Some health care services are prioritized at the expense of others, due to limited resources. Many decision makers set priorities for allocating resources based on evidence derived through health economics and clinical research. The trend towards evidence-informed health policies has gained considerable momentum in Canada, particularly with pharmaceutical policy because drugs are a major cost driver in the health system. It is clear, however, that health policies are not determined solely on the basis of health research evidence. Kristy Armstrong is examining the roles played by evidence and other factors — such as an institution’s values, and the interests of key stakeholders — during decision making about drug coverage in both a regional health authority and a hospital in British Columbia. This study will help clarify the environment in which health policy is set and potentially point to ways of more effectively integrating use of evidence in decision making.
Research Pillar: Health Services
Estimating the economic burden of treating HIV/AIDS in the era of highly active antiretroviral therapy (HAART) with simulation modeling
AIDS is a chronic, life-threatening disease caused by the human immunodeficiency virus (HIV). HIV attacks the immune system, making people more susceptible to certain types of cancers and infection. Untreated patients generally survive about 10 years. Highly active antiretroviral therapy (HAART), which became widely available in 1996, has significantly reduced illness and death from HIV infection. However, the treatment regimen is expensive and the cumulative costs of treatment are growing as life expectancy increases. A crude estimate of treatment costs for HIV patients in Canada — drugs, physician and hospital visits and lab tests — exceeds $800 million a year. Because this cost estimate is based on simplistic assumptions, health care managers have asked for more accurate tools to help make policy decisions in HIV/AIDS management. Getting a handle on actual costs is particularly important given emerging evidence of an increase in the HIV incidence rate, in BC and across Canada. Karissa Johnston is developing a more sophisticated computer simulation model to accurately estimate the annual and lifetime medical costs for treating people infected with HIV. This tool will also predict how costs will change for various treatment protocols and population groups. Health planners will be able to use these estimates to assess the costs and benefits of disease prevention, drug compliance and various treatment strategies.
The epidemiologic and economic burden of illness of methanol and ethylene glycol poisoning in British Columbia
Methanol and ethylene glycol are the principle ingredients in automotive antifreeze products. When ingested, the result is organ failure and death unless treatment is initiated within hours of exposure. Survivors are at risk for blindness from methanol, or severe kidney damage from ethylene glycol, which can require weeks of dialysis. Treatment of methanol and ethylene glycol poisoning includes antidote therapy and use of dialysis to remove the poison. There are currently two antidotes available: ethanol and fomepizole. Ethanol is inexpensive but difficult to administer and causes many adverse effects. A new antidote, fomepizole, is relatively free of adverse effects, easy to use, and may prevent the need for dialysis in some patients, but it is very expensive. Katherine Lepik, a pharmacist with the BC Drug and Poison Information Centre, is researching the incidence, severity, mortality, and cost of methanol and ethylene glycol poisoning in BC. She is examining which age groups are at greatest risk for poisoning, why people are poisoned, and how to use health databases to monitor rates and severity of methanol and ethylene glycol poisoning. Her goal is to help prevent poisonings and ensure hospital staff have the resources and training to appropriately treat patients.
Mending and maintaining the quality of lives: Evaluating the treatment programs provided for mentally disordered offenders in British Columbia
The Forensic Psychiatric Hospital in British Columbia is currently evaluating approximately 30 rehabilitation programs offered to psychiatric patients who are found not criminally responsible for offenses because of severe mental illnesses, such as major mood disorders, schizophrenia and other psychotic disorders. While standard outcome indicators are needed to evaluate the effectiveness of these programs, these are difficult to develop because each patient experiences different symptoms and disabilities. Carol Wong is assessing a patient-centered evaluation tool (called Goal Attainment Scaling) for measuring patient improvement. Using this approach, the treatment team identifies and evaluates the most important goals and outcomes for each patient to achieve in a particular timeframe. Carol is also examining whether a patient’s readiness for treatment has an impact on outcomes, as this factor has consistently been overlooked in practice. The results of this research should help improve the effectiveness of rehabilitation programs, therefore reducing the likelihood of repeat offenses and improving mental health and quality of life for forensic psychiatric patients and their families.
The impact of co-payment and deductibles of prescription drugs: Estimating own and cross price elasticity of demand
Most health services in Canada are covered under the Canada Health Act. One major exception to this coverage is outpatient drugs. Most provinces have instituted cost sharing programs with patients, such as co-payments and deductible plans for prescription drugs. Researchers in the US found overall health care expenditures are reduced when patients make co-payments for prescription drugs, physician visits, or hospital admissions. Dr. Xin Li is investigating whether the opposite is true in Canada, since other health services are publicly funded. Xin is analyzing whether a co-payment plan for medications causes patients to use other “free” health services as substitutes for medication, resulting in an overall increase in health care expenditures. She is focusing on patients with rheumatoid arthritis because expensive drugs are increasingly the mainstay for treatment of the disease. This research will clarify the impact of user fees on the use of health care services among patients with rheumatoid arthritis in BC. The findings could be used to identify the most cost-effective approach for treating rheumatoid arthritis, and potentially, many other conditions.
The relationship between access to health care services and relocation for rural older adults: Is the decision to move one of choice or necessity?
Previous research comparing how older adults use health services in urban and rural areas of Canada is inconclusive and sometimes contradictory. Some research found no differences between urban and rural residents; other studies found that people living in rural areas tend to use fewer services than those in urban centres. Diane Allan is comparing health care use and the mobility patterns of urban and rural residents. She is tracking health service records for people 55 and older on Vancouver Island to determine health service use before and after a move, including physician and hospital visits, home support and long-term residential care. Diane is assessing whether the current health care system is able to accommodate people in rural areas who require more specialized and intensive services, and if a lack of services forces people to relocate closer to the health care they require. One challenge is developing an appropriate measure of rural and urban residence. Diane is comparing traditional measures developed by Statistics Canada, with measures based on geographic information systems (GIS) technology, such as distance to a hospital. From a policy perspective this research may help to clarify why some findings report few differences in health service utilization among rural and urban older adults. If only healthy older adults remain living in rural areas while those with poorer health are forced to relocate to more resource rich environments, similar health utilization does not necessarily suggest an adequate health care system. Diane hopes her research will contribute to determining if and why rural older adults move in order to place these utilization patterns into context.
The organization and utilization of chronic pain health services for Aboriginal and Anglo-Canadians
Chronic pain is a relatively common phenomenon that typically results in considerable health services use as well as significant hardship for the sufferer. Experts generally agree that chronic pain is often poorly managed leading to poor quality of life for the sufferer. Additionally, most experts suggest that access to appropriate chronic pain expertise is a major contributor to poor outcomes in the sufferer despite the existence of a variety of pain management programs/services. Because poorly managed chronic pain is so common, a critical look at chronic pain management services is warranted. Canadian health services must meet the needs of diverse Canadian populations and specialized services have been developed for some ethno-cultural groups. While all Canadian people may experience difficulties accessing health services, some are at a special disadvantage due to unfamiliarity or lack of comfort with our current system. Aboriginal-Canadians, who have historically had difficulties with access to the health care system, have been identified as a population at a special disadvantage. In this study I will speak with Aboriginal and Anglo-Canadian chronic pain sufferers and their health care providers. In addition I will observe how patients and the health professionals who look after them interact with one another. I will also examine materials that are written about current pain management programs and services. This study will lead to recommendations for improvements in the health services for chronic pain for these two populations.
Women with chest pain: Negotiating experiences of emergency department care
Cardiac disease is the number one killer of Canadian women. Research has shown that women and men have different experiences in the health-care system. Although emergency departments (ED) are often the first point of contact for women with cardiac symptoms, this setting has seldom been studied. Yet what happens during a visit to the ED may set the stage for later events. Treating heart attacks is highly time-dependent. If women get to an ED for treatment within four hours of the onset of symptoms, health professionals have a good chance of salvaging heart muscle that would otherwise be destroyed. Sheila Turris is investigating how experiences of emergency department care shape women’s decisions about seeking care in future situations. Specifically, she is examining how women arrive at the decision to seek treatment, and how they negotiate emergency care. This research may improve the quality of care women receive in emergency departments, helping to ensure women seek and get early, more effective treatment for signs of cardiac illness.
Treatment readiness and motivation research: improving quality of care and health outcomes
Treatment refusal, dropout, and relapse are common in individuals with eating disorders, resulting in physical and emotional costs to the patient, societal costs to the community, and economic costs to the health care system. Dr. Josie Geller’s previous research has shown that a patient’s readiness to change is the best predictor of clinical outcomes in the eating disorders. However, there remains a need for validated assessment tools and guidelines to determine which patients are ready for what type of treatment; development and evaluation of interventions that enhance readiness for treatment; and dissemination of findings from this research to clinicians and to community support providers on the benefits of matching treatment to patient readiness. The primary objective of Dr. Geller’s research is to use a patient-focused approach that draws upon applications of psychological models of readiness and motivation for change to improve health service delivery, utilization, and quality of care. Her program aims to provide a set of guiding principles for efficient, cost-effective care that has broad applications to the health care system, including eating disorders, HIV, Hepatitis C, and other emerging priority areas.
Access to kidney transplantation in British Columbia and Alberta
In Canada, there are large regional disparities in the waiting times for kidney transplantation. Previous studies show that these disparities cannot be explained by differences in the rate of organ donation or the incidence of kidney disease; instead, they may be the result of practice differences in referral or acceptance of patients for transplantation. Unlike waiting lists for most other medical services, increased waiting times for transplantation are clearly associated with loss of life. Currently, there is no formal, national system to ensure that medically eligible patients have equal access to transplantation across Canada. Very little research has been conducted regarding regional disparities in access to transplantation. To gain insight into the cause of these differences, Dr. John Gill is following a group of new dialysis patients in BC and Alberta to determine if there is a difference in referral for kidney transplantation or acceptance for transplantation within one year of starting dialysis. He will investigate the reasons why patients who are medically eligible for transplantation may not be referred for transplant, and document provincial differences in the time required to complete the transplant assessment and to activate a patient onto the transplant waiting list. Ultimately, this research will contribute to enhanced patient and physician education, better implementation of protocols to ensure that patients are appropriately referred, and new strategies to minimize regional disparities between provinces.