HEALTH CARE * LES SOINS
Healthpolicy research becominin
a growth industry in Canada
Lynne Cohen C anada has a surfeit of doctors and must limit enrolment in its medical schools, a recent report said, and although that finding will shock few physicians, the source of the report is intriguing. The authors of the thick document, which was prepared for Canada's deputy ministers of health, are Morris Barer and Greg Stoddart. They are members of, respectively, the Centre for Health Services and Policy Research (CHSPR) at the University of British Columbia (UBC) in Vancouver and the Centre for Health Economics and Policy Analysis (CHEPA) at McMaster University in Hamilton, Ont. Although the names of their organizations are unexciting and the title of their report, Toward Integrated Medical Resource Policies For Canada: Background Document, is not the stuff of best-sellers, researchers like Barer and Stoddart are becoming very popular sources of information for politicians and health care officials. "Health care really has become a major agenda item for Lynne Cohen is a freelance writer living in Ottawa. 64
CAN MED ASSOC J 1992; 146 (1)
PA, and to people like Barer and Stoddart. Jonathan Lomas, CHEPA's coordinator, is an associate professor in the Department of Clinical Epidemiology and Biostatistics at McMaster. He and his team of eight CHEPA faculty members, all teachers at McMaster who have special expertise in health policy and one of either the health sciences, social sciences, business or the humanities, produce numerous scholarly reports. More than 30 appeared in 1989 alone. Similar growth is apparent on the West Coast, where CHSPR officially opened its doors in July. "The centre aims to contribute to the improvement of population health by being responsive to the research needs of those responsible for health policy," says a foreword in the manpower report Barer coauthored. CHEPA opened its doors in May 1988, although Lomas says the germination occurred years earlier. The group, which has evolved into a McMaster-based resource centre, holds regular conferences, seminars and continuing-education workshops. Since its founding it has published more than 75 reports. A 1990 report, HSO PerforStoddart: popular source of information
society and for politicians and all governments," explains CHEPA's George Torrance. "Crisis is a strong word, but it's the right one. "It looks like we've been trying to solve problems by throwing money at them and it hasn't worked. In fact, what [officials] are finding, and this is happening worldwide, is that we're spending more and more money on health care, yet serious problems remain. So now people are standing back and saying, 'Why didn't that work? What are we going to do about it?' " In an attempt to find those answers governments are turning to groups like CHSPR and CHE-
LE 1 er JANVIER 1992
mance: A Critical Appraisal of findings are highly regarded beCurrent Research, offers a pierc- cause they are impartial. "We are ing evaluation of this new, non- not part of the marketing battle fee-for-service method of health between pharmaceutical giants," care delivery. It concludes that, in he says. "We're trying to sit back some ways, health service organi- and look at the science, to see if zations, which are funded on a the drugs really work, to take the capitation basis, are simply better cost and the consequences into than the fee-for-service approach consideration, as well as the imat providing optimum care. pact on the quality of life, then to CHEPA reported that HSO pa- balance all of these. tients have lower rates of admis"CHEPA's studies are much sion to hospital than non-HSO like those from Consumer Reones, and that HSO-based doctors ports, telling people what they are manage greater patient loads than getting for their dollar and sepatheir fee-for-service counterparts. rating it from the marketing However, it also noted that HSO hype." patients are less satisfied with In simple terms, says Lomas, their care than other patients. CHEPA and the other health-poliCHEPA is also having an in- cy groups are engaged in "myth ternational impact on the evalua- busting and crystal-ball gazing." tion of drugs. Torrance, professor He says one myth CHEPA is emeritus in business administra- trying to bust "is the question of tion and part-time professor of whether the numbers of elderly epidemiology and biostatistics, is will bankrupt society. We have CHEPA's expert in the develop- found the numbers alone are not ment and application of special the problem. There are aspects to drug-appraisal methods, tech- the care of the elderly, such as the niques that give serious consider- intensity to which they are servation to a medication's cost-effec- iced, or the extent to which they tiveness. "Some drugs may be are using services more now than great for alleviating the condition they used to, which are important targeted," he says, "but the side elements of the problem." effects may be very severe, suffiCHEPA also argues that user ciently severe that they more than fees are not a saviour for an overovercome the good of the drug. Or burdened health care system. the costs may simply be too high." "The user fee won't save money at For instance, Torrance and all," Lomas maintains. his research team argue that the Crystal-ball gazing, meanless expensive streptokinase may while, involves trying to deterbe an excellent substitute for very mine what will be on the health
expensive tissue plasminogen activator. "There is major concern worldwide [regarding] drugs," Torrance maintains, "partly because [there is recognition] that many people are on too many drugs, the elderly especially. There is also the concern that drugs are increasingly expensive. Now, a lot of countries are realizing they could spend a huge proportion of their budget on drugs alone, if everything just keeps going the way it's going." Torrance thinks CHEPA's JANUARY 1, 1992
.L.m. ., ,:,
..w...i.. .h c
Lomas: links with clinicians
care agenda 18 months to 3 years in the future. CHEPA plans the theme of its annual conference at least 18 months in advance, largely guessing what the issue of the day will then be. This year's May conference, which attracted speakers such as Monique &gin, the former federal minister of health, and Dr. John Evans, McMaster's founding dean of health sciences, was entitled Health Care and the Public: Roles, Expectations and Contributions. CHEPA researchers say much of the information they are providing isn't new. "What we are now saying is really no different from what health-service analysts have been saying for many years," says Lomas. "The message has been fairly consistent for those who wish to listen." For example, Torrance says CHEPA's drug-intervention research has "only lately [sparked] tremendous interest worldwide. But we've been burrowing away here at McMaster for 20 years developing and applying these methods. Suddenly, in the last couple of years, the world seems to have discovered us." Even the paper on medical. manpower that was presented to the country's deputy ministers in June is an example of old information finally being noticed. "Data on the practice variations of doctors were first developed in the 1 950s," says Lomas. "And here we are in the 1990s, pretending this is new information." Canada currently has three major health policy and economics research organizations CHEPA, CHSPR and the Groupe recherche interdisciplinaire en sante at l'Universite de Montreal. However, Lomas says similar groups are being organized elsewhere. For instance, the University of Manitoba's recently opened Manitoba Centre for Health Policy and Evaluation will specialize in analysing and making policy recommendations based on data CAN MED ASSOC J 1992; 146 (1)
65
provided by the sophisticated Manitoba Data System, possibly the country's most advanced system for tracking the results of health care interventions. As well, the University of Toronto recently opened a health-management centre that is eventually expected to make its mark in health-policy analysis. "Ours is the biggest centre in terms of the number of researchers and the number of reports we put out," says Torrance. "We got started earlier, although UBC's group had been around almost as long before its official opening this past summer. "We are different from the other groups in terms of what we specialize in." These topics range from the effect of malpractice claims on physician behaviour, a project that is currently in progress, to a project completed in 1989: Do Physicians Induce Demand for Medical Services? Besides its productivity and liaison activities more than 65 provincial, national and international health organizations and governments deal regularly with individual members of CHEPA or the organization itself its location within a major health sciences complex may give CHEPA an edge over other health-policy research groups. "This means we have very strong links with [McMaster's professors of medicine]," says Lomas. "We spend a lot of our everyday time collaborating on research projects with clinicians, as well as just mingling with them. We are always picking up and transferring information between the clinical and health-economics and policy sides of the world." Cooperation among the research centres appears to be far more prevalent than competition. For instance, the national manpower report was a joint effort of researchers from CHSPR and CHEPA, and those two groups
collaborate frequently on projects, and with other groups. In August, for example, CHEPA hosted and worked with a visiting fellow from l'Universite de Montreal, who had previously spent a year at McMaster.
Still, cooperation doesn't stop the groups from bragging about their efforts. In its 1989-90 annual report, CHEPA pointed out that it was currently conducting 101 research projects, "many of which are funded by major research grants won in national and international competition with other investigators." "Right now we are trying to develop research projects for issues we think will 2 or 3 years," says
be important in Lomas. By then, it may be even more fashionable for decision-makers to consult with health-policy research groups before introducing or endorsing any new plans for the health care system.u
THERAPEUTIC INDEX INDEX THERAPEUTIQUE 0
-
66
CAN MED ASSOC J 1992; 146 (1)
Angiotensin converting enzyme inhibitor Prinivil Vasotec
74, 75, 76, Inside Back Cover 66, 67, Inside Front Cover
Antianginal agent Nitrong SR
2, 59
Antibacterial agent Cipro
44 A,B
Antibiotic Ceftin Suprax
13, 73 4, 72
Antihypertensive agent Adalat PA
22, 23, 63
Anti-inflammatory agent Voltaren SR
70, 71, Outside Back Cover
(enalapril maleate) Tablets 2.5, 5, 10, 20 mg
Angiotensin Converting Enzyme Inhibitor INDICATIONS AND CLINICAL USE The treatment of essential or renovascular hypertension; usually administered in association with other drugs, particularly thiazide diuretics. Consider the risk of angioedema (see WARNINGS). Normally used when a diuretic or beta-blocker was ineffective or associated with unacceptable adverse effects. Can also be tried as initial agent where a diuretic and/or beta-blocker is contraindicated or could cause serious adverse effects. Also indicated in the treatment of congestive heart failure, as adjunctive therapy in patients not responding adequately to digitalis and diuretics.
CONTRAINDICATIONS Hypersensitivity to any component; history of angioneurotic edema related to ACE inhibitor therapy. WARNINGS Angioedema, with laryngeal edema and/or shock, may occur and may be fatal. In such cases, discontinue drug promptly and observe patient until swelling subsides. Antihistamines may be useful where swelling is confined to face, lips and mouth. However, where the tongue, glottis or larynx is involved, likely to cause airway obstruction, prompt administration of subcutaneous epinephrine may be indicated.
Symptomatic hypotenslon, which usually occurred during initial therapy or when dose was increased, is more likely in patients who are volume-depleted. For patients in whom an excessive hypotension could result in severe or fatal complications, i.e. those with severe congestive heart failure, ischemic heart or cerebrovascular disease - start therapy under close medical supervision, usually in a hospital. Such patients should be followed closely for the potential fall in blood pressure during first two weeks of therapy or when enalapril or a diuretic is increased. If hypotension occurs, place patient in supine position and if needed, administer IV infusion of normal saline. A transient hypotensive response is not a contraindication to further doses of enalapril. Neutropenia/agranulocytosis and bone marrow depression have been caused by ACE inhibitors. Current experience with enalapril shows incidence to be rare. Consider periodic monitoring of white blood cell counts in patients with collagen vascular disease and renal disease.
PRECAUTIONS Impaired Renal Function Renal function should be assessed before initiating enalapril therapy. Patients with renal insufficiency may require reduced or less frequent doses, and their renal function must be monitored appropriately (see DOSAGE). Renal failure, which has been reported mainly in patients with severe congestive heart failure or underlying renal disease including renal artery stenosis, is usually reversible when treated promptly. Some hypertensive patients with no apparent renal disease have developed increases in BUN and creatinine while on concurrent diuretic/enalapril therapy. Dosage reduction or discontinuation of one or both drugs may be required. Hyperkalemia In clinical trials, hyperkalemia (> 5.7 mmol/L) was observed in approximately 1% of hypertensive patients, and caused discontinuation of therapy in 0.28% of such patients. Risk factors for hyperkalemia development may include renal insufficiency, diabetes mellitus, and concomitant use of agents to treat hypokalemia (see ADVERSE
REACTIONS).
Haemophilus influenzae type B vaccine PedvaxHIB
6, 68, 69
Valvular Stenosis
Theoretically, patients with aortic stenosis who do not develop as much afterload reduction, might be at risk of decreased coronary perfusion when
Smoking cessation aid
treated with vasodilators.
Nicorette
'Trademark Merck & Co., Inc. Merck Frosst Canada Inc., R. U.
8, 9, 71
LE lerJANVIER 1992
Healthpolicy research becominin
a growth industry in Canada
Lynne Cohen C anada has a surfeit of doctors and must limit enrolment in its medical schools, a recent report said, and although that finding will shock few physicians, the source of the report is intriguing. The authors of the thick document, which was prepared for Canada's deputy ministers of health, are Morris Barer and Greg Stoddart. They are members of, respectively, the Centre for Health Services and Policy Research (CHSPR) at the University of British Columbia (UBC) in Vancouver and the Centre for Health Economics and Policy Analysis (CHEPA) at McMaster University in Hamilton, Ont. Although the names of their organizations are unexciting and the title of their report, Toward Integrated Medical Resource Policies For Canada: Background Document, is not the stuff of best-sellers, researchers like Barer and Stoddart are becoming very popular sources of information for politicians and health care officials. "Health care really has become a major agenda item for Lynne Cohen is a freelance writer living in Ottawa. 64
CAN MED ASSOC J 1992; 146 (1)
PA, and to people like Barer and Stoddart. Jonathan Lomas, CHEPA's coordinator, is an associate professor in the Department of Clinical Epidemiology and Biostatistics at McMaster. He and his team of eight CHEPA faculty members, all teachers at McMaster who have special expertise in health policy and one of either the health sciences, social sciences, business or the humanities, produce numerous scholarly reports. More than 30 appeared in 1989 alone. Similar growth is apparent on the West Coast, where CHSPR officially opened its doors in July. "The centre aims to contribute to the improvement of population health by being responsive to the research needs of those responsible for health policy," says a foreword in the manpower report Barer coauthored. CHEPA opened its doors in May 1988, although Lomas says the germination occurred years earlier. The group, which has evolved into a McMaster-based resource centre, holds regular conferences, seminars and continuing-education workshops. Since its founding it has published more than 75 reports. A 1990 report, HSO PerforStoddart: popular source of information
society and for politicians and all governments," explains CHEPA's George Torrance. "Crisis is a strong word, but it's the right one. "It looks like we've been trying to solve problems by throwing money at them and it hasn't worked. In fact, what [officials] are finding, and this is happening worldwide, is that we're spending more and more money on health care, yet serious problems remain. So now people are standing back and saying, 'Why didn't that work? What are we going to do about it?' " In an attempt to find those answers governments are turning to groups like CHSPR and CHE-
LE 1 er JANVIER 1992
mance: A Critical Appraisal of findings are highly regarded beCurrent Research, offers a pierc- cause they are impartial. "We are ing evaluation of this new, non- not part of the marketing battle fee-for-service method of health between pharmaceutical giants," care delivery. It concludes that, in he says. "We're trying to sit back some ways, health service organi- and look at the science, to see if zations, which are funded on a the drugs really work, to take the capitation basis, are simply better cost and the consequences into than the fee-for-service approach consideration, as well as the imat providing optimum care. pact on the quality of life, then to CHEPA reported that HSO pa- balance all of these. tients have lower rates of admis"CHEPA's studies are much sion to hospital than non-HSO like those from Consumer Reones, and that HSO-based doctors ports, telling people what they are manage greater patient loads than getting for their dollar and sepatheir fee-for-service counterparts. rating it from the marketing However, it also noted that HSO hype." patients are less satisfied with In simple terms, says Lomas, their care than other patients. CHEPA and the other health-poliCHEPA is also having an in- cy groups are engaged in "myth ternational impact on the evalua- busting and crystal-ball gazing." tion of drugs. Torrance, professor He says one myth CHEPA is emeritus in business administra- trying to bust "is the question of tion and part-time professor of whether the numbers of elderly epidemiology and biostatistics, is will bankrupt society. We have CHEPA's expert in the develop- found the numbers alone are not ment and application of special the problem. There are aspects to drug-appraisal methods, tech- the care of the elderly, such as the niques that give serious consider- intensity to which they are servation to a medication's cost-effec- iced, or the extent to which they tiveness. "Some drugs may be are using services more now than great for alleviating the condition they used to, which are important targeted," he says, "but the side elements of the problem." effects may be very severe, suffiCHEPA also argues that user ciently severe that they more than fees are not a saviour for an overovercome the good of the drug. Or burdened health care system. the costs may simply be too high." "The user fee won't save money at For instance, Torrance and all," Lomas maintains. his research team argue that the Crystal-ball gazing, meanless expensive streptokinase may while, involves trying to deterbe an excellent substitute for very mine what will be on the health
expensive tissue plasminogen activator. "There is major concern worldwide [regarding] drugs," Torrance maintains, "partly because [there is recognition] that many people are on too many drugs, the elderly especially. There is also the concern that drugs are increasingly expensive. Now, a lot of countries are realizing they could spend a huge proportion of their budget on drugs alone, if everything just keeps going the way it's going." Torrance thinks CHEPA's JANUARY 1, 1992
.L.m. ., ,:,
..w...i.. .h c
Lomas: links with clinicians
care agenda 18 months to 3 years in the future. CHEPA plans the theme of its annual conference at least 18 months in advance, largely guessing what the issue of the day will then be. This year's May conference, which attracted speakers such as Monique &gin, the former federal minister of health, and Dr. John Evans, McMaster's founding dean of health sciences, was entitled Health Care and the Public: Roles, Expectations and Contributions. CHEPA researchers say much of the information they are providing isn't new. "What we are now saying is really no different from what health-service analysts have been saying for many years," says Lomas. "The message has been fairly consistent for those who wish to listen." For example, Torrance says CHEPA's drug-intervention research has "only lately [sparked] tremendous interest worldwide. But we've been burrowing away here at McMaster for 20 years developing and applying these methods. Suddenly, in the last couple of years, the world seems to have discovered us." Even the paper on medical. manpower that was presented to the country's deputy ministers in June is an example of old information finally being noticed. "Data on the practice variations of doctors were first developed in the 1 950s," says Lomas. "And here we are in the 1990s, pretending this is new information." Canada currently has three major health policy and economics research organizations CHEPA, CHSPR and the Groupe recherche interdisciplinaire en sante at l'Universite de Montreal. However, Lomas says similar groups are being organized elsewhere. For instance, the University of Manitoba's recently opened Manitoba Centre for Health Policy and Evaluation will specialize in analysing and making policy recommendations based on data CAN MED ASSOC J 1992; 146 (1)
65
provided by the sophisticated Manitoba Data System, possibly the country's most advanced system for tracking the results of health care interventions. As well, the University of Toronto recently opened a health-management centre that is eventually expected to make its mark in health-policy analysis. "Ours is the biggest centre in terms of the number of researchers and the number of reports we put out," says Torrance. "We got started earlier, although UBC's group had been around almost as long before its official opening this past summer. "We are different from the other groups in terms of what we specialize in." These topics range from the effect of malpractice claims on physician behaviour, a project that is currently in progress, to a project completed in 1989: Do Physicians Induce Demand for Medical Services? Besides its productivity and liaison activities more than 65 provincial, national and international health organizations and governments deal regularly with individual members of CHEPA or the organization itself its location within a major health sciences complex may give CHEPA an edge over other health-policy research groups. "This means we have very strong links with [McMaster's professors of medicine]," says Lomas. "We spend a lot of our everyday time collaborating on research projects with clinicians, as well as just mingling with them. We are always picking up and transferring information between the clinical and health-economics and policy sides of the world." Cooperation among the research centres appears to be far more prevalent than competition. For instance, the national manpower report was a joint effort of researchers from CHSPR and CHEPA, and those two groups
collaborate frequently on projects, and with other groups. In August, for example, CHEPA hosted and worked with a visiting fellow from l'Universite de Montreal, who had previously spent a year at McMaster.
Still, cooperation doesn't stop the groups from bragging about their efforts. In its 1989-90 annual report, CHEPA pointed out that it was currently conducting 101 research projects, "many of which are funded by major research grants won in national and international competition with other investigators." "Right now we are trying to develop research projects for issues we think will 2 or 3 years," says
be important in Lomas. By then, it may be even more fashionable for decision-makers to consult with health-policy research groups before introducing or endorsing any new plans for the health care system.u
THERAPEUTIC INDEX INDEX THERAPEUTIQUE 0
-
66
CAN MED ASSOC J 1992; 146 (1)
Angiotensin converting enzyme inhibitor Prinivil Vasotec
74, 75, 76, Inside Back Cover 66, 67, Inside Front Cover
Antianginal agent Nitrong SR
2, 59
Antibacterial agent Cipro
44 A,B
Antibiotic Ceftin Suprax
13, 73 4, 72
Antihypertensive agent Adalat PA
22, 23, 63
Anti-inflammatory agent Voltaren SR
70, 71, Outside Back Cover
(enalapril maleate) Tablets 2.5, 5, 10, 20 mg
Angiotensin Converting Enzyme Inhibitor INDICATIONS AND CLINICAL USE The treatment of essential or renovascular hypertension; usually administered in association with other drugs, particularly thiazide diuretics. Consider the risk of angioedema (see WARNINGS). Normally used when a diuretic or beta-blocker was ineffective or associated with unacceptable adverse effects. Can also be tried as initial agent where a diuretic and/or beta-blocker is contraindicated or could cause serious adverse effects. Also indicated in the treatment of congestive heart failure, as adjunctive therapy in patients not responding adequately to digitalis and diuretics.
CONTRAINDICATIONS Hypersensitivity to any component; history of angioneurotic edema related to ACE inhibitor therapy. WARNINGS Angioedema, with laryngeal edema and/or shock, may occur and may be fatal. In such cases, discontinue drug promptly and observe patient until swelling subsides. Antihistamines may be useful where swelling is confined to face, lips and mouth. However, where the tongue, glottis or larynx is involved, likely to cause airway obstruction, prompt administration of subcutaneous epinephrine may be indicated.
Symptomatic hypotenslon, which usually occurred during initial therapy or when dose was increased, is more likely in patients who are volume-depleted. For patients in whom an excessive hypotension could result in severe or fatal complications, i.e. those with severe congestive heart failure, ischemic heart or cerebrovascular disease - start therapy under close medical supervision, usually in a hospital. Such patients should be followed closely for the potential fall in blood pressure during first two weeks of therapy or when enalapril or a diuretic is increased. If hypotension occurs, place patient in supine position and if needed, administer IV infusion of normal saline. A transient hypotensive response is not a contraindication to further doses of enalapril. Neutropenia/agranulocytosis and bone marrow depression have been caused by ACE inhibitors. Current experience with enalapril shows incidence to be rare. Consider periodic monitoring of white blood cell counts in patients with collagen vascular disease and renal disease.
PRECAUTIONS Impaired Renal Function Renal function should be assessed before initiating enalapril therapy. Patients with renal insufficiency may require reduced or less frequent doses, and their renal function must be monitored appropriately (see DOSAGE). Renal failure, which has been reported mainly in patients with severe congestive heart failure or underlying renal disease including renal artery stenosis, is usually reversible when treated promptly. Some hypertensive patients with no apparent renal disease have developed increases in BUN and creatinine while on concurrent diuretic/enalapril therapy. Dosage reduction or discontinuation of one or both drugs may be required. Hyperkalemia In clinical trials, hyperkalemia (> 5.7 mmol/L) was observed in approximately 1% of hypertensive patients, and caused discontinuation of therapy in 0.28% of such patients. Risk factors for hyperkalemia development may include renal insufficiency, diabetes mellitus, and concomitant use of agents to treat hypokalemia (see ADVERSE
REACTIONS).
Haemophilus influenzae type B vaccine PedvaxHIB
6, 68, 69
Valvular Stenosis
Theoretically, patients with aortic stenosis who do not develop as much afterload reduction, might be at risk of decreased coronary perfusion when
Smoking cessation aid
treated with vasodilators.
Nicorette
'Trademark Merck & Co., Inc. Merck Frosst Canada Inc., R. U.
8, 9, 71
LE lerJANVIER 1992
