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This policy paper examines potential roles of 'funding policy' to address yawning gaps in continuity of healthcare delivery and inequality in health outcomes across Canada. Funding policy is but one tool available to healthcare decision makers to affect the volume, type, timeliness and cost of healthcare services, products and devices provided to a country's residents. Healthcare funding policies involve trade-offs and conflicts that may drive the 'price' of change to be too high. As Canada exits the COVID-related healthcare crises, the price of healthcare reform may be changing which may cause provinces and territories to consider new healthcare funding policies. The paper begins with a brief background outlining the utility of funding policies to affect the cost-efficiency, effectiveness and equity of healthcare delivered in provinces and territories. Two complementary policy options are proposed that show considerable promise to improve value from healthcare funding. The paper is written from the perspective of the role of the federal government and highlights possible strategies for the federal government to remove barriers to support funding policy reforms in provinces and territories. The federal government is not responsible, nor does it play a meaningful role, in developing, implementing or monitoring funding policy for healthcare organizations or individual providers. This role rests with the respective provinces and territories with the exceptions of federally-insured populations. Nonetheless, the federal government could show leadership in the domain of funding policy by removing provinces' and territories' barriers to policy reforms. To bridge the federal government's strengths with provinces' and territories' barriers, a number of specific recommendations are offered to the federal government for its consideration. First, this policy paper recommends that substantive and meaningful funding policy reform should not consist of solely of paying organizations or people differently. There should be commensurate advancements in: national standards for new streams of data and reporting, organization-building and skills development, and robust risk adjustment. These barriers are not show-stoppers, and activities to remove many barriers are fairly straightforward. Second, the federal government could take a leadership role in immediately supporting episode-based payments. These activities could include national efforts to define episodes of care, link data, establish non-binding payment amounts, and publish health outcome performance measures. Third, deliberate federal leadership is needed to establish and grow new streams of data critical to measuring value – including patient-reported outcomes and non-insured health services, such as physiotherapies and mental health services. These activities will be ground-breaking in Canada from the perspective of measuring health and population outcomes. Fourth, the federal government could lead efforts to link social care data with healthcare data. The measurement and analyses of this data will create a roadmap for future interventions to improve population health. The policies proposed in this paper are based on the federal government 'nudging' provinces and territories to make changes in funding policy by removing barriers. The policies are incremental from an international perspective, though have important consequences for healthcare organizations and individual providers if they were to be implemented and transformational to healthcare performance were the policies proven to be successful in the long-term.

ObjectivesLittle is known about the role of emerging plant-based dietary patterns in cardiovascular disease (CVD) at the national population level. The objectives of this research were to assess the validity and reliability of newly-established plant-based dietary indices, and to evaluate their associations with CVD risk among Canadian adults.
ApproachData were obtained from repeated 24-hour dietary recalls of adult participants in the cross-sectional, nationally representative Canadian Community Health Survey cycle 2004 linked to vital statistics (n=12,323) and cycle 2015 (n=14,026). Plant-based diet quality was assessed with a revised Plant-based Dietary Index (PDI), EAT-Lancet Reference Diet (ERD) score and the latest Dietary Guidelines for Americans Adherence Index (DGAI) 2020. Weighted multivariate analyses were used for testing associations between diet quality and lifestyle characteristics, and weighted multivariable-adjusted Cox proportional-hazards models for associations with CVD risk.
ResultsConstruct validity was confirmed for the revised PDI and DGAI 2020 (but not ERD) as participants in the highest (healthiest) quartile, compared to those in the lowest (least healthy), were more likely to be female (52.63±1.27% compared to 44.8±1.65% for revised PDI; 59.37±2.01% compared to 40.84±1.71% for DGAI 2020), older (50.55±0.39 compared to 45.56±0.43 for revised PDI; 51.57±0.39 compared to 46.35±0.54 for DGAI 2020), to have post-secondary education (32.36±1.55% compared to 21.12±1.31% for revised PDI; 34.17±2.69% compared to 17.87±0.98% for DGAI 2020), and less likely to be daily smokers (8.21±1% compared to 17.06±1.45% for revised PDI; 7.36±1.71% compared to 21.53±1.58% for DGAI 2020) (P-trend<0.0001). No significant associations were observed between dietary index scores and CVD risk.
ConclusionsRevised PDI and DGAI 2020 provided valid and meaningful measures of plant-based eating among Canadians, while validity of ERD was not directly confirmed. Adherence to the plant-based dietary patterns was not associated with CVD risk. Future large-scale analyses are necessary to further evaluate the role of plant-based eating in CVD prevention.

OBJECTIVES: Despite the growing interest in plant-based dietary patterns, no previous studies have evaluated the performance of plant-based dietary indices in a general population. The main objectives of this research were to evaluate the construct validity of plant-based dietary indices and to explore associations between adherence to these indices and risk of cardiovascular disease (CVD). METHODS: Repeated 24-hour dietary recalls were obtained from the nationally representative sample of Canadians (≥18 y of age) in the Canadian Community Health Survey-Nutrition, cycle 2004 linked to vital statistics (n = 12,323) and cycle 2015 (n = 14,026). Scores on the revised Plant-based Dietary Index (PDI), Eat-Lancet Reference Diet (ERD) and latest version of Dietary Guidelines for Americans Adherence Index (DGAI 2020) were computed on the basis of population distribution and government-defined thresholds. Associations between diet quality and lifestyle characteristics were tested using weighted multivariate analyses, whereas associations between the dietary index scores and CVD outcomes were examined using weighted multivariable-adjusted Cox proportional-hazards models. RESULTS: Estimated mean revised PDI, ERD and DGAI scores were 37 ± 0.3 out of 90, 9 ± 0.03 out of 14, and 9 ± 0.04 out of 19, respectively. Construct validity was confirmed for revised PDI and DGAI 2020 indices as participants in the highest (healthiest) quartile, compared to those in the lowest (least healthy), were more likely to be female, older, non-smoker and post-secondary educated (p-trend < 0.0001). No significant associations were found between the index scores and CVD risk, although higher adherence to plant-based dietary patterns was associated with higher intakes of beneficial nutrients and lower risk of obesity. CONCLUSIONS: PDI and DGAI 2020 provided valid measures of plant-based eating among Canadians, while validity of ERD was not confirmed. Further research is needed on developing country-specific plant-based dietary indices with ...

Background: The federal and provincial governments in Canada have invested an enormous amount of resources to measure, report and reduce surgical wait times. Yet these measures under-report the wait period that patients' actually experience, because they do not capture the length of time a patient spends waiting to see the surgeon for a surgical assessment. This unmeasured time is referred to as the "wait one" (W1). Little is known about W1 and the effects that this has on patients' health. Similarly, it is not understood whether patients waiting for surgical assessment actually want or need surgery. Existing administrative and clinical dataset do not capture information on health and decision-making while the patient is waiting for care form a specialist. The objective of this proposed study is to understand the impact that W1 for elective surgeries has on the health of patients and to determine whether this time can be reduced. Methods/Design A prospective survey design will be used to measure the health of patients waiting for surgical assessment. Working with the support of the surgical specialities in Vancouver Coastal Health, we will survey patients immediately after being referred for surgical assessment, and every four months thereafter, until they are seen by the surgeon. Validated survey instruments will be used, including: generic and condition-specific health status questionnaires, pain and depression assessments. Other factors that will be measured include: patients' knowledge about their condition, and their desired autonomy in the decision making process. We have piloted data collection in one surgical specialty in order to demonstrate feasibility. Discussion The results from this study will be used to quantify changes in patients' health while they wait for surgical assessment. Based on this, policy- and decision-makers could design care interventions during W1, aimed at mitigating any negative health consequences associated with waiting. The results from this study will also be used to better understand whether there are factors that predict patients' desire to proceed to surgery. These could be used to guide future research into experimenting with interventions to minimize inappropriate referrals and where they are best targeted. ; Orthopaedics, Department of ; Non UBC ; Medicine, Faculty of ; Population and Public Health (SPPH), School of ; Reviewed ; Faculty

Most provincial governments are considering or introducing changes to hospital funding. Ten years of rapidly increasing expenditures have left them still facing complaints of waiting lists and waiting times. Activity-based funding (ABF) would supplement traditional negotiated global budgets, reimbursing a predetermined amount for each case treated – essentially, a "fee schedule" – thus providing incentives and resources to increase throughput of certain "hot button" procedures and services and to improve efficiency.

OBJECTIVE: The overarching objective of the scoping review was to examine peer reviewed and grey literature for best practices that have been developed, implemented and/or evaluated for delayed discharge involving a hospital setting. Two specific objectives were to review what the delayed discharge initiatives entailed and identify gaps in the literature in order to inform future work. DESIGN: Scoping review. METHODS: Electronic databases and websites of government and healthcare organisations were searched for eligible articles. Articles were required to include an initiative that focused on delayed discharge, involve a hospital setting and be published between 1 January 2004 and 16 August 2019. Data were extracted using Microsoft Excel. Following extraction, a policy framework by Doern and Phidd was adapted to organise the included initiatives into categories: (1) information sharing; (2) tools and guidelines; (3) practice changes; (4) infrastructure and finance and (5) other. RESULTS: Sixty-six articles were included in this review. The majority of initiatives were categorised as practice change (n=36), followed by information sharing (n=19) and tools and guidelines (n=19). Numerous initiatives incorporated multiple categories. The majority of initiatives were implemented by multidisciplinary teams and resulted in improved outcomes such as reduced length of stay and discharge delays. However, the experiences of patients and families were rarely reported. Included initiatives also lacked important contextual information, which is essential for replicating best practices and scaling up. CONCLUSIONS: This scoping review identified a number of initiatives that have been implemented to target delayed discharges. While the majority of initiatives resulted in positive outcomes, delayed discharges remain an international problem. There are significant gaps and limitations in evidence and thus, future work is warranted to develop solutions that have a sustainable impact.

BACKGROUND: The appropriate timing of hip fracture surgery remains a matter of debate. We sought to estimate the effect of changes in timing policy and the proportion of deaths attributable to surgical delay. METHODS: We obtained discharge abstracts from the Canadian Institute for Health Information for hip fracture surgery in Canada (excluding Quebec) between 2004 and 2012. We estimated the expected population-average risks of inpatient death within 30 days if patients were surgically treated on day of admission, inpatient day 2, day 3 or after day 3. We weighted observations with the inverse propensity score of surgical timing according to confounders selected from a causal diagram. RESULTS: Of 139 119 medically stable patients with hip fracture who were aged 65 years or older, 32 120 (23.1%) underwent surgery on admission day, 60 505 (43.5%) on inpatient day 2, 29 236 (21.0%) on day 3 and 17 258 (12.4%) after day 3. Cumulative 30-day in-hospital mortality was 4.9% among patients who were surgically treated on admission day, increasing to 6.9% for surgery done after day 3. We projected an additional 10.9 (95% confidence interval [CI] 6.8 to 15.1) deaths per 1000 surgeries if all surgeries were done after inpatient day 3 instead of admission day. The attributable proportion of deaths for delays beyond inpatient day 2 was 16.5% (95% CI 12.0% to 21.0%). INTERPRETATION: Surgery on admission day or the following day was estimated to reduce postoperative mortality among medically stable patients with hip fracture. Hospitals should expedite operating room access for patients whose surgery has already been delayed for nonmedical reasons. In Canada, hospitals admit 30 000 older adults with hip fracture annually.1 These patients face an increased risk of death, with up to 5% of women and 10% of men dying within 30 days.2,3 It is generally accepted that early operative intervention improves survival by reducing patients' exposure to immobilization and inflammation.4 In 2005, the federal, provincial and territorial governments established a benchmark of 48 hours from admission for 90% of hip fracture surgeries to prevent potentially harmful delays.5 However, delays to hip fracture surgery remain common.6 Patients who are medically stable at presentation may have to wait until a surgeon or an operating room becomes available.7,8 There has been considerable debate about the point at which delaying hip fracture surgery for nonmedical reasons worsens mortality.9–25 This uncertainty leads to prioritization without benefit to the patient or underuse of expeditious surgery that could prevent deaths. Some have argued that understanding the effects of policy change should guide reorganization of operating room resources26 and prioritization in the presence of competing demand.7,27–29 In this paper, we offer 2 new estimates: the effect of possible changes in surgical timing policy in the same population of patients, and the proportion of in-hospital deaths attributable to surgical delays.