Background: It is important to understand Canadians' expectations of health care services and the costs of delivering care in the Emergency Department (ED) in order to continue to provide health care in a sustainable manner. Objectives: To examine the reasons patients present to the ED, and to conduct a cost analysis to compare the costs of seeking care in the ED versus a primary care setting. Methodology: We surveyed patients (n=606) triaged to the cubicles of the ED of The Ottawa Hospital, Civic Campus. The survey asked about their perceived urgency level and their patterns of health service use. Patient surveys were accompanied by physician surveys to assess each patient's level of urgency from a medical perspective. We performed bivariate analysis and logistic regression on survey variables of interest. We also conducted a cost analysis to determine the costs of providing non-urgent care in the ED. Results: Both a presenting symptom of a musculoskeletal injury (OR=2.93, CI 1.42-6.04) and having heard of TeleHealth Ontario (OR=2.08, CI1.08-4.03) were significantly associated with non-urgent ED use from the patient perspective. We also found that non-urgent ED visits cost an average of $248.75, which is significantly more costly than a primary care visit. Implications: Our results provide insights regarding patient factors influencing ED use and relative costs of non-urgent ED visits versus outpatient family doctor visits. However, additional work may be required to identify non-medical factors influencing patient motivations for seeking care in the ED.

Integrative healthcare (IHC), the combination of biomedical disciplines and expertise in various forms of complementary and alternative medicine (CAM), is an example of interdisciplinary collaboration that has emerged over the last two decades. Little has been written so far to gain an understanding of how the healthcare practitioners in such setting collaborate. The main goal of this doctoral dissertation was to better understand what is inside the "black box" of interdisciplinary collaboration within IHC clinics so that appropriate links related to clinic effectiveness and cost-effectiveness as well as patient outcomes could be tested in future research. This thesis explored the concept of interprofessional collaboration in IHC using three theoretical and conceptual models: Input Process Output, Relationship-Centered Care, and Models of Team Healthcare Practice. Inductive and deductive inquiries were conducted through sequential mixed methods and methodological triangulation techniques. Four objectives were proposed to better understand how collaboration was experienced and conceptualized within these clinics and how the related factors interacted with each others. Finally, assumptions of a conceptual model of classification of IHC clinics were tested. Constructs contributing to collaboration included practitioners' attitudes and educational background, as well as external factors such as the healthcare system and financial pressures. Major processes affecting collaboration consisted in communication, patient referral and power relationships. These determinants of collaboration resulted in learning opportunities for practitioners, modified burden of work and ultimately, higher affective commitment toward the clinic. The quantitative inquiry revealed that interpersonal relationships were shown to be central to the collaborative practice of IHC delivery. Additionally, beliefs in the benefits of collaboration were found to play an important role in an IHC collaborative enterprise. Finally, clinic model comparisons confirmed that interprofessional collaboration is modulated by the practice model. Suggestions to improve the conceptual model of classification were made. This multi-method study was the first to summarize systematically the factors that impact and ensue from interprofessional collaboration in the context of Canadian IHC. The framework lay down by this dissertation represents an important step to investigate further the impact of IHC on patients and the Canadian healthcare system and to guide the development of more effective IHC clinics.

Introduction: Enhancing health equity remains of international political importance with endorsement from the World Health Assembly in 2009. The failure of systematic reviews to consider effects on health equity is described by decision-makers as a limitation to using systematic reviews as a basis for evidence-informed decisions. Hence, there is a need for guidance on the role of systematic reviews in assessing effects on health equity. Methods: Four studies were conducted to assess the role of systematic reviews in assessing effects on health equity. A Cochrane Collaboration methodology review and a methodology study assessed methods used in published systematic reviews to assess effects of interventions on health equity across ten categories defined by the acronym PROGRESS-Plus: Place of residence, Race/ethnicity, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital. Plus considers other factors associated with unequal opportunities for good health such as age, disability and developing country settings. A qualitative study assessed implementation factors that are associated with success of interventions in vulnerable populations and mapped these factors to the equity-effectiveness loop framework. An equity plausibility algorithm was developed and tested to predict the likelihood of effects of interventions on health equity. Results: Only 13% of published systematic reviews assess effects on health equity. Four methods were used to assess effects of interventions on health equity: 1) description of people in studies; 2) description of subgroup analyses; 3) analysis of differences; and 4) applicability assessment. Only lout of 20 methodological studies used an analytic method. Implementation factors that predict success of interventions on improving health of homeless people in Ottawa mapped well onto the equity effectiveness loop framework, suggesting this framework can be used to appraise and improve interventions to promote health equity. Testing of the equity plausibility algorithm developed based on these studies showed that 67% of respondents thought that differences in relative effects of interventions were likely across sex and socioeconomic status, but there was little to no inter-rater agreement for these judgments. Discussion: These studies show that systematic reviews lack consideration of effects of interventions on health equity. This dissertation makes recommendations to improve reporting and conduct of systematic reviews to improve the contribution of systematic reviews to the evidence-base on promoting health equity. Methodological research is needed to improve methods for assessing applicability of systematic reviews for populations across PROGRESS-Plus characteristics, by both those who conduct systematic reviews and those who use them as a basis for decision-making.

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