This thesis presents the results of three studies examining the management of migraine in children. First we conducted a systematic review of all clinical trials conducted in children and adolescents of the acute migraine therapy. A meta-analysis of the 26 randomized controlled trials is presented. A single trial with a focus on Emergency Department (ED) management was identified. As such, we then examined current ED practice in two retrospective practice variation studies. The first compared four regional hospital EDs where practice patterns were significantly different between mixed population EDs (both adult and pediatric patients) and the tertiary pediatric ED. The second examined practice variation among ten tertiary pediatric EDs in Canada where significant differences were again observed. Factors that influenced the choice of medications included increasing patient age and the physicians diagnosis of migraine. Important areas of future investigation include: (1) the effectiveness of intravenous fluids alone; and (2) the use of combined medications. / Clinical Epidemiology

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Cette thèse s’intéresse d’une part à la question des variabilités des pratiques dans la prise en charge des cancers, et d’autre part à l’étude des déterminants des inégalités sociales et spatiales d’accès aux soins avec un regard particulier sur les personnes souffrant d’un cancer.Ces dernières années, les autorités publiques constatent de fortes variabilités dans les taux de recours à certaines prises en charges. Le premier chapitre de cette thèse pose la question des déterminants des différences de recours à la prostatectomie en tant que prise en charge du cancer de la prostate. Les résultats montrent une forte influence positive des variables relatives à l’offre de soins, aussi bien au niveau du département que de la région.La lutte contre les inégalités sociales de santé se fait également grâce à des dispositifs comme celui de l’ALD. Le deuxième chapitre s’intéresse aux déterminants du recours aux médecins généralistes et spécialistes, en différenciant pour ces derniers les visites liées ou non à la pathologie ALD. Pour les visites chez le généraliste, les résultats montrent qu’un statut socio-économique défavorisé semble être associé à un plus haut recours aux soins. Concernant les spécialistes, les résultats indiquent un net gradient social en faveur des personnes à haut statut socio-économique, surtout pour les visites non liées aux pathologies ALD.Enfin, depuis 2004, un programme de dépistage organisé du cancer du sein a été mis en place pour toutes les femmes âgées de 50 à 74 ans. L’objectif du dernier chapitre est d’examiner l’influence potentielle de la densité de médecins généralistes et spécialistes sur les taux de recours à ce dépistage sur la période 2005-2012. Il apparaît qu’une densité plus forte de médecins généralistes est significativement associée à un plus haut taux de recours. A l’inverse, une augmentation de la densité de spécialistes tend à avoir une incidence négative. Les estimations soulignent également un effet spatial ; les densités médicales dans les départements voisins ayant également un effet sur le recours au dépistage organisé. / This thesis addresses several issues: on the one hand we focus on medical practice variations; one the other hand we examine determinants of social and spatial inequalities in access to care for individuals with cancer.In recent years, high practice variations are noted by health public authorities. The first chapter wonders about the determinants of variations in the use of prostatectomy as prostate cancer management. Results indicate a strong positive influence of supply-side factors in both régions and départements.Reducing social inequalities in access to care is also achieved thanks particular scheme as the LTI system. The second chapter focuses on the determinants of health care utilization, i.e. GP and specialist physicians. For those, we differentiate between visits related (or not) to LTI conditions. Concerning GP visits, individuals with lower socio-economic status tend to have greater GP visits. Regarding specialist visits, results point out a clear influence of financial factors, especially for non LTI-related visits.Finally, since 2004 organized breast cancer screening program invites all women 50-74 to be screened. The aim of this chapter is to examine the potential influence of supplied-side factors (GP and specialist physician density) on the use of organized cancer screening in France between 2005 and 2012. Results show that a higher GP density is associated with higher screening rates. On the contrary, a higher specialist density tends to diminish the participation rate to organized screening. Results also underline the presence of a spatial effect which means that neighboring behavior in terms of cancer screening has an impact on the cancer screening rate in the observed area.

After numerous renewals and reignitions since the initiation of the "War on Cancer" more than five decades ago, the recent reignition of "Moonshot to Cure Cancer" points to the systemic persistence of cancer as a major cause of loss of life and livelihood. Literature points to the diminishing returns of cancer research through time, as well as heterogeneities in cancer research centers' innovation strategies. This dissertation focuses on the strategic decision by cancer research centers to invest their resources in conducting early phases of clinical trials on new candidate drugs/treatments (resembling exploration) or late phases of clinical trials that push established candidates towards acquiring FDA approvals (resembling exploitation). The extensive clinical trials data suggests that cancer research centers are not only different in their emphasis on exploratory trials, but also in how their emphasis is changing over time. This research studies the dynamics of this heterogeneity in cancer research centers' innovation strategies, how experiential learning and capability development interact to cause dynamics of divergence among learning agents, and how the heterogeneity among cancer research centers' innovation strategies is affected by the dynamics of learning from experience and capability development. The findings of this dissertation shows that endogenous heterogeneities can arise from the process of learning from experience and accumulation of capabilities. It is also shown that depending on the sensitivity of the outcome of decisions to the accumulated capabilities, such endogenous heterogeneities can be value-creating and thus, justified. Empirical analysis of cancer clinical trials data shows that cancer research centers learn from success and failure of their previous trials to adopt more/less explorative tendencies. It also demonstrates that cancer research centers with a history of preferring exploratory or FDA trials have the tendency to increase their preference and become more specialized in one specific type (endogenous specialization). These behavioral aspects of the cancer research centers' innovation strategies provide some of the tools necessary to model the behavior of the cancer research efforts from a holistic viewpoint. / Doctor of Philosophy / The "Moonshot to Cure Cancer" was renewed most recently in September 2022. However, renewal and reignition of this national collective effort is nothing new; this effort started as "War on Cancer" in 1971 and has been reignited numerous times. After more than 50 years of our collective battle to cure cancer, it claims almost 600,000 lives annually and remains as the second leading cause of death in the US. There are a wide variety of cancer research centers from all around the world contributing to this collective effort and they make considerably different decisions regarding their investment in research. There is evidence suggesting that some of the research centers' investment decisions are not optimal and can be improved. It has been shown that systems such as patent regulations can be revised to encourage such improved decisions among cancer research centers. This dissertation focuses on the process of clinical trials for new drugs/treatments for cancer. New drugs/treatments have to pass different phases of trials to ensure that they are safe and effective before they can acquire FDA approvals. Cancer research centers decide whether to invest in early phases of clinical trials for new drug/treatment candidates or invest in late phases of trials for candidates that have already passed the early phases. The clinical trials data show that there has been a sharp rise in number of early phases of trials on new drugs/treatments; however, the same rise cannot be seen in the late phases of trials resulting in approvals. It can also be seen that different research centers put different levels of emphasis on initiating early phases of trials for new drugs/treatments (exploration). In this dissertation, the hypothesis is that this ongoing dilemma that cancer research centers face to invest on how much emphasis to put on exploration in their clinical trials is affected by learning from experience. To test this hypothesis, a mathematical model is used to show differences in decisions can be causes solely by learning from experience, when the decision maker is learning "what to do" from success/failure of previous efforts and learning "how to do it" from practicing and accumulating the required skills. Then, the hypothesis is formally tested using the clinical trials data. The results show that cancer research centers learn from the success and failure of their previous exploratory trials when deciding on their emphasis on exploration. Also, they accumulate skills, resources, and capabilities relevant to the type of research the conduct more often and specialize in either of late- or early-phases of trials. The findings of this dissertation show that learning from experience can cause in differences in decisions. It also finds evidence that cancer research centers learn to place different levels of emphasis on exploration in their clinical trials. These findings can later be used in models of the cancer research ecosystem to study how funding structures and policies can be changed to improve the outcomes of our collective effort to cure cancer.

La recherche économique considère le médecin généraliste comme un agent offrant à l’échange information et services intellectuels en santé à des principaux. L’imparfaite convergence entre leurs objectifs, comme la présence d’incertitudes et d’asymétries d’information, conduisent le médecin à « fixer » les quantités, l’effort fourni et la qualité des soins et services rendus. Cette thèse vise à identifier le rôle des caractéristiques des généralistes, de leur mode d’exercice ou d’organisation, sur la performance de leur activité, en s’appuyant sur trois articles. Le premier analyse les déterminants de la variabilité de prescription d’antibiotiques pour rhinopharyngite aiguë, le second évalue l’impact du travail en équipe avec des infirmières sur la qualité et l’efficience des soins pour les patients diabétiques, et le troisième évalue l’impact de l’exercice regroupé pluriprofessionnel sur l’activité et l’efficience productive des généralistes et l’efficience des recours aux soins ambulatoires de leurs patients. Ces travaux de recherche permettent d’interroger la faiblesse relative de la régulation de l’offre de soins ambulatoire en France en matière de politique de maîtrise de l’évolution des dépenses de santé en comparaison de celle portant sur la demande. / According to economic research, the general practitioner is considered as an agent that offered information and intellectual services in health to principals. Imperfect convergence between their objectives, like the presence of uncertainties and information asymmetries, lead the physician “to fix” the quantities, the effort and the quality of the care and services delivered. Based on three articles, this thesis aims at identifying the role of the characteristics of the general practitioners and of their practice organization, on activity performance. The first articles analyzes the determinants of the antibiotic prescription for acute rhinopharyngitis variability, the second evaluates the impact of team working with nurses on the quality and the efficiency of the care for diabetic patients, and the third evaluates the impact of multi-professional group practices on the activity and the productive efficiency of GPs and on the utilization of ambulatory health care and by their patients. These researches question the relative weakness of the ambulatory health care regulation in France in terms of health care expenditure containment policies in comparison with that bearing on demand.

Service provision in veterinary oncology in Ontario was examined using a mixed methods approach. First, an interview-based qualitative study explored the service expectations of oncology clients at a tertiary referral centre. Next, a survey-based quantitative study established an understanding of oncology service in primary care practice and investigated the treatment recommendations of practitioners for dogs diagnosed with cancer. The first study, which involved 30 individual and dyadic interviews, identified “uncertainty” (attributable to the unpredictable nature of cancer and its treatment) as an overarching psychological feature of clients’ experience. Consequently, “the communication of information” (both content and process) was the foremost service expectation. For clients, it enabled confidence in the service, the ability to make informed patient care decisions, and preparedness for the potential outcomes of those decisions; it also contributed to creating a humanistic environment, which enhanced client resiliency. Findings suggest that services can support client efforts to manage uncertainty through strategic design and delivery of service, and incorporate intentional communication strategies to support clients’ psychological fortitude in managing the cancer journey. The second study, a vignette-based survey of primary care practitioners across Ontario (N=1071) which investigated veterinarian decision-making in relation to oncology care, determined that 56% of practitioners recommended referral as their first choice of intervention, while 28% recommended palliative care, 13% in-clinic treatment, and 3% euthanasia. Recommendations were associated with patient, client and veterinarian factors. Specifically, referral and treatment were recommended for younger dogs, healthier dogs, and dogs with lymphoma versus osteosarcoma; for strongly bonded clients, and financially secure clients; and by veterinarians who graduated from a North American college, had experience with treating cancer, felt confident in the referral centre, and believed treatment was worthwhile, with variation in relation to practitioner gender and the type of medicine practiced. The human-animal bond appeared to be the primary factor associated with practitioners’ advocacy for quality of medical care for patients. Through a blend of qualitative and quantitative methodologies, this thesis contributes to the evidence upon which best practices may be built so as to enhance the quality of patient and client care in veterinary oncology. / Ontario Veterinary College Pet Trust Fund 049406 and 049854