Priority setting for expensive biopharmaceuticals is one of the most important challenges for publicly funded health systems. One of the drivers of rising healthcare expenditures is pharmaceuticals (i.e., drugs). Moreover, people are living longer and their expectation of, and demand for, health care, drugs, and services are continually increasing. The overall aim of this research was to describe and evaluate reimbursement decisions for six expensive biopharmaceuticals across five countries in order to ascertain if the processes were legitimate and fair. I conducted qualitative case studies of six expensive biopharmaceuticals in order to describe and evaluate the priority setting activities of eight committees across five countries, including Canada, England and Wales, Australia, Israel and the United States. Data sources included: 1) 32 documents and 2) 56 interviews with informants. The recommendations process of each committee partially met the four conditions of ‘accountability for reasonableness’. My main finding is that, while a number of values were considered by committees when making reimbursement decisions, committees tended to focus on values of evidence, effectiveness and efficiency, but not the full range of relevant values. Thus, these contexts did not fully meet the conditions of legitimacy and fairness. I have provided an in-depth description of the eight committees’ priority setting activities regarding the study drugs, as well as committee members’, patients’ and industry representatives’ views regarding the process. I developed practical guidance for leaders for improving reimbursement decisions for expensive biopharmaceuticals, the implementation of which would enhance the fairness and legitimacy of priority setting. This study has demonstrated that in order to create a fair and legitimate drug reimbursement process, we need to ensure the incorporation of a wide range of values, and the involvement of multiple stakeholder groups within the deliberative and appeals/revisions processes.

The purpose of this thesis was to analyze factors related to labour market survival and withdrawal behaviour in the profession of Occupational Therapy in Ontario from 1997 to 2006. To provide a portrait of the OT labour market in Ontario overall, and in relation to sector and age, three types of analysis were used: descriptive statistics (including “stay, switch, and leave” analysis), “Stickiness” and “Inflow” analysis, and survival analysis. The largest proportion of OTs worked in the Hospital sector, which had a great ability to retain OTs according to the “Stickiness” analysis. However, when controlling for other variables using survival analysis, none of the sector variables had a significant effect on survival. The youngest and oldest age groups had the highest propensity of leave, due to mobility, family commitments, and retiring (oldest group only). Overall, the profession in Ontario had a strong ability to retain OTs working in the profession during the study period.

No systematic research has been undertaken in Canada on the relationship between hospital performance, organizational monitoring capacity and board governance. This three-part dissertation aims to fill that gap. The conceptual framework elaborated in a theoretical paper and tested in two exploratory empirical studies proposes that boards reflect their institutions, with high performers exhibiting greater capacity to harmonize accountability needs and align governance decision-making and monitoring systems with external performance measurement and reporting requirements. Top team (board and management) characteristics, and governance practices, both proposed elements of “governance capacity,” are hypothesized to reflect and reinforce “organizational monitoring and alignment capacity” thereby contributing directly and indirectly to key aspects of hospital performance including quality of care, financial health and patient satisfaction. Using hierarchical regression analyses, six hypotheses were tested on a sample of 101 acute hospital corporations that participated in the 2005, 2006 and 2007 Ontario Hospital Report Research Collaborative. After controlling for hospital size, evidence of a statistically significant relationship was detected between organizational monitoring and alignment capacity and quality performance, and between one element of governance capacity, governance practices, and financial performance. A relationship was also detected between governance practices and top team characteristics, including diversity, education and turnover. These findings suggest that the relationship between hospital governance and performance is tenuous and that some aspects of performance may be more amenable to governance influence than others. In highly-regulated environments governance space is circumscribed and myriad stakeholders have a stronger pulse on singular aspects of organizational performance than the board. This study argues that the role of boards in environments of distributed governance is to mine the ‘accountability web’ for timely, multivariate intelligence on performance and use it to drive alignment, integration and performance improvement. The contribution of this research, its limitations, and implications for researchers, policymakers and hospital leaders are discussed.

Concerns, Desires and Expectations Of Surgery For Adolescent Idiopathic Scoliosis: A Comparison Of Patients’, Parents’ & Surgeons’ Perspectives. Master of Science, 2008 Unni G. Narayanan Department of Health Policy, Management & Evaluation University of Toronto ABSTRACT This study explored the concerns, desires (goals) and expectations of adolescents undergoing surgery for idiopathic scoliosis, and contrasted their priorities with those of their parents and surgeons. Parents were more concerned than their children about the consequences of scoliosis and of surgery. With the exception of improving physical appearance, surgeons' goals of surgery were different from those of either the patients or parents. There was little agreement among surgeons about the natural history of scoliosis, other goals of surgery and the likelihood of specific outcomes. Parents wanted and expected more from surgery than their children. Parents and patients had greater expectations of surgery than surgeons. Although adolescents had different priorities from their parents, parents were aware of these differences and reliably predicted their children’s priorities. These findings have important implications on shared decision-making and informed consent, and might contribute to better understanding and measurement of outcomes that matter to patients.

Antipsychotic use is an important issue in long-term care (LTC) homes due to their widespread use, the potential for serious adverse events and limited evidence about their efficacy in treating behavioural and psychological symptoms of dementia. Rates of antipsychotic use vary across LTC homes, but little is known about the contribution of physicians to this variation. This study documented the characteristics of physicians who regularly treated residents in Ontario LTC homes and examined variation in antipsychotic prescribing across physicians. In a population-based retrospective cohort of LTC residents, 637 (52.8%) of 1,207 LTC physicians cared for 46,365 (90.4%) of all residents. Overall, 27.3% of residents received antipsychotic therapy, but extremely high prescribers prescribed antipsychotics to 42.8% of their patients. Variation in physician antipsychotic prescribing persisted after controlling for clinical and behavioural resident characteristics. This variation was reduced by 47.1% when LTC homes were accounted for in multilevel cross-classification logistic regression models.

Background: Teleradiology is currently being explored to enhance services for patients seeking emergency neurosurgical diagnoses in Ontario, Canada. Design: Systematic review of literature and cost-consequence analysis. Data sources: Medline, Embase, Cochrane, and Database of Abstracts of Reviews of Effects. Methods: Studies published between 1950 and 2008 describing remote consultations for neurosurgical assessments were retrieved. Two reviewers selected studies through multi-staged content screening and extracted data. Results 12 of 3765 studies met the inclusion criteria: two were randomized controlled trials and ten were case series. Teleradiology [88% (207/236)] and video-conferencing [89% (213/239] consultations produced higher diagnostic accuracy than telephone consultations [64% (150/235), p<0.001]. Savings varied by location and were based on avoided costs for ground and air transportation and hospitalization. Conclusions: There is limited evidence of clinical benefit of teleradiology. Savings associated with reduction in patient transfer rates depend on transportation mode and may be attenuated by higher operational costs.

The purpose of this study was to evaluate the clinical relevance of access targets for elective dental general anaesthesia (GA) by assessing incremental changes in dental disease burden over wait times at SickKids. A retrospective review of dental records were completed for 378 children who were prioritized by their dental and medical status. A scale was developed to measure cumulative dental disease burden over time. Statistically significant correlations were identified between cumulative disease burden and wait times for priority IV (p = 0.004), the entire sample (p < 0.003), DOSDCADCA (p = 0.005), comorbid (p = 0.036), healthy (p = 0.0002), female (p = 0.014) and male (p = 0.008) groups. The mean cumulative disease burden was not different between matched healthy and cormorbid groups (p = 0.38). A trend of increasing dental disease burden for children with longer wait times for dental GA was found but not clinically significant.

Social capital can be defined as a resource found in the relationships between individuals and within the community that facilitates access to resources. Social capital may have an effect on health services utilization. Few studies have explored the impact of social capital on the propensity and frequency of general practitioner visits for immigrants. The relationship between social capital and health services use by immigrants was analyzed using a dataset consisting of socio-demographic data from the 2002 Canadian Community Health Survey linked to physician claims from the Ontario Health Insurance Program for fiscal year 2006. The results suggested that the community belonging aspect of individual social capital was associated with a decrease in the number of GP visits for immigrants. Thus, community services may substitute for formal health care for immigrants.

The Great Lakes has been impaired by elevated concentrations of contaminants, and different regulatory actions are taken to decrease theses concentrations. Recent research of Dr. Azim suggests a decline in mercury levels in the Lake Erie, and an increase in the Hg concentration in the fish communities. This research is a follow up study to examine whether the contaminant levels are indeed increasing. In the first chapter we evaluate the temporal trends of polychlorinated biphenyls (PCBs) in Lake Erie fish over the last 30 years by conducting the Exponential and Dynamic Linear Modeling analysis. DLM analysis in the chapter two detects the PCB and Hg contaminant trends in a broader range. There is a high variability in two contaminants trends. These patterns may be because of factors such as fish physiological parameters, and the impact of invasive species. The results of my research will contribute to the Toxics Reduction Strategy.

Health policy making is fraught with difficult decisions that result from conflicts between people’s values. Citizens are important stakeholders in this process, and it is through methods of public engagement that they can be involved in developing health policy. Deliberative forms, in particular, have the ability to improve decision quality and promote greater acceptance of decisions. This study used the Toronto Health Policy Citizens Council to examine citizens’ values on 7 specific health policy questions asked over a two-year period. A thematic analysis was performed on the transcript content derived from the audiotaped deliberations from Council meetings. Nineteen values were identified. The results suggest that it may be a combination of factors of the health policy topic discussed that shapes the values elicitation seen in this kind of public engagement. In conclusion, citizens councils appear effective at eliciting citizens’ values, and are a good way to actively educate participants about health care.