A taxonomy of demand-driven questions for use by evidence producers, intermediaries and decision-makers: results from a cross-sectional survey.

BACKGROUND: Globally, a growing number of calls to formalize and strengthen evidence-support systems have been released, all of which emphasize the importance of evidence-informed decision making. To achieve this, it is critical that evidence producers and decision-makers interact, and that decision-makers' evidence needs can be efficiently translated into questions to which evidence producers can respond. This paper aims to create a taxonomy of demand-driven questions for use by evidence producers, intermediaries (i.e., people working in between researchers and decision-makers) and decision-makers. METHODS: We conducted a global cross-sectional survey of units providing some type of evidence support at the explicit request of decision-makers. Unit representatives were invited to answer an online questionnaire where they were asked to provide a list of the questions that they have addressed through their evidence-support mechanism. Descriptive analyses were used to analyze the survey responses, while the questions collected from each unit were iteratively analyzed to create a mutually exclusive and collectively exhaustive list of types of questions that can be answered with some form of evidence. RESULTS: Twenty-nine individuals completed the questionnaire, and more than 250 submitted questions were analysed to create a taxonomy of 41 different types of demand-driven questions. These 41 questions were organized by the goal to be achieved, and the goals were grouped in the four decision-making stages (i) clarifying a societal problem, its causes and potential impacts; (ii) finding and selecting options to address a problem; (iii) implementing or scaling-up an option; and (iv) monitoring implementation and evaluating impacts. CONCLUSION: The mutually exclusive and collectively exhaustive list of demand-driven questions will help decision-makers (to ask and prioritize questions), evidence producers (to organize and present their work), and evidence-intermediaries (to connect evidence needs with evidence supply).

The Trajectory of Agency-Employed Nurses in Ontario, Canada: A Longitudinal Analysis (2011-2021).

In Canada, reports of nursing staff shortages, job vacancies and the use of private agency nurses, especially in hospitals, have increased since the start of the COVID-19 pandemic. Media reports suggest the pandemic exacerbated nursing shortages among other issues, and nurses are leaving their traditional positions to work at such agencies. Public spending on agency nurses has increased appreciably. Using 2011 to 2021 regulatory college data on all registered nurses (RNs) and registered practical nurses (RPNs) in the province of Ontario, Canada, we investigated trends in the count and share of nurses working for employment agencies. We also examined the rate at which previously non-agency employed nurses transition to employment in at least one agency job. We found the prevalence of RNs and RPNs reporting agency employment was relatively stable from 2011 to 2019, and decreased slightly in 2020 and 2021. However, there was a small increase in transitions from non-agency employment to working at an agency job. We also found the mean hours of practice in all jobs reported by agency and non-agency nurses increased during the pandemic. Based on these findings, an increase in hours and/or prices for agency nurses may explain the increase in public funding for agency nurses, but it was not driven by an increasing share of nurses working for employment agencies. To fully understand employment agency activity, policymakers may need to monitor hours of work and hourly costs rather than only costs. Further research is required to investigate any long-term effects the pandemic may have had on agency-employment.

Long-term trends in the work hours of physicians in Canada.

BACKGROUND: Physician work hours directly influence patient access to health care services and play a vital role in physician human resource planning. We sought to evaluate long-term trends in hours worked by physicians in Canada, overall and by subgroup. METHODS: We used Statistics Canada's Labour Force Survey to identify physicians via occupation and industry coding information. We estimated descriptive statistics and performed graphical analysis of the average weekly hours worked by physicians over the 1987-2021 period. RESULTS: Overall, weekly physician work hours remained stable from 1987 until 1997, after which they declined. Average weekly hours decreased by 6.9 hours (p < 0.001), from 52.8 in 1987-1991 to 45.9 in 2017-2021. Among male physicians, work hours declined notably after 1997, while those of female physicians remained relatively stable at around 45 per week. Hours worked by married physicians declined significantly, amounting to 7.4 fewer hours per week (p = 0.001). In contrast, unmarried physicians displayed a statistically insignificant decline of 2.2 hours (p = 0.3). The COVID-19 pandemic was associated with a sharp but brief disruption in weekly hours; by the end of 2020, physicians' work hours had returned to prepandemic levels. INTERPRETATION: These findings may indicate a long-term shift in work preferences among Canadian physicians; male physicians may be seeking a better work-life balance, which, in turn, has narrowed the gap in hours worked by sex, with potential implications for pay equity. Policymakers and planners should carefully consider changes in hours worked, rather than just the total number of physicians, to ensure an accurate evaluation of the physician workforce.

Matching the right study design to decision-maker questions: Results from a Delphi study.

Research evidence can play an important role in each stage of decision-making, evidence-support systems play a key role in aligning the demand for and supply of evidence. This paper provides guidance on what type of study designs most suitably address questions asked by decision-makers. This study used a two-round online Delphi approach, including methodological experts in different areas, disciplines, and geographic locations. Participants prioritized study designs for each of 40 different types of question, with a Kendall's W greater than 0.6 and reaching statistical significance (p<0.05) considered as a consensus. For each type of question, we sorted the final rankings based on their median ranks and interquartile ranges, and listed the four study designs with the highest median ranks. Participants provided 29 answers in the two rounds of the Delphi, and reached a consensus for 28 (out of the 40) questions (eight in the first round and 20 in the second). Participants achieved a consensus for 8 of 15 questions in stage I (clarifying a societal problem, its causes, and potential impacts), 12 of 13 in stage II (finding options to address a problem) and four of six in each of stages III (implementing or scaling-up an option) and IV (monitoring implementation and evaluating impact). This paper provides guidance on what study designs are more suitable to give insights on 28 different types of questions. Decision-makers, evidence intermediaries (, researchers and funders can use this guidance to make better decisions on what type of study design to commission, use or fund when answering specific needs.

Characterizing No-shows in the Omani Primary Healthcare Setting.

Objectives: Patient 'no-shows' (failure to keep or cancel appointments) is a global problem that impacts healthcare systems by delaying patient access to healthcare, reducing quality of care, and wasting resources. The no-show phenomenon has not yet been studied in Oman despite it having grown in importance ever since the appointments system was implemented in 2014. This study aimed to characterize the no-shows in primary healthcare facilities in Oman. Methods: We collected and analyzed administrative data during the period 2014-2017 from 14 primary healthcare institutions in Oman focusing on the ophthalmology, ear, nose, and throat, and dermatology clinics therein. Results: The overall no-show rates were > 50.0%. No-show probabilities were higher in males, younger adults, new appointments, early morning appointments, appointments during Ramadan, and appointments scheduled farther in advance. Patient experience with the appointment system reduced the no-show probability. Conclusions: Policymakers should consider these trends to optimize the number of appointments per day, and researchers should further investigate no-shows for other specialties and levels of care.

Multiple jobholding and part-time work among nurses in long-term care homes compared to other healthcare sectors: Evidence from Ontario.

About two-thirds of Canadian COVID-19 related deaths occurred in long-term care homes (LTCHs). Multiple jobholding and excessive part-time work among staff have been discussed as vectors of transmission. Using an administrative census of registered nurses (RNs) and registered practical nurses (RPNs) in the Canadian province of Ontario, this paper contrasts the prevalence of multiple jobholding, part-time/casual work, and other job and worker characteristics across health sectors in 2019 and 2020 to establish whether the LTCH sector deviates from the norms in Ontario healthcare. Prior to COVID-19, about 19% of RNs and 21% of RPNs in LTCHs held multiple jobs. For RPNs, this was almost identical to the RPN provincial average, while for RNs this was 2.5 percentage points above the RN provincial average. In 2020, multiple jobholding fell significantly in LTCHs after the province passed a single site order to reduce COVD-19 transmission. Although there are many similarities across sectors, nurses, especially RNs, in LTCHs differ on some dimensions. They are more likely to be internationally educated and, together with nurses in hospitals, those who work part- time/casual are more likely to prefer full-time hours (involuntary part-time/casual). Overall, while multiple jobholding and part-time work among nurses are problematic for infection prevention and control, these employment practices in LTCHs did not substantially deviate from the norms in the rest of healthcare in Ontario.

The gender earnings gap in medicine: Evidence from Canada.

Despite the gender gap in physician earnings being of concern to many in Canada, its existence is far from universally accepted and there are no studies covering all physicians/regions or addressing earnings rather than billings. This may explain the lack of serious consideration or remedial action by medical associations and governments in negotiations, or tariff and compensation processes. Our study employs 2016 Canadian Census data linked to Canada Revenue Agency taxation records. Rather than focusing on gross billings, we model physician net earnings (after overhead expenses and controlling for hours/weeks of work) including dividends from corporations. Using OLS, and unconditional quantile regression to document the gap across the earnings distribution, we observe that Canadian female physicians, on average, earn 9.3% less than their male counterparts. The average adjusted gap is slightly smaller for family physicians (8.5%) than other specialists (10.2%). Beyond averages, at the top of the income distribution the gap is double that at the median for both family physicians and other specialists. The gap also varies across provinces, from 6.6% in Quebec to 19.8% in Manitoba. Although our results yield somewhat smaller estimates than those from studies using billings/self-reported income, the magnitudes remain appreciable. The findings substantiate the claim that the gender pay gap in Canadian medicine is pervasive.

Inequity in insurance coverage for prescription drugs in New Brunswick, Canada.

OBJECTIVES: To describe the extent to which New Brunswick residents reported having drug insurance coverage supplementary to Canadian Medicare; to examine associations between socioeconomic and demographic characteristics, health status, language identity, and having reported such coverage; and to document any changes in coverage associated with the introduction of the New Brunswick Drug Plan in 2014. METHODS: We used repeated cross-sectional data for New Brunswick from eight cycles of the Canadian Community Health Survey from 2007 to 2017 and undertook logistic regression analysis. RESULTS: We found statistically significant, substantial and policy-relevant socioeconomic differences in the reporting of prescription drug insurance coverage among those 25-64 years and those ≥ 65 years of age, and an increasing reliance on private drug insurance over time. We found that individuals in the second decile of household income were particularly vulnerable to reporting neither public nor private drug coverage. The introduction of the New Brunswick Drug Plan in 2014 does not appear to have led to increased public drug coverage; however, from 2014, the decreasing trend in public drug coverage appears to have ceased. Those who reported lower health status usually had lower odds of reporting private drug coverage but higher odds of reporting public drug coverage. Driven by differences in private coverage, we found that relative to anglophones, francophones were less likely to report any drug coverage. CONCLUSION: Our findings emphasize the shortcomings of drug insurance systems such as that introduced in New Brunswick and substantiate calls for a universal drug program. New Brunswick's increasing reliance on private drug insurance is of concern and warrants additional research.

RéSUMé: OBJECTIFS: Décrire la mesure dans laquelle les résidents du Nouveau-Brunswick ont déclaré avoir une couverture d'assurance médicaments supplémentaire au régime public d'assurance maladie canadien; examiner les associations entre les caractéristiques socioéconomiques et démographiques, l'état de santé, l'identité linguistique et avoir déclaré une telle couverture; et documenter tout changement de couverture associé à l'introduction du Régime médicaments du Nouveau-Brunswick en 2014. MéTHODES: Nous avons utilisé des données transversales répétées du Nouveau-Brunswick de huit cycles de l'Enquête sur la santé dans les collectivités canadiennes de 2007 à 2017 et avons entrepris une analyse de régression logistique. RéSULTATS: Nous avons constaté des différences socioéconomiques statistiquement significatives, substantielles et pertinentes en matière de politiques dans la déclaration de la couverture d'assurance médicaments chez les 25 à 64 ans et les 65 ans et plus, et une dépendance croissante à l'égard de l'assurance médicaments privée au fil du temps. Nous avons constaté que les personnes appartenant au deuxième décile du revenu du ménage étaient particulièrement vulnérables au fait de ne pas avoir déclaré d'assurance médicaments publique ou privée. La mise en place du Régime médicaments du Nouveau-Brunswick en 2014 ne semble pas avoir entraîné une augmentation de la couverture publique des médicaments; cependant, à partir de 2014, la tendance à la baisse de la couverture publique des médicaments semble avoir cessé. Ceux qui ont déclaré un état de santé inférieur avaient généralement une cote exprimant la probabilité plus faible de déclarer une assurance médicaments privée, mais plus élevée de déclarer une couverture publique des médicaments. En raison des différences de couverture privée, nous avons trouvé que, par rapport aux anglophones, les francophones étaient moins susceptibles de déclarer une couverture pour les médicaments. CONCLUSION: Nos résultats mettent en évidence les lacunes des systèmes d'assurance médicaments comme celui mis en place au Nouveau-Brunswick et justifient les appels en faveur d'un programme universel de médicaments. La dépendance croissante du Nouveau-Brunswick à l'égard de l'assurance médicaments privée est préoccupante et justifie des recherches supplémentaires.

Associations of health services utilization by prescription drug coverage and immigration category in Ontario, Canada.

Canada is the only high-income country with a universal healthcare system that does not provide prescription drug coverage for all its residents. This study examines whether Canadians' prescription drug coverage status is associated with their health services use and how this association differs by gender across non-migrants and three categories of migrants: economic immigrants, family-class immigrants, and refugees. Very few studies have examined differences across these migrant groups, and there is a need to do so as they experience varying health disparities. This study contributes to the prescription drug coverage, migration and health literature by employing an intersectional lens to analyze a sample of Ontario working-aged residents (n=39,792) generated from linking the Canadian Community Health Survey (2005, 2008, 2013, 2014) and Longitudinal Immigrant Database. Predicted probabilities and average marginal effects from multivariable logistic regression models were generated, and interaction effects between prescription drug coverage and immigrant status were examined. The study reveals important differences in the use of health services across prescription drug coverage groups by immigration status. As the general debate about universal pharmacare in Canada is ongoing, this study reveals that drug insurance is positively associated with health services use of most migrants and non-migrants, however, some immigrant women may still experience barriers to access general practitioner services. If pharmacare is introduced, ongoing evaluation is needed to ensure that its implementation produces equitable outcomes for all.

Exploring the Results of the Ontario Home Care Minimum Wage Change.

Background: :In 2014, Ontario increased its "minimum wage" for personal support workers (PSWs) in publicly funded home care. Objective: The objective of this article is to determine the short-term results of this policy for home care PSWs' wages, hours and job stability. Methods: This study uses descriptive graphs and ordinary least squares and unconditional quantile regressions, using PSWs across Canada as comparison groups. Results: Pre-policy nominal wages for Ontario home care PSWs stagnated, whereas real wages declined. The policy increased home care PSWs' wages without noticeably affecting hours or job stability. However, wages were already increasing for low-wage home care workers in the rest of Canada. Conclusions: Ontario exercises monopsony power in the home care market and, before the wage increase, kept nominal wages stable compared to rising real and nominal wages in the rest of Canada. This PSW-specific wage increase did not represent a drastic change relative to market conditions.

Delisting eye examinations from public health insurance: Empirical evidence from Canada regarding impacts on patients and providers.

This paper examines the impacts of delisting routine eye exam services on patient eye care utilization and on providers' labour market outcomes in a public healthcare system. Provincial governments in Canada started to de-insure routine eye examinations from the basket of publicly insured healthcare services in the early 1990s. We explore these policy changes across Canadian provinces to estimate the impacts of delisting from the supply- and demand-sides. Demand side analysis suggests that, on average, for the working age population delisting decreased the probability of using eye care. However, the number of visits among those who continued to use eye care services did not change. Additionally, the delisting may have had unintended consequences by causing a large negative impact among low-income individuals, and there is suggestive evidence of a positive spillover on utilization by publicly-funded patients over age 64. On the supply side, using Canadian census data we find that delisting eye exams decreased optometrists' weekly work hours, raised their annual work weeks and had little effect on their income.

Socioeconomic differences in prescription drug supplemental coverage in Canada: A repeated cross-sectional study.

BACKGROUND: Efforts to achieve universal healthcare coverage are fraught with challenges, not only in low- and middle-income countries but also in high-income ones. Canada, for example, is the only high-income country with universal health insurance that does not include universal coverage for prescription drugs. We first described the extent to which Canadians reported supplementary drug insurance coverage (public or private). Second, we examined associations between individuals' socioeconomic and demographic characteristics and self-reported drug insurance coverage. METHODS: We used logistic regressions and repeated cross-sectional data from two national (2015, 2016) and six Ontario (2005, 2008, 2013-2016) cycles of the Canadian Community Health Survey. RESULTS: We found large socioeconomic differences in the reporting of prescription drug insurance coverage. Individuals of lower socioeconomic status had higher odds of reporting public drug coverage or no coverage while those of higher socioeconomic status had higher odds of reporting private coverage. Respondents' reports indicated that public drug plans were more likely to cover those in poorer health while private plans were more likely to cover those in very good or excellent health. We also documented substantial underreporting of public drug coverage. which may also have access implications. INTERPRETATION: Both the lack of prescription drug insurance and misunderstandings about one's insurance coverage point to limits in Canada's drug insurance system.

Payment models in primary health care: A driver of the quantity and quality of medical laboratory utilization.

Physician payment models' incentives regarding many aspects of primary health care are not well understood. We focus on the case of medical laboratory utilization and examine how physicians' laboratory test ordering patterns change following a switch to a blended capitation payment model from one with fee for service enhanced with pay for performance. Also, within blended capitation, we examine differences between traditional staffing and interdisciplinary teams. Using a propensity score weighted fixed-effects specification to address selection, it is estimated that the switch to capitation leads to a short-run average of 3% fewer laboratory requisitions per patient. Patients' laboratory utilization also becomes more concentrated with the rostering physician. More importantly, using diabetes-related laboratory tests as a case study, after joining the blended model, physicians order 3% fewer inappropriate/redundant tests, and the addition of an interdisciplinary care team makes the reduction about 9%. Advances in both continuity and quality seem to be associated with blended capitation.

Measuring Physicians' Incomes with a Focus on Canadian-Controlled Private Corporations.

Understanding physician remuneration and its growth is extremely complex, much more so than for a typical worker. Highlighting one narrow aspect of this issue, this paper focuses on governments' increased incentives for physicians to incorporate and the ensuing physician response in the period 1996-2011. Nationally, incorporation rates increased for both general practitioners and specialists between 1996 and 2011. We observe that the largest changes in provincial regulation were in Ontario, and incorporation increased from 18% in 2001 to 54% five years later. Incorporation is less common in Quebec, where the incentives were the weakest. Married male physicians, middle-aged physicians (regardless of sex), physicians with higher incomes and physicians born outside of Canada are all more likely to incorporate their practices. On average, incorporated physicians realized a 4% reduction in personal income taxes and accumulated retained earnings of at least $10,000 per annum in their Canadian-controlled private corporations in our data period. The benefits of incorporation stem largely from retained earnings and income splitting. Many physicians benefit from one or both; however, the benefits of incorporation are not equally distributed. Sex, marital status and income affect the magnitude of the financial benefit of incorporation.

Blended capitation and incentives: Fee codes inside and outside the capitated basket.

Blended capitation physician payment models incorporating fee-for-service (FFS), pay-for-performance and/or other payment elements seek to avoid the extremes of both FFS and capitation. However, evidence is limited regarding physicians' responses to blended models, and potential shifts in service provision across payment categories within the practice. We examine the switch from FFS to a blended capitation-FFS model for primary care physicians in group practice. The empirical analysis shows patients experiencing 9-14% reductions in capitated services and simultaneous increases of 10-22% in FFS services from their rostering physicians. Unusually, our data permit changes among non-rostering physicians to be observed. Other physicians within the rostering group reduce the provision of capitated fee codes, with no net change in FFS services. All other physicians in the jurisdiction reduce both capitated and FFS services, which is consistent with patients concentrating their primary care with one provider as a result of capitation.

Rates of inappropriate laboratory test utilization in Ontario.

BACKGROUND: Medical laboratory tests ordered redundantly represent one of the targets for reducing diagnostic testing without negatively, and possibly positively, affecting patient care. We study a clearly defined category of excessive laboratory utilization for nine analytes where inappropriate diagnostic testing is defined in terms of the time interval between tests; that is, ordering a test too soon following the previous order of the same test. METHODS: Population data from the near universal public Ontario Health Insurance Plan for the years 2006-2010 are employed where the tests are fulfilled by community medical laboratories. The analytes selected for consideration are thyroid stimulating hormone, hemoglobin A1c, lipid profile, serum protein electrophoresis, immunofixation, quantitative immunoglobulins, Vitamin D, Vitamin B12, and folate. RESULTS: For the nine analytes studied, the percentage of inappropriate tests ranged from 6% to 20%. Large proportions of these inappropriate tests were completed >2weeks prior to the minimum threshold to reorder defined by practice guidelines and/or were repeated excessively within a year. Between 60% and 85% of the time, the ordering physician of an inappropriate test was the same physician who ordered the previous test. Specialists were more likely than primary care physicians to order repeat tests too soon. CONCLUSIONS: A sizeable proportion of testing for these analytes was inappropriate according to practice guidelines. It is recommended that systems for preventing unnecessary repeat testing are investigated by the funding agencies and that reducing inappropriate testing be considered as a design element for electronic medical records and related information technology systems.

Ontario primary care models: a descriptive study.

BACKGROUND: Between 2001 and 2006, the Ontario government introduced a menu of new primary care models, with elements such as patient enrolment and minimum group sizes, and various combinations of fee-for-service, capitation, pay-for-performance and salary. From the statistical perspective of physicians, as opposed to patients, we looked at the distribution of physician characteristics, group size and patient visit patterns across models to describe primary care practice in Ontario. METHODS: Using administrative data for fiscal year 2010/11 containing information on physician characteristics, patient rostering status, patient visits and other practice information, we described similarities and differences across primary care models. RESULTS: Our sample included 11 626 family physicians. Compared with physicians in the new primary care models, physicians in fee-for-service models are much more likely to work part-time and many, particularly younger and female physicians, do not work in full-year full-scope practices. Among the new primary care models, physicians in capitated models are slightly younger, are less likely to be an international medical graduate, work in smaller physician teams and do not practice in urban areas. On average, physicians saw and rostered 1888 patients. Although there is still substantial variation within each model, fee-for-service physicians saw the fewest patients; physicians in capitated models saw somewhat more, and those in the noncapitated models saw the most patients. INTERPRETATION: Practice and physician characteristics vary systematically across models. A high percentage of rostered patients see physicians outside the group with which they are rostered. Group-based primary care models may not have a large impact on group integration and continuity in the provision of primary care services.

Mandatory universal drug plan, access to health care and health: Evidence from Canada.

This paper examines the impacts of a mandatory, universal prescription drug insurance program on health care utilization and health outcomes in a public health care system with free physician and hospital services. Using the Canadian National Population Health Survey from 1994 to 2003 and implementing a difference-in-differences estimation strategy, we find that the mandatory program substantially increased drug coverage among the general population. The program also increased medication use and general practitioner visits but had little effect on specialist visits and hospitalization. Findings from quantile regressions suggest that there was a large improvement in the health status of less healthy individuals. Further analysis by pre-policy drug insurance status and the presence of chronic conditions reveals a marked increase in the probability of taking medication and visiting a general practitioner among the previously uninsured and those with a chronic condition.