Vancouver, BC, Canada: University of British Columbia (doctoral dissertation).
University of British Columbia, Vancouver, BC, Canada
Amidst concerns about escalating health spending, examining variation in health care delivery may reveal opportunities for improved efficiency. Influential research in the United States (US) has concluded that health care spending and service use vary substantially from place to place, and this cannot be explained by differences in the health status of populations or by better outcomes of care in higher-spending regions. Whether similar patterns exist in Canada is not clear.
This thesis uses administrative health data to examine how and why health care use and costs vary within the Canadian province of British Columbia (BC). We developed networks of patients, physicians, and hospitals that correspond to actual service use, in order to ensure that observation of variation was not obscured by unit of analysis. We also identified areas of the province representing distinct health service environments, as an improvement over existing urban/rural classifications in understanding the role of geographic context. Access to individual level data allowed more complete adjustment for population characteristics than is typically possible.
In contrast to the US, this thesis suggests that variation in costs of physician and hospital services in BC is largely explained by population health status. The very different environments for health services that exist among metropolitan, non-metropolitan, and remote regions of the province also explained some area-level variation. Despite modest variation in total costs, there are clear differences in patterns of service use across the province due to substitution between categories of care (such as inpatient and outpatient, or generalist and specialist services). Though differences in costs are modest, marked differences in health outcomes are evident, and require further scrutiny.
Results show there are no areas with systematically higher volume or more intensive service provision for populations with similar health needs. However, this does not mean that important variation does not exist and cannot be uncovered. It may be that examining variation at the level of provider, among population groups, or in treatment for specific diseases or conditions will yield more actionable results. Ultimately policy reforms aimed at system-wide quality and efficiency, rather than targeted at high-spending regions, will likely prove most promising.
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