Emergency department (ED) overcrowding is a challenge faced by many hospitals. One approach to mitigate overcrowding is to anticipate high levels of overcrowding. The purpose of this study was to forecast a measure of ED overcrowding four hours in advance to allow clinicians to prepare for high levels of overcrowding. The chosen measure of ED overcrowding was ED length of stay compliance measures set by the Ontario government. A feed-forward artificial neural network (ANN) was designed to perform a time series forecast on the number of patients that were non-compliant. Using the ANN compared to historical averages, a 70% reduction in the root mean squared error was observed as well as good discriminatory ability of the ANN model with an area under the receiver operating characteristic curve of 0.804. Therefore, using ANNs to forecast ED overcrowding gives clinicians an opportunity to be proactive, rather than reactive, in ED overcrowding crises.

Emergency department (ED) overcrowding is a challenge faced by many hospitals. One approach to mitigate overcrowding is to anticipate high levels of overcrowding. The purpose of this study was to forecast a measure of ED overcrowding four hours in advance to allow clinicians to prepare for high levels of overcrowding. The chosen measure of ED overcrowding was ED length of stay compliance measures set by the Ontario government. A feed-forward artificial neural network (ANN) was designed to perform a time series forecast on the number of patients that were non-compliant. Using the ANN compared to historical averages, a 70% reduction in the root mean squared error was observed as well as good discriminatory ability of the ANN model with an area under the receiver operating characteristic curve of 0.804. Therefore, using ANNs to forecast ED overcrowding gives clinicians an opportunity to be proactive, rather than reactive, in ED overcrowding crises.

This study investigates the use of five broad accountability mechanisms by gathering the perceptions of charities involved in the Canadian effort to reduce under-5 mortality abroad. While annual deaths in children under the age of 5 declined from an estimate of over 24.0 million in 1960 to under 8.0 million in 2010, mortality reduction goals have been established and missed for decades. As worldwide economies worsen, the amount of funds available for development assistance can be expected to decrease. This study seeks to determine if having accountability mechanisms is perceived to improve organizational behaviour, results and/or reduce costs. It uses a mixed methods approach including: a literature review to gain an understanding of accountability, effectiveness, development and under-5 mortality; key informant interviews to gain an understanding of funders, charities and development; a survey to gather the information required to answer the research questions; and a multiple-case study to gain a better appreciation of how accountability is used and to gather evidence of survey responses. The study investigates: which accountability mechanisms charities have, why they have them and the associated accountability holders; standards body memberships; the relationship between accountability mechanisms and various organizational characteristics; and the perceived effects of accountability mechanisms on organizational behaviour, results and costs. The survey finds that: charities say that they adopt accountability mechanisms because it is a good management practice that is perceived to improve organizational behaviour and results while not incurring costs in excess of the benefits; charities are more likely to adopt accountability mechanisms due to internal pressures than external pressures; the use of accountability mechanisms increases with organization size; and there is a greater difference in use of accountability mechanisms between small and large charities than there is between medium and large charities. The multiple-case study confirms the survey results. This study fills a gap in the literature by providing a Canadian perspective on the use of accountability mechanisms and the relationships amongst them and their perceived effects on organizational behaviour, results and costs. As economic burdens increase, increased accountability may lead to improved results even with fewer dollars.

In Canada and internationally, increases in Home Care (HC) services for the elderly have been a policy priority in recent decades. HC services include Home Health Care (HHC) and Homemaking/Personal Support (HM). The primary objectives of this study were to explore the interrelationship among publicly funded, privately funded, and informal HC services in terms of potential for substitution, and between publicly funded HHC and HM services; and the determinants of the receipt of each type of HC services. Stabile, Laporte, and Coyte’s family home care decision model (2006) was extended, to develop an understanding of the demand for HHC and HM services separately and to include different household arrangements. The consequential hypotheses were tested in two empirical studies. Individual panel data for those aged 65 and over were derived from 8 biannual waves of the Canadian National Population Health Survey (1994-95 to 2008-09). A Panel Two-Stage Residual Inclusion method was used to estimate the likelihood of the receipt of HC services, adjusting for socio-demographic, health status, disability, dependence on help with Activities of Daily Living (ADLs), and regional characteristics. The results showed that receipt of publicly funded HM is complementary with receipt of publicly funded HHC services after adjusting for functional and health status. Receipt of publicly funded and privately funded HM services did not show an effect on each other. Receipt of publicly funded HM did not affect the receipt of informal HM services. The availability of informal care from a partner or other adult sharing the household reduced the likelihood of publicly funded HM receipt. Age, dependence on help with ADLs, health status and income are determinants of the propensity to receive publicly funded HHC and HM services as well as privately funded and informal HM. Findings in this study suggest that changes in the availability of publicly funded HC services may not greatly affect the provision of informal care in Canada. The complementary effect between publicly funded HHC and HM services and the income effect in the receipt of publicly and privately funded HC services may raise concerns about equitable access to HC services in Canadian jurisdictions.

Background: This thesis is composed of three studies testing the effect of the Colon Cancer Check (CCC) program, the organized screening program for colorectal cancer in Ontario, on screening participation. In the first paper, we described the trends of participation to Fecal Occult Blood Test (FOBT) and endoscopy, and the trend of ‘up-to-date’ consistent with guidelines, overall and stratified by demographic characteristics between 2005 and 2011. In the second paper, we tested the effect of physician’s recommendation on FOBT participation and disparities in participation. In the third paper, we measured the effect of the CCC program on FOBT participation using an interrupted time series. Methods: We identified six annual cohorts of individuals eligible for CRC screening in Ontario between 2005 and 2011 by linking the Registered Persons Database to Ontario Health Insurance Plan and 2006 Census from Statistics Canada. We used descriptive statistics to describe the trends of participation. The effect of physician’s recommendation on screening participation was tested using multiple logistic regression analysis. The effect of the CCC program on FOBT participation was tested using segmented regression analysis. Results: An increasing trend in FOBT participation and ‘up-to-date’ status was observed across all demographic characteristics. The disparity gaps persisted over time by gender, income, recent registrant and age. The rural/urban gap was removed. Physician’s recommendation tripled the likelihood of FOBT participation (prevalence rate ratio=3.23, CI= 3.22-3.24) and mitigated disparities. The CCC led to a temporary increase in level (8.2‰ person-month) in FOBT participation followed by a decline in trend and then a plateau. The increase in level was significant across all population sub-groups. Conclusions: We found that CRC screening has increased in Ontario across all subgroups of the population but remained suboptimal. Disparities in screening participation were identified. Proposed strategies to improve performance include interventions to increase the rate of physician’s recommendation at the practice level, tailored interventions to motivate under-users and public media campaigns.

This thesis investigates the effects of immigration status, country of origin, and duration in Canada on three main health outcomes, namely health care utilization, occurrences of hypertension and heart disease, and body mass index. The first two chapters are cross-sectional studies that utilize data derived from linked national health survey and Ontario databases, whereas the third chapter is a longitudinal study which draws data from the longitudinal National Population Health Survey (NPHS). The first chapter examines the role of immigration status and country of origin in explaining the use of three types of health services: primary care physicians, specialists, and hospitals. The findings suggest that immigrants, especially those who are male and have low educational attainment, use more primary care physicians than comparable non-immigrants. However, immigrants are found to use fewer expensive health services, i.e. specialist and hospital care, compared to Canadian-born residents. Likewise, immigrants from non-traditional source countries make even fewer visits to specialists than do those who came from traditional source countries. The second chapter investigates the associations of immigration status, occurrence of hypertension, and occurrence of heart disease. Findings from this chapter show that immigrants have comparable odds of hypertension and heart disease to those of Canadian-born residents after adjusting for other factors. The third chapter examines the effects of time since arrival in Canada on the change in BMI over the 14-year period. This chapter shows that, holding other factors constant, an additional year in Canada leads to a 0.14% increase in an individual’s BMI. This association is found to be more pronounced for women than men and for married than non-married individuals. The effect of time since arrival in Canada on the change in BMI is reduced to 0.07% after controlling for sample selection bias, suggesting that by ignoring the sample selection issue, the effects of time since arrival in Canada on the change in BMI may be overestimated.

The perceived level of self-determination in health care in four First Nations communities in Canada is examined through a multiple case study approach. Twenty-three participants from federal, provincial and First Nations governments as well as health care professionals in the communities of Blood Tribe, Lac La Ronge, Garden Hill and Wasagamack First Nations provided insight into the diversity of perception of self-determination in First Nations health care. The difference in definition between Aboriginal and the federal and provincial governments is a factor in the varying perceptions of the level of control First Nations communities have over their health care system. Participants from the four First Nations communities perceived their level of self-determination over their health care system to be much lower than the level perceived by provincial and federal government participants. The organization and delivery of health care is based on the location of the community, the availability of the human resources, the level of communication, the amount of community resources, and the ability to self-manage. The socio-political history including impact of contact, residential schools, and integration of Aboriginal worldview are factors in the organization and delivery of health care as well as the perceived level of self-determination that the community sees. The duration and intensity of contact influences how health care is organized as the communities become more familiarized with the biomedical model that most Canadians use. Having a holistic health care system that includes acknowledging the socio-political history, culture, language, worldview and traditional medicines is important to the four First Nations communities, but this has not been fully embraced in any of the communities. Despite their differences, all four communities are working toward self-determination that hopefully would result in an ‘ideal’ First Nations health care system which is holistic, cultural, spiritual, and interdisciplinary and ultimately lead to full management of the health care system.

The implementation of Electronic Medical Records (EMRs) may lead to improved quality of primary health care. To investigate this, we conducted a mixed methods study of eighteen Toronto family physicians who implemented EMRs in 2006 and nine comparison family physicians who continued to use paper records. We used a controlled before-after design and two focus groups. We examined five preventive services with Pay for Performance incentives: Pap smears, screening mammograms, fecal occult blood testing, influenza vaccinations and childhood vaccinations. There was no difference between the two groups: after adjustment, combined preventive services for the EMR group increased by 0.7% less than for the non-EMR group (p=0.55, 95% CI -2.8, 3.9). Physicians felt that EMR implementation was challenging.

Health system restructuring combined with the preferences of palliative care recipients to be cared for at home has lead to a shift in the delivery of care from the hospital to the home setting. An analysis was conducted on five main home-based palliative care health service components: home-based nurse visits, home personal support worker visits, home-based physician visits, ambulatory physician visits, and other ambulatory and home-based visits. First, we assessed the proportion of total cost associated with the main services at different time points over the palliative care trajectory. Second we examined the socio-demographic and clinical factors that predict the propensity and intensity of service use, using a two-part model. The results suggest that the greatest contributor to the total cost of home-based palliative care was personal support worker visits, followed by nurse visits. The regression analysis revealed that patient age as well as functional status most often predicted health service use.

Breast cancer is a growing international health epidemic, and patients in low and middle income countries (LMCs) have worse outcomes than those in high income countries. High quality, well-implemented guidelines help improve patient outcomes, but are often not resource-sensitive, and support therapies that may not be feasible in LMCs. A systematic review to address the content, quality, and resource-sensitivity of international breast cancer guidelines was completed. Also, a survey of global physicians evaluated the impact of resource setting on practice patterns and guideline use. Guideline use did not appear to be directed by quality (which was variable across guidelines) or resource-sensitivity (found in few guidelines). However, practice patterns were found to vary by resource setting and by continent, often due to the cost of certain therapies. In order for guidelines to better impact global breast cancer outcomes, they need to be of higher quality, more resource-sensitive, and better implemented.