Provincial Ministries Of Health Research Articles

The Canadian birth place study: examining maternity care provider attitudes and interprofessional conflict around planned home birth.

BackgroundAvailable birth settings have diversified in Canada since the integration of regulated midwifery. Midwives are required to offer eligible women choice of birth place; and 25-30% of midwifery clients plan home births. Canadian provincial health ministries have instituted reimbursement schema and regulatory guidelines to ensure access to midwives in all settings. Evidence from well-designed Canadian cohort studies demonstrate the safety and efficacy of midwife-attended home birth. However, national rates of planned home birth remain low, and many maternity providers do not support choice of birth place.MethodsIn this national, mixed-methods study, our team administered a cross-sectional survey, and developed a 17 item Provider Attitudes to Planned Home Birth Scale (PAPHB-m) to assess attitudes towards home birth among maternity providers. We entered care provider type into a linear regression model, with the PAPHB-m score as the outcome variable. Using Students’ t tests and ANOVA for categorical variables and correlational analysis (Pearson’s r) for continuous variables, we conducted provider-specific bivariate analyses of all socio-demographic, education, and practice variables (n=90) that were in both the midwife and physician surveys.ResultsMedian favourability scores on the PAPHB–m scale were very low among obstetricians (33.0), moderately low for family physicians (38.0) and very high for midwives (80.0), and 84% of the variance in attitudes could be accounted for by care provider type. Amount of exposure to planned home birth during midwifery or medical education and practice was significantly associated with favourability scores. Concerns about perinatal loss and lawsuits, discomfort with inter-professional consultations, and preference for the familiarity of the hospital correlated with less favourable attitudes to home birth. Among all providers, favourability scores were linked to beliefs about the evidence on safety of home birth, and confidence in their own ability to manage obstetric emergencies at a home birth.ConclusionsIncreasing the knowledge base among all maternity providers about planned home birth may increase favourability. Key learning competencies include criteria for birth site selection, management of obstetric emergencies at planned home births, critical appraisal of literature on safety of home birth, and inter-professional communication and collaboration when women are transferred from home to hospital.

HEALTH TECHNOLOGY ASSESSMENT IN AN ARGENTINEAN PROVINCE: ADAPTING EXISTING TOOLS

This study reports on the development of a critical process for health technologies incorporation concerning an Argentinean Provincial Ministry of Health (MOH) in collaboration with the University of Lanús from 2008 to 2010. We describe the approach developed to adapt selected international experiences to provincial scenario. Bibliographic review, regulations examination, key informants interviews and iterative adjustments after various stages of consultation and consensus building with main local players, contribution from foreign experts, and piloting of process and instruments for ultimate fine-tuning are described. We examine final proposal in the light of new updated studies. Analysis of regulations revealed that rules governing the provincial system were historically linked to administrative resolutions in relation to procurement with poor consideration to clinical, epidemiological, organizational, and health policy aspects. Key informants from hospitals, MOH, and other governmental agencies agreed on the lack of a process capable of guaranteeing a decision about health technology incorporation based on a transparent use of the best available information, ready to deal with competitive pressures. This adaptation provided a structured and explicit process (introduction, implementation, and development) as well as essential and supporting tools. MOH adopted the proposal for its progressive implementation while institutional evaluation capacity develops. Further studies are needed on the value placed on health technology assessment-based processes and recommendations by clinicians, managers, policy makers, and patients.

Cost-Effectiveness of Spinal Cord Stimulation Therapy in Management of Chronic Pain

To evaluate the cost-effectiveness of spinal cord stimulation (SCS) and conventional medical management (CMM) compared with CMM alone for patients with failed back surgery syndrome (FBSS), complex regional pain syndrome (CRPS), peripheral arterial disease (PAD), and refractory angina pectoris (RAP). Markov models were developed to evaluate the cost-effectiveness of SCS vs CMM alone from the perspective of a Canadian provincial Ministry of Health. Each model followed costs and outcomes in 6-month cycles. Health effects were expressed as quality-adjusted life years (QALYs). Costs were gathered from public sources and expressed in 2012 Canadian dollars (CAN$). Costs and effects were calculated over a 20-year time horizon and discounted at 3.5% annually, as suggested by the National Institute of Clinical Excellence. Cost-effectiveness was identified by deterministic and probabilistic sensitivity analysis (50,000 Monte-Carlo iterations). Outcome measures were: cost, QALY, incremental net monetary benefit (INMB), incremental cost-effectiveness ratio (ICER), expected value of perfect information (EVPI), and strategy selection frequency. The ICER for SCS was: CAN$ 9,293 (FBSS), CAN$ 11,216 (CRPS), CAN$ 9,319 (PAD), CAN$ 9,984 (RAP) per QALY gained, respectively. SCS provided the optimal economic path. The probability of SCS being cost-effective compared with CMM was 75-95% depending on pathology. SCS generates a positive INMB for treatment of pain syndromes. Sensitivity analyses demonstrated that results were robust to plausible variations in model costs and effectiveness inputs. Per-patient EVPI was low, indicating that gathering additional information for model parameters would not significantly impact results. SCS with CMM is cost-effective compared with CMM alone in the management of FBSS, CRPS, PAD, and RAP.

Paying Hospital-Based Doctors: Fee for Whose Service?

Canadian specialist doctors are paid mainly through fee-for-service for the procedures they perform.Nationwide, more than 80 percent of surgical specialists’ income comes from fee-for-service payments that are negotiated collectively with provincial health ministries. Surgical specialists make up about 20 percent of all full-time equivalent physicians, and fee-for-service payments to them accounted for close to $4 billion nationwide in 2011/12. Because physicians’ decisions are the major drivers for most healthcare costs, getting the incentives right regarding the way doctors are paid is critical in ensuring Canadians receive good value for money from the healthcare system.Whereas most hospital-based specialist doctors are paid via fee-for-service by provincial insurance plans, most hospital funding comes through a separate pipe, in the form of lump-sum amounts not linked to the number and quality of services provided. The result is a system in which neither specialists’ time nor hospital resources are efficiently used, contributing to high costs and long waiting lists. One contributing factor to waiting lists, and one reason why many recently graduated specialists in Canada are unemployed or underemployed, is a lack of complementary facilities, such as operating rooms, and the lack of complementary professionals, such as anaesthesiologists, nurses and so on. When a medical procedure requires hospital facilities as well as specialist time, the fee should be shared between hospitals and specialists in ways that give both a stake in producing high-quality care at low costs. We propose that hospital-based physicians be paid directly from hospital budgets as opposed to the current practice of paying them separately through provincial insurance plans. Hospitals would then engage doctors and pay them appropriately – either by salary, fee-for-service, or a blend of methods. This would result in stronger incentives for providers to better deploy resources but may also lead to potential side effects, such as cost shifting and lower quality of care. In this Commentary, we discuss how incentives to both hospitals and doctors could be carefully designed to avoid pitfalls and to promote more efficient use of resources.

Insight into implementation of facility-based integrated management of childhood illness strategy in a rural district of Sindh, Pakistan

BackgroundIntegrated management of childhood illnesses (IMCI) strategy has been proven to improve health outcomes in children under 5 years of age. Pakistan, despite being in the late implementation phase of the strategy, continues to report high under-five mortality due to pneumonia, diarrhea, measles, and malnutrition – the main targets of the strategy.ObjectiveThe study determines the factors influencing IMCI implementation at public-sector primary health care (PHC) facilities in Matiari district, Sindh, Pakistan.DesignAn exploratory qualitative study with an embedded quantitative strand was conducted. The qualitative part included 16 in-depth interviews (IDIs) with stakeholders which included planners and policy makers at a provincial level (n=5), implementers and managers at a district level (n=3), and IMCI-trained physicians posted at PHC facilities (n=8). Quantitative part included PHC facility survey (n=16) utilizing WHO health facility assessment tool to assess availability of IMCI essential drugs, supplies, and equipments. Qualitative content analysis was used to interpret the textual information, whereas descriptive frequencies were calculated for health facility survey data.ResultsThe major factors reported to enhance IMCI implementation were knowledge and perception about the strategy and need for separate clinic for children aged under 5 years as potential support factors. The latter can facilitate in strategy implementation through allocated workforce and required equipments and supplies. Constraint factors mainly included lack of clear understanding of the strategy, poor planning for IMCI implementation, ambiguity in defined roles and responsibilities among stakeholders, and insufficient essential supplies and drugs at PHC centers. The latter was further substantiated through health facilities’ survey findings, which indicated that none of the facilities had 100% stock of essential supplies and drugs. Only one out of all 16 surveyed facilities had 75% of the total supplies, while 4 out of 16 facilities had 56% of the required IMCI drug stock. The mean availability of supplies ranged from 36.6 to 66%, while the mean availability of drugs ranged from 45.8 to 56.7%.ConclusionOur findings indicate that the Matiari district has sound implementation potential; however, bottlenecks at health care facility and at health care management level have badly constrained the implementation process. An interdependency exists among the constraining factors, such as lack of sound planning resulting in unclear understanding of the strategy; leading to ambiguous roles and responsibilities among stakeholders which manifest as inadequate availability of supplies and drugs at PHC facilities. Addressing these barriers is likely to have a cumulative effect on facilitating IMCI implementation. On the basis of these findings, we recommend that the provincial Ministry of Health (MoH) and provincial Maternal Neonatal and Child Health (MNCH) program jointly assess the situation and streamline IMCI implementation in the district through sound planning, training, supervision, and logistic support.

Factors Associated with Initiation of Chronic Renal Replacement Therapy for Patients with Kidney Failure

Patients with kidney failure sometimes do not receive chronic renal replacement therapy (RRT), even though this may reduce their life expectancy. This study aimed to identify factors associated with initiation of chronic RRT. This cohort study was conducted with Albertans aged >18 years between May 2002 and March 2009, using linked data from the provincial renal programs, clinical laboratories, and provincial health ministry. This study focused on those who developed kidney failure, defined by an estimated GFR (eGFR) <15 ml/min per 1.73 m(2) at last measurement during follow-up, together with prior CKD (eGFR <60 ml/min per 1.73 m(2) at least 90 days earlier). Multivariable Cox proportional hazards models were used to determine factors significantly associated with initiation of chronic RRT. In total, 7901 participants had eGFR <15 ml/min per 1.73 m(2) at last measurement. After adjustment, older participants were less likely to initiate chronic RRT. Remote residence location, dementia, and metastatic cancer also decreased the likelihood of initiating RRT. The cumulative probability of initiating RRT during follow-up was 76.8% for urban-dwelling men aged <50 years without comorbidity, but was only 3.2% among remote-dwelling women aged ≥70 years with dementia and metastatic cancer. In contrast, patients with diabetes and heavy/severe proteinuria were more likely to initiate chronic RRT. There is substantial variability in the likelihood of RRT initiation for patients with eGFR <15 ml/min per 1.73 m(2). Further studies are needed to delineate factors that influence this outcome.

Cost Effectiveness of Intrathecal Drug Therapy in Management of Chronic Nonmalignant Pain

To evaluate the cost effectiveness of intrathecal drug therapy (IDT) compared with conventional medical management (CMM) for patients with refractory chronic noncancer pain. A probabilistic Markov model was developed to evaluate the cost effectiveness of IDT versus CMM from the perspective of a Canadian provincial Ministry of Health using data from our pain clinic. The model followed costs and outcomes in 6-month cycles. Health effects were expressed as quality-adjusted life years (QALYs) gained. Resources use included drugs, physician visits, laboratory tests, scans, and hospitalizations. Unit costs were gathered from public sources and were expressed in 2011 Canadian dollars. Costs and effects were evaluated over a time horizon of 10 years and discounted at 5% per annum after the first year. Cost effectiveness was identified by deterministic and probabilistic sensitivity analyses (50,000 Monte Carlo iterations). Over 10 years, total costs were $61,442 for IDT and $48,408 for CMM. Thus, the incremental effectiveness of IDT was 1.1508 QALYs at an incremental cost of $13,034, resulting in an incremental cost-effectiveness ratio of $11,326/QALY gained. The probability of IDT providing a cost-effective alternative to CMM was 50% and 84% at a willingness-to-pay threshold of $14,200 and $20,000/QALY, respectively. The results were most sensitive to the cost of CMM, the probability of reaching an optimal health state with dual-drug IDT, and the effectiveness of CMM therapy. Sensitivity analyses showed that results were robust to plausible variations in model costs and effectiveness inputs. IDT is cost effective compared with CMM in the management of chronic noncancer pain.

The Burden of Celiac Disease in Canada: More Work Needed to Lighten the Load

Celiac disease was first recognized as a distinct clinical entity more than 60 years ago. However, its full spectrum and impact have only been appreciated over the past decade. In part, this reflects the increasing availability of serological testing that has enabled earlier diagnosis, and a greater appreciation of the protean clinical manifestations and high prevalence of gluten sensitivity. In the current issue of the Canadian Journal of Gastroenterology, Pulido et al (1) (pages 449–453) surveyed the memberships of the Canadian Celiac Association and the Fondation Quebecoise de la Maladie Coeliaque to characterize a Canadian adult population with celiac disease. Remarkably, 5912 of 10,693 invitees responded. Key findings included an average diagnostic delay of 12.0 years and a high prevalence of persistent symptoms despite the avoidance of gluten. Methodological shortfalls, however, must be acknowledged. Most notably, the retrospective survey design is prone to both response bias and recall bias, and members of national celiac organizations represent a highly selected subset of the overall population with celiac disease. Nonetheless, these data provide useful insight into the symptom burden and clinical challenges faced by patients with celiac disease. To some extent, delayed diagnosis of celiac is understandable, given that ‘classic’ presentations are now rare and many patients initially present with extraintestinal signs such as anemia. However, diagnostic delay can have important health consequences that range from persistent symptoms to micronutrient deficiencies and even malignancies. There is ample evidence that celiac disease remains underdiagnosed in Western populations and that its incidence is increasing (2). What is the solution? Population-based screening remains controversial; however, better education of health care providers and proactive screening of those at increased risk could help. In Canada, more consistent access to serological screening assays is needed because not all provincial health ministries reimburse the test. The primary treatment for celiac disease is elimination of gluten from the diet on diagnosis (3). For most patients, this is highly effective, but persistent symptoms are common, as demonstrated by Pulido et al (1). There are three potential explanations for such therapeutic failure. Some patients have symptoms unrelated to gluten sensitivity, and other competing etiologies must be investigated. Other patients may either surreptitiously or unintentionally continue to ingest gluten, which mandates a careful review of diet and other environmental exposures. However, the most challenging scenario is that of refractory celiac disease, for which novel approaches are needed. Nonresponsive celiac disease is classified as either type I, in which duodenal lymphocytic infiltration resembles untreated disease, or type II, in which lymphocytes carry an abnormal immunophenotype with oligoclonal expansion. The prognosis of the latter is less favourable. The traditional medical approach to such patients has included corti-costeroids and immunosuppression. However, a number of novel and targeted approaches to nonresponsive disease are on the horizon. For example, larazotide acetate is an oral peptide that affects tight junction function that has shown promise in phase II placebo-controlled trials (4). Oral endopeptidases that convert residual dietary gluten to nontoxic peptides are in clinical trials (5) and preventive vaccines have been proposed. In animal models, a copolymer of hydroxyethyl methacrylate and styrene sulfonate appears to prevent digestion of dietary gluten to toxic peptides (6). Of course, probiotics are also being explored to modulate intestinal immune responses (7). Despite promise for the future, celiac disease remains a lifelong diagnosis that requires ongoing multidisciplinary care and careful longitudinal review. Both gastroenterologists and primary care practitioners play important roles in monitoring adherence and detecting the metabolic consequences of micronutrient deficiency. However, involvement of a skilled dietitian, both for initial instruction and for ongoing review of dietary adherence, is critical to treatment success. Support groups such as the Canadian Celiac Association (www.celiac.ca) provide valuable resources for patients, families and care-givers. Effective advocacy from such organizations has contributed to the enhanced availability of reliably gluten-free alternatives throughout the hospitality, grocery and transportation industries in Canada. Pulido et al (1) have helped to shed light on the burden of illness of celiac disease in Canada. While the past decade has witnessed great progress in the detection, support and management of people living with celiac disease, much work remains. These and similar observations from other jurisdictions call for the investment of the funds, effort and infrastructure required to eliminate the burden of celiac disease altogether.

The use of syndromic surveillance for decision-making during the H1N1 pandemic: A qualitative study

BackgroundAlthough an increasing number of studies are documenting uses of syndromic surveillance by front line public health, few detail the value added from linking syndromic data to public health decision-making. This study seeks to understand how syndromic data informed specific public health actions during the 2009 H1N1 pandemic.MethodsSemi-structured telephone interviews were conducted with participants from Ontario’s public health departments, the provincial ministry of health and federal public health agency to gather information about syndromic surveillance systems used and the role of syndromic data in informing specific public health actions taken during the pandemic. Responses were compared with how the same decisions were made by non-syndromic surveillance users.ResultsFindings from 56 interviews (82% response) show that syndromic data were most used for monitoring virus activity, measuring impact on the health care system and informing the opening of influenza assessment centres in several jurisdictions, and supporting communications and messaging, rather than its intended purpose of early outbreak detection. Syndromic data had limited impact on decisions that involved the operation of immunization clinics, school closures, sending information letters home with school children or providing recommendations to health care providers. Both syndromic surveillance users and non-users reported that guidance from the provincial ministry of health, communications with stakeholders and vaccine availability were driving factors in these public health decisions.ConclusionsSyndromic surveillance had limited use in decision-making during the 2009 H1N1 pandemic in Ontario. This study provides insights into the reasons why this occurred. Despite this, syndromic data were valued for providing situational awareness and confidence to support public communications and recommendations. Developing an understanding of how syndromic data are utilized during public health events provides valuable evidence to support future investments in public health surveillance.

Evaluating the impact of a novel restricted reimbursement policy for quinolone antibiotics: A time series analysis

BackgroundPublicly-funded drug plans often use prior authorization policies to limit drug prescribing. To guide physician prescribing of a class of antibiotics with broad antimicrobial activity (quinolone antibiotics) in accordance with new prescribing guidelines, Alberta’s provincial health ministry implemented a new mechanism for formulary restriction entitled the optional special authorization (OSA) program. We conducted an observational study to determine the impact of this new formulary restriction policy on antimicrobial prescription rates as well as any clinical consequences.MethodsQuinolone antibiotic use, and adherence with quinolone prescribing guidelines, was assessed before and after implementation of the OSA program in patients with common outpatient infections using an administrative data cohort and a chart review cohort, respectively. At the same time this policy was implemented to limit quinolone prescribing, two new quinolone antibiotics were added to the formulary. Using administrative data, we analysed a total of 397,534 unique index visits with regard to overall antibiotic utilization, and through chart review, we analysed 1681 charts of patients with infections of interest to determine the indications for quinolone usage.ResultsUsing segmented regression models adjusting for age, sex and physician enrollment in the OSA program, there was no statistically significant change in the monthly rate of all quinolone use (−3.5 (95% CI −5.5, 1.4) prescriptions per 1000 index visits) following implementation of the OSA program (p = 0.74). There was a significant level change in the rate of quinolone antibiotic use for urinary tract infection (−33.6 (95% CI: -23.8, -43.4) prescriptions and upper respiratory tract infection (−16.1 (95%CI: -11.6, -20.6) prescriptions per 1000 index visits. Among quinolone prescriptions identified on chart review, 42.5% and 58.5% were consistent with formulary guidelines before and after the implementation of the OSA program, respectively (p = 0.002). There was no change in hospitalization, mortality or use of physician services after implementation of the OSA program.ConclusionsDespite the addition of two new quinolone antibiotics to the formulary, we found that there was no change in the use of quinolones after implementation of a new formulary restriction policy for outpatients with common outpatient infections.

Spatial analysis to locate new clinics for diabetic kidney patients in the underserved communities in Alberta

Canadians with chronic diseases often live far away from healthcare facilities, which may compromise their level of care. We used a new method for selecting optimal locations for new healthcare facilities in remote regions. We used a provincial laboratory database linked to data from the provincial health ministry. From all patients with serum creatinine measured at least once between 2002 and 2008 in Alberta, Canada, we selected those with diabetes and an estimated glomerular filtration rate (eGFR) of 15-60 mL/min/1.73 m(2). We then used two methods to select potential locations for new clinics that would serve the greatest number of remote-dwelling patients: plots showing the unadjusted density of such patients per 100 km(2) and SatScan analysis presenting the prevalent clusters of patients on the basis of chronic kidney disease (CKD) rates (adjusted for population size). We studied 32,278 patients with concomitant diabetes and CKD. A substantial number of patients (8%) resided >200 km from existing nephrologists' clinics. Density plots mapped with ArcGIS were useful for localizing a large cluster of underserved patients. However, objective assessment with SatScan technique and ArcGIS permitted us to detect additional clusters of patients in the northwest and southeast regions of Alberta--and suggested potential locations for new clinics in these areas. Objective techniques such as SatScan can identify clusters of underserved patients with CKD and identify potential new facility locations for consideration by decision-makers. Our findings may also be applicable to patients with other chronic diseases.

Genetic testing and services in Argentina

Argentina is a middle-income country with a population of 40 million people. The structure of morbidity and mortality approaches that of more developed nations, with congenital and genetic disorders contributing significantly to ill health. The health delivery system is mixed, with public, social security, and private sectors which together spend close to 10% of the GNP. Health subsectors are decentralized at provincial and municipality levels, where health planning and financing occurs, leading to fragmentation, inefficiency, and inequities. There are about 41 clinical genetic units in major medical centers in large cities, staffed by about 120 clinical geneticists, although only a few units are fully comprehensive genetic centers. Duplications, deficiencies, and poor regionalization and coordination affect health care delivery in general and in genetics. Funding for genetic services is limited due to poor understanding and lack of political will on the part of health authorities. Recently, however, there have been some interesting initiatives by national and provincial ministries of health to improve genetic services delivery by increasing coordination and regionalization. At the same time, training in genetics of health professionals is occurring, particularly in primary health care, and registries of congenital defects are being put in place. These developments are occurring in conjunction with a new awareness by health authorities of the importance of genetics in health care and research, a heightened activism of patient organizations demanding services for neglected conditions, as well as of women movements for the right to safe abortion.

Perceived usefulness of syndromic surveillance in Ontario during the H1N1 pandemic.

BackgroundDespite the growing popularity of syndromic surveillance, little is known about if or how these systems are accepted, utilized and valued by end users. This study seeks to describe the use of syndromic surveillance systems in Ontario and users' perceptions of the value of these systems within the context of other surveillance systems.MethodsOntario's 36 public health units, the provincial ministry of health and federal public health agency completed a web survey to identify traditional and syndromic surveillance systems used routinely and during the pandemic and to describe system attributes and utility in monitoring pandemic activity and informing decision-making.ResultsSyndromic surveillance systems are used by 20/38 (53%) organizations. For routine surveillance, laboratory, integrated Public Health Information System and school absenteeism data are the most frequently used sources. Laboratory data received the highest ratings for reliability, timeliness and accuracy (‘very acceptable’ by 92, 51 and 89%). Hospital/clinic screening data were rated as the most reliable and timely syndromic data source (50 and 43%) and ED visit data the most accurate (48%). During the pandemic, laboratory data were considered the most useful for monitoring the epidemiology and informing decision-making while ED screening and visit data were considered the most useful syndromic sources.ConclusionsEnd user perceptions are valuable for identifying opportunities for improvement and guiding further investments in public health surveillance.

A review of screening mammography participation and utilization in Canada

Participation rate is an important indicator for a screening program's effectiveness; however, the current approach to measuring participation rate in Canada is not comparable with other countries. The objective of this study is to review the measurement of screening mammography participation in Canada, make international comparisons, and propose alternative methods. Canadian breast cancer screening program data for women aged 50 to 69 years screened between 2004 and 2006 were extracted from the Canadian Breast Cancer Screening Database (CBCSD). The fee-for-services (FSS) mammography data (opportunistic screening mammography) were obtained from the provincial ministries of health. Both screening mammography program participation and utilization were examined over 24 and 30 months. Canada's screening participation rate increases from 39.4% for a 24-month cut-off to 43.6% for a 30-month cut-off. The 24-month mammography utilization rate is 63.1% in Canada, and the 30-month utilization rate is 70.4%. Due to the differences in health service delivery among Canadian provinces, both programmatic participation and overall utilization of mammography at 24 months and 30 months should be monitored.

Of Silos and Systems: The Issue of Regionalizing Health Care

Regionalization refers to the creation of an intermediary administrative and governance structure (often referred to as a regional health authority or board) that assumes respon sibility for organizing and delivering health care services to a defined population. The formation of a regional health board shifts the responsibility for decisions about funding and allocating health care resources away from both individual organizations (for example, a community hospital board) and the provincial ministry of health. The main goals of regionalization are to help contain rising health care costs (through economies of scale), to improve responsiveness to and accountability for population health needs, and to increase public participation in health care decision-making. In essence, the responsibility for providing health care services moves away from the “silos” of fragmented, individual organizations (as just one example, before regionalization in Saskatchewan, the province had more than 400 individual health care organizations, such as acute care hospitals and community care groups) to a “system” of health care that is delivered in an integrated fashion by a single regional organization. Regionalization of health care delivery began in the late 1980s and early 1990s in all provinces except Ontario. These initiatives were undertaken in response to observations from a number of federal and provincial commissions, task forces, and public forums aimed at finding ways to improve the health care system. Each province has developed regional health boards that vary in number, scope of responsibilities, and membership. While some provinces have separate boards to oversee institutional and community services, most have regional health boards with a wide range of responsibilities, including medical clinics, health promotion and prevention, youth and family services, public health, cancer care, mental health, hospitals, and residential care programs. In most provinces, the members of regional health boards are appointed by the provincial minister of health. Although there are a number of recognized challenges associated with operating an effective regional health board, I will focus on just 4 of these. One fundamental challenge is the requirement to characterize the relative importance of a wide variety of health care needs within the region. Advocates believed that regionalization would create equity of allocation of health care services; however, with the closure of many small-town hospitals and an apparent shift in power to urban centres, some would argue against this belief. To help make appropriate and equitable decisions, regional health boards would ideally use a valid and dynamic funding formula. However, such formulas require a complex amount of individual-level data, which reflects the second challenge: although individual-level data enable us to identify and account for important factors influencing health care needs, it is often difficult to access highquality, reliable epidemiological data. Ironically, the human resources and infrastructure needed to effectively gather and interpret this information may in fact exacerbate the problem of higher health care expenditures. A third challenge to the operation of regional health boards is the fact that many boards have limited authority to control major expenditures, such as physician fees and drug costs, as well as limited authority to create policy. Without devolution of power from provincial ministries of health, regional boards become another layer of administration in the health care system. Finally, public representation on regional health boards may be one of the biggest challenges of all. Although having such representation reflects a noble intent, selection of public members can be difficult. For example, if only one member of the public is involved on a particular board, it is critical to demonstrate that the individual selected speaks for the needs of all residents within the region. Inclusion of a public member with a vested interest in a limited number of issues can be harmful not only to the internal decision-making process of the

"We suffer from being lost": formulating policies to reclaim youth in mental health transitions.

The greatest financial and institutional weaknesses in mental health services affect individuals between the ages of 16 and 25. The current project sought to identify bodies of evidence supporting effective transitional pathways and to engage policy leaders in a discussion of youth mental health transitions to highlight stakeholder perspectives. Three efficacious pathways from youth health service environments to adult health service structures were identified in the literature: the Protocol/Reciprocal Agreement Structure, the Transition Program Model and the Shared Management Framework. Evidence was presented to a panel of policy officials occupying various roles, up to the position of assistant deputy minister, from the provincial ministries of health, education, child and youth services and training, colleges and universities in Ontario. The panel was then engaged in a discussion regarding youth mental health transitions, and thematic analysis was used to identify policy- and practice-level considerations. The Shared Management Framework was recommended as the preferred transitional model from a policy perspective; however, continued research is required to determine the appropriateness of this approach for all stakeholders involved in youth mental health transitions.

Progress toward integrating care for seniors in Canada

Introduction: Integrating care is a developing feature of provincial health delivery in Canada for those with chronic conditions. The purposes of this project were to review the conceptual understandings underlying integrated care, examine the features of models of cost-effective care for the elderly, and then ascertain to what extent Canadian provinces were implementing these features. Method: These goals were accomplished through a review of the integrated care literature followed by a survey of the Canadian provinces. A pre-tested questionnaire was sent to each of the ten provincial Ministries of Health in 2008. The questionnaire collected basic background information and then asked a series of open- and close-ended questions about each of the best practice features of integrated care as found in the literature review. Results: System improvements in integrating care for the elderly are being implemented in Canadian provincial health care systems. There has been substantial improvement in the delivery of case management services but the supply of some community services could be improved. As well, the linkages amongst primary, acute and community care remain weak. Discussion and conclusion: Providing an adequate supply of services is an ongoing issue in many provinces and could be the result of either inadequate funding and/or poor targeting of scarce resources. While it is promising that so many provinces are starting to break down the silos amongst types of health care service providers, much remains to be accomplished. These issues are at the core of integrating care and are among the challenges being faced by other countries.

Achalasia: incidence, prevalence and survival. A population‐based study

Studies of achalasia epidemiology are important as they often yield new insights into disease etiology. In this study, our objective was to carry out the first North American population-based study of achalasia epidemiology using a governmental administrative database. All residents in the province of Alberta, Canada receive universal healthcare coverage as a benefit. The provincial health ministry, Alberta Health and Wellness, maintains a central stakeholder database of patient demographic information and physician billing claims. We defined an achalasia case as a billing claim submitted for the years 1996-2007 with an ICD-9-CM code of 530.0 or 530 and a Canadian Classification of Procedure treatment code of 54.92A (endoscopic balloon dilation) or 54.6 (esophagomyotomy). A preliminary validation study of the case definition demonstrated a sensitivity of 85% and specificity of 99% for known cases and controls. A total of 463 achalasia cases were identified from 1995 to 2008 (59.6% males). Mean age at diagnosis was 53.1 years. In 2007, the achalasia incidence was 1.63/100,000 (95% CI 1.20, 2.06) and the prevalence was 10.82/100,000 (95% CI 9.70, 11.93). We observed a steady increase in the overall prevalence rate from 2.51/100,000 in 1996 to 10.82/100,000 in 2007. Survival of achalasia cases was significantly less than age-sex matched population controls (P < 0.0001). Using a population-based approach, the incidence and prevalence of treated achalasia is 1.63/100,000 and 10.82/100,000, respectively. The disease appears to have a stable incidence but a rising prevalence. Survival of achalasia cases is significantly less than age-matched healthy controls.

Comparison of the metabolic and economic consequences of long‐term treatment of schizophrenia using ziprasidone, olanzapine, quetiapine and risperidone in Canada: a cost‐effectiveness analysis

Second-generation antipsychotic agents have varying propensities to cause weight gain, elevated lipid levels and associated long-term complications. This study evaluates the cost-effectiveness of four second-generation antipsychotic agents used in Canada for the treatment of schizophrenia (ziprasidone, olanzapine, quetiapine, risperidone) with a focus on their long-term metabolic consequences. Using data from the Clinical Antipsychotic Trials of Intervention Effectiveness Study, a semi-Markov model was developed to predict the incidence and associated costs of type 2 diabetes, cardiovascular complications (e.g. angina, myocardial infarction, stroke, cardiovascular disease death), and acute psychiatric hospitalizations in patients with chronic schizophrenia treated over 5 years. Incremental costs per quality-adjusted life year (QALY) gained were calculated from the perspective of the Canadian provincial ministries of health. Scenario and probabilistic sensitivity analyses were performed. The total average cost of treatment with ziprasidone was $25,301 versus $28,563 with olanzapine, $26,233 with quetiapine and $21,831 with risperidone. Ziprasidone had the lowest predicted number of type 2 diabetes cases and cardiovascular disease events, and the highest QALY gains. Patients receiving quetiapine had the highest predicted number of hospitalizations. Ziprasidone was less costly and resulted in more QALYs compared with olanzapine and quetiapine. Compared with risperidone, ziprasidone was more costly and had higher QALYs, with an incremental cost per QALY gained of $218,060. Compared with olanzapine and quetiapine, ziprasidone produced savings to the health care system. Although ziprasidone generated incremental expenditures versus risperidone, it resulted in more QALYs. Based on this analysis, ziprasidone treatment possesses cost and therapeutic advantages compared with olanzapine and quetiapine.

Survey of iodine deficiency and intestinal parasitic infections in school-going children: Bie Province, Angola

To obtain baseline pre-intervention prevalence levels of iodine deficiency and parasitic and helminth infections in school-going children in Bie Province, Angola. A cross-sectional study conducted in randomly selected schools. The target population was children aged 6-10 years. Bie Province, Angola. A total of 1029 children sampled, with 791 stool samples and 826 urine samples collected from twenty-four schools. Widespread severe and moderate deficiencies in iodine. Children in five schools were severely iodine deficient. All sampled schoolchildren were iodine deficient to a greater or lesser extent. In all, 80 % of all children across the twenty-four schools were infected with one or a combination of intestinal helminths and intestinal protozoa. These findings have serious implications for the cognitive development of Angolan children, as well as for Angola's development in terms of productivity and economic potential. It is strongly recommended that the provincial and national Ministries of Health, in collaboration with international health agencies, immediately plan and implement a strategy to provide sufficient iodine through iodised oil capsules and iodised salt to the iodine-deficient population. National coalitions need to be strengthened among the government, partners and salt producers. It is also recommended that all the children in schools be de-wormed for multiple helminth species at least twice a year.