The Canadian health system is undergoing reform. Over the past decade a prominent trend has been creation of health regions. This structural shift is concurrent with a greater emphasis on population health and the broad determinants of health. In parallel, there is a movement toward more intersectoral collaboration (i.e., collaboration between diverse segments of the health system, and between the health system and other sectors of society). The purpose of this exploratory study is to determine the self-reported level of internal action (within regional health authorities) and intersectoral collaboration around 10 determinants of health by regional health authorities across Canada.
From September 2003 to February 2004, we undertook a survey of regional health authorities in Canadian provinces (N = 69). Using SPSS 12.0, we generated frequencies for the self-reported level of internal and intersectoral action for each determinant. Other analyses were done to compare rural/suburban and urban regions, and to compare Western, Central and Eastern Canada.
Of the 10 determinants of health surveyed, child development and personal health practices were self-reported by the majority of health regions to receive greatest attention, both internally and through intersectoral activities. Culture, gender and employment/working conditions received least attention in most regions.
The exploratory survey results give us the first Canadian snapshot of health regions' activities in relation to the broad range of non-medical determinants of health. They provide a starting data set for baselining future progress, and for beginning deeper analyses of specific areas of action and intersectoral collaboration.
In 2005, the median waiting time for total hip and knee joint replacements in Ontario was greater than 6 months, which is considered longer than clinically appropriate. Demand is expected to increase and exacerbate already long waiting times. Solutions are needed to reduce waiting times and improve waiting list management.
We developed a discrete event simulation model of the Ontario total joint replacement system to evaluate the effects of 4 management strategies on waiting times: (1) reductions in surgical demand; (2) formal clinical prioritization; (3) waiting time guarantees; and (4) common waiting list management.
If the number of surgeries performed increases by less than 10% each year, then demand must be reduced by at least 15% to ensure that, within 10 years, 90% of patients receive surgery within their maximum recommended waiting time. Clinically prioritizing patients reduced waiting times for high-priority patients and increased the number of patients at all priority levels who received surgery each year within recommended maximum waiting times by 9.3%. A waiting time guarantee for all patients provided fewer surgeries within recommended waiting times. Common waiting list management improved efficiency and increased equity in waiting across regions.
Dramatically increasing the supply of joint replacement surgeries or diverting demand for surgeries to other jurisdictions will reduce waiting times for total joint replacement surgery. Introducing a strictly adhered to patient prioritization scheme will ensure that more patients receive surgery within severity-specific waiting time targets. Implementing a waiting time guarantee for all patients will not reduce waiting times--it will only shuffle waiting times from some patients to others. To reduce waiting times to clinically acceptable levels within 10 years, increases in the number of surgeries provided greater than those observed historically or reductions in demand are needed.
Transparent priority setting in health care based on specific ethical principles is requested by the Swedish Parliament since 1997. Implementation has been limited. In this case, transparent priority setting was performed for a second time round and engaged an entire health care organisation.
Objectives were to refine a bottom-up priority setting process, reach a political decision on service limits to make reallocation towards higher prioritised services possible, and raise systems knowledge.
An action research approach was chosen. The national model for priority setting was used with addition of dimensions costs, volumes, gender distribution and feasibility. The intervention included a three step process and specific procedures for each step which were created, revised and evaluated regarding factual and functional aspects. Evaluations methods included analyses of documents, recordings and surveys.
Vertical and horizontal priority setting occurred and resources were reallocated. Participants' attitudes remained positive, however less so than in the first priority setting round. Identifying low-priority services was perceived difficult, causing resentment and strategic behaviour. The horizontal stage served to raise quality of the knowledge base, level out differences in ranking of services and raise systems knowledge.
Existing health care management systems do not meet institutional requirements for transparent priority setting. Introducing transparent priority setting constitutes a complex institutional reform, which needs to be driven by management/administration. Strong managerial commitment is required.
This case study describes the priority-setting process undertaken by health care providers in the Municipal District of Taber, Alta., to improve and integrate chronic disease services within a fixed budget.
Providers first reviewed the current chronic disease management system, then considered alternatives based on program priorities and costs and benefits of potential changes.
Despite reaching consensus that a chronic disease clinic was the top priority for funding, providers were unable to redesign services accordingly. Redesign efforts were hampered by the groups' difficulty in identifying services that should receive fewer resources in order to fund priority areas, inexperience with priority-setting frameworks, group composition, the belief that many programs were already at "bare bone" funding levels, and perceptions of limited budget control. In the end, recommendations were made to use attrition to release resources, establish multi-disciplinary teams and group visits, where appropriate, and relocate providers to a centralized location. Upon review of study outcomes, Taber providers were granted more decision-making authority.
Overall, the use of a systematic priority-setting process, culminating in recommendations for action, has moved Taber providers closer to an integrated model of service delivery. It is recommended that formal priority-setting frameworks continue to be used in Taber for primary care renewal or at any level where consideration of existing evidence and projected costs is required.
To quantify and compare the preferences of researchers and laypeople in Canada regarding the outcomes of basic biomedical research.
In autumn 2010, the authors conducted a cross-sectional, national survey of basic biomedical researchers funded by Canada's national health research agency and a representative sample of Canadian citizens to assess preferences for research outcomes across five attributes using a discrete choice experiment. Attributes included advancing scientific knowledge (assessed by published papers); building research capacity (assessed by trainees); informing decisions in the health products industry (assessed by patents); targeting economic, health, or scientific priorities; and cost. The authors reduced a fractional factorial design (18 pairwise choices plus an opt-out option) to three blocks of six. They also computed part worth utilities, differences in predicted probabilities, and willingness-to-pay values using nested logit models.
Of 3,260 potential researchers, 1,749 (53.65% response rate) completed the questionnaire, along with 1,002 citizens. Researchers and citizens prioritized high-quality scientific outcomes (papers, trainees) over other attributes. Both groups disvalued research targeted at economic priorities relative to health priorities. Researchers granted a premium to proposals targeting scientific priorities.
Citizens and researchers fundamentally prioritized the same outcomes for basic biomedical research. Notably, they prioritized traditional scientific outcomes and disvalued the pursuit of economic returns. These findings have implications for how academic medicine assigns incentives and value to basic health research and how biomedical researchers and the public may jointly contribute to setting the future research agenda.
Priority wait lists are common for managing access to cardiac surgery in publicly funded health systems. We evaluated whether longer delays contribute to the probability of death before surgery among patients prioritized into the less urgent category.
We studied records of 9233 patients registered for isolated coronary artery bypass graft (CABG) in British Columbia, Canada. The primary outcome was death before surgery. We estimated the probability that a patient, who could be removed from the list as a result of surgery, death, or other competing events, dies on or before a certain wait-list week.
Despite similar death rates in semiurgent and nonurgent groups, 0.63 (95% confidence interval, 0.46-0.80) versus 0.58 (0.36-0.80) per 1000 patient-weeks, nonurgent patients were remaining on the list longer, which contributed to higher cumulative incidence of all-cause death than in semiurgent group (adjusted odds ratio = 1.66; 1.03-2.68). By 52 weeks on the wait list, 0.9% (0.6-1.1) and 1.3% (0.8-1.8) of patients died in semiurgent and nonurgent groups, respectively (P
A comprehensive Swedish public health policy was adopted by the Swedish Parliament, the Riksdag, in April 2003. It pushes health up on the political agenda and affords equity in health high priority. The first phase of implementation of the policy, 2003-5, is described in the 2005 Public Health Policy Report published by the Swedish National Institute of Public Health (SNIPH). For the purpose of investigating the implementation, SNIPH has monitored the development of 42 determinants and used reports from 22 central agencies and eight county administrative boards together with interviews with all Sweden's county councils (21) and a questionnaire sent out to all municipalities (290). The experiences from the implementation of the policy are that: the determinants approach-focusing on structural factors in society, people's living conditions, and health behaviors that affect health-is in general well understood and emphasizes the role of other sectors in public health; the use of indicators to follow up exposures to determinants is of key importance; the support to actors outside the health service is needed to identify their public health role; a continuous steering from the government and other political bodies is of vital importance; public health promotion on the regional level needs a higher level of coordination; municipalities need more skills development. Sweden has a new government that was elected in September 2006; the new government has retracted the former government's public health policy communication submitted to the Riksdag in the spring of 2006, but does not intend to change the public health policy.
Until 2007, when the new legislation on health care becomes effective, the right to receive free health care services in Denmark, or "health benefits," are described in a comprehensive set of legislation, including laws, executive orders and legal guidelines. This contribution provides an overview of the current main legislation regulating the Danish "health benefit basket" and describes the regulatory mechanisms for the provision of curative care at Danish hospitals and primary health care offices. Although the services are both financed and planned by the counties, they differ substantially in the way that benefits are regulated.
Cites: J Health Serv Res Policy. 2002 Jul;7(3):133-4212171743