Female-dominated specialties such as obstetrics and gynaecology (OBGYN) face longstanding compensation disparities. With the sharp rise in inflation over the past decade, it is unclear whether these gaps have widened. We conducted a retrospective analysis using data from the Canadian Institute for Health Information's National Physician Database (fiscal year [FY] 2015-2024); Supply, Distribution, and Migration of Physicians in Canada data set (FY 2015-2024); and Statistics Canada's Consumer Price Index. Compensation trends were assessed nationally and by province, normalized to FY 2015, and compared between female-dominated specialties (OBGYN, pediatrics) and matched male-dominated specialties (urology, internal medicine). OBGYN compensation increased by 3.7% over the study period, whereas inflation increased by 27.1%, resulting in an effective 23.4% decrease in compensation. This is compared with increases of 20.7% for surgical specialties and 16.8% for medical specialties. Provincial variation was substantial, with Nova Scotia experiencing greater increases in compensations, whereas Québec experienced gross decreases in OBGYN compensation. Compared with male-dominated specialties, the female-dominated specialties of OBGYN and pediatrics experienced less compensation growth. Overall, compensation in female-dominated specialties has not kept pace with inflation, resulting in significant real-wage erosion and widening disparities relative to male-dominated specialties. These findings underscore the need for pay equity-focused reforms in provincial physician compensation models.

Bundled payments are often proposed to improve surgical care value by shifting financial risk from payers to providers. While they may generate savings, evidence from international programs and Ontario shows mixed cost effects and modest utilization changes. They are also not a substitute for the capacity reforms needed to address Canada's surgical backlogs. Key implementation challenges - including selecting participating teams, building analytic and data infrastructure to evaluate proposals and set prices, designing shared-savings arrangements and aligning incentives within multidisciplinary teams - cannot be overlooked. Without careful design and piloting, bundled payments risk limited savings and unintended consequences.

Background Many female-specific health services in Canada are delivered by obstetrician-gynecologists and family physicians. However, little is known about how patterns of care delivery, physician workforce supply, and patient characteristics have changed over time, limiting evidence-informed workforce and health system planning. Objective To examine long-term trends in outpatient women's health service delivery, physician workforce supply, and patient characteristics in Alberta and identify implications for workforce planning, access, and health system reform. Methods This population-based cohort study used linked administrative health data from Alberta between 1994 and 2020 to analyze outpatient visits for female-specific health services to obstetrician-gynecologists or family medicine physicians. We estimated temporal trends in visit rates by health complaint, physician characteristics, and patient reproductive life stage (reproductive, perimenopausal, or postmenopausal), and comorbidities. Results Over a 26-year period, >2 million females accessed care from 416 obstetrician-gynecologists and 7,658 family medicine physicians. While the number of obstetrician-gynecologists and family medicine physicians per 1000 females increased (from 0.11 to 0.15 and 2.21 to 2.57, respectively), the average number of visits per physician per 1000 females declined (from 291 to 250 and 834 to 625, respectively). The nature and volume of visits varied by life stage. Physician and patient demographics shifted with more women physicians, patients with multimorbidity, and a U-shaped relationship between neighbourhood income and specialist utilization. Conclusion Findings suggest that physician supply alone may provide an incomplete picture of the resources required to meet women's health care needs. Future workforce planning efforts may benefit from considering changes in patient complexity, patterns of care delivery across physician types, and potential inequities in access to specialty services.

RATIONALE:Variation in health care delivery exists at many levels (e.g., provider, practice, system) and can often be explained by various factors at each level. Understanding clinical variation presents an opportunity to improve the value of health care by identifying low-value care (overuse), gaps in high-value care (underuse), and how they can be improved. Numerous methods exist to describe or quantify clinical variation; however, these are not well identified or applied consistently. AIM:A mapping review was used to identify and characterize available methods to describe and quantify clinical variation. METHOD:We systematically searched health care and health services-related literature for variation and related terms used in titles and abstracts. Titles and abstracts were screened for inclusion. We then identified graphical and statistical methods used, health care specialty, study setting, and health system performance area (e.g., quality, access, costs) using a keyword analysis. RESULTS:Of the 16,969 papers screened, we excluded 10,866 that did not measure a care process or health outcome, measure variation at the person-level or higher, or analyze routinely collected data. We included 6,103 full-text studies, which were analyzed using a keyword analysis. Most studies used basic methodological approaches (e.g., regression, crude comparisons, ranges). Fewer than 1000 studies used multilevel models, a more advanced methodologic approach that quantifies the magnitude and source of variation. Multilevel models were not commonly used to study variation in health care quality. CONCLUSIONS:While understanding clinical variation is important for all health systems, the methods used are usually able to identify but not quantify or explain variation. This review advances our knowledge of the scope and application of these methods and can be used to improve the measurement of variation to increase the value and equity of health care.

OBJECTIVES:To describe the demographic and social identities of participants in contemporary Canadian randomized clinical trials (RCTs). STUDY DESIGN AND SETTING:A meta-epidemiologic study included published reports of phase 2 and 3 RCTs that exclusively recruited adults living in Canada and were registered on ClinicalTrials.gov between January 1, 2010, and December 31, 2019. Study design and participant demographics were abstracted from eligible articles in duplicate using frameworks for understanding participant diversity such as PROGRESS-PLUS. RESULTS:We identified 118 RCTs with 17,387 participants. Most reported participant sex (n = 105, 89.0%), few reported gender (n = 12, 10.2%), and none reported both. Among articles reporting sex, there were 11,066 female (63.6%), 5402 male (32.8%), and one intersex (<0.1%) participants. There were 477 women (54.1%) and 404 men (45.9%) participants. No studies reported gender diverse participants. When excluding studies that only recruited one sex and/or gender, 51.8% of participants were male (n = 4774/9219) and 47.5% were men (n = 446/850). Race and/or ethnicity was reported for 4124 participants (23.7%) in 31 of 118 (26.3%) of RCTs; of these, 72.0% were White (n = 2969), 2.7% were Black (n = 113), and 0.2% were Indigenous (n = 7). Eligibility criteria related to specific PROGRESS-PLUS factors were rare except for cognition (n = 42, 35.6%), substance use (n = 25, 21.7%), pregnancy (n = 29, 24.5%), breastfeeding (n = 16, 13.6%), and older age (n = 26, 22.0%). CONCLUSION:The data are encouraging regarding representation of female and women participants in Canadian trials. Due to underreporting of other identities, we cannot identify additional groups who may be underrepresented. Work to improve reporting of race and/or ethnicity, among other identities, is needed. PLAIN LANGUAGE SUMMARY:Clinical trials tell us what drugs and procedures are helpful for patients. In certain specialties, like cancer and heart disease, clinical trials are made up mostly of men, White people, and younger people. This means that the results of these trials may be different for other groups of people, especially older people, women, and racialized people, who are more likely to have these diseases. We looked at the demographic identities of all participants in 118 Canadian clinical trials that were done between 2010 and 2019. Of the 17,387 participants, there were 11,066 female, 5402 male, 477 women, 404 men, and one intersex participant. We could find the race and/or ethnicity for only 4124 participants in 31 of the trials. Most participants (72.0%) were White, and only 2.7% were Black and 0.2% were Indigenous. These results tell us that reporting of identities in Canadian clinical trials is incomplete. Canadian clinical trialists should do a better job telling us who is in their trials. These results suggest that Canadian clinical trials are not representative of the general population, and that we need to explore the reasons that people are not participating in clinical trials.

BACKGROUND:Many provinces are considering an expanded role for for-profit diagnostic imaging facilities. We describe trends over time in the use of cardiac imaging studies, a subset of diagnostic imaging, in the for-profit and publicly operated facilities in Alberta. Alberta has allowed testing in private facilities since the 1970s, with formalized guidelines released in 1998. METHODS:We performed a retrospective, population-based analysis using administrative data from Alberta, Canada between 1995 and 2020 to describe the annual rates of cardiac diagnostic tests for both inpatient and outpatient settings, and trends in invasive cardiac treatments like angioplasty and coronary artery bypass grafting. RESULTS:A 3.95-fold increase in the rate of outpatient cardiac imaging per 100,000 Albertans was observed between 1998 and 2020, driven by an increase in testing at private, for-profit facilities. The rate of invasive cardiac treatments did not increase substantially over this same period. This has resulted in a net cost to Alberta of over $694 million (in 2020 dollars) in additional spending above predicted levels since 1998. CONCLUSIONS:After the implementation of imaging guidelines, a sustained and substantial increase in cardiac imaging facilities and rates was observed, including in Albertans classified as low risk for cardiac disease. A similar increase was not observed among cardiac treatment procedures, which would be anticipated if increased testing was due to changes in underlying population risk.

Respectful maternity care in healthcare facilities during childbirth is a growing concern around the world. It is more than just an important component of care quality; it is also a human right. The aim of this study was to develop and validate a tool to assess respectful maternity care practices among healthcare providers in Nepal. We systematically searched primary studies published until May 2023, adhering to PRISMA guidelines. Studies evaluating causal effects of payment methods on perinatal outcomes were included. Quality was assessed using the JBI-MAStARI tools. Due to heterogeneity in the studies, a meta-analysis was not feasible; findings were summarized narratively and presented in tables/ figures. Fifty-three studies were included, focusing on prenatal care (62

Introduction: One in ten Canadians face kidney disease. Both patients and providers have been calling for strategies to address the needs of individuals with early-stage chronic kidney disease. This population faces a high burden of multimorbidity (occurrence of two or more chronic conditions) and requires coordinated care across multiple providers and healthcare settings. However, there is a risk of fragmented care when coordinating across primary and nephrology care sectors, which may lead to poor access to and integration of services for patients. Person-centered integrated care (PC-IC) is a recognized approach for enhancing the management of chronic kidney disease and improving health outcomes. Nevertheless, there is limited evidence available to guide the delivery of PC-IC for this specific population. Audience: Our aim is to provide insight into the perspectives of patients with early-stage chronic kidney disease and multimorbodity, along with their caregivers and healthcare providers. Team: We have assembled a strong team of researchers, clinicians, and patient partners. Our team brings complementary skills for conducting the proposed research, including expertise in quantitative, qualitative, and mixed methods, patient-orientated research, primary care and nephrology research in remote, rural, and urban settings, integrated care, and health economics and service delivery. Two of our patient partners, Ms. Verdin and Ms. Russon, actively participate in the planning and execution of this study. They are actively involved in research team meetings and play a crucial role in promoting the dissemination of our research findings. Methods: We conducted a cross-sectional survey study using the Rainbow Model of Integrated Care Measurement Tools (RMIC-MTs). Our recruitment efforts targeted patients, caregivers, and healthcare providers through various channels, including networks, social media, and direct referrals from healthcare professionals within Health Services and Primary Care Networks in Alberta. We conducted descriptive analyses to detect variances tied to respondent roles and background characteristics. Additionally, the integrated case assessments were examined and compared to those of an international collaborative network of dialysis clinics in 23 different countries. Results: During the conference, we will present the preliminary findings regarding the perceptions of integrated renal care among patients and healthcare providers in Alberta. We will also provide a comparative analysis with an international renal care network. Furthermore, we will unveil and discuss variations in integrated care perspectives among subgroups, considering the roles and background characteristics of the participants. Discussion: This research enhances our understanding of the challenges and opportunities, both at the national and international levels, associated with delivering person-centered integrated renal care. The insights gained from this study will serve as a foundational element for a patient-oriented research initiative aimed at collaboratively devising an innovative approach to PC-IC. In the subsequent phase of our work, we will identify and prioritize barriers and facilitators that impact PC-IC in Alberta, Canada. This will be accomplished through qualitative interviews and the application of a modified Nominal Group Technique.

Background Many factors beyond patient need influence the care that patients receive, including the way physicians are paid, and how services are delivered. In Alberta, outpatient non-invasive cardiac imaging (“cardiac imaging”) is paid for publicly but performed at private, for-profit (investor/physician owned) facilities. We investigated patient, physician, and geographic factors associated with cardiac imaging in patients at low cardiovascular risk seeing specialist physicians in Alberta, Canada. Methods This was a population-based retrospective cohort study using administrative health data from Alberta, Canada, where nearly all outpatient cardiac imaging is done at privately for-profit community-based facilities. We used administrative health data to identify a cohort of adult (aged ≥18 years) patients at low cardiovascular risk who were assessed by a cardiologist or internal medicine specialist for a new outpatient visit for a cardiac-related reason between April 1, 2011 and December 30, 2019 in Alberta. The primary outcome was cardiac imaging. Explanatory variables included patient and physician characteristics, including payment model (fee for service (FFS) or salary-based), and geography. We used multilevel, multivariable logistic regression models to measure the association between these factors and cardiac imaging. Results We identified 398,095 patients at low cardiovascular risk, of whom 27.5% received at least one cardiac imaging test. Compared to those seen by FFS cardiologists (and controlling for patient and geographic differences), patients seen by salary-based internal medicine specialists had the lowest odds of receiving cardiac imaging (OR=0.055, P < 0.001, CI 0.036–0.086), followed by those seen by FFS internal medicine specialists (OR=0.010, P < 0.001, CI 0.068–0.14), and salary-based cardiologists (OR=0.27, P < 0.001, CI 0.16–0.45). Findings were robust across multiple sensitivity analyses. Conclusions Physician payment models and specialty are strongly associated with non-invasive cardiac imaging among patients at low cardiovascular risk.

Background: Sodium glucose-cotransporter 2 inhibitors (SGLT2is) have been shown to reduce the risk of cardiorenal complications in select patient populations, yet their real-world uptake in clinical practice is limited. The objective of this study was to assess the factors influencing prescriber variation in SGLT2i use. Methods: Using administrative data from Alberta, Canada, we conducted a population-based cohort study of adults with a new prescription for any oral antihyperglycemic medication between 2014-2021. We used multilevel logistic regression to examine how patient and prescriber characteristics were associated with SGLT2i prescription and used the median odds ratio to quantify variation at the prescriber level. Results: Of 339,314 patients prescribed a new antihyperglycemic medication, 0.8% (n = 2852) were prescribed an SGLT2i. SGLT2i prescribing was more likely among male patients, younger patients, and those with obesity or heart failure. However, substantial variation was present in prescriber behaviour for SGLT2i, and prescriber factors had a greater influence on SGLT2i prescribing than patient-level factors (median odds ratio 3.55). Although family physicians accounted for greatest numbers of SGLT2i prescriptions overall, subspecialists, such as cardiologists, were more likely to prescribe SGLT2is (odds ratio 13.5, 95% confidence interval 8.9-20.5). Conclusions: The rate of new SGLT2i prescriptions was low during the study period. Both patient-and prescriber-level factors are associated with SGLT2i prescription, although variation in prescribing SGLT2i medications appears to be driven primarily by prescriber factors. Family physicians are responsible for the majority of SGLT2i prescriptions and represent a key provider group in aligning SGLT2i prescribing with guideline recommendations.

Since the passage of the Canada Health Act (1985), there have been many advisory bodies established by successive federal governments, each tasked with providing advice and making recommendations about where and how to improve the health system. Our analysis of interviews with advisory board members and implementers (e.g., ministry of health leaders, staff and consultants) addresses why participants perceived their advice and recommendations were generally not implemented and informal strategy groups used to facilitate implementation. We recommend that future health system advisory bodies focus on coalition building during policy development, integrate implementation plans into policy recommendations and evaluate the impact of policy recommendations.

Abstract Background Despite longstanding efforts and calls for reform, Canada’s incremental approach to healthcare changes has left the country lagging behind other OECD nations. Reform to the Canadian healthcare system is essential to develop a higher performing system. This study sought to gain a deeper understanding of the views of Canadian stakeholders on structural and process deficiencies and strategies to improve the Canadian healthcare system substantially and meaningfully. Methods We conducted individual, ~ 45-minute, semi-structured virtual interviews from May 2022 to August 2022. Using existing contacts and snowball sampling, we targeted one man and one woman from five regions in Canada across four stakeholder groups: (1) public citizens; (2) healthcare leaders; (3) academics; and (4) political decision makers. Interviews centered on participants’ perceptions of the state of the current healthcare system, including areas where major improvements are required, and strategies to achieve suggested enhancements; Donabedian’s Model (i.e., structure, process, outcomes) was the guiding conceptual framework. Interviews were audio-recorded, transcribed verbatim, and de-identified, and inductive thematic analysis was performed independently and in duplicate according to published methods. Results The data from 31 interviews with 13 (41.9%) public citizens, 10 (32.3%) healthcare leaders, 4 (12.9%) academics, and 4 (12.9%) political decision makers resulted in three themes related to the structure of the healthcare system (1. system reactivity; 2. linkage with the Canadian identity; and 3. political and funding structures), three themes related to healthcare processes (1. staffing shortages; 2. inefficient care; and 3. inconsistent care), and three strategies to improve short- and long-term population health outcomes (1. delineating roles and revising incentives; 2. enhanced health literacy; 3. interdisciplinary and patient-centred care). Conclusion Canadians in our sample identified important structural and process limitations to the Canadian healthcare system. Meaningful reforms are needed and will require addressing the link between the Canadian identity and our healthcare system to facilitate effective development and implementation of strategies to improve population health outcomes.

In their article, Wiler and colleagues concluded that payment models must address 7 interwoven challenges if they are to incentivize specialists to join total cost of care models and achieve the Centers for Medicare & Medicaid Services' goal of 100% of beneficiaries included in accountable care organizations by 2030. The editorialists discuss strategies for addressing these challenges.

AIMS:Prior studies suggest that sodium-glucose cotransporter-2 inhibitors (SGLT2is) may decrease the incidence of atrial fibrillation (AF). However, it is unknown whether SGLT2i can attenuate the disease course of AF among patients with pre-existing AF and Type II diabetes mellitus (DM). In this study, our objective was to examine the association between SGLT2i prescription and arrhythmic outcomes among patients with DM and pre-existing AF. METHODS AND RESULTS:We conducted a population-based cohort study of adults with DM and AF between 2014 and 2019. Using a prevalent new-user design, individuals prescribed SGLT2i were matched 1:1 to those prescribed dipeptidyl peptidase-4 inhibitors (DPP4is) based on time-conditional propensity scores. The primary endpoint was a composite of AF-related healthcare utilization (i.e. hospitalization, emergency department visits, electrical cardioversion, or catheter ablation). Secondary outcome measures included all-cause mortality, heart failure (HF) hospitalization, and ischaemic stroke or transient ischaemic attack (TIA). Cox proportional hazard models were used to examine the association of SGLT2i with the study endpoint. Among 2242 patients with DM and AF followed for an average of 3.0 years, the primary endpoint occurred in 8.7% (n = 97) of patients in the SGLT2i group vs. 10.0% (n = 112) of patients in the DPP4i group [adjusted hazard ratio 0.73 (95% confidence interval 0.55-0.96; P = 0.03)]. Sodium-glucose cotransporter-2 inhibitors were associated with significant reductions in all-cause mortality and HF hospitalization, but there was no difference in the risk of ischaemic stroke/TIA. CONCLUSION:Among patients with DM and pre-existing AF, SGLT2is are associated with decreased AF-related health resource utilization and improved arrhythmic outcomes compared with DPP4is.

Background The influence of fee‐for‐service reimbursement on cardiac imaging has not been compared with other payment models. Furthermore, variation in ordering practices is not well understood. Methods and Results This retrospective, population‐based cohort study using linked administrative data from Alberta, Canada included adults with chronic heart disease (atrial fibrillation, coronary artery disease, and heart failure) seen by cardiac specialists for a new outpatient consultation April 2012 to December 2018. Generalized linear mixed‐effects models estimated the association of payment model (including the ability to bill to interpret imaging tests) and the use of cardiac imaging and quantified variation in cardiac imaging. Among 31 685 adults seen by 308 physicians at 136 sites, patients received an observed mean of 0.67 (95% CI, 0.67–0.68) imaging tests per consultation. After adjustment, patients seeing fee‐for‐service physicians had 2.07 (95% CI, 1.68–2.54) and fee‐for‐service physicians with ability to interpret had 2.87 (95% CI, 2.16–3.81) times the rate of receiving a test than those seeing salaried physicians. Measured patient, physician, and site effects accounted for 31% of imaging variation and, following adjustment, reduced unexplained site‐level variation 40% and physician‐level variation 29%. Conclusions We identified substantial variation in the use of outpatient cardiac imaging related to physician and site factors. Physician payment models have a significant association with imaging use. Our results raise concern that payment models may influence cardiac imaging practice. Similar methods could be applied to identify the source and magnitude of variation in other health care processes and outcomes.

Background: Choosing Wisely Canada (CWC) recommends avoiding noninvasive advanced cardiac testing (e.g., exercise stress testing [EST], echocardiography and myocardial perfusion imaging [MPI]) for preoperative assessment in patients scheduled to undergo low-risk noncardiac surgery. In this study, we assessed the temporal trends in testing, overlapping with the introduction of the CWC recommendations in 2014, and patient and provider factors associated with low-value testing. Methods: In this population-based retrospective cohort study, we used linked health administrative data in Alberta, Canada, to identify adult patients who underwent elective noncardiac surgery between Apr. 1, 2011, and Mar. 31, 2019, who had preoperative noninvasive advanced cardiac tests (EST, echocardiography or MPI) within 6 months before surgery. We included electrocardiography as an exploratory outcome. We excluded patients at high risk using the Revised Cardiac Risk Index (score ≥ 1 considered to indicate high risk), and modelled patient and temporal factors associated with the number of tests. Results: We identified 1 045 896 elective noncardiac operations performed in 798 599 patients and 25 599 advanced preoperative cardiac tests; 2.1% of operations were preceded by advanced cardiac testing. The incidence of testing increased over the study period, and, by 2018/19, patients were 1.3 times (95% confidence interval 1.2–1.4) more likely to receive a preoperative advanced test compared to 2011/12. Urban patients were more likely to receive a preoperative advanced cardiac test than their rural counterparts. Electrocardiography was the most common preoperative cardiac test, preceding 182 128 procedures (17.4%). Interpretation: Preoperative advanced cardiac testing was infrequent in adult Albertans who underwent low-risk elective noncardiac operations. Despite CWC recommendations, the use of some tests appears to be increasing, and there was substantial variation across geographic areas.

We hosted a deliberative dialogue with citizens (n = 3), policy researchers (n = 3), government decision makers (n = 3) and health system leaders (n = 3) to identify evidence-informed policy options to improve the value of Canadian healthcare. The analysis resulted in three themes: (1) the need for a vision to guide reforms, (2) community-based care and (3) community-engaged care. Results suggest the need for a new paradigm: community-focused health systems. Such a paradigm could serve as a North Star guiding healthcare transformation, improving value by aligning citizen and healthcare system goals, prioritizing spending on services that address the social determinants of health and improving quality and equity.

Cardiac electrophysiology is a constantly evolving speciality that has benefited from technological innovation and refinements over the past several decades. Despite the potential of these technologies to reshape patient care, their upfront costs pose a challenge to health policymakers who are responsible for the assessment of the novel technology in the context of increasingly limited resources. In this context, it is critical for new therapies or technologies to demonstrate that the measured improvement in patients' outcomes for the cost of achieving that improvement is within conventional benchmarks for acceptable health care value. The field of Health Economics, specifically economic evaluation methods, facilitates this assessment of value in health care. In this review, we provide an overview of the basic principles of economic evaluation and provide historical applications within the field of cardiac electrophysiology. Specifically, the cost-effectiveness of catheter ablation for both atrial fibrillation (AF) and ventricular tachycardia, novel oral anticoagulants for stroke prevention in AF, left atrial appendage occlusion devices, implantable cardioverter defibrillators, and cardiac resynchronization therapy will be reviewed.