total all-cause healthcare costs associated with IBS-C were $3,856 (in 2010 U.S. dollars), of which 21.8% were for pharmacy costs (see Table).Table: Adjusteda mean all-cause costs for IBS-C patients and controls in 2010Conclusion: IBS-C is associated with a substantial economic burden even after controlling for general and gastrointestinal-related comorbidities. The majority of incremental costs are attributable to medical services. Disclosure: Qian Cai, Abhishek Kavati, Hiangkiat Tan, and Judith Stephenson: employees of Healthcore, Inc., which is a consultancy whose activities related to the project are funded by Forest Laboratories, Inc., and Ironwood Pharmaceuticals; Robyn Carson and Jessica Buono: employees of Forest Laboratories, Inc. and own stock and/or stock options in Forest Laboratories, Inc.; Phil Sarocco and William Spalding: employees of Ironwood Pharmaceuticals, Inc. and own stock and/or stock options in Ironwood Pharmaceuticals. This research was supported by an industry grant from Forest Laboratories, Inc., and Ironwood Pharmaceuticals, Inc., were involved in the study design; collection, analysis and data interpretation; and decision to submit these data for presentation. Study was sponsored by Forest Laboratories, Inc., and Ironwood Pharmaceuticals, Inc.

Community-based social and recreational programs for older adults with intellectual and/or developmental disabilities: Perceptions of barriers and accommodations to access

The purpose of this study was to generate an initial understanding of the types of supports or accommodations needed, as well as the barriers or challenges present when attempting to provide publicly funded, community-based social and recreational services for older adults with intellectual and/or developmental disabilities (I/DD). Survey research was used to investigate the perceptions of case managers and recreation program providers within Health Planning Region IV in the Commonwealth of Virginia, regarding their views on the necessary supports and potential barriers encountered when older persons with I/DD attempt to access these types of programs and services. Findings suggest that both case managers and providers of recreation services perceive the following to be primary needs in providing community-based social and recreational programs for this population: recreational programs specifically designed to meet the needs of older adults with I/DD; transportation, particularly evenings and weekends; and staff adequately cross-trained in aging, disability, and recreation. Both sets of respondents shared the perception that most staff are not adequately trained in the provision of recreational services. Transportation, available during weekends and evenings when many people are engaged in recreational pursuits, is a critical support need. The promotion of purposeful recreation programming, designed with needs and desires of all older adults in mind and staffed by highly qualified recreation professionals, such as certified therapeutic recreation specialists, could go far in ensuring that these services contribute to personal growth, meaningful involvement, and quality of life.

Risk of acute myocardial infarction and sudden cardiac death in patients treated with cyclo-oxygenase 2 selective and non-selective non-steroidal anti-inflammatory drugs: nested case-control study

Controversy has surrounded the question about whether high-dose rofecoxib increases or naproxen decreases the risk of serious coronary heart disease. We sought to establish if risk was enhanced with rofecoxib at either high or standard doses compared with remote non-steroidal anti-inflammatory drug (NSAID) use or celecoxib use, because celecoxib was the most common alternative to rofecoxib. We used data from Kaiser Permanente in California to assemble a cohort of all patients age 18-84 years treated with a NSAID between Jan 1, 1999, and Dec 31, 2001, within which we did a nested case-control study. Cases of serious coronary heart disease (acute myocardial infarction and sudden cardiac death) were risk-set matched with four controls for age, sex, and health plan region. Current exposure to cyclo-oxygenase 2 selective and non-selective NSAIDs was compared with remote exposure to any NSAID, and rofecoxib was compared with celecoxib. During 2302029 person-years of follow-up, 8143 cases of serious coronary heart disease occurred, of which 2210 (27.1%) were fatal. Multivariate adjusted odds ratios versus celecoxib were: for rofecoxib (all doses), 1.59 (95% CI 1.10-2.32, p=0.015); for rofecoxib 25 mg/day or less, 1.47 (0.99-2.17, p=0.054); and for rofecoxib greater than 25 mg/day, 3.58 (1.27-10.11, p=0.016). For naproxen versus remote NSAID use the adjusted odds ratio was 1.14 (1.00-1.30, p=0.05). Rofecoxib use increases the risk of serious coronary heart disease compared with celecoxib use. Naproxen use does not protect against serious coronary heart disease.

Individual and Regional Determinants of Mammography Uptake

Background: Analysis of mammography utilization has traditionally been performed from an individual-level perspective. The purpose of this study was to explore the combined influence of individual- and regional-level determinants of mammography utilization. Methods: Logistic hierarchical multilevel modelling was used to investigate the influences of region of residence and individual characteristics on mammography utilization. Socio-economic status information about health planning regions was derived from the 1996 Canadian Census. Individual-level information was extracted from the 1996 National Population Health Survey. Results: After controlling for individual-level education, regions with fewer high school graduates had lower levels of mammography utilization. A cross-level interaction between regional-level education and individual-level social involvement was found. Other individual-level variables associated with screening confirmed previous literature findings. Conclusion: Our findings suggest that higher levels of participation in social activities modify the detrimental influence on mammography utilization of living in a less educated region. This challenges the current focus of mammography screening research on individual-level determinants of uptake. Multilevel, synergistic strategies to possibly achieve higher levels of screening should be considered by health promotion program planners.

Individual and regional determinants of mammography uptake.

Analysis of mammography utilization has traditionally been performed from an individual-level perspective. The purpose of this study was to explore the combined influence of individual- and regional-level determinants of mammography utilization. Logistic hierarchical multilevel modelling was used to investigate the influences of region of residence and individual characteristics on mammography utilization. Socioeconomic status information about health planning regions was derived from the 1996 Canadian Census. Individual-level information was extracted from the 1996 National Population Health Survey. After controlling for individual-level education, regions with fewer high school graduates had lower levels of mammography utilization. A cross-level interaction between regional-level education and individual-level social involvement was found. Other individual-level variables associated with screening confirmed previous literature findings. Our findings suggest that higher levels of participation in social activities modify the detrimental influence on mammography utilization of living in a less educated region. This challenges the current focus of mammography screening research on individual-level determinants of uptake. Multilevel, synergistic strategies to possibly achieve higher levels of screening should be considered by health promotion program planners.

Prenatal HIV Testing in Ontario

To describe the knowledge, attitudes and practices of prenatal care providers in relation to prenatal HIV testing.A stratified random sample of 784 family physicians, 200 obstetricians and 103 midwives providing prenatal care in 3 health planning regions in Ontario received a questionnaire.Response was 622/1087 (57%). Almost half of participants (43%) were not aware of Ontario's prenatal HIV testing policy. Eighty-five percent of participants reported that they offered or ordered HIV testing for all pregnant women. Sixty-six percent agreed that women should have a choice about whether to test or not, and midwives were more supportive of having an informed consent process than were physicians.Knowledge about the risks and benefits of prenatal HIV testing needs to be improved, and standards for informed consent should be re-evaluated to achieve the most ethical process with the least complexity.

Prenatal HIV testing in Ontario: knowledge, attitudes and practices of prenatal care providers in a province with low testing rates.

To describe the knowledge, attitudes and practices of prenatal care providers in relation to prenatal HIV testing. A stratified random sample of 784 family physicians, 200 obstetricians and 103 midwives providing prenatal care in 3 health planning regions in Ontario received a questionnaire. Response was 622/1087 (57%). Almost half of participants (43%) were not aware of Ontario's prenatal HIV testing policy. Eighty-five percent of participants reported that they offered or ordered HIV testing for all pregnant women. Sixty-six percent agreed that women should have a choice about whether to test or not, and midwives were more supportive of having an informed consent process than were physicians. Knowledge about the risks and benefits of prenatal HIV testing needs to be improved, and standards for informed consent should be re-evaluated to achieve the most ethical process with the least complexity.

Home Care After Hip Fracture in a Health Planning Region

Health-care restructuring has increased the focus on integrating health care. Therefore the study purpose was to quantify patient movement from hospital to home care before restructuring occurred in a health planning district. Hospital discharge abstracts and home care records identified patients with a hip fracture who used home care (n = 353). Patients from acute care were more likely than rehabilitation or convalescent inpatients to wait > 3 days for home care after hospital discharge (RR 1.54, 95% CI 1.18, 2.00). Institution-dwellers were more likely than community-dwellers to wait > 3 days for home care (RR 2.35, 95% CI 1.86, 2.97). Home care rehabilitation clients were more likely than non-rehabilitation users to wait > 3 days for home care (RR 2.10, 95% CI 1.42, 3.09). Waiting time for home care is associated with hospital care setting and the home care service utilized. Evaluations of restructuring efforts should consider accounting for these relationships.

Variations in mental health needs and fee-for-service reimbursement for physicians in Ontario.

The study examined the match between mental health needs and physician fee-for-service reimbursements for mental health care within age and gender groups and health planning regions in Ontario, Canada. Indicators of need (mental disorder, reported disability, and self-rated mental health) from an epidemiologic survey of 9,953 Ontario household residents were compared with per capita reimbursement rates derived from an administrative data set containing all fee-for-service expenditures for mental health care paid by the provincial health plan. Few gender differences were found in overall need, but need varied significantly by age. Those in greatest need were adolescent males and females, who had rates of need from two to four times higher than older respondents. Regional variations in need were less evident. By contrast, per capita reimbursement showed marked gender differences, with rates for women generally twice the rates for men. Considerable variations in reimbursement were also found across age groups; these variations did not match variations in need. Highly urbanized areas had per capita reimbursement rates between two and four times the rates for less populated areas. Despite Ontario's universal-access health care system, notable discrepancies between need and resource use are evident for males, adolescents, and residents of less urbanized areas. Solutions require a combination of public education, provider training, attention to physician availability and practice patterns, and continuous monitoring of how resources are allocated relative to need.

Enthusiasm or uncertainty: small area variations in the use of mammography services in Ontario, Canada.

STUDY OBJECTIVE: To examine the variation in mammography utilisation in relation to age group and indication across health planning regions in Ontario, Canada. DESIGN: This study includes all women aged...

Small area analysis of lumbar spine surgery in South Australia.

The hospital separation records for 1987 in the health planning regions of South Australia were reviewed using a selection algorithm to identify all hospitalizations involving a lumbar spine surgery (LSS) for low back or leg pain. Among 16 health planning regions (two additional regions were excluded from the analysis because of the low number of observations) the LSS rate varied almost four-fold, from 25 to 92/100,000, with a mean of 55/100,000. The effect of 24 socioeconomic and health care supply characteristic variables upon observed differences in rates were tested. The unemployment rate was the only significant variable in the analysis, explaining 11% of the variation in the surgery rates for the 16 regions. This finding is in agreement with studies from other countries that suggest that characteristics of small areas do not substantially predict the rates of elective surgical procedures. The decision-making processes of surgeons and their patients remain poorly defined; the contributions to the rate of lumbar spine surgery by the health care delivery system, physician behaviours or patient expectations are not yet identified.

A population-based evaluation of the impact of interventions for improving care to cancer patients in the home setting.

A federally-funded demonstration project was conducted by the Illinois Cancer Council and the Illinois Department of Public Health to determine if the introduction of modest changes in the home health system would effect certain cancer patient patterns of care and outcomes. Certified home health agencies in two health planning regions of Illinois were randomized into one of three study groups, two of which received an intervention (oncology nurse specialist with continuing education on cancer, or continuing education on cancer alone), and the third was an "observation only" group. The pre/post differences of a number of evaluation parameters were investigated. Overall, the group which received the services of the oncology nurse specialist and continuing education on cancer demonstrated the largest percentage increase in cancer patient referrals to home care, and experienced a significant decrease in cancer patient mortality. No significant difference among cancer patients in the three study groups was noted for hospitalization rate or incidence of physiologic complications while on agency caseload.