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<p><strong>Background and Objectives: </strong>Previous research has examined the effect of family physician continuity of care within end-of-life care cancer patients and its association with reduced use of acute care services. However, such research has not been examined in the end of life homecare cancer population.<strong> Objectives: </strong>To investigate the association of family physician continuity with location of death, hospital and emergency room (ER) visits in the last 2 weeks of life in end of life homecare cancer patients.<strong> Research Design: </strong>Retrospective study involving secondary data analysis of 7 linked databases<strong>. Subjects: </strong>All those who died of cancer between January 1, 2006 to December 31, 2006 in Ontario who had at least 1 visit to a family physician and enrolled in homecare for at least 2 weeks.<strong> Methods: </strong>The relationship of family physician continuity of care and location of death, and hospital and ER visits in the last 2 weeks of life was examined using logistic regression.<strong> Results: </strong>The Usual Provider of Care (UPC) measure demonstrated a dose response relationship with increasing continuity resulting in decreased odds of dying in the hospital and visiting the hospital and ER in the last 2 weeks of life. The Family Physician visits per week measure demonstrated a threshold effect relationship with location of death and hospital visits and dose response relationship with ER visits in the last 2 weeks of life. <strong>Conclusions:</strong> These results demonstrate an association between family physician continuity of care and location of death and visits to the hospital and ER in the last 2 weeks of life. This indicates the need for more involvement of family physicians in end of life cancer care.</p> / Master of Science (MSc)

<p>This thesis focuses on two important areas of health economics: health dynamics during pre-adulthood, and physician behaviour. The first two essays seek to explore the important factors that determine the health production process during the period of pre-adulthood. The third chapter then turns the focus to physician labour and service provision behaviours.</p> <p>The first chapter examines the impact of family social economic status (SES) and neighbourhood environment on the dynamics of child <em>physical</em> health development. It examines the distribution of health outcomes and health transitions and explores the determinants of these distributions by estimating the contributions of family SES, neighbourhood status, unobserved heterogeneity and pure state dependence.</p> <p>The second chapter extends the research on health development in pre-adulthood by examining the roles of family SES, early childhood life-events, unobserved heterogeneity and pure state dependence in explaining the distribution of depression among adolescents and young adults. It also explicitly models the depression dynamics and quantifies both the mobility and persistence of this type of <em>mental</em> health problem from adolescence to early adulthood.</p> <p>The third chapter examines whether and how pay-for-performance (P4P) payments can motivate physician service provision to improve the quality of health care. It exploits a natural experiment in the province of Ontario, Canada to identify empirically the impact of P4P incentives on the provision of targeted primary care services, and whether physicians’ responses differ by age, practice size and baseline compliance level.</p> / Doctor of Philosophy (PhD)

The American medical profession has publicly pondered its roles and duties since its inception in the 18th century. Recently, that discussion has included whether or not advocacy by physicians is a responsibility of the profession. The following work is an argument and plan to support the ethical, professional imperative of physician advocacy. The historical underpinnings of the American medical profession suggest a responsibility to patients and interactions with society. In addition, there is a strong bioethical argument in favor of physician advocacy as an essential duty. Although there is a well-recognized set of barriers to physician advocacy, this article details solutions to help implement advocacy as a daily practice in the lives of all physicians. This piece will describe a way forward for physicians to take on their professional responsibility to advocate. / Urban Bioethics

We conduct an evaluation of the cross-cultural ‘export’ of the Objective Structured Clinical Examination (OSCE), a well-established Western medical education assessment tool that is in keeping with Competency-Based Medical Education (CBME) principles, into the new socio-economic setting of Rwanda. The evaluation framework of ‘assessment utility’ is applied, where the utility of an assessment is described conceptually as the multiplicative function of its validity (V), reliability (R), educational impact (E), cost/feasibility (C) and acceptability (A). A mixed-methods approach of both quantitative and qualitative data analysis is used. The quantitative findings support high content and face validity, high reliability, high acceptability and achievable cost and feasibility of the OSCE, all of which would suggest high utility. The analysis of qualitative data identifies some important threats to validity, namely perceived significant gaps in training in the internship program that were thought to likely be the underlying reason for the low mean assessment scores. This threat to the validity of the results appears to influence and limit the acceptability of the assessment in this context. While it is believed that it would be suitable as a formative assessment, primarily for the purpose of ‘assessment for learning’, it was not felt that it was currently acceptable as a summative or high-stakes ‘assessment of learning’, until and unless training deficits are addressed. Currently, the OSCE is seen to have greatest value in its potential for educational impact by acting as both a driver and a marker for change both at the individual and programmatic levels. Many principles of CBME and the concept of ‘entrustability’ as a criterion-referenced assessment standard were well-received cross-culturally, when training and assessment were viewed in tandem. Our study highlights the importance of using a comprehensive evaluation framework that includes both quantitative and qualitative methods to accurately characterize the utility of an assessment. / Thesis / Master of Science (MSc) / This is a case-study where the Objective Structured Clinical Examination (OSCE), a well-established, performance-based and resource-intensive Western medical education assessment tool, was introduced to the culturally different, resource-limited setting of Rwanda. What we wanted to evaluate is how the OSCE was received in the Rwandan medical training system. What we found is that generally, the OSCE was received in a positive way. Both examiners and participants thought it was a relevant, realistic, feasible, valuable test for doctors in training. However, examiners also felt that the candidates did not do as well as they could have on the test not because they were fundamentally bad doctors, but because there were major gaps in their training. The OSCE therefore demonstrated its usefulness by identifying these deficiencies in training. Examiners felt that addressing these gaps in training was most important and should be done before any institutional body uses the OSCE results to decide who should get a medical license or not.