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Objective To estimate the impact of the coronavirus disease 2019 (COVID-19) pandemic on FP finances in Alberta. Design A financial model that included fees, visits per day, number of days of practice, and overhead costs. Setting Alberta before, during, and after the COVID-19 pandemic. Participants Hypothetical fee-for-service FP practices. Interventions Changes in practice modes caused by the pandemic and changes to fees set by the Government of Alberta (no interventions were controlled by the researchers). Main outcome measures Annual average FP billings and annual average FP income after overhead expenses. Results Practice changes related to COVID-19 could result in a reduction in average FP income (billings after expenses) of 27% to 78%. Conclusion Practice pattern changes, including the rapid adoption of telemedicine owing to the COVID-19 pandemic, will reduce incomes for fee-for-service community FP practices in Alberta. Fees at current levels could make some practices unsustainable.

Objectives To describe the trends in pharmacologic treatment for patients newly diagnosed with chronic obstructive pulmonary disease (COPD) in Alberta, Canada. Methods We linked Alberta health databases to identify patients aged ≥35 years with incident COPD between April 2010 and March 2017. Incident cases were defined as those who did not have a hospitalization or outpatient visit with COPD in the previous 2 years. Patients were categorized into two groups: 1) incident cases at a hospital and 2) incident cases at an outpatient clinic, and both were followed until death or being censored by 31 March 2018. Utilization of COPD medication for 30 days following incident event and adherence in maintenance therapy over time were reported. Results The study included 33,169 patients with incident COPD (hospital: 9,089; outpatient: 24,080). In 18,666 (56.3%) patients starting medication within 30 days of the incident event (2010: 52.7%; 2016: 56.6%; p=0.002), SABA (60.5%) and LABA/ICS (41.6%) were most commonly used. ICS (without LABA) was used in 14.2% and was used as monotherapy in 4.5% of patients. The proportion of patients who initiated any ICS was similar (hospital: 56.7%; outpatient: 55.7%; p=0.194) and decreased in both settings over time (p

Objective The objective of this study was to estimate the provincial and nationwide costs of industry-sponsored drug clinical trials (CTs) in Canada. Methods We used the Aggregate Analysis of ClinicalTrials.gov (AACT) database, and included all industry-sponsored drug CTs that were conducted in Canada and completed in 2016. We estimated the costs of the study drugs using the market price. Estimates of the costs of management and patient services were based on industry contracts. Results The sample included 394 CTs that were conducted in 2039 facilities in Canada and provided services for 20,126 Canadian enrollees. Two-thirds of the CTs (277 of 394) were in the non-cancer category. On average, the drug costs per patient were 89,680 Canadian dollars ($Can) during the lifespan of the CTs, and were higher in cancer CTs than in non-cancer CTs ($Can216,876 vs. $Can65,274). The total costs of industry-sponsored drug CTs completed in 2016 was $Can2093.7 million. Drug costs accounted for the majority of this total ($Can1804.9 million). Ontario ($Can781.2 million) and Quebec ($Can757.5 million) had the highest costs. Conclusion The costs of industry-sponsored drug CTs completed in 2016 when measured in terms of market prices in Canada were valued at $Can2.1 billion. Electronic supplementary material The online version of this article (10.1007/s41669-019-0161-0) contains supplementary material, which is available to authorized users.

Objective Our objective was to describe the costs of industry-sponsored clinical trials for medical devices in Northern Alberta, Canada. Methods We used centralized data to identify all industry-sponsored medical device clinical trials initiated in Northern Alberta from 2012 to 2016. For each arm of each trial, we calculated the price of devices provided by the sponsor and the cost of clinical and administrative services that were incurred to clinically operationalize the treatment. Results Our sample consisted of 18 device trials initiated between January 2012 and January 2016. The overall cost (Canadian dollars [$Can], year 2018 values) per enrolee was $Can18,243 for the experimental arm and $Can13,827 for the control arm. Devices were the highest cost component, at $Can13,446 per enrollee in the experimental arm. Clinical costs in the control arms were higher on average ($Can7202 vs. 2504) than those in the experimental arms. Conclusion Data from industry-sponsored clinical trials can provide important information on the full costs of device-related interventions. As device costs rise, and as policy makers require more evidence on device-related treatments, the cost of medical device-driven interventions should be documented along with their effectiveness.

Objective Low productivity while at work (presenteeism) has been reported to produce significant cost excesses for organizations and economies. However, many of these reports have been based on estimates drawn from self-report instruments that are not supported by evidence showing their efficacy. Thus, the aim of this study was to assess associations between responses to leading self-report tests of presenteeism and self-recorded on-the-job productivity. Methods Health care worker self-ratings of productivity were taken from a questionnaire that contained the key item from each presenteeism instrument. Productivity levels were drawn from employee reported daily work activity logs. Results Test-based productivity estimates did not show strong associations with daily recordings of work activity. Conclusions Associations were too low to recommend any test as a proxy measure for reported productivity. It is suggested that objective measures of work output be explored.

Recently, both the Canadian and provincial governments have instituted policies to reduce manufacturers’ prices for generic ($250 million sales annually) and brand name ($1,300 million sales annually) drugs. Both government groups made estimates of the financial magnitude of changes in drug prices, but neither has estimated the impact on retail pharmacies. We used a Cost-Volume-Profit model combined with operational data collected nationally to estimate the national impact of the pricing policy changes on pharmacy gross profits. Results show the average value of gross profits per pharmacy per year was approximately $440,000. It is estimated that the policy changes will lead to a 6.8% reduction in gross profits. Adding reductions in rebates for generic drugs, the pharmacies’ reductions in gross profits will be 7.2%. In conclusion, policy-makers often ignore how their pricing changes influence the financial position of pharmacies, even though the impact can be substantial.

BackgroundCanada has a long history of the use of clinical evidence to support healthcare decision making. Given improvements in data holdings and analytic capacity in Canada and stakeholder interest, the purpose of this study is to reflect on perceptions of the value of real-world evidence in pricing and reimbursement decisions, barriers to its optimal use in pricing and reimbursement, current initiatives that may lead to its increased use, and what role the pharmaceutical industry may play in this.Methods/ResultsTo capture stakeholder perceptions, ninety-one participants identified as key stakeholders were identified according to background roles and geography and invited to participate in four round table discussions conducted under Chatham House rule. Important themes emerging from these discussions included: (i) the need to understand what “real world” evidence means; (ii) barriers to using real world evidence from differences in access, governance, inter-operability, system structures, expertise, and quality across Canadian health systems; (iii) differing views on industry's role.ConclusionsThe use of real-world data in Canada to inform pricing and reimbursement decisions is far from routine but nascent and slowly increasing. Barriers, including interoperability concerns, may also apply to other federated health systems that need to focus on the networking of healthcare administrative data across provincial jurisdictional boundaries. There also appears to be a desire to see better use of pragmatic trials linked to these administrative data sets. Emerging initiatives are under way to use real world evidence more broadly, and include identification of common data elements and approaches to networking data.

Clinical research is funded by industry, governments, charities, and hospitals. It is important to know the economic commitment of the various funding bodies, but until now there has been no national source available which provides these data. We surveyed the major funders to provide such a measure. There is evidence that government and charity funding of medical research is a trigger for private sector research investment; therefore, tracking all sources of funding for clinical research will provide policy-makers with an overall picture of health research funding. These data support policy decision-making related to clinical research in Canada.

Objective: The purpose of this study is to measure provincial spending for mental health services in fiscal year (FY) 2013 and to compare these cost estimates to those of FY 2003. Methods: This study estimated the costs of publicly funded provincial mental health services in FY 2013 and compared them to the estimates for FY 2003 from a previously published report. Our data were obtained from publicly accessible databases. The cross-year cost comparisons for provincial mental health services were restricted to general and psychiatric hospital inpatients, clinical payments to physicians and psychologists, and prescribed psychotropic medications. Total public expenditures were inflation adjusted and expressed per capita and as a percentage of the total provincial health spending. Results: Total public spending for mental health and addiction programs/services was estimated to be $6.75 billion for FY 2013. The largest component of the expenditures was hospital inpatient services ($4.02 billion, 59.6%), followed by clinical payments to physicians or psychologists ($1.69 billion, 25%), and then publicly funded prescribed psychotherapeutic medications ($1.04 billion, 15.4%). Nationally, the portion of total public spending on health that was spent on mental health decreased from FY 2003 to FY 2013 from 5.4% to 4.9%. Conclusion: Our results reveal that mental health spending, as a proportion of public health care expenditures, decreased in the decade from FY 2003 to FY 2013. Due to large differences in how the provinces report community mental health services, we still lack a comprehensive picture of the mental health system.

Since 2000, 5 studies have been published that each purported to estimate aggregate national mental health costs in Canada. Each of these studies used a different method. Our aim was to compare the studies, and we created a framework for the different elements used to assess mental health costs (direct costs, indirect costs, transfer payments, and “human” costs). In addition, each study used different parameters (population covered, diagnosis) and cost components to estimate the economic impact of mental health. Our framework can help analysts to understand the purpose of different cost components. We conclude that to achieve a consensus on the magnitude of mental health costs, we need to use more standardized approaches.

We present a database listing local government mask orders for COVID-19 that were enacted between April and September, 2020, prior to the date that the governors issued statewide mask wearing mandates. We obtained data from a Google search of web pages of local and national commercial and public broadcasters and newspapers, and of the orders themselves. In the database, we present data identifying the county, municipality or tribal council, date of the order, and the source’s internet address. In the 34 states with statewide orders, local governments in 21 of these states issued mandates in 218 municipalities, 155 counties, and 1 tribal council. The dataset can be accessed from https://doi.org/10.7939/DVN/NDFEHK

Face masks have become the bulwark of COVID-19 prevention in the US. Between 10 April and 1 August, 2020, 33 state governors issued orders requiring businesses to require their customers and employees to wear face masks, and persons outdoors who could not social distance to do the same. We documented the policies and enforcement actions for these policies in each of the states. We used governors’ orders and journalists’ news reports as our sources. Our results show that the states used a variety of state and local (county and municipality) agencies to enforce business prevention behaviors and primarily local law enforcement agencies to enforce outside mask-wearing behaviours. In particular, law enforcement officers demonstrated a strong preference for educating non-mask wearers, and indicated a reluctance to resort to civil penalties that were enacted in the state orders. Businesses expressed a preference to have government agencies enforce non-mask wearing behaviours. But there was also a widespread reluctance on the part of local law enforcement to resort to legal remedies.

The United States federal government developed a COVID-19 blueprint for states to follow; it included the issuance by state/local governments of “stay at home” orders coupled with lists of essential services. Suppliers of these services would be exempt from closure so their workers could fulfill their essential functions. The blueprint was embraced by the states in a variety of ways. In this paper, we identify how business closure rules were enacted across the states for each of 15 types of services. The outcome measures were: “open” “open with restrictions” and “closure”. For six business types, most states permitted businesses to open. In four types, businesses were mainly closed. In three, they were allowed to open with restrictions. In the rest, there was a mixture of outcomes. In sum, the federal blueprint resulted in a regulatory patchwork as it spread throughout the country.

Background. The Aerobika® oscillating positive expiratory pressure (OPEP) device is a hand-held, drug-free medical device that has been shown to improve lung function and improve health-related quality of life in patients with chronic obstructive pulmonary disease (COPD). We estimated the cost-effectiveness of this device among postexacerbation COPD patients in the Canadian healthcare system. Methods. We performed a cost-utility analysis using a Markov model to compare both costs and outcome of patients with COPD who had recently experienced an exacerbation between 2 treatment arms: patients who used the Aerobika® device and patients who did not use the Aerobika® device. This cost-utility analysis included costs based on the Alberta healthcare system perspective as these represent Canadian experience. A one-year horizon with 12 monthly cycles was used. Results. For a patient after 1 year, the use of the Aerobika® device would save $694 in healthcare costs and produce 0.04 more in quality-adjusted life years (QALYs) in comparison with no positive expiratory pressure (PEP)/OPEP therapy. In other words, the economic outcome of the device was dominant (i.e., more effective and less costly). The probability for this device to be the dominant strategy was 72%. With a willingness to pay (WTP) threshold of $50,000 per QALY gained, the probability for the Aerobika® device to be cost-effective was 77%. Conclusions. Given one of the major treatment goals in the GOLD guidelines is to minimize the negative impact of exacerbations and prevent re-exacerbations, the Aerobika® OPEP device should be viewed as a potential component of a treatment strategy to improve symptom control and reduce the risk of re-exacerbations in patients with COPD.

This article explores a literary record, the Old English Advent Lyrics, in the reception history of the literary portrayals of the Virgin Mary in order to determine if there are distinctive features in its portrayal of this subject. In the process a review is made of the five poems within this text where Mary is a subject. This examination reveals that the poet relied more upon words, phrases, and ideas about Mary found in earlier liturgical and literary portraits of the Virgin Mary from the Roman Latin liturgy and period theological writings to construct these portrayals of Mary than upon related portrayals of her found in Latin texts of the canonical Scripture. Further, it also leads to the conclusion that, building upon these prior portraits, the poet has expanded Mary's role in order to offer her more veneration. While evidence is manifest in the second, fourth, ninth, and twelfth poems in the Advent Lyrics, it is especially apparent in the seventh poem, where Mary appears as an angelic messenger and spiritual teacher in her relationship with Joseph.

In a randomised trial comparing transobturator tape (TOT) to retropubic tension-free vaginal tape (TVT) for women with stress urinary incontinence (SUI), vaginal examination at 12 months showed that tapes were palpable for 80.0 % of the TOT group versus 26.7 % of the TVT group. We hypothesized that this difference would lead to more women in the TOT group experiencing vaginal mesh erosion or other serious adverse events compared to women in the TVT group 5 years after surgery. All participants were invited to join the follow-up study after being randomised to receive TOT or TVT for SUI. Consenting women had a vaginal examination, a pad test for urinary incontinence (UI) and completed Health-related Quality of Life Questionnaires (HRQOL). Women unable to attend the clinic completed questionnaires only. The primary composite outcome incorporated mesh exposure, urinary retention, repeat incontinence surgery and moderate to severe pelvic pain. Assuming 80 % follow-up, our study would have 67 % power to detect a difference in primary outcome (two-sided 5 % level of significance). Comparisons between groups used chi-square tests and t tests. One hundred and seventy-six (88.4 %) women participated in the 5-year follow-up (83 TOT, 93 TVT). The primary composite outcome occurred in 21.8 % of the TOT and 27.6 % of the TVT groups [difference =−5.8 %, 95 % confidence interval (CI) −18.9 % to 7.3 %, p value 0.39)] Vaginal examination found more women with palpable tapes in the TOT versus the TVT group (48.5 % versus 22.4 %, p value 0.001). There were no other significant differences between groups. Serious adverse events and tape effectiveness did not differ between groups at 5 years. Palpable tape remains a concern for women who receive TOT for treating SUI.

Purpose: In pharmaceutical clinical trials, industrial sponsors pay for study drugs and related healthcare services. We conducted a study to determine industry’s economic contribution of these trials to the Alberta healthcare system. Methods: We used data from two trial centers for cancer and non-cancer trials at the University of Alberta. For each trial (cancer, non-cancer), we calculated the cost of drugs provided by the sponsors using the market price, the cost of clinical services, and the cost of administrative services that they paid. We extrapolated these results to all trials in Alberta based on information obtained from the registration website ClinicalTrials.gov. Results: Our sample consisted of 40 non-cancer and 39 cancer drug trials which were initiated in 2012. The monetary value of the industry sponsors’ contribution was $799,055 per non-cancer and $630,243 per cancer drug trial. Drugs (in-trial and post-trial) accounted for 84% of the total contribution of the non-cancer drug trials whereas it represented 93% of all trial-related contributions in the cancer category. The total province-wide contribution of industry-sponsored drug trials which were initiated in 2012 was estimated to be $101 million, including open-label drugs in the non-cancer category. Conclusions: Industry-sponsored pharmaceutical trials represent a major economic contributor to clinical research within the province.

Adding universal rectal screening to urogenital screening should positively impact rectal Chlamydia trachomatis (CT) incidence in affected populations. A dynamic Markov model was used to evaluate costs and outcomes of three rectal CT screening strategies among women attending sexually transmitted infection clinics in Alberta, Canada: universal urogenital-only screening (UG-only), additional selected (exposure-based) rectal screening (UG+SR), and additional universal rectal screening (UG+UR). The model included two mutually exclusive health states: infected and susceptible. Additionally, the model included two rounds of transmission: male sex partners of women infected with rectal-only CT and female sex partners of those men. CT complications impacting patients’ quality of life (QALY) were considered. Alberta and Canadian data were used to estimate model inputs. We used a health care perspective, a time period of 10 years, and a discount rate of 3% for analyses. Compared to UG-only screening, the incremental cost effectiveness ratios (ICERs) were CA$34,000 and CA$49,000 per QALY gained for UG+SR and UG+UR screening strategies, respectively. Compared to UG+SR, the ICER was CA$62,000 per QALY gained for the UG+UR strategy. Both adjunct selected and universal rectal screening strategies are cost effective compared to UG-only screening, and UG+UR screening is cost effective when compared to UG+SR screening.

The nine hole peg test (9HPT) is an emerging outcome measure in clinical trials in multiple sclerosis (MS). In this study we investigated how performance on the 9HPT at baseline is related to annualized direct MS related cost.We enrolled patients with a definite diagnosis of MS from two Canadian MS centers. 9HPT and demographic information were recorded at baseline, and patients prospectively recorded all MS related costs for 6months. Costs were compared among five groups according to the baseline 9HPT, and we built a multiple linear regression model including cost (dependent variable) and 9HPT at baseline, age, disease duration, sex and disease course (independent predictor variables).We analyzed data from 298 patients. Cost significantly increased with increasing 9HPT scores (p0.0001), with the costs for health care providers, changes to the home or car and long-term care dominating in the most disabled patient groups. The 9HPT score was a significant predictor of cost in the regression model (p=0.006).Performance on the 9HPT is closely related to cost. Our data add another aspect of patient relevance to using the 9HPT as an outcome measure in clinical trials.

Objectives To estimate the monetary benefits of ramipril and its distribution over time among four beneficiaries in Canada: the drug developing manufacturer, generic manufacturers, the healthcare sector and employment sectors. Methods Monetary benefits to developing and generic manufacturers were defined as the profits from the drug. A dynamic Markov model was used to estimate monetary benefits to the healthcare and employment sectors in terms of cost avoidance associated with prevented cardiovascular events, including stroke, myocardial infarction and heart failure, and lost productivity due to disability and premature death in the working population. Key findings Cumulative monetary benefits of ramipril over 18 years (1994–2011) were estimated at CA$3.9 billion, of which the developing manufacturer accounted for 41%, generic manufacturers 4%, the healthcare sector 40% and employment sectors 15%. The benefits for the developing manufacturer were dominant before, but dramatically decreased after, the patent period. Benefits for the healthcare sector started to decrease from 2007, corresponding to the decreasing population taking ramipril during the same period. Higher compliance or efficacy lead to larger benefits for the healthcare and employment sectors, whereas monetary benefits for manufacturers were unchanged. Conclusion Societal monetary benefits of ramipril are distributed differently for the four beneficiaries and over time. Patent, compliance and efficacy play a vital role in the determination of the benefits. High pricing of generic drugs probably makes the benefits to the healthcare and employment sectors lower than expected because that most likely influences some patients to discontinue or switch to alternative drugs.

Because health care resources are constrained, decision-making processes often require clarifying the potential costs and savings associated with different options. This involves calculating a program's costs. The chosen costing perspective defines the costs to be considered and can ultimately influence decisions. Yet reviews of the literature suggest little attention has been paid to the perspective in economic evaluations. This article's purpose is to explore how the costing perspective can affect cost estimates.As a vehicle for our discussion, we use service use data for clients enrolled in 6 Ontario early psychosis intervention programs. Governmental and nongovernmental payer costing perspectives are considered. We examine annual costs associated with early psychosis intervention clients enrolled for ≤12 months versus those enrolled for12 months. This also allows for an assessment of the impact that choice of time horizon can make on the results.The difference in total between group cost for hospital, emergency room, and physicians is $2499; the12-month group has relatively higher mean costs. When all governmental and nongovernmental costs are considered, there is a mean between-group cost difference of $1272, with lower mean costs for the12-month group.Although the Ministry of Health bears a large proportion of costs, other governmental agencies and the private sector can incur a sizeable share. This example demonstrates the potential importance of including other cost perspectives with the hospital sector in analyses as well as the impact of time horizon on cost estimates.

Objectives This study aimed to evaluate the trends and regional variation of stroke hospital care in 30-day in-hospital mortality, hospital length of stay (LOS), and 1-year total hospitalization cost after implementation of the Alberta Provincial Stroke Strategy. Methods New ischemic stroke patients (N = 7632) admitted to Alberta acute care hospitals between 2006 and 2011 were followed for 1 year. We analyzed in-hospital mortality with logistic regression, LOS with negative binomial regression, and the hospital costs with generalized gamma model (log link). The risk-adjusted results were compared over years and between zones using observed/expected results. Results The risk-adjusted mortality rates decreased from 12.6% in 2006/2007 to 9.9% in 2010/2011. The regional variations in mortality decreased from 8.3% units in 2008/2009 to 5.6 in 2010/2011. The LOS of the first episode dropped significantly in 2010/2011 after a 4-year slight increase. The regional variation in LOS was 15.5 days in 2006/2007 and decreased to 10.9 days in 2010/2011. The 1-year hospitalization cost increased initially, and then kept on declining during the last 3 years. The South and Calgary zones had the lowest costs over the study period. However, this gap was diminishing. Conclusions After implementation of the Alberta Provincial Stroke Strategy, both mortality and hospital costs demonstrated a decreasing trend during the later years of study. The LOS increased slightly during the first 4 years but had a significant drop at the last year. In general, the regional variations in all 3 indicators had a diminishing trend.

Background Mental illness has been widely cited as a driver of costs in the criminal justice system. Objective The objective of this paper is to estimate the additional mental health service costs incurred within the criminal justice system that are incurred because of people with mental illnesses who go through the system. Our focus is on costs in Alberta. Methods We set up a model of the flow of all persons through the criminal justice system, including police, court, and corrections components, and for mental health diversion, review, and forensic services. We estimate the transitional probabilities and costs that accrue as persons who have been charged move through the system. Costs are estimated for the Alberta criminal justice system as a whole, and for the mental illness component. Results Public expenditures for each person diverted or charged in Alberta in the criminal justice system, including mental health costs, were $16,138. The 95% range of this estimate was from $14,530 to $19,580. Of these costs, 87% were for criminal justice services and 13% were for mental illness-related services. Hospitalization for people with mental illness who were reviewed represented the greatest additional cost associated with mental illnesses. Conclusion Treatment costs stemming from mental illnesses directly add about 13% onto those in the criminal justice system.

Drug use negatively affects adherence to and outcomes of antiretroviral treatment (ART). This study evaluated the cost-effectiveness of integrating methadone maintenance treatment (MMT) with ART for HIV-positive drug users (DUs) in Vietnam. A decision analytical model was developed to compare the costs and consequences of 3 HIV/AIDS treatment strategies for DUs: (1) only ART, (2) providing ART and MMT in separated sites (ART-MMT), and (3) integrating ART and MMT with direct administration (DAART-MMT). The model was parameterized using empirical data of costs and outcomes extracted from the MMT and ART cohort studies in Vietnam, and international published sources. Probabilistic sensitivity analysis was conducted to examine the model's robustness. The base-case analysis showed that the cost-effectiveness ratio of ART, DAART-MMT, and ART-MMT strategies was USD 1358.9, 1118.0 and 1327.1 per 1 Quality-Adjusted Life Year (QALY), equivalent to 1.22, 1.00, and 1.19 times Gross Domestic Product per capita (GDPpc). The incremental cost-effectiveness ratio for DAART-MMT and ART-MMT versus ART strategy was 569.4 and 1227.8, approximately 0.51 and 1.10 times GDPpc/QALY. At the willingness to pay threshold of 3 times GDPpc, the probability of being cost-effective of DAART-MMT versus ART was 86.1%. These findings indicated that providing MMT along with ART for HIV-positive DUs is a cost-effective intervention in Vietnam. Integrating MMT and ART services could facilitate the use of directly observed therapy that supports treatment adherence and brings about clinically important improvements in health outcomes. This approach is also incrementally cost-effective in this large injection-driven HIV epidemic.

Objectives: In Canada, most mental health services are embedded in the public health care system. Little is known of the cost distribution within the mental health population. Our study aims to estimate the depression care costs of patients with a depression diagnosis, ranking them by the increasing total depression health care costs. Methods: For fiscal year 2007/08, we extracted administrative health care records from across the continuum, including physicians, outpatient services, and hospitals. Using a unique patient identifier, all service costs were merged for each person. Costs were summed by service categories and then divided by the served population into 10 equal-size groups. Further, we divided costs in the top decile into 10 percentile groups. Results: There were 208 167 people (5.9% of Albertans) who had at least 1 health care visit for depression. The total cost for depression treatment services was $114.5 million, an average $550 per treated person. In the first 9 deciles, most costs were for general practitioners. By the ninth decile, cost per person was about $400. Within the tenth decile, costs increased regularly, and in the top 1 percentile (1 % of patients) there was an increase of cost per patient to $25 826 from $5792 in the previous percentile. Conclusion: Per person costs were highly skewed. Until the ninth decile, the cost increased slowly, consisting of mainly physician costs. In the last decile, costs increased substantially, mainly because of hospitalizations. Thus both primary care and specialist care play key roles.

Objective Specific methodological challenges are often encountered during cancer-related economic evaluations. The objective of this study was to provide specific guidance to analysts on the methods for the conduct of high-quality economic evaluations in oncology by building on the Canadian Agency for Drugs and Technologies in Health Guidelines for the Economic Evaluation of Health Technologies (third edition). Methods Fifteen oncologists, health economists, health services researchers, and decision makers from across Canada identified sections in Canadian Agency for Drugs and Technologies in Health guidelines that would benefit from oncology-specific guidance. Fifteen sections of the guidelines were reviewed to determine whether 1) Canadian Agency for Drugs and Technologies in Health guidelines were sufficient for the conduct of oncology economic evaluations without further guidance specific for oncology products or 2) additional guidance was necessary. A scoping review was conducted by using a comprehensive and replicable search to identify relevant literature to inform recommendations. Recommendations were reviewed by representatives of academia, government, and the pharmaceutical industry in an iterative and formal review of the recommendations. Results Major adaptations for guidance related to time horizon, effectiveness, modeling, costs, and resources were required. Recommendations around the use of final outcomes over intermediate outcomes to calculate quality-adjusted life-years and life-years gained, the type of evidence, the source of evidence, and the use of time horizon and modeling were made. Conclusions This article summarizes key recommendations for the conduct of economic evaluations in oncology and describes methods required to ensure that economic assessments in oncology are conducted in a standardized manner.

Methadone maintenance treatment (MMT) is efficacious in reducing drug use that may improve HIV/AIDS care and treatment outcomes. This study evaluated the incremental cost-effectiveness of MMT for HIV-positive drug users from the perspective of health service providers. A sample of 370 HIV-positive drug users (age: mean ± SD: 29.5 ± 5.9 years; 95.7% male) taking MMT in multi-sites was assessed at baseline, three, six and nine months. Costs of MMT services were analyzed and converted to the year 2009. Quality-adjusted life years (QALYs) were modeled from changes in health-related quality of life of patients using the modified World Health Organization Quality of Life - Brief Version (WHOQOL-BREF). Inverse probability-of-treatment weights, constructed using propensity score of non-responses, were applied to adjust for potential confounding. Over nine months, MMT substantially improved QALYs of HIV/AIDS patients (0.076 QALY [0.066-0.084]). The increments in QALY were large and stabilized in those patients taking antiretroviral treatment and abstinent to drug use. For one QALY gained, the MMT program would cost US$3745.3, approximately 3.2 times Vietnam GDP per capita in 2009. The cost-effectiveness of MMT intervention was robust against HIV advanced status or co-morbidity, e.g., TB treatment, but it might not be cost-effective for those patients who continued to use drug. Findings of this study indicate that providing MMT for HIV-positive drug users is a cost-effective intervention in Vietnam. Integrating MMT to HIV/AIDS care and treatment services would be beneficial in injection-driven HIV epidemics.

Informal caregiving is a complex concept, and inconsistencies are found in the literature regarding how to measure it. The differences in tasks included in the definition of caregiving, as well as the different methods used to measure caregiving time may explain the huge variations in results found in the literature. The current paper aimed to lay out the challenges of how to calculate the time spent by informal caregivers on providing care and assistance to an ill person at home. It also proposes a method for measuring informal caregiving time, which attempts to distinguish between "normal" activities and "caregiving" activities. The proposed measurement method is then applied to a cohort of informal caregivers of palliative care patients. The illustration study revealed that this method brought advantages comparatively to other methods, and that persisting challenges remain in measuring informal caregiving time. We conclude that, the estimate of time spent caregiving for palliative care patients may be useful in guiding support programs for the families taking care of a loved one at home during the palliative phase of care.

Objective In 2004, the three-module, three-year long patient safety program, Managing Obstetrical Risk Efficiently (MORE OB ), was introduced to all clinicians providing obstetrical services in Alberta. We report on an outcomes evaluation of this initiative. Methods Provincial hospital discharge abstracts for each mother and infant were obtained from 2003 through 2008. A pre–post design with a multivariate analysis was conducted for each relevant maternal and fetal outcome. Results For maternal outcomes, third- and fourth-degree tears and length of stay were significantly decreased. For newborn outcomes, severe morbidity was significantly reduced. Conclusion The MORE OB program was associated with improvement in selected maternal and fetal health outcome indicators. When a patient safety program is introduced as an intensive, long-term continuing education and quality improvement initiative, health outcomes can be significantly impacted.

Objective: This study aimed to highlight the trajectory of palliative care costs over the last five months of life in five urban centres across Canada. Subjects: The study sample was comprised of 160 terminally ill patients and their main informal caregivers. Research Design: A first interview took place in the patient’s home, and subsequent follow-up interviews were conducted by telephone at two week intervals until the patient’s passing. Measures: Participants were asked to provide information on the goods and services they used related to the patients’ health condition, and on informal caregiving time. Results: The overall costs of care gradually increased from the fifth to the last month of the patients’ life. A large part of this cost increase was attributable to inpatient care. Among outpatient care costs the largest increase was observed for home care. Informal care costs were particularly high over the last 3 months of life. Conclusions: The knowledge gained from this study would be useful to policy makers when developing policies that could help families caring for a terminally ill loved one at home.

Objectives: The objective of this study was to investigate predictors of emergency department (ED) return visits for pediatric mental health care. The authors hypothesized that through the identification of clinical and health system variables that predict return ED visits, which children and adolescents would benefit from targeted interventions for persistent mental health needs could be determined. Methods: Data on 16,154 presentations by 12,589 pediatric patients (≤17 years old) were examined from 2002 to 2006, using the Ambulatory Care Classification System (ACCS), a provincewide database for Alberta, Canada. Multivariable logistic regressions identified predictors, while survival analyses estimated time to ED return. Results: In the multivariable analysis, there were four patient factors significantly associated with ED return. Male sex (odds ratio [OR] = 0.78; 99% confidence interval [CI] = 0.69 to 0.89) was associated with a lower rate of return, as was child age. The likelihood of ED return increased with age. Children ≤5 years (OR = 0.26; 99% CI = 0.14 to 0.46) and between ages 6 and 12 (OR = 0.64; 99% CI = 0.51 to 0.79) were less likely to return, compared to 13- to 17-year-olds. Patients with families receiving full assistance for covering government health care premiums were more likely to return compared to those with no assistance (OR = 1.59; 99% CI = 1.33 to 1.91). Patients were more likely to return if their initial presentation was for a mood disorder (OR = 1.72; 99% CI = 1.46 to 2.01) or psychotic-related illness (OR = 2.53; 99% CI = 1.80 to 3.56). There were two modest health care system predictors in the model. The likelihood of return decreased for patients triaged as nonurgent (OR = 0.62; 99% CI = 0.45 to 0.87) versus those triaged as urgent (level 3 acuity) and increased for patients with visits to general (vs. pediatric) EDs (OR = 1.25; 99% CI = 1.03 to 1.52). ED region (urban vs. rural) did not predict return. Within 72 hours of discharge, 6.1 and 8.7% of patients diagnosed with a mood disorder and psychotic-related illness, respectively, returned to the ED. Throughout the study period, 28.5 and 36.6% of these diagnostic populations, respectively, returned to the ED. Conclusions: Among children and adolescents who accessed the ED for mental health concerns, being female, older in age, in receipt of social assistance, and having an initial visit for a mood disorder or psychotic-related illness were associated with return for further care. How patient presentations were triaged and whether visits were made to a pediatric or general ED also affected the likelihood of return. ACADEMIC EMERGENCY MEDICINE 2010; 17:177–186 © 2010 by the Society for Academic Emergency Medicine

To compare the effectiveness of transobturator tape with tension-free vaginal tape (TVT) in terms of objective cure of stress urinary incontinence (SUI) at 12 months postoperatively.Women with SUI were randomly allocated to either transobturator tape or TVT procedures and reviewed at 12 months after surgery. The primary outcome was objective evidence of "cure," evaluated by standardized pad test (cure defined as less than 1 g urine leaked). Other outcomes included complications, subjective cure, incontinence-related quality of life, return to usual sexual activity, and satisfaction with surgery. Primary analysis compared the proportion of patients in each group who were cured at 12-month follow-up.A total of 199 women participated (94 in the transobturator tape group, 105 in the TVT group). Sixty-eight women (81%) in the transobturator tape group were cured, compared with 67 (77%) in the TVT group (relative risk 1.05, 95% confidence interval 0.90-1.23, P=.577). On vaginal examination, the tape was palpable for 68 women (80%) in the transobturator tape group and for 24 (27%) in the TVT group (relative risk 0.22, 95% confidence interval 0.13-0.37, P.001). More women in the transobturator tape group experienced groin pain during vaginal palpation (13 [15%] in the transobturator tape group and five [6%] in the TVT group, P=.044). Quality of life improved significantly from baseline in both groups (30-point improvement in IIQ-7 score for both groups).At 12 months, the majority of women had minimal leakage and their quality of life had improved significantly, but differences were not observed between groups. The presence of palpable tape, particularly among the transobturator tape group, is concerning; longer follow-up is needed to determine whether this outcome leads to extrusion or resolves over time.ClinicalTrials.gov, www.clinicaltrials.gov, NCT00234754.I.

Objectives We sought to identify chronic pain patients' preferences for levels of improvement in pain-related morbidity (PRM) by measuring their willingness to pay (WTP) for reducing their pain intensity and pain-related disability. Methods The study was a cross-sectional nonrandomized design. Participants were recruited from a tertiary multidisciplinary pain center in Canada. A computer-administered discrete-choice experiment was used to explore participants' WTP for various levels of improvement to PRM. Participants chose between two varying combination of treatments that differed in terms of their level of improvement in pain intensity, level of improvement in pain-related disability, and out-of-pocket monthly cost. Results The WTP to completely minimize PRM was $1428 per month. Reduction in pain intensity was valued more highly than functional improvement. For every dollar, an individual was WTP to improve his/her disability to the lowest severity (mild), he/she was WTP approximately $2 to reduce pain intensity to moderate and $3 to reduce pain intensity to mild. The potential return on investment in terms of health improvement gained was $3318 per patient visit per year. Conclusion The morbidity associated with chronic pain is worth approximately $1428 for every month in the chronic pain health state. From the patient's perspective, treatment and management strategies that focus on reducing pain intensity would have the greatest impact on improving health-related quality of life. Valuing health improvement in monetary terms allows for direct monetary comparisons between the costs of chronic pain interventions and their associated health returns.

What is the best way to pay providers to deliver health services? The research evidence strongly suggests that there is no single answer; rather, one must consider the incentives and disincentives inherent in alternative health-care funding models. This article suggests a conceptual framework for categorizing payment mechanisms that highlights different policy options and their associated tradeoffs. It concentrates on the following: distinctions between need, demand, and utilization as they affect the rationale for government involvement; models of the possible funding flows (two-way, three-way, and four-way) as they affect policy levers; and implications of various approaches to payment. The framework is then used to clarify the advantages and disadvantages of particular approaches to financing health care and to clarify the tradeoffs involved. Sommaire: Quel est le meilleur moyen de payer les fournisseurs pour leur prestation de services de sante? Les donnees probantes de la recherche laissent fortement entendre qu'il n'existe pas une seule et unique reponse; il faut plutot tenir compte des incitatifs et des desincitatifs inherents aux autres modeles de financement des soins de sante. Pour classer par categories les mecanismes de paiement, le present article propose un cadre conceptuel qui souligne differentes options de politiques et les compromis qui leur sont associes. Il se concentre sur : les distinctions entre besoin, demande et utilisation qui ont une incidence sur la justification de l'intervention du gouvernement; les modeles des flux de financement possibles (a deux, trois et quatre directions) qui ont une incidence sur les leviers politiques; et les implications de diverses approches a l'egard du paiement. Le cadre est alors utilise pour preciser les avantages et les inconvenients des approches particulieres concernant le financement des soins de sante, et pour clarifier les compromis impliques.

Objectives:The aim of this study was to assess the evidence that reuse of medical devices marketed for single use only (SUDs) is safe, effective and cost-effective, and to consider the use and health services impact of this practice in Canada.Methods:A systematic review was performed of studies that reported clinical or economic outcomes following reuse of SUDs in humans. Direct costs of adverse health events associated with SUD reuse and indications of budget impact were obtained using data for devices for laparoscopic cholecystectomy and coronary angioplasty. Legal and ethical issues were reviewed, drawing on material relevant to Canada. Data on current reuse of SUDs were obtained through a survey of Canadian acute care hospitals.Results:Studies of variable quality suggested that SUD reuse could be safe and effective, and would give cost savings, if there were no adverse events. Eliminating reuse of SUDs for laparoscopic cholecystectomy and coronary angioplasty would add less than 0.1 percent to costs of the procedures over 1 year. Adverse health events associated with device reuse create liability risks; patients should be informed of any known or foreseeable risks of reuse. Most of the 28 percent (111/398) of acute hospitals that reprocess SUDs do so in-house. Some do not have a written policy or an incident reporting mechanism.Conclusions:There is insufficient evidence to establish the safety, efficacy and cost-effectiveness of reusing SUDs. Legal and ethical issues require attention to minimize liability and maintain patient safety and trust. Some hospitals that reprocess SUDs do not have adequate documentation. These findings do not support the reuse of SUDs in Canadian hospitals.

Summary. The objective of this paper was to conduct an analysis of the health services costs for persons who have been diagnosed with hepatitis C, from the time of diagnosis. Data were based on 1230 persons diagnosed with hepatitis C in 1998 in the Capital Health region of Alberta. Identifiers and dates of diagnosis were sent to Alberta Health and Wellness where records were linked to those of physician visits and billings, as well as hospital (inpatient and outpatient) visit records. Costs were assigned to all visits, and data were analysed for one pre- and two post-diagnosis years. Total cost per person increased from $2630 (Canadian) to $3514 between the pre- and first post-diagnosis year. They then returned to $2694 in the second post-diagnosis year. Liver-related costs were a low portion of the total in all periods, though they increased following diagnosis. Mental-health related costs were the largest component. Observational data present a more balanced picture of the costs of persons with hepatitis C, though most current estimates are not based on such data. Our results indicate that, when analysed within the picture of the entire person, liver-related costs (which have been the focus of most studies to date) are the tip of the iceberg.

Summary: The burden of disease and associated healthcare costs of syphilis are significant despite widespread screening and treatment. Our objective was to conduct an economic evaluation using a simulation model when comparing enzyme immunoassay (EIA) initial testing and Inno-Lia (IL) confirmatory testing (EIA + IL) with rapid plasma reagin (RPR) initial testing and Treponema pallidum particle agglutination assay (TPPA) and fluorescent treponemal antibody absorption assay (FTA-ABS) confirmatory testing (RPR + TPPA/FTA). Estimates of prevalence, test costs and utilization of services for 2006 were derived from Alberta databases. Estimates of test characteristics were derived from the available literature. The incremental cost-effectiveness ratio was Canadian $461 per additional correct diagnosis (less costly and more effective). EIA + IL is cost-effective when compared with RPR + TPPA/FTA for screening and diagnosis of syphilis.

Purpose BCIRG 001 demonstrated prolonged disease-free (DFS) and overall survival (OS) but increased toxicity for adjuvant docetaxel, doxorubicin, and cyclophosphamide (TAC) versus 5-fluorouracil, doxorubicin, cyclophosphamide (FAC) in women with node positive breast cancer (BC). This study evaluates quality-adjusted survival and cost-effectiveness of adjuvant TAC versus FAC, taking downstream decisions and events into account, including palliative chemotherapy with taxanes. Methods We developed a Markov model for a cohort of women with node positive BC eligible for adjuvant anthracyclines. Data input included clinical and resource utilization data collected prospectively from BCIRG 001. Treatment decisions and outcomes with disease recurrence were based on a systematic literature review with validity reviewed by a national panel of Canadian BC oncologists. Direct costs for resource utilization following Canadian practice patterns were included. Unit costs were obtained from provincial cost list and published drug list prices. Utility scores were derived from the literature. An incremental cost-effectiveness ratio (ICER) in cost per quality-adjusted life-years (QALY) gained for TAC versus FAC was calculated. Results For 1,000 women with node positive BC, the model showed that TAC would lead to a gain of 313 QALY (370 life years) at an additional cost of $5.8 Million Canadian dollars (Cdn) compared to FAC, over a 10-year time horizon. The ICER of TAC versus FAC was $18,505.54 Cdn per QALY gained. Sensitivity analyses supported the robustness of the model. By one-way sensitivity analyses of over 50 model variables, 95% of the cumulative ICER variation was from $6,000 to $28,000 Cdn/QALY. By multivariate Monte Carlo simulation, there was a 70% probability that the ICER would be under $50,000 CdN/QALY. Conclusion For women with node positive BC, TAC improves DFS and OS compared to FAC and is a cost-effective adjuvant chemotherapy strategy.

Background:Hyperbaric oxygen therapy (HBOT) has been proposed as an adjunct to standard methods of care for diabetic foot ulcers (DFU). Its use may decrease the risk of infection and lower extremity amputations (LEAs). As part of a Canadian assessment, we estimated the cost-effectiveness and budget impact of HBOT in this application.Methods:We developed a decision model comparing adjunctive HBOT with standard care alone. The population was a 65-year-old cohort with DFU. The time horizon was 12 years taken from a Ministry of Health perspective. The health states were a healed wound with or without a minor LEA, an unhealed wound with no related surgery, and a major LEA. Efficacy data were based on outcomes reported in studies included in a literature review. Cost and capacity needs for treating DFU patients in Canada were estimated using prevalence data from the literature, and cost and utilization data from government records.Results:The 12-year cost for patients receiving HBOT was CND$40,695 compared with CND$49,786 for standard care alone. Outcomes were 3.64 quality-adjusted life-years (QALYs) for those receiving HBOT and 3.01 QALYs for controls. Estimated cost to treat all prevalent DFU cases in Canada was CND$14.4–19.7 million/year over 4 years. If seven-person HBOT chambers were used, a further nineteen to thirty-five machines would be required nationally.Conclusions:Adjunctive HBOT for DFU is cost-effective compared with standard care. Additional HBOT capacity would be needed if it were to be adopted as the standard of care throughout Canada.

Decisions about nurse staffing levels in intensive care units (ICUs) should be guided by research to ensure optimal outcomes. This descriptive correlational study in a large Thai hospital was designed to evaluate the effect of nurse staffing levels on the costs of care, in terms of medical care cost per patient day and health personnel cost per patient day, in ICUs. The costing data were collected prospectively from the records of 242 critically ill patients while the nurse staffing levels were extracted from hospital management reports. The findings showed that a nurse staffing model with a higher number of registered nurses (RNs) led to an increase in the health personnel cost per patient day. However, a greater number of RNs was associated with improved patient safety and efficiency, thereby reducing the length of stay and the costs of care in the long term. This study provides evidence to support decisions by hospital administrators concerning RN staffing levels.

BACKGROUND: Lung cancer is the leading cause of cancer morbidity and mortality. In addition, lung cancer has a significant economic impact on society.OBJECTIVE: To present an economic analysis of the actual care costs of lung cancer which will allow comparison with, and verification of, cost estimates that were developed through modelling and opinion.METHODS: A chart review was conducted of incident cases (circa 1998) of primary bronchogenic lung cancer. Cases were censored at two years from the date of diagnosis. Relevant clinical and health utilization data were collected. Health utilization data included hospital and institutional outpatient (ie, ambulatory clinic) costs. Cost estimates were derived for over 200 specific health services. The present analysis was performed from the economic perspective of the health care institution.RESULTS: A total of 13,389 health service events were captured with an estimated total cost of $8.4 million. Laboratory tests, diagnostic imaging and ambulatory visits constituted 86% of the service events while patient admissions and therapy constituted 76% of the costs. The vast majority of overall costs occurred just before, or within, three months of diagnosis. The median nonsmall cell lung cancer and small cell lung cancer case costs were $10,928 (range $9,234 to $11,047) and $15,350 (range $13,033 to $21,436), respectively.CONCLUSION: The results agree with the literature that the majority of lung cancer case costs are realized around the date of diagnosis (ie, early phase). The present study illustrates Canadian health care system lung cancer case costs based on actual care received versus hypothetical care algorithms.

Background: Significant gaps in the evidence base on costs in rural communities in Canada and elsewhere are reported in the literature, particularly regarding costs to families. However, it remains unclear whether the costs related to all resources used by palliative care patients in rural areas differ to those resources used in urban areas. Aim: The study aimed to compare both the costs that occurred over 6 months of participation in a palliative care program and the sharing of these costs in rural areas compared with those in urban areas. Design: Data were drawn from two prior studies performed in Canada, employing a longitudinal, prospective design with repeated measures. Setting/participants: The urban sample consisted of 125 patients and 127 informal caregivers. The rural sample consisted of 80 patients and 84 informal caregivers. Most patients in both samples had advanced cancer. Results: The mean total cost per patient was CAD26,652 in urban areas, while it was CAD31,018 in rural areas. The family assumed 20.8% and 21.9% of costs in the rural and urban areas, respectively. The rural families faced more costs related to prescription medication, out-of-pocket costs, and transportation while the urban families faced more costs related to formal home care. Conclusion: Despite the fact that rural and urban families assumed a similar portion of costs, the distribution of these costs was somewhat different. Future studies would be needed to gain a better understanding of the dynamics of costs incurred by families taking care of a loved one at the end of life and the determinants of these costs in urban versus rural areas.

Objectives: Economic evaluations, although not formally used in purchasing decisions for medical devices in Canada, are still being conducted and published. The aim of this study was to examine the way that prices have been included in Canadian economic evaluations of medical devices.Methods: We conducted a review of the economic concepts and implications of methods used for economic evaluations of the eleven most implanted medical devices from the Canadian perspective.Results: We found Canadian economic studies for five of the eleven medical devices and identified nineteen Canadian studies. Overall, the device costs were important components of total procedure cost, with an average ratio of 44.1 %. Observational estimates of the device costs were obtained from buyers or sellers in 13 of the 19 studies. Although most of the devices last more than 1 year, standard costing methods for capital equipment was never used. In addition, only eight studies included a sensitivity analysis for the device cost. None of the sensitivity analyses were based on actual price distributions.Conclusions: Economic evaluations are potentially important for policy making, but although they are being conducted, there is no standardized approach for incorporating medical device prices in economic analyses. Our review provides suggestions for improvements in how the prices are incorporated for economic evaluations of medical devices.

OBJECTIVE Neurosurgical resources are concentrated in tertiary referral centers, whereas emergencies identified from district general hospitals are traditionally referred by telephone consultation (TC). Recent advances in communication technology offer the alternative options of teleradiology (TR) and video consultation (VC). This study aimed to determine the differences among these three consultation methods on the basis of their process-of-care indicators, clinical outcomes, and cost-effectiveness. METHODS Patients with emergency neurosurgical conditions (head injury, stroke, and miscellaneous) from a district general hospital were randomized to three different modes of consultation: TC, TR, or VC. Process-of-care indicators (postresuscitation Glasgow Coma Scale score, consultation time required, diagnostic accuracy, and transfer decision and safety), 6-month clinical outcome, and cost-effectiveness of the three consultation modes were correlated. RESULTS In a 3-year period, 710 patients were recruited and randomized to the three consultation modes (n = 235, 239, and 236, respectively). Demographic and clinical data were comparable. TR and VC showed a definite advantage in diagnostic accuracy over TC (89.1 and 87.7% versus 63.8%; P < 0.001). However, duration of the corresponding consultation process was longer for TR and VC than TC (1.01 and 1.3 h versus 0.70 h). A high failure rate (30%) was noted in VC. Thirty-three percent of patients were transferred to the neurosurgical center after consultation. The difference in consultation modes did not have an impact on transfer rate and safety. There was a trend toward more favorable outcome (61%; P = 0.12) and a reduced mortality (25%; P = 0.025) in TR compared with TC (54 and 34%, respectively) and VC (54 and 33%, respectively). The mean cost per patient in the VC group was slightly higher than the other two groups (TC versus TR versus VC = 14,000 US dollars versus 14,400 US dollars versus 16,300 US dollars, respectively), but the differences were not statistically significant. CONCLUSION Emergency neurosurgical consultation assisted by TR and VC achieved a higher diagnostic accuracy in comparison with conventional TC. Although VC did not show an advantage over TR in process-of-care indicators, clinical outcome, and cost, it has been proven to be a safe mode of consultation in emergency neurosurgery.

Objective: To describe the relationship between obesity class and workforce participation and the influence of demographic, socioeconomic, and comorbid disease states on this relationship using population-based Canadian data. Research Methods and Procedures: Responses from 73, 531 adults surveyed in the Canadian Community Health Survey 2000 to 2001 who provided complete information regarding variables of interest were analyzed. Workforce participation was defined as individuals reporting that they held and were present at a job or business in the week before survey administration. The association between obesity and workforce participation was explored using logistic regression after adjusting for demographic, socioeconomic, and obesity-related comorbidities. Results: In univariate analysis, obese individuals had lower odds of participating in the workforce. In the fully adjusted model, increasing obesity was associated with decreasing odds of workforce participation, with Class I, II, and III obesity having odds ratios (95% confidence interval) of 0.94 (0.89 to 0.99), 0.85 (0.77 to 0.94), and 0.66 (0.57 to 0.78), respectively. Obese individuals were also less likely to be employed and more likely to be absent from work. Discussion: Obesity is associated with lower workforce participation. This association appears to be independent of associated comorbidity and sociodemographic factors. These results indicate that the economic impact of obesity alone on workforce productivity is larger than previous reports suggest.

Background: The World Health Organization in 2000 cited specific chronic diseases (chronic obstructive pulmonary disease, heart disease, diabetes and certain cancers) as major and preventable health hazards. There have subsequently been calls for increased investment in prevention activities. Currently there is no information on the economic magnitude of these promotion activities. In this study, we present an estimate of the investment in Alberta, by public organization, for chronic disease prevention activities which provide information that promotes behaviour changes in adults at risk. Methods: We surveyed board members of the Alberta Healthy Living Network (AHLN) to obtain economic data and information on activities related to chronic disease (primary) prevention. We also asked for further contacts on programs in other agencies. We continued the (“snowball”) process until no new agencies were identified. Agencies provided the information on a survey form. Results: In 2003 in Alberta, the cost of publicly provided information to change risk behaviours related to chronic diseases for persons over 20 was $24.9 million. This investment was diffused over a large number of bodies. Anti-smoking programs used the largest proportion of the money. The total cost per person at risk was about $15. Regional Health Authorities spend about 1/10th of 1% of their budget on these activities. Discussion: There are difficulties in collecting and organizing society-level data on chronic disease prevention. Nevertheless, all indications are that the amount of resources devoted in this area is small, and much smaller than has been suggested.

STUDY DESIGN A retrospective, population-based analysis. OBJECTIVES To analyze the utilization of a variety of healthcare services for persons with and without a chronic back disorder, and to identify factors associated with specific patterns of healthcare resource use. SUMMARY OF BACKGROUND DATA Although there have been studies of how chronic back disorders influence the use of specific healthcare services, we do not currently have a broad, population-based overview of how this condition influences healthcare service utilization. METHODS Person-level data were taken from the 2000-2001 Canadian Community Health Survey (CCHS), a nationwide cross-sectional survey of health determinants, health status, and health system utilization of Canadians. A series of binary logistic regressions examining healthcare resource utilization were performed on a full study sample (n = 113,229), as well as a restricted sample (n = 36,713) with attention focused on subjects with a single diagnosis of a chronic back disorder. RESULTS Persons with chronic back disorders were more likely to use physician resources (multivariate odds ratio [OR] = 1.2; 95% confidence interval, 1.1-1.2), and nonphysician resources (OR range, 2.1-3.6) compared with persons without the condition, with chiropractic care having an odds ratio of 3.6 (95% confidence interval, 3.5-3.8). Higher socioeconomic status, the presence of activity-limiting pain, and depressive symptoms were associated with a significant increase in utilization of almost all healthcare services. CONCLUSIONS With increasing disability as indicated by the presence of pain and functional limitations, and the presence of depressive symptoms, the higher the utilization of physician and nonphysician resources, with the exception of chiropractic care, which appears to be used by those with less severe symptoms. Lower socioeconomic status was associated with significantly lower receipt of services for almost all healthcare providers.