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\"Unequal access to health care is a problem in Canada much studied by journalists, academics, and policy makers. There is a growing recognition that existing theories on, and approaches to, health inequities are limited in their ability to capture how these inequities are produced through changing, co-constituted, and intersecting effects of multiple forms of oppression.

Background Urban environments can influence many aspects of health and well-being and access to health care is one of them. Access to primary health care (PHC) in urban settings is a pressing research and policy issue in Canada. Most research on access to healthcare is focused on national and provincial levels in Canada; there is a need to advance current understanding to local scales such as neighbourhoods. Methods This study examines spatial accessibility to family physicians using the Three-Step Floating Catchment Area (3SFCA) method to identify neighbourhoods with poor geographical access to PHC services and their spatial patterning across 14 Canadian urban settings. An index of spatial access to PHC services, representing an accessibility score (physicians-per-1000 population), was calculated for neighborhoods using a 3km road network distance. Information about primary health care providers (this definition does not include mobile services such as health buses or nurse practitioners or less distributed services such as emergency rooms) used in this research was gathered from publicly available and routinely updated sources (i.e. provincial colleges of physicians and surgeons). An integrated geocoding approach was used to establish PHC locations. Results The results found that the three methods, Simple Ratio, Neighbourhood Simple Ratio, and 3SFCA that produce City level access scores are positively correlated with each other. Comparative analyses were performed both within and across urban settings to examine disparities in distributions of PHC services. It is found that neighbourhoods with poor accessibility scores in the main urban settings across Canada have further disadvantages in relation to population high health care needs. Conclusions The results of this study show substantial variations in geographical accessibility to PHC services both within and among urban areas. This research enhances our understanding of spatial accessibility to health care services at the neighbourhood level. In particular, the results show that the low access neighbourhoods tend to be clustered in the neighbourhoods at the urban periphery and immediately surrounding the downtown area.

Health care office staff and providers may discriminate against people of low socioeconomic status, even in the absence of economic incentives to do so. We sought to determine whether socioeconomic status affects the response a patient receives when seeking a primary care appointment. In a single unannounced telephone call to a random sample of family physicians and general practices (n = 375) in Toronto, Ontario, a male and a female researcher each played the role of a patient seeking a primary care physician. Callers followed a script suggesting either high (i.e., bank employee transferred to the city) or low (i.e., recipient of social assistance) socioeconomic status, and either the presence or absence of chronic health conditions (diabetes and low back pain). We randomized the characteristics of the caller for each office. Our primary outcome was whether the caller was offered an appointment. The proportion of calls resulting in an appointment being offered was significantly higher when the callers presented themselves as having high socioeconomic status than when they presented as having low socioeconomic status (22.6% v.14.3%, p = 0.04) and when the callers stated the presence of chronic health conditions than when they did not (23.5% v. 12.8%, p = 0.008). In a model adjusted for all independent variables significant at a p value of 0.10 or less (presence of chronic health conditions, time since graduation from medical school and membership in the College of Family Physicians of Canada), high socioeconomic status was associated with an odds ratio of 1.78 (95% confidence interval 1.02–3.08) for the offer of an appointment. Socioeconomic status and chronic health conditions had independent effects on the likelihood of obtaining an appointment. Within a universal health insurance system in which physician reimbursement is unaffected by patients' socioeconomic status, people presenting themselves as having high socioeconomic status received preferential access to primary care over those presenting themselves as having low socioeconomic status.

National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015. We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure–the Healthcare Quality and Access (HAQ) Index–on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r=0·88), an index of 11 universal health coverage interventions (r=0·83), and human resources for health per 1000 (r=0·77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time. Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28·6 to 94·6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40·7 (95% uncertainty interval, 39·0–42·8) in 1990 to 53·7 (52·2–55·4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21·2 in 1990 to 20·1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73·8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015. This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-system characteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world. Bill & Melinda Gates Foundation.

Access to health care based on need rather than ability to pay was the founding principle of the Canadian health-care system. Medicare was born in one province in 1947. It spread across the country through federal cost sharing, and eventually was harmonised through standards in a federal law, the Canada Health Act of 1984. The health-care system is less a true national system than a decentralised collection of provincial and territorial insurance plans covering a narrow basket of services, which are free at the point of care. Administration and service delivery are highly decentralised, although coverage is portable across the country. In the setting of geographical and population diversity, long waits for elective care demand the capacity and commitment to scale up effective and sustainable models of care delivery across the country. Profound health inequities experienced by Indigenous populations and some vulnerable groups also require coordinated action on the social determinants of health if these inequities are to be effectively addressed. Achievement of the high aspirations of Medicare's founders requires a renewal of the tripartite social contract between governments, health-care providers, and the public. Expansion of the publicly funded basket of services and coordinated effort to reduce variation in outcomes will hinge on more engaged roles for the federal government and the physician community than have existed in previous decades. Public engagement in system stewardship will also be crucial to achieve a high-quality system grounded in both evidence and the Canadian values of equity and solidarity.

The United States is in the midst of the most sweeping health insurance expansions and market reforms since the enactment of Medicare and Medicaid in 1965. Our 2013 survey of the general population in eleven countries-Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States-found that US adults were significantly more likely than their counterparts in other countries to forgo care because of cost, to have difficulty paying for care even when insured, and to encounter time-consuming insurance complexity. Signaling the lack of timely access to primary care, adults in the United States and Canada reported long waits to be seen in primary care and high use of hospital emergency departments, compared to other countries. Perhaps not surprisingly, US adults were the most likely to endorse major reforms: Three out of four called for fundamental change or rebuilding. As US health insurance expansions unfold, the survey offers benchmarks to assess US progress from an international perspective, plus insights from other countries' coverage-related policies. [PUBLICATION ABSTRACT]

The coronavirus disease 2019 (COVID-19) pandemic has had a massive impact on waits for elective operations, with tens of thousands of scheduled surgeries being cancelled or postponed across Canada. Provincial governments will likely not only reopen elective surgical capacity when it is deemed safe, but also target new funding to address the backlog of cases. There is a dearth of research on whether the provinces’ approaches to managing wait lists are equitable from a patients’ needs perspective or if they are associated with patients’ perception of outcomes. The surgical cost models used in the past won’t be useful to governments and hospital managers. New models based on hospitals’ marginal costs, associated with running on weekends or off-hours and social distancing parameters, will be needed. Surgeon input, collaboration and leadership during the strategy development, implementation and management of surgical wait lists postpandemic will be imperative, as these decisions will significantly affect the health and lives of many Canadians.

Background Many Canadian adolescents and young adults with mental health problems face delayed detection, long waiting lists, poorly accessible services, care of inconsistent quality and abrupt or absent inter-service transitions. To address these issues, ACCESS Open Minds, a multi-stakeholder network, is implementing and systematically evaluating a transformation of mental health services for youth aged 11 to 25 at 14 sites across Canada. The transformation plan has five key foci: early identification, rapid access, appropriate care, the elimination of age-based transitions between services, and the engagement of youth and families. Methods The ACCESS Open Minds Research Protocol has multiple components including a minimum evaluation protocol and a stepped-wedge cluster randomized trial, that are detailed in this paper. Additional components include qualitative methods and cost-effectiveness analyses. The services transformation is being evaluated at all sites via a minimum evaluation protocol. Six sites are participating in the stepped-wedge trial whereby the intervention (a service transformation along the key foci) was rolled out in three waves, each commencing six months apart. Two sites, one high-population and one low-population, were randomly assigned to each of the three waves, i.e., randomization was stratified by population size. Our primary hypotheses pertain to increased referral numbers, and reduced wait times to initial assessment and to the commencement of appropriate care. Secondary hypotheses pertain to simplified pathways to care; improved clinical, functional and subjective outcomes; and increased satisfaction among youth and families. Quantitative measures addressing these hypotheses are being used to determine the effectiveness of the intervention. Discussion Data from our overall research strategy will help test the effectiveness of the ACCESS Open Minds transformation, refine it further, and inform its scale-up. The process by which our research strategy was developed has implications for the practice of research itself in that it highlights the need to actively engage all stakeholder groups and address unique considerations in designing evaluations of complex healthcare interventions in multiple, diverse contexts. Our approach will generate both concrete evidence and nuanced insights, including about the challenges of conducting research in real-world settings. More such innovative approaches are needed to advance youth mental health services research. Trial registration number Clinicaltrials.gov, ISRCTN23349893 (Retrospectively registered: 16/02/2017).

In Ontario, despite the increasing prevalence of Parkinson’s disease (PD), barriers to access-to-care for people with Parkinson’s disease (PwP) and their caregivers are not well understood. The objective of this study is to examine spatial patterns of health care utilization among PwP and identify factors associated with PD-related health care utilization of individuals in Ontario. We employed a retrospective, population-based study design involving administrative health data to identify PwP as of March 31, 2018 (N = 35,482) using a previously validated case definition. An enhanced 2-step floating catchment area method was used to measure spatial accessibility to PD care and a descriptive spatial analysis was conducted to describe health service utilization by geographic area and specialty type. Negative binomial regression models were then conducted to identify associated geographic, socioeconomic, comorbidity and demographic factors. There was marked spatial variability in PD-related service utilization, with neurology and all provider visits being significantly higher in urban areas (CMF>1.20; p<0.05) and family physician visits being significantly higher (CMF >1.20; p<0.05) in more rural areas and remote areas. More frequent visits to family physicians were associated with living in rural areas, while less frequent visitation was associated with living in areas of low spatial accessibility with high ethnic concentration. Visits to neurologists were positively associated with living in areas of high spatial accessibility and with high ethnic concentration. Visits to all providers were also positively associated with areas of high spatial accessibility. For all outcomes, less frequent visits were found in women, older people, and those living in more deprived areas as years living with PD increased. This study demonstrates the importance of geographic, socioeconomic and individual factors in determining PwP’s likelihood of accessing care and type of care provided. Our results can be expected to inform the development of policies and patient care models aimed at improving accessibility among diverse populations of PwP.

Although there has been a lot of focus on supportive environments for physical activity and nutrition, the family environment in childhood is particularly important and can have farreaching consequences on physical and mental health, as well as mortality.18 Children who experience multiple forms of abuse, witness domestic violence and grow up in a household where family members are mentally ill, substance abusers or sent to prison, are \"12 times more likely to have attempted suicide, 7 times more likely to be alcoholic, and 10 times more likely to have injected street drugs\" by the time they reach adulthood.19 On the positive side, developing a relationship of support with an \"alternative support figure\" (e.g., grandparent, elder, friend or health worker) can serve as \"a corrective emotional experience [that] allows the subject to work through his/her negative childhood experiences and acquire modalities of interaction that enable him/her to function more effectively in the world.\"20 This forms part of a continuum of strategies from victim identification and care to multisectoral structural interventions that better support parents and children, promote nurturing relationships, empower women and change social norms to ideally prevent violence in the first place.21 Although clinical practice guidelines in this domain lack evidence to recommend universal screening of asymptomatic patients,23,24 failure to identify hidden social challenges can lead to \"misdiagnosis and a path of inappropriate investigations\" (e.g., failing to ask about exposure to violence in the work-up of pelvic pain)25 or inappropriate care plans (e.g., prescribing medicines that patients cannot afford).26 In a study involving a survey of patient perceptions on care integration between mainstream health care services and community-based services that address the social determinants, more than 40% of patients reported that their family doctor was unaware of their struggles (e.g., obtaining enough to feed themselves, arranging transportation to clinic visits or paying for medicines).27 Even when women presented with bruises and broken bones, only 14% had been asked about violence as a potential cause by their primary care provider,28 although over 170 000 women in Canada are victims of violence each year according to police-reported data and over 1 600 000 according to self-reported data.29 Therefore, recent clinical guidance has encouraged physicians to have a heightened awareness of clinical flags and patient cues, using \"selective enquiry based on clinical considerations\" to work social history questions into the patient encounter in a more seamless way.30 Physicians who know how to ask about social challenges are more likely to report helping their patients work through these issues.31 Indeed, all patients may struggle with social challenges and require support in various spheres at different stages in their lives, and challenges such as discrimination, social isolation or exposure to violence can occur regardless of socioeconomic status.32 Community-oriented primary care is the \"integration of public health practice with the delivery of primary care services\" with the aim of improving the health of a defined population.67 Communityoriented primary care is a form of \"community diagnosis\" and \"community treatment\" blended with clinical patient care that has a long history68 and continues to inspire innovative approaches to support disadvantaged patient groups.69 In a study involving a cohort of over 1000 disadvantaged patients in San Antonio, Texas, a community-oriented primary care approach using health promoters acting as cultural brokers between patients and physicians, as well as helping to map out, mobilize and connect patients with resources in the local community, resulted in a 24% decrease in admissions to hospital and a cost savings of over US$250 000 per year.\"70