The use of prescription drugs outside of hospitals is not addressed in the Canada Health Act or by any legislation that would ensure national standards for accessibility. As a result, public pharmaceutical insurance programs designed to provide access to prescription medicines outside of hospitals have evolved independently in each province and territory. In May 2003, BC instituted Fair PharmaCare, an income-based catastrophic drug coverage program which links individuals’ private financial contributions to the costs of their medicines (either out-of-pocket or through their private insurance), with their household income. Current research suggests that the implementation of income-based drug coverage has shifted the financial burden away from public sources toward private ones, which raises several important questions regarding equity. Using data from three comprehensive, population-level health care databases, namely: 1) the BC PharmaNet; 2) the British Columbia Linked Health Database (BCLHD); and 3) Fair Pharmacare registration files, Ms. Hanley is investigating the degree of income-related inequity in medicine use before and after the BC policy change in the general population, and in specific subpopulations (e.g., drug use after myocardial infarction). The analysis of specific subpopulations will allow for evaluation of the use of essential medicines and of medications known to be safe and effective. Further, it will enable greater needs standardization. Additionally, she is evaluating the redistributive effect of the policy change on income distribution in BC, specifically focusing on determining inequity in pharmaceutical financing among individuals of equivalent incomes. Taken overall, the results of the project will provide timely and relevant evidence to federal and provincial policy makers, as well as all Canadians, when Pharmacare reform is increasingly on the policy agenda.
Research Pillar: Health Services
An Innovative Approach to Providing Patient Care: Examining the Role of the Nurse Practitioner in Primary Care Group Medical Visits
As the Canadian population ages, primary health care has increased its focus on the prevention and management of chronic disease in the elderly. However, access to primary care providers such as family doctors has become more difficult in recent years. Consequently, nurse practitioners (NPs) are increasingly delivering primary health services for people with chronic disease through what’s called the group medical visit (GMV). GMVs are a model of care delivery in which primary care is offered in a group format, instead of single patient/provider format. GMVs are being implemented across BC as part of the practice support program aimed at improving the primary health care system in the province. Past work indicates that patients and providers of GMVs are satisfied with GMVs. However, research on their effectiveness is limited. Laura Housden is examining the role of NPs in providing GMVs in BC and whether or not the GMV format is associated with quality patient care, such as patient self management of disease and chronic disease health indicators. To that end, she is conducting in-depth interviews with NPs currently providing GMVs. Direct observation of GMVs will be undertaken to better understand the process of the visit and context of the appointments. Chart audits will also be done to determine quality of care. The results of Ms. Housden’s research will provide a greater understanding of the role of NPs in providing GMVs, as well as the effectiveness of this care model in reaching and caring for people with chronic illnesses. Ultimately, this information could help to inform public health policy in BC.
A cross-national evaluation of opioid dependence treatment service systems in Canada and the United States
Methadone maintenance treatment (MMT) is the most effective form of treatment for opioid dependence, a chronic, recurrent disease. However, the availability and means by which MMT is delivered varies greatly, both locally and internationally. Understandably, the resulting accessibility, quality and comprehensiveness of care provided through the various treatment practices have important public health implications, and require careful consideration. Notably, there are vast differences between the drug treatment systems in California and British Columbia. Treatment for opioid dependence remains restricted in California due to regulatory constraints on treatment settings, (i.e. registered drug treatment centres), and physician practice, (i.e. limits on the number of patients per physician). Nonetheless, treatment through drug treatment centres may offer some advantages. In comparison, access to MMT in BC has improved following administrative transfer from the federal government to provincial colleges of physicians and subsequent deregulation through the introduction of community-based treatment (i.e. office-based prescription and dispensation in community-based pharmacies). Community-based treatment may maximize access, albeit at a relatively high cost, although the economic merits of maximizing access are well-established. Building on his earlier research in this area, Mr. Nosyk is working to identify differences in patient characteristics, treatment outcomes and costs of opioid dependence treatment systems in both the countries, with a specific focus on the performance of the treatment systems in terms of effectiveness, efficiency and equity. The knowledge gained from his research can be extended to estimate the health and economic impact of introducing treatment services at the population-level, and corresponds with long-term recommendations to expand services to provide more comprehensive treatment for substance users in BC.
Knowledge representation in Health Research: the Canadian Influenza Research Network model
The Public Health Agency of Canada estimates that influenza infection currently results in an average of 20,000 hospitalizations and 4,000 deaths each year. Therefore, an influenza pandemic would have severe health, economic and social consequences. The Public Health Agency of Canada/Canadian Institutes of Health Research Influenza Research Network (PCIRN) was developed to identify research gaps in the country's pandemic influenza preparedness initiative. To facilitate the initiative, research will be done at various sites across the country, supported by a common information technology (IT) group. An essential mission of the IT support group is to develop standards ensuring proper communication and knowledge transmission amongst the different members of the network. Currently, differences in interpretation of the 'meaning' of data or semantic heterogeneity pose a significant challenge to combine information from multiple heterogeneous sources. In order to efficiently integrate information generated by the various centres constituting the network, a consistent representation of data must be adopted.
Mélanie Courtot's research centres on the development of a model to unambiguously interpret influenza data. Working in collaboration with Dr. Scheuermann, leader of the BioHealthBase project, the equivalent of the PCIRN network in the United States, Ms. Courtot will develop a guideline outlining the minimum information required, and derive a data model that captures the necessary elements and the semantic relationships between them, which will allow for the integration of Canadian and American data, thereby assisting in the development of a North American influenza data network. Establishment of standards for unambiguous data representation and investigation modeling will improve the integration and re-use of information produced, and ultimately increase the quality and re-usability of that information and decrease the cost of health care.
The Impact of a Resident Work Schedule Change on Patient Safety
After graduation from medical school, physician education continues in a residency program in the individual's chosen area of specialty (e.g., Surgery, Internal Medicine). Residency programs have grueling schedules with frequent on-call shifts. These shifts are at least 24 hours in length, starting from the morning of one day and extending to the next day. In teaching hospitals, residents often provide first line care and make important decisions independent of direct supervision. Their clinical performance is thus an important determinant of patient safety. Some have argued that shift length should be reduced to a more reasonable amount (e.g. <16 continuous hours) to reduce fatigue and medical errors, and to improve safety.
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Reducing the Acute Care Burden of Childhood Asthma on Health Services in British Columbia
The study addresses the burden of pediatric asthma in BC and the value a short course of oral steroids provides in reducing the acute care burden of asthma. The goal is to implement and evaluate an intervention to reduce the acute care burden of asthma exacerbations.
Older Persons’ Transitions in Care
The purpose of this program of research is to improve care for frail elderly people in nursing homes and secondarily, to reduce the burden of elderly patients on emergency department resources and to give decision makers tools to identify potentially modifiable elements to improve the quality of care of residents who move between nursing homes and emergency departments.
Exit Strategies: The Timing and Impacts of Physician Retirements
Much has been made over the past fifteen years about the actual or impending shortage of physicians in Canada. The aging of the patient population increases the need, while the aging of the physician population reduces the supply. Recent dramatic increases in the number of medical students being trained in Canada should go some distance in addressing supply concerns. Less well-understood is the potential effect of changes in physicians’ decisions about when, and how quickly, to retire. Despite the fact that retirement decisions can have a large influence on the total available supply of physicians, surprisingly little is known about those decisions. The purpose of this project is to fill in some of those gaps in our understanding.
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Leadership and Health System Re-Design
The purpose of this initiative is to develop leadership capacity in the Canadian health care system. This will be done by identifying and addressing gaps in applied research and practical knowledge within and between the researcher and decision-maker communities. These individuals will be brought together as networks so they can better understand and learn from each other. The networks (one national and five regional nodes) will carry out research on how to identify and apply the qualities of effective leadership in regional settings across Canada and how to adapt the knowledge learned into professional development and degree programs offered in those regions.
An Integrated Regional Trauma Care Data System Linking Clinical Care and Process Outcome Evaluation
The purpose of this study is to devise a comprehensive strategy for continuous improvement of trauma care system that addresses substantial gaps in the availability of information regarding processes and outcomes of trauma care in British Columbia.