Comparing Health And Health Care Use In Canada And The United States

The association between ultra-processed food consumption and health-related quality of life differs across lifestyle and socioeconomic strata

BACKGROUND

In this prospective study, we aimed to examine the association between ultra-processed foods and health-related quality of life (HRQoL) and to evaluate the effect of lifestyle and socioeconomic factors on this association.

METHODS

This study included 1766 adults (aged 18 to 78, 54.3% women), who took part in the Tehran Lipid and Glucose study. The Short-Form 12-Item Health Survey version 2 was used to determine HRQoL, which includes the physical component summary (PCS) and mental component summary (MCS) scores. Ultra-processed food consumption was assessed using a validated semi-quantitative food frequency questionnaire. Lifestyle (physical activity and smoking status) and socioeconomic factors (education level and employment status) were also determined. General linear models (GLM) were applied to estimate the mean (95% confidence interval) for MCS and PCS scores across the ultra-processed foods tertiles. Additionally, the effect of lifestyle and socioeconomic factors on the relationship between ultra-processed foods and HRQoL was examined using GLM.

RESULTS

The median consumption of ultra-processed foods was 11.9% (IQR: 8.2 to 16.8) of total energy intake. There was a significant inverse association between ultra-processed foods consumption and PCS, but not MCS, after adjustment for confounding factors. Significant interactions were observed between ultra-processed food consumption, sex, and occupation on PCS score (all P values < 0.001). The interaction test tended to be significant for smoking status, education levels, and physical activity levels. As ultra-processed food consumption increased, the PCS score significantly decreased in women (P = 0.043), low physical active subjects (P = 0.014), smokers (P = 0.015), and lower-educated individuals (P = 0.022). Non-employed individuals with higher ultra-processed food intake showed a decline in their PCS and MCS scores. While there was no significant difference in MCS score among different strata of lifestyle and socioeconomic status across tertiles of ultra-processed foods.

CONCLUSIONS

Higher intake of ultra-processed foods was associated with poorer physical health, particularly among women, those with unhealthy lifestyles, and low socioeconomic conditions.

Treatment Patterns and Outcomes in Pancreatic Cancer: A Comparative Analysis of Ontario and the USA

BACKGROUND

Comparative studies evaluating quality of care in different healthcare systems can guide reform initiatives. This study seeks to characterize best practices by comparing utilization and outcomes for patients with pancreatic cancer (PC) in the USA and Ontario, Canada.

METHODS

Patients (age ≥ 66 years) with PC were identified from the Ontario Cancer Registry and SEER-Medicare databases from 2006 to 2015. Demographics and treatment (surgery, radiation, chemotherapy, or multimodality (surgery and chemotherapy)) were described. In resected patients, neoadjuvant therapy, readmission, and 30- and 90-day postoperative mortality rates were calculated. Survival was assessed using Kaplan-Meier curves.

RESULTS

This study includes 38,858 and 11,512 patients with PC from the USA and Ontario, respectively. More female patients were identified in the USA (54.0%) versus Ontario (46.9%). In the entire cohort, US patients received more radiation in addition to other therapies (18.8% vs. 13.5% Ontario) and chemotherapy alone (34.3% vs. 19.0% Ontario). While rates of resection were similar (13.4% USA vs.12.5% Ontario), multimodality therapy was more common in the UAS (9.0% vs. 6.4%). Among resected patients, neoadjuvant chemotherapy was uncommon in both groups, although more frequent in the USA (12.0% vs. 3.2% Ontario). The 30- and 90-day postoperative mortality rates were lower in Ontario vs. the USA (30-day: 3.26% vs. 4.91%; 90-day: 7.08% vs. 10.96%), however, overall survival was similar between the USA and Ontario.

CONCLUSIONS

We observed substantive differences in treatment and outcomes between PC patients in the USA and Ontario, which may reflect known differences in healthcare systems. Close evaluation of healthcare policies can inform initiatives to improve care quality.

The Potential of Social Policies in Preventing Dementia: An Ecological Study Using Systematic Review and Meta-Analysis

Social policies determine the distribution of factors (e.g. education, cardiovascular health) protecting against the development of dementia in Alzheimer's disease (AD). However, the association between social policies and the likelihood of AD without dementia (ADw/oD) has yet to be evaluated. We estimated this association in an ecological study using systematic review and meta-analysis. Four reference databases were consulted; 18 studies were included in the final analysis. ADw/oD was defined as death without dementia in people with clinically significant AD brain pathology. The indicators of social policy were extracted from the Organisation for Economic Co-operation and Development database (OECD). The probability of ADw/oD with moderate AD brain pathology was inversely associated with the Gini index for disposable income, poverty rate, and certain public expenditures on healthcare. ADw/oD with advanced AD brain pathology was only associated with public expenditures for long-term care. Social policies may play a role in maintaining and sustaining cognitive health among older people with AD.

Similarities in COVID-19 Mortality Between Canadian Provinces and American States Before Vaccines Were Available

Canada and the USA are often compared for their markedly different approaches to health care despite cultural similarities and sharing the world's longest international boundary. The period between the onset of the COVID-19 pandemic in January 2020 and the availability of a vaccine in December 2020 offers an ideal opportunity to compare subnational Canadian and American pandemic mortality. Preventing the spread of COVID-19 was through compliance with health orders and best practices; treatment was only available to those admitted to hospitals and whose lives were at risk. Using publicly available data from the Johns Hopkins University 2019 Novel Coronavirus Visual Dashboard, we seek to uncover if there were any similarities in Canadian provinces' and American states' monthly COVID-19 mortality per 100,000 people, building on a broader scientific push towards understanding the successes and failures of different health systems in the pandemic. The similar province and state cumulative COVID-19 mortality rate trajectories identified in our analyses do not amount to intuitive comparative jurisdictions which suggests the importance of identifying localized pandemic responses.

A comparison of health and socioeconomic gradients in health between the United States and Canada

Data from the early 2000s indicated worse overall health and larger socioeconomic (SES) health inequalities in the U.S. than in Canada. Yet, sociopolitical contexts, health levels, and SES-health inequalities have changed in both countries during the intervening two decades. Drawing on new data, we update the comparison of health levels and SES-health gradients between the two countries. Analyses, focused on self-rated health, are based on two complementary sets of data sources: Resilience and Recovery (RR) data, a harmonized U.S.-Canada survey of social conditions collected in 2020 (N = 3743); and a pair of leading nationally representative health data sources from each country: the National Health Interview Surveys (NHIS, N = 104,027) and the Canadian Community Health Survey (CCHS, N = 97,605), both collected in 2017-2018. Health levels and disparities, net of demographic and socioeconomic covariates, were estimated using modified Poisson models for relative comparisons; descriptives and predicted levels of fair/poor health show the comparisons from absolute perspective. Both data sources show that U.S. adults continue to have significantly worse health than Canadians; the disadvantage may be due to SES differences between the two populations. However, the two data sources yield conflicting findings on SES-health inequalities: the RR data indicate no difference between the two countries in socioeconomic health gradients, while the NHIS/CCHS data show a significantly steeper gradient in the U.S. than in Canada for both education and income. Canadian adults continue to report better health than their U.S. peers, but it is unclear whether health inequalities remain smaller as well. We discuss potential reasons for the conflicting findings and call for a large new cross-national data collection, which will enable scholars and policymakers to better understand health and wellbeing in the U.S. and Canadian contexts.

Do changes in primary care service use over time differ by neighbourhood income? Population-based longitudinal study in British Columbia, Canada

Background

Strong primary care systems have been associated with improved health equity. Primary care system reforms in Canada may have had equity implications, but these have not been evaluated. We sought to determine if changes in primary care service use between 1999/2000 and 2017/2018 differ by neighbourhood income in British Columbia.

Methods

We used linked administrative databases to track annual primary care visits, continuity of care, emergency department (ED) visits, specialist referrals, and prescriptions dispensed over time. We use generalized estimating equations to examine differences in the magnitude of change by neighbourhood income quintile, adjusting for age, sex/gender, and comorbidity, and stratified by urban/rural location of residence. We also compared the characteristics of physicians providing care to people living in low- and high-income neighbourhoods at two points in time.

Results

Between 1999/2000 and 2017/8 the average number of primary care visits per person, specialist referrals, and continuity of care fell in both urban and rural settings, while ED visits and prescriptions dispensed increased. Over this period in urban settings, primary care visits, continuity, and specialist referrals fell more rapidly in low vs. high income neighbourhoods (relative change in primary care visits: Incidence Rate Ratio (IRR) 0.881, 95% CI: 0.872, 0.890; continuity: partial regression coefficient -0.92, 95% CI: -1.18, -0.66; specialist referrals: IRR 0.711, 95%CI: 0.696, 0.726), while ED visits increased more rapidly (IRR 1.06, 95% CI: 1.03, 1.09). The percentage of physicians who provide the majority of visits to patients in neighbourhoods in the lower two income quintiles declined from 30.6% to 26.3%.

Conclusion

Results raise concerns that equity in access to primary care has deteriorated in BC. Reforms to primary care that fail to attend to the multidimensional needs of low-income communities may entrench existing inequities. Policies that tailor patterns of funding and allocation of resources in accordance with population needs, and that align accountability measures with equity objectives are needed as part of further reform efforts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01679-4.

Comparison of mortality hazard ratios associated with health behaviours in Canada and the United States: a population-based linked health survey study

BACKGROUND

Modern health surveillance and planning requires an understanding of how preventable risk factors impact population health, and how these effects vary between populations. In this study, we compare how smoking, alcohol consumption, diet and physical activity are associated with all-cause mortality in Canada and the United States using comparable individual-level, linked population health survey data and identical model specifications.

METHODS

The Canadian Community Health Survey (CCHS) (2003-2007) and the United States National Health Interview Survey (NHIS) (2000, 2005) linked to individual-level mortality outcomes with follow up to December 31, 2011 were used. Consistent variable definitions were used to estimate country-specific mortality hazard ratios with sex-specific Cox proportional hazard models, including smoking, alcohol, diet and physical activity, sociodemographic indicators and proximal factors including disease history.

RESULTS

A total of 296,407 respondents and 1,813,884 million person-years of follow-up from the CCHS and 58,232 respondents and 497,909 person-years from the NHIS were included. Absolute mortality risk among those with a 'healthy profile' was higher in the United States compared to Canada, especially among women. Adjusted mortality hazard ratios associated with health behaviours were generally of similar magnitude and direction but often stronger in Canada.

CONCLUSION

Even when methodological and population differences are minimal, the association of health behaviours and mortality can vary across populations. It is therefore important to be cautious of between-study variation when aggregating relative effect estimates from differing populations, and when using external effect estimates for population health research and policy development.

Health-related quality of life and economic burden of prurigo nodularis

BACKGROUND

Prurigo nodularis (PN) is an understudied, pruritic inflammatory skin disease. Little is known about the effect of PN on quality of life and its associated economic burden.

OBJECTIVE

To quantify the impact of PN on quality of life and its economic implications.

METHODS

A cohort study of PN patients (n = 36) was conducted using the Health Utilities Index Mark 3 questionnaire. Control data from US adults (n = 4187) were obtained from the 2002-2003 Joint Canada/United States Survey of Health. Quality-adjusted life year loss and economic costs were estimated by comparing the Health Utilities Index Mark 3 scores of the PN patients with those of the controls.

RESULTS

The PN patients had lower overall health performance compared to the controls, (mean ± SE, 0.52 ± 0.06 vs 0.86 ± 0.003, respectively, P < .001). In multivariable regression, PN was found to be associated with worse health performance (coefficient -0.34, 95% CI [-0.46 to -0.23]), most prominent in the pain subdomain (coefficient -0.24, 95% CI [-0.35 to -0.13]). This correlated to an average of 6.5 lifetime quality-adjusted life years lost per patient, translating to an individual lifetime economic burden of $323,292 and a societal burden of $38.8 billion.

CONCLUSION

These results demonstrate that PN is associated with significant quality-of-life impairment, similar to the level of other chronic systemic conditions. PN is also associated with a substantial individual economic burden, emphasizing the necessity of research on effective treatment options.

Psychometric testing of a set of patient-reported instruments to assess healthcare interventions for autistic adults

LAY ABSTRACT

Interventions to improve healthcare for autistic adults are greatly needed. To evaluate such interventions, researchers often use surveys to collect data from autistic adults (or sometimes, their supporters), but few survey measures have been tested for use with autistic adults. Our objective was to create and test a set of patient- or proxy-reported survey measures for use in studies that evaluate healthcare interventions. We used a community-based participatory research (CBPR) approach, in partnership with autistic adults, healthcare providers, and supporters. We worked together to create or adapt survey measures. Three survey measures focus on things that interventions may try to change directly: (1) how prepared patients are for visits; (2) how confident they feel in managing their health and healthcare; and (3) how well the healthcare system is making the accommodations patients feel they need. The other measures focus on the outcomes that interventions may hope to achieve: (4) improved patient-provider communication; (5) reduced barriers to care; and (6) reduced unmet healthcare needs. We then tested these measures in a survey of 244 autistic adults recruited from 12 primary care clinics in Oregon and California, USA (with 194 participating directly and 50 participating via a proxy reporter). Community partners made sure items were easy to understand and captured what was important about the underlying idea. We found the survey measures worked well in this sample. These measures may help researchers evaluate new healthcare interventions. Future research needs to assess whether interventions improve healthcare outcomes in autistic adults.

Chinese and South Asian ethnicity, immigration status and head and neck cancer outcomes: A population based study

OBJECTIVE

While it is known that certain ethnic and immigrant groups are at increased risk of developing head and neck cancer, the individual effects of immigration status and ethnicity on head and neck cancer outcomes is less clear. We sought examine the independent effects of immigration and Chinese and South Asian ethnicity on overall survival in a head and neck cancer patient population.

METHODS

This was a population-based retrospective matched cohort study using linked Ontario administrative databases between 1994 and 2017. Incident cancer cases were captured in long-standing residents of Chinese and South Asian ethnicity, Chinese and South Asian immigrants, as well as a reference population. Subjects were followed until death. A hard-matching approach was used to adjust for key differences and ensure both groups were balanced with respect to age, sex and cancer site. Cox proportional hazard models were used to estimate the impact of Chinese and South Asian ethnicity on overall survival while further adjusting for baseline covariates.

RESULTS

Among 1639 immigrants with head and neck cancer, matched to 3278 controls, the overall 5-year survival rate was 66% and 59%, respectively. After adjusting for between group-differences, all-cause mortality was lower for immigrants (HR 0.76[95%CI 0.69-0.83]) and individuals of Chinese ethnicity (HR 0.78[95%CI 0.68-0.90]), relative to the general population.

CONCLUSIONS

In Ontario, immigrants experience lower mortality rates following a head and neck cancer diagnosis. Individuals of Chinese ethnicity with head and neck cancer experience a survival advantage, relative to South Asian individuals and the general population.

Patient and caregiver experiences at a specialized primary care center for autistic adults

Background: Little is known about the extent to which patient-centered medical homes meet the needs of autistic adults. Materials & methods: We conducted a cross-sectional survey of autistic adult patients (n = 47) and caregivers of autistic adult patients (n = 66) receiving care through one patient-centered medical home specifically designed to meet the needs of this population. We performed post hoc comparisons of our results to previously published data from a national sample of autistic adults. Results: Participants reported high levels of satisfaction with care, frequent preventive healthcare use and few unmet healthcare needs. Autistic adults in our sample reported significantly higher satisfaction and fewer unmet healthcare needs. Conclusion: A patient-centered medical home tailored to the needs of autistic adults is a promising approach to healthcare delivery for meeting this population's needs.

Health-Related QOL and Economic Burden of Chronic Pruritus

Chronic pruritus (CP) has considerable implications for QOL. However, its impact on health-related QOL and economic burden is not fully characterized. We administered a cross-sectional survey on 132 patients with CP using the Health Utilities Index Mark 3 instrument. Normative data from healthy adults (n = 4,187) were obtained from the Joint Canada/US Survey of Health. Quality-adjusted life-year loss and economic costs were estimated on the basis of Health Utilities Index Mark 3 scores of patients with CP versus controls. Patients with CP had lower overall health performance than the control (0.56 ± 0.03 vs. 0.86 ± 0.003, P < 0.001). In multivariable regression, CP was associated with worse overall health performance (coefficient = -0.30, 95% confidence interval = -0.33 to -0.27), most accentuated in the domains of pain (coefficient = -0.24, confidence interval = -0.28 to -0.21) and emotion (coefficient = -0.11, confidence interval = -0.13 to -0.10). The reduced Health Utilities Index Mark 3 score correlated with 5.5 average lifetime quality-adjusted life-years lost per patient. Using conservative estimates for willingness to pay, the quality-adjusted life-year loss translated to an individual lifetime economic burden of $274,921 and a societal burden of $88.8 billion. CP is associated with significant QOL impairment. The economic burden of CP highlights the necessity for further research into management options.

Comparison of Treatment, Cost, and Survival in Patients With Metastatic Colorectal Cancer in Western Washington, United States, and British Columbia, Canada

PURPOSE

Few studies have directly compared health care utilization, costs, and outcomes between patients treated in the US multipayer health system and Canada's single-payer system. Using cancer registry and claims data, we assessed treatment types, costs, and survival for patients with metastatic colorectal cancer (mCRC) in Western Washington State (WW) and British Columbia (BC).

MATERIALS AND METHODS

Patients age ≥ 18 years diagnosed with mCRC in 2010 and later were identified from the BC Cancer database and a regional database linking WW SEER to claims from Medicare and two large commercial insurers. Demographics, treatment characteristics, costs of systemic therapy, and survival data were obtained from these databases and compared between the two regions.

RESULTS

A total of 1,592 patients from BC and 901 from WW were included in the study. Median age was similar (BC, 66 years; WW, 63 years), but patients in BC were more likely to be male (57.1% v 51.2%; P ≤ .01) and to have de novo metastatic disease (61.0% v 38.3%; P ≤ .01). The use of radiation therapy was similar between regions (BC, 31.2%; WW, 33.9%; P = .18), but primary tumor resection was more common in BC (74.1% v 66.3%; P ≤ .01) as was hepatic metastasectomy (12.4% v 2.3%; P ≤ .01). Similar percentages of patients received systemic therapy (BC, 68.8%; WW, 67.1%; P = .40), but costs were significantly higher for first-line systemic therapy in WW ($6,226 v $15,792 per patient per month; P ≤ .01). Median overall survival was similar (BC, 16.9 months; WW, 18 months).

CONCLUSION

Cost of systemic therapy for mCRC was significantly higher for patients in WW than in BC, but this did not translate to a difference in overall survival.

Creating Accessible Survey Instruments for Use with Autistic Adults and People with Intellectual Disability: Lessons Learned and Recommendations

Despite growing appreciation of the need for research on autism in adulthood, few survey instruments have been validated for use with autistic adults. We conducted an institutional ethnography of two related partnerships that used participatory approaches to conduct research in collaboration with autistic people and people with intellectual disability. In this article, we focus on lessons learned from adapting survey instruments for use in six separate studies. Community partners identified several common problems that made original instruments inaccessible. Examples included: (1) the use of difficult vocabulary, confusing terms, or figures of speech; (2) complex sentence structure, confusing grammar, or incomplete phrases; (3) imprecise response options; (4) variation in item response based on different contexts; (5) anxiety related to not being able to answer with full accuracy; (6) lack of items to fully capture the autism-specific aspects of a construct; and (7) ableist language or concepts. Common adaptations included: (1) adding prefaces to increase precision or explain context; (2) modifying items to simplify sentence structure; (3) substituting difficult vocabulary words, confusing terms, or figures of speech with more straightforward terms; (4) adding hotlinks that define problematic terms or offer examples or clarifications; (5) adding graphics to increase clarity of response options; and (6) adding new items related to autism-specific aspects of the construct. We caution against using instruments developed for other populations unless instruments are carefully tested with autistic adults, and we describe one possible approach to ensure that instruments are accessible to a wide range of autistic participants.

LAY SUMMARY

Why is this topic important?: To understand what can improve the lives of autistic adults, researchers need to collect survey data directly from autistic adults. However, most survey instruments were made for the general population and may or may not work well for autistic adults.What is the purpose of this article?: To use lessons learned from our experience adapting surveys-in partnership with autistic adults-to create a set of recommendations for how researchers may adapt instruments to be accessible to autistic adults.What did the authors do?: Between 2006 and 2019, the Academic Autism Spectrum Partnership in Research and Education (AASPIRE) and the Partnering with People with Developmental Disabilities to Address Violence Consortium used a participatory research approach to adapt many survey instruments for use in six separate studies. We reviewed records from these partnerships and identified important lessons.What is this recommended adaptation process like?: The adaptation process includes the following:  (1) Co-creating collaboration guidelines and providing community partners with necessary background about terminology and processes used in survey research; (2) Collaboratively selecting which constructs to measure; (3) Discussing each construct so that we can have a shared understanding of what it means; (4) Identifying existing instruments for each construct; (5) Selecting among available instruments (or deciding that none are acceptable and that we need to create a new measure); (6) Assessing the necessary adaptations for each instrument; (7) Collaboratively modifying prefaces, items, or response options, as needed; (8) Adding "hotlink" definitions where necessary to clarify or provide examples of terms and constructs; (9) Creating new measures, when needed, in partnership with autistic adults;(10)Considering the appropriateness of creating proxy report versions of each adapted measure; and(11)Assessing the adapted instruments' psychometric properties.What were common concerns about existing instruments?: Partners often said that, if taking a survey that used the original instruments, they would experience confusion, frustration, anxiety, or anger. They repeatedly stated that, faced with such measures, they would offer unreliable answers, leave items blank, or just stop participating in the study. Common concerns included the use of difficult vocabulary, confusing terms, complex sentence structure, convoluted phrasings, figures of speech, or imprecise language. Partners struggled with response options that used vague terms. They also felt anxious if their answer might not be completely accurate or if their responses could vary in different situations. Often the surveys did not completely capture the intended idea. Sometimes, instruments used offensive language or ideas. And in some cases, there just were not any instruments to measure what they thought was important.What were common adaptations?: Common adaptations included: (1) adding prefaces to increase precision or explain context; (2) modifying items to simplify sentence structure; (3) substituting difficult vocabulary words, confusing terms, or figures of speech with more straightforward terms; (4) adding hotlinks that define problematic terms or offer examples or clarifications; (5) adding graphics to increase clarity of response options; and (6) adding new items related to autism-specific aspects of the construct.How will this article help autistic adults now or in the future?: We hope that this article encourages researchers to collaborate with autistic adults to create better survey instruments. That way, when researchers evaluate interventions and services, they can have the right tools to see if they are effective.

Health-related quality of life and economic implications of cutaneous T-cell lymphoma

BACKGROUND

Cutaneous T-cell lymphoma (CTCL) has been associated with considerable physical, psychological and financial burden. However, its impact on health-related quality of life (QoL) and economic costs are not well studied.

OBJECTIVES

To measure the QoL impact and financial burden of CTCL.

METHODS

A cross-sectional survey of 67 patients with CTCL was conducted using the Ontario Health Utilities Index Mark 3 (HUI3) questionnaire. Normative population data (n = 3310) were obtained from the 2002-2003 Joint Canada/United States Survey of Health. Economic cost was estimated using quality-adjusted life-year (QALY) loss derived from HUI3 scores.

RESULTS

Patients with CTCL had significantly lower aggregate HUI3 scores than the general population (0·68 vs. 0·87, P < 0·001). Multivariable regression analysis adjusting for demographics and comorbidities showed CTCL was associated with significantly poorer performance overall (-0·13, 95% CI -0·21 to -0·06, P < 0·001) and in domains of speech (-0·03, 95% CI -0·05 to -0·01, P = 0·01), ambulation (-0·04, 95% CI -0·08 to 0·00, P = 0·03), emotion (-0·07, 95% CI -0·12 to -0·02, P = 0·01), and pain (-0·07, 95% CI -0·13 to -0·01, P = 0·03). These health utility decrements yielded an average loss of 1·48 QALYs per patient. Using a $50 000 per QALY willingness-to-pay threshold, CTCL was associated with an individual lifetime burden of $73 889 and U.S. societal burden of $2·86 billion.

CONCLUSIONS

These findings suggest CTCL has a pervasive impact on QoL, comparable with debilitating conditions such as end-stage renal disease. The substantial economic burden of CTCL underscores the potential societal benefit of prompt diagnosis and effective management. What's already known about this topic? Cutaneous T-cell lymphoma is associated with physical, psychological and financial burden. What does this study add? The overall quality-of-life impact of cutaneous T-cell lymphoma has not previously been measured using a generic health utility instrument. In this study, we compare the overall quality-of-life burden of patients with cutaneous T-cell lymphoma with that of other populations and calculate the economic burden of the disease.

Content of inpatient rehabilitation for patients with traumatic brain injury: A comparison of Canadian and American facilities

Objective: To compare components of inpatient rehabilitation (IR) for patients with traumatic brain injury (TBI) between Canada and the US facilities. Design: Secondary analysis of the TBI-practice-based evidence dataset. Participants: Patients with TBI who had a higher Functional Independence Measure (FIM^TM) cognitive function score (≥21) that were admitted to 1 IR facility in Canada (n = 103) and 9 IR facilities in the US (n = 401). Main measures: demographic and clinical characteristics, type and intensity of activities by discipline, discharge location, FIM-Rasch score, social participation and quality of life. Results: Time from injury to rehabilitation admission was significantly longer in the Canadian cohort and they experienced a longer rehabilitation length of stay (p < .001, Cohen's d > .8). Patients in Canada received a greater total time of individual therapy and lower intensity of interventions per week from all disciplines. They also showed a higher score at discharge in FIM components, while US patients had better cognitive recovery and community participation long-term post-discharge. Conclusions: This study informs stakeholders of the large variation in service provision for patients who were treated in these two countries. These findings suggest the need for robust analyzes to investigate predictors of short and long-term outcomes considering the variation in health-care delivery. List of abbreviations: TBI: traumatic brain injury, CSI: comprehensive severity index, LoS: length of stay, OT: occupational therapy, PT: physical therapy, SLP: speech language pathology, IR: inpatient rehabilitation.

Care of acute conditions and chronic diseases in Canada and the United States: Rapid systematic review and meta-analysis

This study tested the hypothesis that socioeconomically vulnerable Canadians with diverse acute conditions or chronic diseases have health care access and survival advantages over their counterparts in the USA. A rapid systematic review retrieved 25 studies (34 independent cohorts) published between 2003 and 2018. They were synthesized with a streamlined meta-analysis. Very low-income Canadian patients were consistently and highly advantaged in terms of health care access and survival compared with their counterparts in the USA who lived in poverty and/or were uninsured or underinsured. In aggregate and controlling for specific conditions or diseases and typically 4 to 9 comorbid factors or biomarkers, Canadians' chances of receiving better health care were estimated to be 36% greater than their American counterparts (RR=1.36, 95% CI 1.35-1.37). This estimate was significantly larger than that based on general patient or non-vulnerable population comparisons (RR=1.09, 95% CI 1.08-1.10). Contrary to prevalent political rhetoric, three studies observed that Americans experience more than twice the risk of long waits for breast or colon cancer care or of dying while they wait for an organ transplant (RR=2.36, 95% CI 2.09-2.66). These findings were replicated across externally valid national studies and more internally valid, metropolitan or provincial/state comparisons. Socioeconomically vulnerable Canadians are consistently and highly advantaged on health care access and outcomes compared to their American counterparts. Less vulnerable comparisons found more modest Canadian advantages. The Affordable Care Act ought to be fully supported including the expansion of Medicaid across all states. Canada's single payer system ought to be maintained and strengthened, but not through privatization.

Health-Related Quality of Life according to the Socioeconomic Status of Living Areas in Iranian Children and Adolescents: Weight Disorders Survey

BACKGROUND

Health-related quality of life (HRQoL) has become a major concern in the field of children's health research. We assessed HRQoL among Iranian children and adolescents according to the socioeconomic status (SES) of their living region.

METHODS

Via multistage cluster sampling from rural and urban school students aged 6 to 18 years, this nationwide study was conducted from 2011 to 2012. HRQoL was assessed using the adolescent core version of the Pediatric Quality of Life questionnaire. Through survey data analysis methods, the data were compared according to the SES of the living region, sex, and the living area.

RESULTS

Overall, 23043 students participated in the survey (participation rate=92.2%). The mean age of the participants was 12.55±3.31 years. Boys accounted for 50.8% of the study population, and 73.4% were from urban areas. At national level, the mean of the HRQoL total score was 81.7 (95% CI: 81.3 to 82.1) with a mean of 83.5 (95% CI: 83.0 to 84.1) for the boys and 79.8 (95% CI: 79.1 to 80.5) for the girls. The highest and the lowest scores, respectively, belonged to social functioning (90.0 [95% CI: 89.7 to 90.3]) and emotional functioning (78.2 [95% CI: 77.7 to 78.7]). The highest total HRQoL score belonged to the second highest SES region of the country (mean=83.1; 95% CI: 82.5 to 83.7). The association between total HRQoL and the score of all the subscales and SES in the living area was statistically significant (P<0.001).

CONCLUSION

The results of the present study showed that in the children and adolescents, SES was associated with HRQoL. Accordingly, HRQoL and the related SES differences should be considered one of the priorities in health research and health policy.

Bismarck and the Long Road to Universal Health Coverage

The 2015 Sustainable Development Goals (SDGs) state that All United Nations Member States have agreed to try to achieve Universal Health Coverage by 2030. This includes financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. Universal health coverage (UHC) means inclusion and empowerment for all people to access medical care, including treatment and prevention services. UHC exists in all the industrial nations except the US, which has a mixed public-private system and struggles with closing the gap between the insured and the uninsured population. Middle- and low-income countries face many challenges for UHC achievement, including low levels of funding, lack of personnel, weak health management, and issues of availability of services favoring middle- and upper-class communities. Community health services for preventive and curative health services for needs in populations at risk for poor health in low-income countries must be addressed with proactive health promotion initiatives for the double burden of infectious and noncommunicable diseases. Each nation will develop its own unique approach to national health systems, but there are models used by a number of countries based on principles of national responsibility for health, social solidarity for providing funding, and for effective ways of providing care with comprehensiveness, efficiency, quality, and cost containment. Universal access does not eliminate social inequalities in health by itself, including a wide context of reducing social inequities. Understanding national health systems requires examining representative models of different systems.

Health reform is necessarily a continuing process as all countries must adapt to face challenges of cost constraints, inequalities in access to care, aging populations, emergence of new disease conditions and advancing technology including the growing capacity of medicine, public health and health promotion. The growing stress of increasing obesity, diabetes, and other chronic diseases, requires nations to modify their health care systems. Learning from the systems developed in different countries helps to learn from the processes of change in other countries.

Health-related quality of life and economic burden of vestibular loss in older adults

Objectives

Vestibular loss is a debilitating condition, and despite its high prevalence in older adults, the quality of life (QoL) burden of vestibular loss in older individuals has not been well-studied. This report quantifies the impact on overall QoL and identifies domains of health most affected. We hypothesize vestibular loss will be associated with impairment in diverse domains of health-related QoL.

Study Design

Prospective, case-control study.

Methods

A convenience sample of 27 patients age ≥60 years with vestibular physiologic loss was recruited from an academic neurotology clinic. The patients did not have any identifiable cause of their vestibular loss other than aging. The convenience sample was compared to an age-matched cross-sectional sample of the general US population (n = 1266). The main outcome was QoL measured by the Ontario Health Utilities Index Mark III (HUI3).

Results

Compared to the general population, patients with vestibular loss had significantly lower overall unadjusted HUI3 scores (-0.32, p < 0.001). Multivariate regression analysis showed vestibular loss was significantly associated with poorer performance in vision (-0.11 p < 0.0001), speech (-0.15, p < 0.0001), dexterity (-0.13, p < 0.0001), and emotion (-0.07, p = 0.0065). Adjusted aggregate HUI3 was also significantly lower for vestibular loss (-0.15, p = 0.0105). These QoL decrements resulted in an average loss of 1.30 Quality-Adjusted Life Years (QALYs). When using a $50,000/QALY willingness-to-pay threshold, vestibular loss was associated with a $64,929 lifetime economic burden per affected older adult, resulting in a total lifetime societal burden of $227 billion for the US population ≥60 years of age.

Conclusions

Loss of vestibular function with aging significantly decreases quality of life across multiple domains of well-being. These QoL reductions are responsible for heavy societal economic burdens of vestibular loss, which reveal potential benefits of prompt diagnosis and treatment of this condition.

Level of Evidence

3.

Breast Cancer Care in California and Ontario: Primary Care Protections Greatest Among the Most Socioeconomically Vulnerable Women Living in the Most Underserved Places

BACKGROUND

Better health care among Canada's socioeconomically vulnerable versus America's has not been fully explained. We examined the effects of poverty, health insurance and the supply of primary care physicians on breast cancer care.

METHODS

We analyzed breast cancer data in Ontario (n = 950) and California (n = 6300) between 1996 and 2000 and followed until 2014. We obtained socioeconomic data from censuses, oversampling the poor. We obtained data on the supply of physicians, primary care and specialists. The optimal care criterion was being diagnosed early with node negative disease and received breast conserving surgery followed by adjuvant radiation therapy.

RESULTS

Women in Ontario received more optimal care in communities well supplied by primary care physicians. They were particularly advantaged in the most disadvantaged places: high poverty neighborhoods (rate ratio = 1.65) and communities lacking specialist physicians (rate ratio = 1.33). Canadian advantages were explained by better health insurance coverage and greater primary care access.

CONCLUSIONS

Policy makers ought to ensure that the newly insured are adequately insured. The Medicaid program should be expanded, as intended, across all 50 states. Strengthening America's system of primary care will probably be the best way to ensure that the Affordable Care Act's full benefits are realized.

Update to the Report of Nationally Representative Values for the Noninstitutionalized US Adult Population for Five Health-Related Quality-of-Life Scores

BACKGROUND

The most recent reports of nationally representative health-related quality-of-life (HRQOL) values for the United States used data that were collected over a decade ago.

OBJECTIVES

To update these values using data from 2011, stratified by age and sex.

METHODS

This study used data from two sources-the 2011 Medical Expenditures Panel Survey (MEPS) and the 2011 National Health Interview Survey (NHIS). Both are nationally representative surveys of the US noninstitutionalized civilian population. The MEPS was used to calculate four HRQOL scores: categorical self-rated health, mental and physical component summaries from the short form-12 items (SF-12) health survey, and the health state short form-6 dimensions (SF-6D). We also estimated Quality of Well-Being Scale scores from the NHIS. We reported means and quartiles for all continuous scores, stratified by decade of age and sex.

RESULTS

There were 23,906 eligible subjects in the 2011 MEPS and 32,242 eligible subjects in the 2011 NHIS. All age and sex categories had instrument completion rates above 84%. Females reported lower mean scores than did males across all ages and instruments. In general, those in older age groups reported lower scores than did those in younger age groups, with the exception of the mental component summary scores from the SF-12 health survey. When compared with previous reports, these new values were generally lower than those in previous reports but rarely reached minimally important difference criteria.

CONCLUSIONS

This report updates US nationally representative age- and sex-stratified estimates for five HRQOL scores using data from 2011. These values are important for use in both generalized comparisons of health status and in cost-effectiveness analyses.

EDUCATIONAL ATTAINMENT AS A PROTECTIVE FACTOR FOR PSYCHIATRIC DISORDERS: FINDINGS FROM A NATIONALLY REPRESENTATIVE LONGITUDINAL STUDY

OBJECTIVE

This study examined cross-sectional and longitudinal relationships between educational attainment and psychiatric disorders (i.e., mood, anxiety, substance use, and personality disorders) using a nationally representative survey of US adults.

METHOD

We used data from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (N = 34,653). Bivariate and multiple logistic regressions examined cross-sectional and longitudinal associations between educational attainment and a variety of past-year and incident anxiety, mood, and substance use disorders, controlling for sociodemographics and psychiatric disorder comorbidity.

RESULTS

Adjusted cross-sectional data indicated that educational attainment below a graduate or professional degree at Wave 2 was associated with significantly higher odds of substance use and/or dependence disorders (adjusted odds ratio range (AORR = 1.55-2.55, P < 0.001). Longitudinal adjusted regression analyses indicated that individuals reporting less than a college education at Wave 1 were at significantly higher odds of experiencing any incident mood (AORR 1.49-1.64, P < 0.01), anxiety (AORR 1.35-1.69, P < 0.01), and substance use disorder (AORR 1.50-2.02, P < 0.01) at Wave 2 even after controlling for other sociodemographic variables and psychiatric comorbidity.

CONCLUSION

Findings lend support to other published research demonstrating that educational attainment is protective against developing a spectrum of psychiatric disorders. Mechanisms underlying this relationship are speculative and in need of additional research.

Using Linear Equating to Map PROMIS(®) Global Health Items and the PROMIS-29 V2.0 Profile Measure to the Health Utilities Index Mark 3

BACKGROUND

Preference-based health-related quality of life (HR-QOL) scores are useful as outcome measures in clinical studies, for monitoring the health of populations, and for estimating quality-adjusted life-years.

METHODS

This was a secondary analysis of data collected in an internet survey as part of the Patient-Reported Outcomes Measurement Information System (PROMIS(®)) project. To estimate Health Utilities Index Mark 3 (HUI-3) preference scores, we used the ten PROMIS(®) global health items, the PROMIS-29 V2.0 single pain intensity item and seven multi-item scales (physical functioning, fatigue, pain interference, depressive symptoms, anxiety, ability to participate in social roles and activities, sleep disturbance), and the PROMIS-29 V2.0 items. Linear regression analyses were used to identify significant predictors, followed by simple linear equating to avoid regression to the mean.

RESULTS

The regression models explained 48 % (global health items), 61 % (PROMIS-29 V2.0 scales), and 64 % (PROMIS-29 V2.0 items) of the variance in the HUI-3 preference score. Linear equated scores were similar to observed scores, although differences tended to be larger for older study participants.

CONCLUSIONS

HUI-3 preference scores can be estimated from the PROMIS(®) global health items or PROMIS-29 V2.0. The estimated HUI-3 scores from the PROMIS(®) health measures can be used for economic applications and as a measure of overall HR-QOL in research.

Health care: a brave new world

The current U.S. health care system, with both rising costs and demands, is unsustainable. The combination of a sense of individual entitlement to health care and limited acceptance of individual responsibility with respect to personal health has contributed to a system which overspends and underperforms. This sense of entitlement has its roots in a perceived right to health care. Beginning with the so-called moral right to health care (all life is sacred), the issue of who provides health care has evolved as individual rights have trumped societal rights. The concept of government providing some level of health care ranges from limited government intervention, a 'negative right to health care' (e.g., prevention of a socially-caused, preventable health hazard), to various forms of a 'positive right to health care'. The latter ranges from a decent minimum level of care to the best possible health care with access for all. We clarify the concept of legal rights as an entitlement to health care and present distributive and social justice counter arguments to present health care as a privilege that can be provided/earned/altered/revoked by governments. We propose that unlike a 'right', which is unconditional, a 'privilege' has limitations. Going forward, expectations about what will be made available should be lowered while taking personal responsibility for one's health must for elevated. To have access to health care in the future will mean some loss of personal rights (e.g., unhealthy behaviors) and an increase in personal responsibility for gaining or maintaining one's health.

Controversies with Kalydeco: Newspaper coverage in Canada and the United States of the cystic fibrosis "wonder drug"

BACKGROUND

The cystic fibrosis drug, Kalydeco, has attracted attention both for its effectiveness in particular CF patients and its substantial price tag. An analysis of newspaper portrayals of Kalydeco provides an opportunity to examine how policy issues associated with rare diseases and orphan drugs are being represented in the popular press.

METHODS

We conducted a content analysis of 203 newspaper articles in Canada and the U.S. that mention Kalydeco. Articles were analyzed for their main frame, discussion of Kalydeco, including issues of drug development, patient access, and reimbursement, and overall tone.

RESULTS

In Canadian newspaper coverage, 77.4% of articles were framed as human interest stories featuring individual patients seeking public funding for Kalydeco, yet only 7.5% mentioned any budgetary limitations in doing so. In contrast, U.S. newspaper coverage was framed as a financial/economic story in 43.1% of articles and a medical/scientific story in 27.8%.

CONCLUSIONS

Newspaper coverage varied significantly between Canada, where Kalydeco is predominantly a story about increasing patient access through full government funding, and the U.S., where Kalydeco is largely a financial story about the economic impact of Kalydeco. The difference in coverage may be due to differences in public funding between the healthcare systems of these two countries.

Predictors of trajectories of epilepsy-specific quality of life among children newly diagnosed with epilepsy

OBJECTIVE

The objective of this study was to identify two-year trajectories of epilepsy-specific health-related quality of life (HRQOL) among children newly diagnosed with epilepsy and to evaluate the predictive value of a comprehensive set of medical, psychosocial, and family factors.

METHODS

Ninety-four children with epilepsy (8.14 ± 2.37 years of age and 63% male) and their caregivers participated in this study. Caregivers completed the Quality of Life in Childhood Epilepsy Questionnaire (QOLCE) and measures of psychological and family functioning at one month postdiagnosis. The QOLCE was also given at eight additional time points during the subsequent two years as a part of a large observational study in children with epilepsy. Adherence data were collected via MEMS TrackCaps, and medical information was collected through chart review.

RESULTS

Unique trajectories were identified for the overall QOLCE scale, as well as the subscales. Most trajectory models for the QOLCE subscales contained at least one at-risk trajectory for children, indicating that there is a subgroup of children experiencing poor long-term HRQOL. Health-related quality-of-life trajectories remained predominantly stable during the two-year period following treatment initiation. The number of AEDs, internalizing problems, and externalizing problems emerged as the most consistent predictors across the HRQOL domains.

SIGNIFICANCE

Medical and psychosocial interventions, such as cognitive-behavioral strategies, should target modifiable factors (e.g., internalizing symptoms, externalizing symptoms, number of AEDs trialed) shortly after diagnosis to improve HRQOL for children with epilepsy over the course of their disease.

Racial Disparities in Access to Care Under Conditions of Universal Coverage

BACKGROUND

Racial disparities in access to regular health care have been reported in the U.S., but little is known about the extent of disparities in societies with universal coverage.

PURPOSE

To investigate the extent of racial disparities in access to care under conditions of universal coverage by observing the association between race and regular access to a doctor in Canada.

METHODS

Racial disparities in access to a regular doctor were calculated using the largest available source of nationally representative data in Canada--the Canadian Community Health Survey. Surveys from 2000-2010 were analyzed in 2014. Multinomial regression analyses predicted odds of having a regular doctor for each racial group compared to whites. Analyses were stratified by immigrant status--Canadian-born versus shorter-term immigrant versus longer-term immigrants--and controlled for sociodemographics and self-rated health.

RESULTS

Racial disparities in Canada, a country with universal coverage, were far more muted than those previously reported in the U.S. Only among longer-term Latin American immigrants (OR=1.90, 95% CI=1.45, 2.08) and Canadian-born Aboriginals (OR=1.34, 95% CI=1.22, 1.47) were significant disparities noted. Among shorter-term immigrants, all Asians were more likely than whites, and among longer-term immigrants, South Asians were more like than whites, to have a regular doctor.

CONCLUSIONS

Universal coverage may have a major impact on reducing racial disparities in access to health care, although among some subgroups, other factors may also play a role above and beyond health insurance.

Using business intelligence to analyze and share health system infrastructure data in a rural health authority

Background

Health care organizations gather large volumes of data, which has been traditionally stored in legacy formats making it difficult to analyze or use effectively. Though recent government-funded initiatives have improved the situation, the quality of most existing data is poor, suffers from inconsistencies, and lacks integrity. Generating reports from such data is generally not considered feasible due to extensive labor, lack of reliability, and time constraints. Advanced data analytics is one way of extracting useful information from such data.

Objective

The intent of this study was to propose how Business Intelligence (BI) techniques can be applied to health system infrastructure data in order to make this information more accessible and comprehensible for a broader group of people.

Methods

An integration process was developed to cleanse and integrate data from disparate sources into a data warehouse. An Online Analytical Processing (OLAP) cube was then built to allow slicing along multiple dimensions determined by various key performance indicators (KPIs), representing population and patient profiles, case mix groups, and healthy community indicators. The use of mapping tools, customized shape files, and embedded objects further augment the navigation. Finally, Web forms provide a mechanism for remote uploading of data and transparent processing of the cube. For privileged information, access controls were implemented.

Results

Data visualization has eliminated tedious analysis through legacy reports and provided a mechanism for optimally aligning resources with needs. Stakeholders are able to visualize KPIs on a main dashboard, slice-and-dice data, generate ad hoc reports, and quickly find the desired information. In addition, comparison, availability, and service level reports can also be generated on demand. All reports can be drilled down for navigation at a finer granularity.

Conclusions

We have demonstrated how BI techniques and tools can be used in the health care environment to make informed decisions with reference to resource allocation and enhancement of the quality of patient care. The data can be uploaded immediately upon collection, thus keeping reports current. The modular design can be expanded to add new datasets such as for smoking rates, teen pregnancies, human immunodeficiency virus (HIV) rates, immunization coverage, and vital statistical summaries.

Unmet health care needs of older people: prevalence and predictors in a French cross-sectional survey

Background: Unmet health care needs are associated with negative health outcomes, yet there is a paucity of data on this problem among older people. Objective: To identify unmet health care needs and associated factors among older people in France. Methods: This is a cross-sectional population study of people aged 70 years or older in which 2350 respondents were interviewed in 2008–10. During a standardized interview, a nurse examined health problems, functional abilities and use of health care resources. Unmet health care needs were defined as situations in which a participant needed health care and did not receive it. Results: The mean age was 83.2 ± 7.4 years. Almost all participants reporting a chronic disease (98.6%) had consulted a physician in the previous 6 months. Unmet health care needs were found in 23.0% of the sample and mainly consisted of lack of dental care (prevalence of 17.7%), followed by lack of management of visual or hearing impairments (prevalence of 4.4% and 3.1%, respectively). Age was the main factor associated with unmet health care needs [compared with people aged 70–79: odds ratio_{80–89 years} = 2.26 (1.70–3.03), odds ratio_{90 years and over} = 3.85 (2.71–5.45)]. Other associated factors were regular smoking, homebound status, poor socioeconomic conditions, depression, limitations in instrumental activities of daily living and low medical density. Conclusion: Unmet health care needs affect almost one-quarter of older people in France. Efforts should be made to improve oral health and develop home care, especially for the oldest-olds.

Comparison of healthcare experiences in autistic and non-autistic adults: a cross-sectional online survey facilitated by an academic-community partnership

BACKGROUND

Little is known about the healthcare experiences of adults on the autism spectrum. Moreover, autistic adults have rarely been included as partners in autism research.

OBJECTIVE

To compare the healthcare experiences of autistic and non-autistic adults via an online survey.

METHODS

We used a community-based participatory research (CBPR) approach to adapt survey instruments to be accessible to autistic adults and to conduct an online cross-sectional survey. We assessed preliminary psychometric data on the adapted scales. We used multivariate analyses to compare healthcare experiences of autistic and non-autistic participants.

RESULTS

Four hundred and thirty-seven participants completed the survey (209 autistic, 228 non-autistic). All adapted scales had good to excellent internal consistency reliability (alpha 0.82-0.92) and strong construct validity. In multivariate analyses, after adjustment for demographic characteristics, health insurance, and overall health status, autistic adults reported lower satisfaction with patient-provider communication (beta coefficient -1.9, CI -2.9 to -0.9), general healthcare self-efficacy (beta coefficient -11.9, CI -14.0 to -8.6), and chronic condition self-efficacy (beta coefficient -4.5, CI -7.5 to -1.6); higher odds of unmet healthcare needs related to physical health (OR 1.9 CI 1.1-3.4), mental health (OR 2.2, CI 1.3-3.7), and prescription medications (OR 2.8, CI 2.2-7.5); lower self-reported rates of tetanus vaccination (OR 0.5, CI 0.3-0.9) and Papanicolaou smears (OR 0.5, CI 0.2-0.9); and greater odds of using the emergency department (OR 2.1, CI 1.8-3.8).

CONCLUSION

A CBPR approach may facilitate the inclusion of people with disabilities in research by increasing researchers' ability to create accessible data collection instruments. Autistic adults who use the Internet report experiencing significant healthcare disparities. Efforts are needed to improve the healthcare of autistic individuals, including individuals who may be potentially perceived as having fewer disability-related needs.

Access to medical care: how do women in Canada and the United States compare?

OBJECTIVES

The purpose of this study is to determine if access to medical care and utilization of cancer screenings differs between women in the United States and Canada. This study examined this question by comparing women in Canada to women in the United States who have insurance coverage and those who do not.

METHOD

This study used data from the 2002/03 Joint Canada United States Survey of Health and examined access to medical care and cancer screenings. A binary probit model was used to address several measures of access to medical care and cancer screening utilization.

RESULTS

This study finds five significant differences between insured American and Canadian women. Canadian women are better off in terms of ever having a mammogram, having a regular doctor, and having access to needed medicine, but fare worse in terms of having had a recent mammogram and having perceived unmet healthcare needs. With the exception of having recent mammograms, there is no statistical difference between uninsured and insured American women.

CONCLUSION

Although this study does not show that one group is strictly better off, it does show that there are significant differences between the two groups of women.

Societal context and the production of immigrant status-based health inequalities: a comparative study of the United States and Canada

BACKGROUND

We compare disparities in health status between first-generation immigrants and others in the United States (US) and Canada.

METHODS

We used data from the Joint Canada-US Survey of Health. The regression models adjusted for demographics, socioeconomic status, and health insurance (the US).

RESULTS

In both countries, the health advantage belonged to immigrants. Fewer disparities between immigrants and those native-born were seen in Canada versus the US. Canadians of every immigrant/race group fared better than US native-born Whites.

DISCUSSION

Fewer disparities in Canada and better overall health of all Canadians suggest that societal context may create differences in access to the resources, environments, and experiences that shape health and health behaviors.

A Comparative Study of Population Health in the United States and Canada during the Neoliberal Era, 1980–2008

This article draws on the vast evidence that suggests, on one hand, that socioeconomic inequalities in health are present in every society in which they have been measured and, on the other hand, that the size of inequalities varies substantially across societies. We conduct a comparative case study of the United States and Canada to explore the role of neoliberalism as a force that has created inequalities in socioeconomic resources (and thus in health) in both societies and the roles of other societal forces (political, economic, and social) that have provided a buffer, thereby lessening socioeconomic inequalities or their effects on health. Our findings suggest that, from 1980 to 2008, while both the United States and Canada underwent significant neoliberal reforms, Canada showed more resilience in terms of health inequalities as a result of differences in: ( a) the degree of income inequality, itself resulting from differences in features of the labor market and tax and transfer policies, ( b) equality in the provision of social goods such as health care and education, and ( c) the extent of social cohesiveness across race/ethnic- and class-based groups. Our study suggests that further attention must be given to both causes and buffers of health inequalities.

Comparison of health care utilization: United States versus Canada

OBJECTIVE

To compare health care utilization between Canadian and U.S. residents.

DATA SOURCES

Nationally representative 2007 surveys from the Medical Expenditure Panel Survey for the United States and the Canadian Community Health Survey for Canada.

STUDY DESIGN

We use descriptive and multivariate methods to examine differences in health care utilization rates for visits to medical providers, nurses, chiropractors, specialists, dentists, and overnight hospital stays, usual source of care, Pap smear tests, and mammograms.

PRINCIPAL FINDINGS

The poor and less educated were more likely to utilize health care in Canada than in the United States. The differences were especially pronounced for having a usual source of care and for visits to providers, specialists, and dentists. Health care use for residents with high incomes and higher levels of education were not markedly different between the two countries and often higher for U.S residents. Foreign-born residents were more likely to use health care in Canada than in the United States. The descriptive results were confirmed in multivariate regressions.

CONCLUSIONS

Given the magnitude of our results, the health insurance structure in Canada might have played an important role in improving access to care for subpopulations examined in this study.

Comparing social determinants of self-rated health across the United States and Canada

A large body of research shows that social determinants of health have significant impact on the health of Canadians and Americans. Yet, very few studies have directly compared the extent to which social factors are associated with health in the two countries, in large part due to the historical lack of comparable cross-national data. This study examines differences in the effect of a wide-range of social determinants on self-rated health across the two populations using data explicitly designed to facilitate comparative health research-Joint Canada/United States Survey of Health. The results show that: 1) sociodemographic and socioeconomic factors have substantial effects on health in each country, though the size of the effects tends to differ-gender, nativity, and race are stronger predictors of health among Americans while the effects of age and marital status on health are much larger in Canada; the income gradient in health is steeper in Canada whereas the education gradient is steeper in the U.S.; 2) Socioeconomic status (SES) mediates or links sociodemographic variables with health in both countries-the observed associations between gender, race, age, and marital status and health are considerably weakened after adjusting for SES; 3) psychosocial, behavioural risk and health care access factors are very strong determinants of health in each country, however being severely/morbidly obese, a smoker, or having low life satisfaction has a stronger negative effect on the health of Americans, while being physically inactive or having unmet health care needs has a stronger effect among Canadians; and 4) risk and health care access factors together play a relatively minor role in linking social structural factors to health. Overall, the findings demonstrate the importance of social determinants of health in both countries, and that some determinants matter more in one country relative to the other.

Disability in two health care systems: access, quality, satisfaction, and physician contacts among working-age Canadians and Americans with disabilities

BACKGROUND

An overarching question in health policy concerns whether the current mix of public and private health coverage in the United States can be, in one way or another, expanded to include all persons as it does in Canada. As typically high-end consumers of health care services, people with disabilities are key stakeholders to consider in this debate. The risk is that ways to cover more persons may be found only by sacrificing the quantity or quality of care on which people with disabilities so frequently depend. Yet, despite the many comparisons made of Canadian and U.S. health care, few focus directly on the needs of people with disabilities or the uninsured among them in the United States. This research is intended to address these gaps. Given this background, we compare the health care experiences of working-age uninsured and insured Americans with Canadian individuals (all of whom, insured) with a special focus on disability. Two questions for research guide our inquiry: (1) On the basis of disability severity level and health insurance status, are there differences in self-reported measures of access, utilization, satisfaction with, or quality of health care services within or between the United States and Canada? (2) After controlling covariates, when examining each level of disability severity, are there any significant differences in these measures of access, utilization, satisfaction, or quality between U.S. insured and Canadian persons?

METHODS

Cross-sectional data from the Joint Canada/United States Survey of Health (JCUSH) are analyzed with particular attention to disability severity level (none, nonsevere, or severe) among three analytic groups of working age residents (insured Americans, uninsured Americans, and Canadians). Differences in three measures of access, one measure of satisfaction with care, one quality of care measure, and two varieties of physician contacts are compared. Multivariate methods are then used to compare the healthcare experiences of insured U.S. and Canadian persons on the basis of disability level while controlling covariates.

RESULTS

In covariate-controlled comparisons of insured Americans and Canadians, we find that people with disabilities report higher levels of unmet need than do their counterparts without disabilities, with no difference in this result between the nations. Our findings on access to medications and satisfaction with care among people with disabilities are similar, suggesting worse outcomes for people with disabilities, but few differences between insured U.S. and Canadian individuals. Generally, we find higher percentages who report having a regular physician, and higher contact rates with physicians among people with disabilities than among people without them in both countries. We find no evidence that total physician contacts are restricted in Canada relative to insured Americans at any of the disability levels. Yet we do find that quality ratings are lower among Canadian respondents than among insured Americans. However, bivariate estimates on access, satisfaction, quality, and physician contacts reveal particularly poor outcomes for uninsured persons with severe disabilities in the United States. For example, almost 40% do not report having a regular physician, 65% report that they need at least one medication that they cannot afford, 45% are not satisfied with the way their care is provided, 40% rate the overall quality of their care as fair or poor, and significant reductions in contacts with two types of physicians are evident within this group as well.

CONCLUSION

Based on these results, we find evidence of disparities in health care on the basis of disability in both Canada and the United States. However, despite the fact that Canada makes health insurance coverage available to all residents, we find few significant reductions in access, satisfaction or physician contacts among Canadians with disabilities relative to their insured American counterparts. These results place a spotlight on the experiences of uninsured persons with disabilities in America and suggest further avenues for research.

Health-related quality of life in adults reporting arthritis: analysis from the National Health Measurement Study

Background

Arthritis is the leading cause of disability in the United States. We assess the generic health-related quality-of-life (HRQOL) among a nationally representative sample of US adults with and without self-reported arthritis.

Methods

The NHMS, a cross-sectional survey of 3,844 adults (35–89 years) administered EuroQol-5D (EQ-5D), Health Utilities Index Mark 2 (HUI2) and 3 (HUI3), SF-36v2™, Quality of Well-being Scale self-administered form (QWB-SA), and the Health and Activities Limitations index (HALex) to each respondent via a telephone interview. Weighted multiple linear regression was used to generate age-gender-arthritis-stratified unadjusted HRQOL means and means adjusted for sociodemographic, socioeconomic covariates and comorbidities by arthritis–age category.

Results

The estimated population prevalence of self-reported arthritis was 31%. People with arthritis were more likely to be woman, older, of lower socioeconomic status, and had more self-reported comorbidities than were those not reporting arthritis. Adults with arthritis had lower HRQOL on six different indexes compared with adults without arthritis, with overall differences ranging from 0.03 (QWB-SA, age-group 65–74) to 0.17 (HUI3, age-group 35–44; all P-value < .05).

Conclusion

Arthritis in adults is associated with poorer HRQOL. We provide age-related reference values for six generic HRQOL measures in people with arthritis.

Gender differences in health-related quality-of-life are partly explained by sociodemographic and socioeconomic variation between adult men and women in the US: evidence from four US nationally representative data sets

PURPOSE

The purpose of this study was to describe gender differences in self-reported health-related quality-of-life (HRQoL) and to examine whether differences are explained by sociodemographic and socioeconomic status (SES) differentials between men and women.

METHODS

Data were from four US nationally representative surveys: US Valuation of the EuroQol EQ-5D Health States Survey (USVEQ), Medical Expenditure Panel Survey (MEPS), National Health Measurement Study (NHMS) and Joint Canada/US Survey of Health (JCUSH). Gender differences were estimated with and without adjustment for sociodemographic and SES indicators using regression within and across data sets with SF-6D, EQ-5D, HUI2, HUI3 and QWB-SA scores as outcomes.

RESULTS

Women have lower HRQoL scores than men on all indexes prior to adjustment. Adjusting for age, race, marital status, education and income reduced but did not remove the gender differences, except with HUI3. Adjusting for marital status or income had the largest impact on estimated gender differences.

CONCLUSIONS

There are clear gender differences in HRQoL in the United States. These differences are partly explained by sociodemographic and SES differentials.

Access to primary and preventive care among foreign-born adults in Canada and the United States

OBJECTIVE

To conduct cross-country comparisons and assess the effect of foreign birth on access to primary and preventive care in Canada and the United States.

DATA SOURCES

Secondary data from the 2002 to 2003 Joint Canada-United States Survey of Health.

STUDY DESIGN

Descriptive and comparative analyses were conducted, and logistic regression models were used to assess the effect of immigrant status and country of residence on access to care. Outcomes included measures of health care systems and processes, utilization, and patient perceptions.

PRINCIPAL FINDINGS

In adjusted analyses, immigrants in Canada fared worse than nonimmigrants regarding having timely Pap tests; in the United States, immigrants fared worse for having a regular doctor and an annual consultation with a health professional. Immigrants in Canada had better access to care than immigrants in the United States; most of these differences were explained by differences in socioeconomic status and insurance coverage across the two countries. However, U.S. immigrants were more likely to have timely Pap tests than Canadian immigrants, even after adjusting for potential confounders.

CONCLUSIONS

In both countries, foreign-born populations had worse access to care than their native-born counterparts for some indicators but not others. However, few differences in access to care were found when direct cross-country comparisons were made between immigrants in Canada versus the United States, after accounting for sociodemographic differences.

Comparing Racial and Immigrant Health Status and Health Care Access in Later Life in Canada and the United States

Il y a peu de recherche comparative en existence sur les expériences de la santé et les conditions de groupes minoritaires au Canada et aux États-Unis, malgré le fait que les deux pays ont des populations racialement diverses avec une proportion significative des immigrants. Cet article explore les disparités raciales et immigrantes en santé et soins d’accès entre les deux pays. L’étude portait sur l’âge mûr et la vieillesse, compte tenu du changement et de la diversité croissante dans la politique de santé et les soins de santé, tel que Medicare. L’analyse de régression logistique des données de l’Enquête de la santé Canada/États-Unis 2002–2003 montre que l’effet conjoint de la race et de la nativité de santé – différences en santé entre indigènes blancs et étrangers blancs et non-blancs est en grande partie négligeable au Canada, mais considérable aux États-Unis. Americains indigènes non-blancs et américains nés à l’étranger au sein des groupes d’âge 45-à-64 et 65-et-plus expériencent une désavantage significative dans l’état de santé et aussi de l’accès aux soins, indépendamment de la couverture d’assurance-maladie et des facteurs démographiques, socio-économiques et de la mode de vie.

Do major cardiovascular outcomes in patients with stable ischemic heart disease in the clinical outcomes utilizing revascularization and aggressive drug evaluation trial differ by healthcare system?

BACKGROUND

The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial enrolled patients from 3 distinct healthcare systems (HCSs) in North America. The primary aim of this study was to determine whether there is a treatment difference in cardiovascular outcomes by HCS.

METHODS AND RESULTS

The study population included 968 patients from the US Department of Veterans Affairs (VA), 386 from the US non-VA, and 931 from Canada with different comorbidities and prognoses. The primary outcome was all-cause mortality or nonfatal myocardial infarction (MI) during the median 4.6-year follow-up. Baseline demographics were similar between percutaneous coronary intervention and optimal medical therapy treatment groups within each HCS. After follow-up, the primary end point of total mortality and nonfatal MI was not statistically significant between percutaneous coronary intervention and optimal medical therapy, regardless of HCS: VA, 22.3% versus 21.9% (hazard ratio, 1.05; 95% CI, 0.80-1.38; P=0.95); US non-VA, 15.8% versus 21.8% (hazard ratio, 0.70; 95% CI, 0.43-1.12; P=0.24); Canadian HCS, 17.3% versus 13.5% (hazard ratio, 1.30; 95% CI, 0.93-1.83; P=0.17). The interaction between HCSs and treatment was not statistically significant. Long-term mortality was significantly higher in the VA system as a result of significantly greater comorbidity and worse left ventricular function.

CONCLUSIONS

In the COURAGE trial, addition of percutaneous coronary intervention to optimal medical therapy did not improve 5-year survival or reduce MI or other major adverse cardiovascular events regardless of whether patients were Canadian or American or US veterans or non-veterans. Outcome differences were largely explained by differences in baseline characteristics known to affect long-term prognosis.

The unmet health care needs of homeless adults: a national study

OBJECTIVES

We assessed the prevalence and predictors of past-year unmet needs for 5 types of health care services in a national sample of homeless adults.

METHODS

We analyzed data from 966 adult respondents to the 2003 Health Care for the Homeless User Survey, a sample representing more than 436,000 individuals nationally. Using multivariable logistic regression, we determined the independent predictors of each type of unmet need.

RESULTS

Seventy-three percent of the respondents reported at least one unmet health need, including an inability to obtain needed medical or surgical care (32%), prescription medications (36%), mental health care (21%), eyeglasses (41%), and dental care (41%). In multivariable analyses, significant predictors of unmet needs included food insufficiency, out-of-home placement as a minor, vision impairment, and lack of health insurance. Individuals who had been employed in the past year were more likely than those who had not to be uninsured and to have unmet needs for medical care and prescription medications.

CONCLUSIONS

This national sample of homeless adults reported substantial unmet needs for multiple types of health care. Expansion of health insurance may improve health care access for homeless adults, but addressing the unique challenges inherent to homelessness will also be required.

Comparing population health in the United States and Canada

BACKGROUND

The objective of the paper is to compare population health in the United States (US) and Canada. Although the two countries are very similar in many ways, there are potentially important differences in the levels of social and economic inequality and the organization and financing of and access to health care in the two countries.

METHODS

Data are from the Joint Canada/United States Survey of Health 2002/03. The Health Utilities Index Mark 3 (HUI3) was used to measure overall health-related quality of life (HRQL). Mean HUI3 scores were compared, adjusting for major determinants of health, including body mass index, smoking, education, gender, race, and income. In addition, estimates of life expectancy were compared. Finally, mean HUI3 scores by age and gender and Canadian and US life tables were used to estimate health-adjusted life expectancy (HALE).

RESULTS

Life expectancy in Canada is higher than in the US. For those < 40 years, there were no differences in HRQL between the US and Canada. For the 40+ group, HRQL appears to be higher in Canada. The results comparing the white-only population in both countries were very similar. For a 19-year-old, HALE was 52.0 years in Canada and 49.3 in the US.

CONCLUSIONS

The population of Canada appears to be substantially healthier than the US population with respect to life expectancy, HRQL, and HALE. Factors that account for the difference may include access to health care over the full life span (universal health insurance) and lower levels of social and economic inequality, especially among the elderly.

Socioeconomic status and utilization of health care services in Canada and the United States: findings from a binational health survey

OBJECTIVES

Building on Andersen's behavioral model for the utilization of health care services, we examined factors associated with utilization of physician and hospital services among adults in Canada and the United States, with a focus on socioeconomic status (enabling resources in Andersen's framework).

METHODS

Using the 2002-2003 Joint Canada/United States Survey of Health, we conducted country-specific multivariate logistic regressions predicting doctor contacts/visits and overnight hospitalizations in the past year, controlling for predisposing characteristics, enabling resources, and several factors representing perceived need for health care. All analyses were appropriately weighted to yield nationally representative results.

RESULTS

Several measures of socioeconomic status-having a regular medical doctor, education, and, in the US income and insurance coverage-were associated with doctor contacts or visits in both countries, along with various predisposing and need factors. However, these same measures were not associated with hospitalizations in either country. Instead, only the individual's predisposing characteristics (eg, age and sex) and his/her need for health care predicted utilization of hospital services in Canada and the United States. Insurance coverage status in the United States became a significant predictor of hospitalizations when count data were analyzed via Poisson regression.

CONCLUSIONS

Given our particular outcome measures, adults in Canada and the United States exhibited similar patterns of hospital utilization, and socioeconomic status played no explanatory role. However, relative to Canadian adults, we found disparities in doctor contacts among US adults-between those with more income and those with less, between those with health insurance and those without-after adjusting for health care needs and predisposing characteristics.

Health Lifestyles in the U.S. and Canada: Are We Really So Different?

OBJECTIVE: Some research suggests that social, political, and cultural life in the U.S. and Canada are growing divergent. We use health lifestyle theories to extend prior research and compare the U.S. and Canada on population health indicators. METHODS: The population health indicators include health behaviors, fertility, and cause-specific mortality for each of the United States (and Washington D.C.), and Canadian Provinces and Territories (N=64). RESULTS: Canada and the U.S. are significantly different on many health lifestyle variables. But, levels of the health lifestyle variables converge at the U.S./Canada border, and some U.S. States and Canadian Provinces or Territories exhibit similar health lifestyle patterns, regardless of whether they share an international border (these are mapped in the paper). CONCLUSIONS: Although Canada and the U.S. differ on major population health indicators, some States, Provinces, and Territories exhibit marked similarities. Our paper concludes with a discussion about how our comparative perspective might inform population health policies.

Sustained responders have better quality of life and productivity compared with treatment failures long after antiviral therapy for hepatitis C

OBJECTIVES

We sought to compare the health status of patients with a sustained response to antiviral therapy for hepatitis C virus (HCV) infection with that of treatment failures, using health-related quality of life and preference (utility) measures.

METHODS

Sustained responders had undetectable HCV viral levels 6 months after antiviral therapy. After antiviral therapy, participants completed, by mail or interview, the hepatitis-specific Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36), the Health Utilities Index Mark 2/3 (HUI2/3), and time trade-off (TTO) for current health. The respondents provided information on demographics, history of substance abuse, comorbidities, and health history. Detailed clinical information was obtained by chart review. The respondents also indicated whether they missed work, volunteer opportunities, or household activities during the previous 3 months because of hepatitis C infection or its treatment.

RESULTS

A total of 235 patients (133 responders and 102 treatment failures) completed questionnaires at an average of 3.7 years after the end of treatment. Treatment failures had significantly lower scores on the eight SF-36 domains (P<0.01), lower scores on the hepatitis-specific domains (P<0.0001), and lower physical (42.5 vs. 49.2) and mental (40.5 vs. 46.1) component summary scores (P<0.01). HUI3 (0.57 vs. 0.70), HUI2 (0.74 vs. 0.80), SF-6D (0.65 vs. 0.71), and TTO (0.84 vs. 0.89) were lower for treatment failures (P<0.05). The regression-adjusted difference in HUI3, SF-6D, physical summary score, and mental summary score was 0.08 (P=0.04), 0.05 (P=0.004), 5.22 (P=0.001), and 5.73 (P<0.0001), respectively. Differences in the HUI2 and TTO scores were not significant after adjustment for demographic and clinical variables. Treatment failures were more likely to have missed work, volunteer opportunities, or household activities in the previous 3 months because of hepatitis C infection or its treatment (44 vs. 9%, P<0.001).

CONCLUSIONS

Patients with a sustained response to antiviral therapy for chronic HCV infection have better quality of life than treatment failures do. Our study validates the benefits associated with the sustained response to antiviral therapy in a real-world clinic population and shows that these benefits are maintained over the long term.

The role of health insurance in explaining immigrant versus non-immigrant disparities in access to health care: comparing the United States to Canada

Using a cross-national comparative approach, we examined the influence of health insurance on U.S. immigrant versus non-immigrant disparities in access to primary health care. With data from the 2002/2003 Joint Canada/United States Survey of Health, we gathered evidence using three approaches: 1) we compared health care access among insured and uninsured immigrants and non-immigrants within the U.S.; 2) we contrasted these results with health care access disparities between immigrants and non-immigrants in Canada, a country with universal health care; and 3) we conducted a novel direct comparison of health care access among insured and uninsured U.S. immigrants with Canadian immigrants (all of whom are insured). Outcomes investigated were self-reported unmet medical needs and lack of a regular doctor. Logistic regression models controlled for age, sex, nonwhite status, marital status, education, employment, and self-rated health. In the U.S., odds of unmet medical needs of insured immigrants were similar to those of insured non-immigrants but far greater for uninsured immigrants. The effect of health insurance was even more striking for lack of regular doctor. Within Canada, disparities between immigrants and non-immigrants were similar in magnitude to disparities seen among insured Americans. For both outcomes, direct comparisons of U.S. and Canada revealed significant differences between uninsured American immigrants and Canadian immigrants, but not between insured Americans and Canadians, stratified by nativity. Findings suggest health care insurance is a critical cause of differences between immigrants and non-immigrants in access to primary care, lending robust support for the expansion of health insurance coverage in the U.S. This study also highlights the usefulness of cross-national comparisons for establishing alternative counterfactuals in studies of disparities in health and health care.