Exploring the Business Case for Improving Quality of Care for Patients With Chronic Rotator Cuff Tears.

BACKGROUND AND OBJECTIVES: Currently, management of patients presenting with chronic rotator cuff tears in Alberta is in need of quality improvements. This article explores the potential impact of a proposed care pathway whereby all patients presenting with chronic rotator cuff tears in Alberta would adopt an early, conservative management plan as the first stage of care; ultrasound investigation would be the preferred tool for diagnosing a rotator cuff tear; and only patients are referred for surgery once conservative measures have been exhausted. METHODS: We evaluate evidence in support of surgery and conservative management, compare care in the current state with the proposed care pathway, and identify potential solutions in moving toward optimal care. RESULTS: A literature search resulted in an absence of indications for either surgical or conservative management. Conservative management has the potential to reduce utilization of public health care resources and may be preferable to surgery. The proposed care pathway has the potential to avoid nearly Can $87 000 in public health care costs in the current system for every 100 patients treated successfully with conservative management. CONCLUSION: The proposed care pathway is a low-cost, first-stage treatment that is cost-effective and has the potential to reduce unnecessary, costly surgical procedures.

Effect of a vitamin and mineral supplementation on glycemic status: Results from a community-based program.

AIMS: Diet is a major risk factor for type 2 diabetes mellitus. As cofactors necessary for enzyme function of all metabolic pathways, vitamins and minerals have the potential to improve glucose metabolism. We investigated the effects of a nutrient intervention program on glycemic status. METHODS: We used a form of natural experiment to compare Pure North program participants (n = 1018) that received vitamin D alone (Vital 1) or vitamin D in combination with other nutrients (Vital 2) during two different time periods. Changes in 25-hydroxyvitamin D [25(OH)D], high-sensitivity C reactive protein (hs-CRP), glycated hemoglobin (HbA1c) and glycemic status were characterized over one and two years. RESULTS: Serum 25(OH)D concentrations increased significantly in both Vital 1 (to 111  ±â€¯â€¯49 nmol/L) and Vital 2 (to 119  ±â€¯â€¯52 nmol/L) over one year. HbA1c and hs-CRP were significantly reduced over time in Vital 2. Higher 25(OH)D levels after one year were associated with larger decreases in HbA1c and hs-CRP in Vital 2. At one year, 8% of Vital 2 and 16% of Vital 1 participants progressed from normoglycemia to prediabetes/diabetes, whereas 44% of Vital 2 and 8% of Vital prediabetes/diabetes subjects regressed to normoglycemia. CONCLUSIONS: Vitamin D combined with other nutrients was associated with a reduced risk of progression to diabetes and with an increased rate of reversion to normoglycemia in high risk participants. The results suggest that nutrient supplementation regimes may provide a safe, economical and effective means for lowering diabetes risk. Further examination of this potential via randomized controlled trials is warranted.

Innovation, productivity, and pricing: Capturing value from precision medicine technology in Canada.

For new technology and innovation such as precision medicine to become part of the solution for the fiscal sustainability of Canadian Medicare, decision-makers need to change how services are priced rather than trying to restrain emerging technologies like precision medicine for short-term cost savings. If provincial public payers shift their thinking to be public purchasers, value considerations would direct reform of the reimbursement system to have prices that adjust with technologically driven productivity gains. This strategic shift in thinking is necessary if Canadians are to benefit from the promised benefits of innovations like precision medicine.

A natural experimental study of the protective effect of home ownership on household food insecurity in Canada before and after a recession (2008-2009).

OBJECTIVES: Home ownership as opposed to renting is associated with lower rates of food insecurity, the latter being a marker of household economic deprivation associated with adverse health outcomes. It is unclear whether this relationship persists during a major economic decline, or whether different subgroups of home owners are equally protected. The 2008-2009 recession in Canada was tied to events in the United States related to inappropriate mortgage financing; the impact of the recession on food insecurity among home owners may identify policies to mitigate recessionary outcomes. METHODS: We used a before-and-after natural experimental design using data from the Canadian Community Health Survey (CCHS) cycles 2007/2008 (pre-recession) and 2009/2010 (post-recession) with information on household food insecurity, home ownership versus renting, and socio-demographics. Applying multivariable logistic regression, we examined changes in household food insecurity by housing tenure and sex over the period. RESULTS: Pre-recession, food insecurity affected 3.3% of home owners and 17.1% of renter households. Among home owners, the risk of food insecurity increased post-recession by 10%, which was not statistically significant. Post-recession, and with adjustment, although renters' higher absolute risk of food insecurity persisted, male-respondent home owners experienced the highest rate of increase in food insecurity prevalence by subgroup (OR = 1.26, 95% CI: 1.06-1.50) versus renters (OR = 1.17, 95% CI: 1.05-1.29). CONCLUSION: Housing policies in Canada protected most home owners from precarity during the 2008-2009 economic recession; however, male-respondent home owners exhibited a unique economic vulnerability during this time. Implications of Canadian home ownership policies are discussed in light of differential vulnerability of home owner groups.

Further validation and reliability testing of the Rotator Cuff Quality of Life Index (RC-QOL) according to the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines.

BACKGROUND: The Rotator Cuff Quality of Life Index (RC-QOL) was developed to evaluate quality of life in patients with rotator cuff disorders (RCD). The purpose of this study was to provide additional reliability, validity, and responsiveness testing in accordance with the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines. METHODS: Preliminary patient interviews included 15 patients. Seventy patients (mean age, 58; standard deviation, 9 years) with RCD were evaluated. Methodology testing included internal consistency, test-retest reliability, measurement error, content validity, and construct validity. Responsiveness, interpretability, and generalizability were also analyzed. RESULTS: The Cronbach α was 0.96 (95% confidence interval, 0.89-0.99; range, 0.72-0.94). The intraclass correlation coefficient for the RC-QOL was 0.87 (95% confidence interval, 0.79-0.85; range, 0.77-0.88). The standard error of measurement was 8 (range, 7-13). The smallest detectable change was 3 (range, 2-4). Content validity was confirmed through standardized patient interviews. All a priori hypotheses were confirmed. No floor or ceiling effects were present. The minimally clinical important difference ranged between 7 and 14 points. The study met the COSMIN criteria for interpretability and generalizability. CONCLUSION: The RC-QOL is a reliable and valid measure of health-related quality of life in patients with chronic RCD. The results of this study added to the methodologic quality assessment of the RC-QOL, completing 7 of 10 COSMIN criteria.

Impact of a guaranteed annual income program on Canadian seniors' physical, mental and functional health.

OBJECTIVE: Although there is widespread recognition that poverty is a key determinant of health, there has been less research on the impact of poverty reduction on health. Recent calls for a guaranteed annual income (GAI), defined as regular income provided to citizens by the state regardless of work status, raise questions about the impact, relative to the costs, of such a population health intervention. The objective of this study was to determine the impact of Canadian seniors' benefits (Old Age Security/Guaranteed Income Supplement, analogous to a GAI program) on the self-reported health, self-reported mental health and functional health of age-eligible, low-income seniors. METHODS: We used the 2009-2010 Canadian Community Health Survey to examine unattached adult respondents with an annual income of $20,000 or less, stratified by seniors' benefits/GAI eligibility (55-64 years: ineligible; 65-74 years: eligible). Using regression, we assessed self-reported health, selfreported mental health and functional health as measured by the Health Utilities Index, as outcomes for seniors' benefits/GAI-eligible and -ineligible groups. RESULTS: We found that individuals age-eligible for seniors' benefits/GAI had better health outcomes than recipients of conditional income assistance programs. Eligibility for seniors' benefits/GAI after age 64 was associated with better self-reported health, functional health and self-reported mental health outcomes, and these effects were observed until age 74. CONCLUSION: Using seniors' benefits as an example, a GAI leads to significantly better mental health and improved health overall. These improvements are likely to yield reduced health care costs, which may offset the costs associated with program expansion.

A Fifth Option for Funding Long-Term Care in Canada - Shift the Resources from Medical Treatment and Universal Pension Entitlements.

Needs for non-medical residential care services, long-term care (LTC), will increase over the next 30 years as Canada's population ages. Adams and Vanin (2016) explore four options for raising the public and private monies required to meet LTC needs. In this commentary, I raise a fifth option for finding the resources to meet emerging LTC needs. An alternative approach is to divert resources from Canada's well-resourced, but inefficient, medical treatment system. The dividend of provinces pursuing long overdue reforms to medicare is the liberation of public funds to finance emerging priorities for Canadians like LTC.

Autism research funding allocation: can economics tell us if we have got it right?

There is a concern that the allocation of autism spectrum disorder (ASD) research funding may be misallocating resources, overemphasizing basic science at the expense of translational and clinical research. Anthony Bailey has proposed that an economic evaluation of autism research funding allocations could be beneficial for funding agencies by identifying under- or overfunded areas of research. In response to Bailey, we illustrate why economics cannot provide an objective, technical solution for identifying the "best" allocation of research resources. Economic evaluation has its greatest power as a late-stage research tool for interventions with identified objectives, outcomes, and data. This is not the case for evaluating whether research areas are over- or underfunded. Without an understanding of how research funding influences the likelihood and value of a discovery, or without a statement of the societal objectives for ASD research and level of risk aversion, economic analysis cannot provide a useful normative evaluation of ASD research.

When working is not enough: food insecurity in the Canadian labour force.

OBJECTIVE: Food insecurity, lack of access to food due to financial constraints, is highly associated with poor health outcomes. Households dependent on social assistance are at increased risk of experiencing food insecurity, but food insecurity has also been reported in households reporting their main source of income from employment/wages (working households). The objective of the present study was to examine the correlates of food insecurity among households reliant on employment income. DESIGN: Working households reporting food insecurity were studied through analysis of the Canadian Community Health Survey, 2007-2008, employing descriptive statistics and logistic regression. Food insecurity was measured using the Household Food Security Survey Module; all provinces participated. SETTING: Canada. SUBJECTS: Canadian households where main income was derived through labour force participation. Social assistance recipients were excluded. RESULTS: For the period 2007-2008, 4% of working households reported food insecurity. Canadian households reliant on primary earners with less education and lower incomes were significantly more likely to experience food insecurity; these differences were accentuated across some industry sectors. Residence in Quebec was protective. Working households experiencing food insecurity were more likely to include earners reporting multiples jobs and higher job stress. Visible minority workers with comparable education levels experienced higher rates of food insecurity than European-origin workers. CONCLUSIONS: Reliance on employment income does not eliminate food insecurity for a significant proportion of households, and disproportionately so for households with racialized minority workers. Increases in work stress may increase the susceptibility to poor health outcomes of workers residing in households reporting food insecurity.

Legislated changes to federal pension income in Canada will adversely affect low income seniors' health.

OBJECTIVE: This study uses a population health intervention modeling approach to project the impact of recent legislated increases in age eligibility for Canadian federally-funded pension benefits on low income seniors' health, using food insecurity as a health indicator. METHOD: Food insecurity prevalence and income source were assessed for unattached low income (<$20,000 CAD) persons aged 60-64 years (population weighted n=151,350) versus seniors aged 65-69 years (population weighted n=151,485) using public use data from the Canadian Community Health Survey Cycle 4.1 (2007-2008). RESULTS: Seniors' benefits through federal public pension plans constituted the main source of income for the majority (79.4%) of low income seniors aged 65-69 years, in contrast to low income seniors aged 60-64 years who reported their main income from employment, employment insurance, Workers' Compensation, or welfare. The increase in income provided by federal pension benefits for low income Canadians 65 and over coincided with a pronounced (50%) decrease in food insecurity prevalence (11.6% for seniors ≥65 years versus 22.8% for seniors <65 years). CONCLUSION: Raising the age of eligibility for public pension seniors' benefits in Canada from 65 to 67 years will negatively impact low income seniors' health, relegating those who are food insecure to continued hardship.

Drinking water fluoridation and oral health inequities in Canadian children.

OBJECTIVES: One argument made in favour of drinking water fluoridation is that it is equitable in its impact on oral health. We examined the association between exposure to fluoridation and oral health inequities among Canadian children.PARTICIPANTS, SETTING AND INTERVENTION: We analyzed data from 1,017 children aged 6-11 from Cycle 1 of the Canadian Health Measures Survey, a cross-sectional, nationally representative survey that included a clinic oral health examination and a household interview. The outcome measure was a count of the number of decayed, missing (because of caries or periodontal disease) or filled teeth, either deciduous or permanent (dmftDMFT). Data were analyzed using linear (ordinary least squares) and multinomial logistic regression; we also computed the concentration index for education-related inequity in oral health. Water fluoridation status (the intervention) was assigned on the basis of the site location of data collection. OUTCOMES: Fluoridation was associated with better oral health (fewer dmftDMFT), adjusting for socio-economic and behavioural variables, and the effect was particularly strong for more severe oral health problems (three or more dmftDMFT). The effect of fluoridation on dmftDMFT was observed across income and education categories but appeared especially pronounced in lower education and higher income adequacy households. dmftDMFT were found to be disproportionately concentrated in lower-education households, though this did not vary by fluoridation status. CONCLUSIONS: The robust main effect of fluoridation on dmftDMFT and the beneficial effect across socio-economic groups support fluoridation as a beneficial and justifiable population health intervention. Fluoridation was equitable in the sense that its benefits were particularly apparent in those groups with the poorest oral health profiles, though the nature of the findings prompts consideration of the values underlying the judgement of health equity.

Social rates of return to investment in skills assessment and residency training of international medical graduates in Alberta.

Governments and physician organizations in Canada have identified current and anticipated future shortages of physicians. The creation of opportunities for licensure for the sizeable population of unlicensed international medical graduates (IMG) residing in Canada can alleviate some of the shortage of medical manpower. We examine whether expenditures on IMG skills assessment, training and licensing are a socially desirable use of resources. We estimate the financial rate of return to Alberta taxpayers from resources allocated to the Alberta International Medical Graduate (AIMG) program, started in 2001. Our estimates show that resources allocated to providing skills assessment and residency training opportunities for IMGs that lead to licensing as a Canadian physician generate real annual rates of return of 9-13%.