Health Services Research and Government's Spending on Healthcare Programs: A Welcome Misalignment?

Excluding capital projects, spending on hospitals, physicians and drugs makes up more than two thirds of provincial and territorial governments' healthcare spending (CIHI 2019). One expects that health services and policy research would be aligned with where the money flows and yet, there is a misalignment. For example, research as published by Healthcare Policy, is not so neatly aligned with provincial and territorial governments' healthcare spending patterns. In this issue, for instance, there are only two such articles – one related to medication adherence and cost, and another related to payment policy associated with a hospital's alternative level of care utilization. The previous issue of Healthcare Policy was similarly focused, with only two articles the study settings of which were primary care.

What does this misalignment mean? Is something important missing between research and governments’ emphases?

There are several possible reasons for the mismatch that bear careful evaluation: Canadian hospital-, physician- and drug-related health services and policy research is being published elsewhere; these three sectors are not as attractive to researchers because there is little policy movement in them; provincial and territorial governments have not aligned their research imperatives with local research centres very well; or research funders – including the Canadian Institutes of Health Research – are not aligning their funded projects with the governments' policy imperatives or programs. Some or all of these reasons may be true.

Irrespective of the causal factors associated with applied health services and policy research outputs, one thing is certain: contemporaneous topics being generated by the Canadian health services research community are conclusively oriented in directions other than hospitals, physicians or drugs.

Provinces' and territories' recent initiatives on integrating care, strengthening allied sectors and between-sector innovations are rightly drawing attention from researchers. This activity is now paying dividends to government decision makers and policy makers with applied research outputs. Publications in these areas represent an important new emphasis on health and healthcare beyond the medicare-funded hospital and physician sectors. Healthcare Policy welcomes these developments and will continue to provide a forum for peer review, engagement and dissemination.

In the editorial of the previous issue of Healthcare Policy, I noted that all of the articles came from Ontario (Sutherland 2020). This issue has the same provincial bias – most of the articles' settings are in Ontario. I will work to encourage authors to address important issues of generalizability and diversity in other settings so that all provincial, territorial and federal decision and policy makers feel compelled to think through the implications of Healthcare Policy's manuscripts in their settings.

In this issue

Leading this issue of Healthcare Policy is a commentary by Thomas and Flood (2020), which presents the contemporaneous issue of falling rates of childhood vaccination, the concept of vaccine hesitancy and mass immunization. Underlined with examples drawn from Ontario, the authors make a case for elimination of non-medical exemptions to vaccination due to religion or conscience. Describing that more data is needed, the authors posit that mandatory vaccinations, albeit controversial, can withstand Charter challenges.

The commentary is followed by a rejoinder (Beaman 2020). The author agrees that additional data is needed to inform the balance between individual and societal interests and potential harms. Beaman also adds that the COVID-19 pandemic and the rights of children may similarly affect the court's possible positions regarding mandatory vaccinations.

Guerriere et al. (2020) used a qualitative design-based study to explore relationships between a family caregiver's labor force transitions during a patient's phase of palliative care. Based in two of Ontario's palliative care programs, primary caregivers of palliative care patients were interviewed and changes in employment status measured. The study found changes reported by the participants – some described working more and others, working less – possibly associated with episodes of intense caregiving demand.

In their paper, Wong et al. (2020) explore public funding of alternate level of care (ALC), a chronic issue affecting cancer surgery patients among provinces' hospitals. Using population-based data, and in the context of episode-based funding for cancer surgery, the study found that hospitals' volume of ALC days among cancer surgery patients was small and that the per day cost of ALC is not far from $1,000. The authors posited that a combination of policies that integrate sectors is needed to improve ALC within Ontario.

Leadership in digital innovation in healthcare is complex; federal agencies, provincial programs and a hospital's local priorities and initiatives muddy the waters about who is responsible for identifying and implementing innovations. Desveaux et al (2020) from Ontario leveraged a digit health symposium to conduct a qualitative study examining the role of academic medical centres in vetting and promulgating digital health innovations. The authors concluded that academic medical centres can play a unique role as catalysts of adoption of digital health innovations.

Identifying residents of retirement homes is challenging. Gaps in administrative data mean that residents of retirement homes cannot be confidently identified. These gaps have significant implications for health services research aimed at the elderly and frail. Addressing this problem, Brath et al. (2020) developed methods for using postal codes to identify retirement home residents in Ontario. This method-oriented paper provides a roadmap for other provinces' researchers and governments to develop similar tools for measuring health- and healthcare-seeking behaviours of these residents.

Using repeated cross-sectional design and data from the Canadian Community Health Survey, Amoud et al. (2020) studied the association between prescription medication cost coverage and type 2 diabetes and hypertension oral medication adherence among adults in Ontario and New Brunswick. Adjusted results found that lacking insurance for drug costs was associated with poorer adherence over the study period. The authors conclude that this study provides additional evidence that medication costs are likely associated with medication adherence and impacting disease progression.

Feldman et al. (2020) report the results of a survey of Canadian rheumatologists' perceptions regarding a physical therapist's ability to appropriately refer patients. According to the findings, rheumatologists acknowledged that physical therapists could appropriately refer patients for specialty care. However, this conclusion was offset by the finding that a low proportion of respondents would accept a therapist's referrals. The authors concluded that a financial lever was needed: rheumatologists would be more likely to accept referrals from physiotherapists if they could bill for full consultations.

In a cross-sectional study conducted in Ontario, Veloce et al. (2020) explored whether the general public distinguished between the terms nutritionist and dietitian. The study found that there was substantial confusion regarding the difference between the terms, and concluded that this confusion had the potential to cause harm to Ontarians because dietitians have a regulatory responsibility for standards of care. The authors proposed legislative amendments to clarify the use of terms to reduce confusion about the respective roles and training.