To examine medical care use and costs, patterns of morbidity and co-morbidity, and other patient characteristics of high users of physician services in British Columbia.
This population-based study uses physician claims, hospital discharge summaries and vital statistics data linked at the level of the individual to compare characteristics of high users, other users and non-users of physician services in the Province of British Columbia, Canada. The study included all enrolled adults in the universal health care plan during fiscal year 1996/97. High users were defined as the most costly 5% of users of fee-reimbursed services. Key variables included age, sex, an ecological socio-economic status indicator and a comprehensive set of morbidity indicators, derived from the diagnoses recorded on the utilization records.
The top 5% of users consumed a disproportionate 30% of spending on physician services. High users were overwhelmingly characterized by a significant burden of morbidity. Over 80% had at least six different types of morbidity during the study year compared with fewer than 20% of other users. High users were also much more likely to have major diagnoses that were both acute and chronic in nature. Co-morbidity involving psychosocial and chronic medical conditions was also very common.
High users of physician services are overwhelmingly characterized by multiple and complex health problems. Policy tools based on a philosophy of deterrence such as cost-sharing are unlikely to have much impact on their costs and will likely do considerable harm.
In 1998/99, the British Columbia Medical Association (BCMA) asked physicians to withdraw elective services on a series of 20 Rationed Access Days (RADs). This work stoppage was called to protest continued free proration triggered by total physician billings exceeding a fixed budget cap. This paper examines how physicians' practice activity changed on RADs, the rates of participation in this job action and characteristics of those physicians who participated.
Population-based cohort study of physicians based on administrative data.
All full-time physicians billing the provincial healthcare plan.
Participation in the RAD initiative was inferred by comparing physicians' average daily billings on RADs, Sundays, holidays and regular weekdays. Using thresholds established from these distributions, the number of RADs observed by each physician in 1998/99 was calculated and examined in relation to their demographics, location and prior years of practice activity.
For the 4,131 physicians studied, average daily payments on RADs were similar to those on Sundays and holidays but much lower than those on non-holiday, non-RAD weekdays. Using billing thresholds of $200 (for GPs) and $400 (for specialists), we found a high degree of participation with the study population observing a median of 15 of the 20 scheduled RADs. While there were some differences in participation among age groups, geography and the prior years of practice activity, the differences were small.
This study found high solidarity in the BCMA's 1998/99 RAD initiative. Most full-time fee-for-service FS physicians appeared to participate in at least three-quarters of the 20 scheduled RADs.
Justice Emmett Hall's landmark 1964 Royal Commission report is remarkable as, among other things, a very early Canadian example of successful knowledge brokering. It predates by about three decades even the earliest discourse in Canadian health research circles about knowledge translation, knowledge transfer, knowledge exchange, knowledge brokers, and the like.
Few measures of health related quality of life exist for use with preschool aged children. The objective of this study was to assess reliability and validity of a new multidimensional generic measure of health-related quality of life developed for use with preschool children.
Cross-sectional survey sent to parents as their child turned 3 1/2 years of age. The setting was the province of British Columbia, Canada. Patients included all babies admitted to tertiary level neonatal intensive care units (NICU) at birth over a 16-month period, and a consecutive sample of healthy babies. The main outcome measure was a new full-length questionnaire consisting of 3 global items and 10 multi-item scales constructed to measure the physical and emotional well-being of toddlers and their families.
The response rate was 67.9%. 91% (NICU) and 84% (healthy baby) of items correlated with their own domain above the recommended standard (0.40). 97% (NICU) and 87% (healthy baby) of items correlated more highly (> or = 2 S.E.) with their hypothesized scale than with other scales. Cronbach's alpha coefficients varied between.80 and.96. Intra-class correlation coefficients were above.70. Correlations between scales in the new measure and other instruments were moderate to large, and were stronger than between non-related domains. Statistically significant differences in scale scores were observed between the NICU and healthy baby samples, as well as between those diagnosed with a health problem requiring medical attention in the past year versus those with no health problems.
Preliminary results indicate the new measure demonstrates acceptable reliability and construct validity in a sample of children requiring NICU care and a sample of healthy children. However, further development work is warranted.
Canada is strongly influenced by US cross-border direct-to-consumer advertising (DTCA) and has held consultations to discuss introduction of DTCA since 1996. This article describes a survey of Canadian drug policy experts carried out in 2001, during one such legislative review. The survey results are compared to more recent DTCA policy developments.
We recruited key informants on pharmaceutical policy to complete a faxed questionnaire that queried their opinions on DTCA information quality, effects on drug and health care use, and regulatory issues. Respondents were asked about the evidence they had used to back their opinions. Analysis was descriptive.
Of 79 identified potential participants, 60 (76%) participated, 40% of whom were from federal and provincial government; 3% were private insurers; 18%, 15%, and 8% were from health professional groups, consumer groups, and patient groups, respectively; 8% and 7% were from pharmaceutical and advertising industries, respectively. Opinions were highly polarized on the effects of DTCA on drug and health care use. Advertising and pharmaceutical industry respondents were generally positive, public sector, health professional and consumer groups generally negative. Over 80% believed DTCA leads to higher private and public drug costs and more frequent physician visits. Fewer judged billboards or television to be appropriate media for DTCA than magazines or the Internet, and most believed that children and adolescents should not be targeted.
Given the polarization observed within this survey, we examined how DTCA policy has evolved in Canada since 2001. The federal government has legislative authority over DTCA, but bears few of the additional costs potentially incurred through policy change. These fall to the provinces, which provide an eroding patchwork of public coverage for prescription drugs in the face of rapidly increasing costs. No new federal legislation has been tabled since 2001. However, considerable shifts in administrative policy have occurred, all supportive of expanded advertising. Thus, the law continues to be restrictive but its application less so.
Health services and population health research often depends on the ready availability of administrative health data. However, the linkage of survey-based data to administrative data for health research purposes has raised concerns about privacy. Our aim was to compare consent rates to data linkage in two samples of caregivers and describe characteristics associated with consenters.
Subjects included caregivers of children admitted at birth to neonatal intensive care units (NICU) in British Columbia and caregivers of a sample of healthy children. Caregivers were asked to sign a consent form enabling researchers to link the survey information with theirs and their child's provincially collected health records. Bivariate analysis identified sample characteristics associated with consent. These were entered into logistic regression models.
The sample included 1,140 of 2,221 NICU children and 393 of 718 healthy children. The overall response rate was 55% and the response rate for located families was 67.1%. Consent to data linkage with the child data was given by 71.6% of respondents and with caregiver data by 67% of respondents. Families of healthy children were as likely to provide consent as families of NICU children. Higher rates of consent were associated with being a biological parent, not requiring survey reminders, involvement in a parent support group, not working full-time, having less healthy children, multiple births and higher income.
The level of consent achieved suggests that when given a choice, most people are willing to permit researcher access to their personal health information for research purposes. There is scope for educating the public about the nature and importance of research that combines survey and administrative data to address important health questions.
To explore the redistributive impact of two different pharmaceutical financing policies (age-based versus income-based pharmacare) on the distribution of income in British Columbia (B.C.), Canada.
Using household-level data on all payments that are used to finance prescription drugs in B.C. (including taxation and private payments), we performed a redistributive analysis to indicate how much income inequality in the province changed as a result of payments made for prescription drugs. We also illustrated changes in vertical equity (different treatment according to ability-to-pay) and horizontal equity (equals, according to ability-to-pay, being treated equally) between the two years separately through a pre-post policy examination.
We found that payments made to finance prescription drugs increased overall income inequality in the province. This negative impact was larger after the move to income-based pharmacare. Our results also show increasing horizontal inequity after the policy change, and suggest that the increased reliance on out-of-pocket payments was a major source of the negative impact on the B.C.'s overall income distribution. We also show that the consequences of the move to income-based pharmacare would have been less severe had the level of public financing not decreased substantially between the two years.
The increase in income inequality in B.C. following the policy change was an unintended consequence of the move to income-based pharmacare. This finding is worth consideration as countries and jurisdictions weigh pharmaceutical policy alternatives.