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Biomedical subjects

Robert G Evans

Publications and source records attributed to Robert G Evans.

11 recordsLinked to original sources
PubMed2005

The impact of deficit reduction on the nursing labour market in Canada: unintended consequences of fiscal reform.

INTRODUCTION: Beginning in 1992, governments throughout Canada began reducing expenditures in an effort to eliminate fiscal deficits and reduce their alarmingly high debt burden. As part of this deficit-fighting era, governments reduced hospital expenditure levels quite dramatically. Some of the current problems in the Canadian healthcare system - the recent unrest in the nursing labour market in particular - are often attributed to this hospital downsizing era. METHODS: This article examines trends in the labour market for registered nurses in Canada during the hospital downsizing period. Of particular interest is the effect of hospital spending reforms on nurse employment levels in hospitals and on the age structure of the nursing workforce. After identifying the trends, the main factors driving the trends are discussed. RESULTS: Results indicate that a decrease in the demand for nursing labour resulted in large staff layoffs during the restructuring period, particularly among the youngest age groups. DISCUSSION/CONCLUSION: The evidence does not support the claim that deteriorating wages and working conditions in hospitals led nurses to quit their jobs during the hospital downsizing period.

Adult↗
PubMed2004

Beneath the calm surface: the changing face of physician-service use in British Columbia, 1985/86 versus 1996/97.

BACKGROUND: Although expenditures on health care are continually increasing and often said to be unsustainable, few studies have examined these trends at the level of services delivered to individual patients. We analyzed trends in the various components that contributed to changes in overall expenditures for physician services in British Columbia from 1985/86 to 1996/97. METHODS: We obtained data on all fee-for-service payments to physicians in each study year using the British Columbia Linked Health Data set and analyzed these at the level of individual patients. We disaggregated overall billing levels by year into the following components: number of physicians seen by each patient, number of visits per physician, number of services rendered on each visit and average price of those services. We removed the effect of inflation on fees by adjusting to those in 1988. We used direct age-standardization to isolate and measure the effect of demographic changes. We used the Consumer Price Index to determine the effects of inflation. RESULTS: Total payments to fee-for-service physicians in British Columbia rose 86.3% over the study period. The increase was entirely accounted for by the combined effects of population growth (28.9%), aging (2.1%) and general inflation (41.4%). Service use per capita rose 10.5%; this increase was offset by a decline of 9.4% in inflation-adjusted fees. The average cost of age-adjusted per-capita services rendered by general or family practitioners (GP/FPs) increased very little (3.3%) over the 11-year period, compared with a nearly one-third (31.8%) increase for medical specialists. Although there was a dramatic increase in the number of GP/FPs seen on average by each patient (32.9%), this increase was offset by the combination of decreases in the number of visits per physician (-14.9%), the number of services provided per visit (-8.0%) and the "real cost" of each service provided (-3.5%). Visits to medical specialists increased by about 20% over the study period in all age groups. However, for each person 65 years of age or over receiving any services, the average fee-adjusted expenditures increased 24.8%, almost 4 times the rate of increase for people younger than 65. The use of surgical services grew 26.5% for seniors while declining -2.0% for people under age 65. INTERPRETATION: These findings suggest a form of "homeostasis" in aggregate-level service use and cost. The supposed inflationary effects of population aging and increasing "abuse of the system" by patients were not found.

Adolescent↗
PubMed2003

How does direct-to-consumer advertising (DTCA) affect prescribing? A survey in primary care environments with and without legal DTCA.

BACKGROUND: Direct-to-consumer advertising (DTCA) of prescription drugs has increased rapidly in the United States during the last decade, yet little is known about its effects on prescribing decisions in primary care. We compared prescribing decisions in a US setting with legal DTCA and a Canadian setting where DTCA of prescription drugs is illegal, but some cross-border exposure occurs. METHODS: We recruited primary care physicians working in Sacramento, California, and Vancouver, British Columbia, and their group practice partners to participate in the study. On pre- selected days, patients aged 18 years or more completed a questionnaire before seeing their physician. We asked these patients' physicians to complete a brief questionnaire immediately following the selected patient visit. By pairing individual patient and physician responses, we determined how many patients had been exposed to some form of DTCA, the frequency of patients' requests for prescriptions for advertised medicines and the frequency of prescriptions that were stimulated by the patients' requests. We measured physicians' confidence in treatment choice for each new prescription by asking them whether they would prescribe this drug to a patient with the same condition. RESULTS: Seventy-eight physicians (Sacramento n = 38, Vancouver n = 40) and 1431 adult patients (Sacramento n = 683, Vancouver n = 748), or 61% of patients who consulted participating physicians on pre-set days, participated in the survey. Exposure to DTCA was higher in Sacramento, although 87.4% of Vancouver patients had seen prescription drug advertisements. Of the Sacramento patients, 7.2% requested advertised drugs as opposed to 3.3% in Vancouver (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.2-4.1). Patients with higher self- reported exposure to advertising, conditions that were potentially treatable by advertised drugs, and/or greater reliance on advertising requested more advertised medicines. Physicians fulfilled most requests for DTCA drugs (for 72% of patients in Vancouver and 78% in Sacramento); this difference was not statistically significant. Patients who requested DTCA drugs were much more likely to receive 1 or more new prescriptions (for requested drugs or alternatives) than those who did not request DTCA drugs (OR 16.9, 95% CI 7.5-38.2). Physicians judged 50.0% of new prescriptions for requested DTCA drugs to be only "possible" or "unlikely" choices for other similar patients, as compared with 12.4% of new prescriptions not requested by patients (p < 0.001). INTERPRETATION: Our results suggest that more advertising leads to more requests for advertised medicines, and more prescriptions. If DTCA opens a conversation between patients and physicians, that conversation is highly likely to end with a prescription, often despite physician ambivalence about treatment choice.

Adult↗
PubMed2003

Consuming research, producing policy?

The authors' 1990 article "Producing Health, Consuming Health Care" presented a conceptual framework for synthesizing a rapidly growing body of findings on the nonmedical determinants of health. The article received a very positive response, and here the authors reflect on what lessons might be learned from that response about the style or content of effective interdisciplinary communication. Much substantive knowledge has been accumulated since 1990, and a number of different frameworks have been developed before and since. The authors situate theirs within this literature and consider how they might have modified it if they "knew then what they know now." They ask what impact this article, and the much broader stream of research on the determinants of health, has had on public policy?

Canada↗
PubMed2003

Do Canadian civil servants care about the health of populations?

OBJECTIVES: This article describes Canadian civil servants' awareness of, attitudes toward, and self-reported use of ideas about the determinants of health. METHODS: Federal and provincial civil servants in departments of finance, labor, social services, and health were surveyed. RESULTS: With civil servants in finance departments a notable exception, most Canadian civil servants see the health of populations as a relevant outcome for their sectors. Many (65%) report that ideas about the determinants of health have already influenced policymaking in their sector, but most (83%) say they need more information about the health consequences of the policy alternatives their departments face. CONCLUSIONS: Civil servants should consider developing accountability structures for health and researchers should consider producing and transferring more policy-relevant research.

Attitude to Health↗
PubMed2002

The doctor is out: physician participation in the Rationed Access Day work stoppage in British Columbia, 1998/99.

BACKGROUND: In 1998/99, the British Columbia Medical Association (BCMA) asked physicians to withdraw elective services on a series of 20 Rationed Access Days (RADs). This work stoppage was called to protest continued free proration triggered by total physician billings exceeding a fixed budget cap. This paper examines how physicians' practice activity changed on RADs, the rates of participation in this job action and characteristics of those physicians who participated. DESIGN: Population-based cohort study of physicians based on administrative data. POPULATION: All full-time physicians billing the provincial healthcare plan. METHODS: Participation in the RAD initiative was inferred by comparing physicians' average daily billings on RADs, Sundays, holidays and regular weekdays. Using thresholds established from these distributions, the number of RADs observed by each physician in 1998/99 was calculated and examined in relation to their demographics, location and prior years of practice activity. RESULTS: For the 4,131 physicians studied, average daily payments on RADs were similar to those on Sundays and holidays but much lower than those on non-holiday, non-RAD weekdays. Using billing thresholds of $200 (for GPs) and $400 (for specialists), we found a high degree of participation with the study population observing a median of 15 of the 20 scheduled RADs. While there were some differences in participation among age groups, geography and the prior years of practice activity, the differences were small. INTERPRETATION: This study found high solidarity in the BCMA's 1998/99 RAD initiative. Most full-time fee-for-service FS physicians appeared to participate in at least three-quarters of the 20 scheduled RADs.

British Columbia↗
PubMedDate not supplied

Phantoms in the snow: Canadians' use of health care services in the United States.

To examine the extent to which Canadian residents seek medical care across the border, we collected data about Canadians' use of services from ambulatory care facilities and hospitals located in Michigan, New York State, and Washington State during 1994-1998. We also collected information from several Canadian sources, including the 1996 National Population Health Survey, the provincial Ministries of Health, and the Canadian Life and Health Insurance Association. Results from these sources do not support the widespread perception that Canadian residents seek care extensively in the United States. Indeed, the numbers found are so small as to be barely detectible relative to the use of care by Canadians at home.

Adult↗