THE EPIDEMIOLOGY AND HEALTH ECONOMICS OF ANKLE INJURIES

The thesis focuses on a central theme of the epidemiology and health economics of ankle sprains to inform health policy and the provision of health services. It describes the burden, prognosis, resource utilization, and costs attributed to these injuries. The first manuscript systematically reviewed 34 studies on the direct and indirect costs of treating ankle and foot injuries. The overall costs per patient ranged from $2,075- $3,799 (2014 USD) for ankle sprains; $290-$20,132 for ankle fractures; and $6,345-$45,731 for foot fractures, reflecting differences in injury severity, treatment methods, and study characteristics. The second manuscript provided an epidemiological and economic profile of non-fracture ankle and foot injuries in Ontario using linked databases from the Institute for Clinical Evaluative Sciences. The incidence rate of ankle sprains was 16.9/1,000 person-years. Annually, ankle and foot injuries cost $21,685,876 (2015 CAD). The mean expenses per case were $99.98 (95% CI, $99.70-100.26) for any injury. Costs ranged from $133.78-$210.75 for ankle sprains and $1,497.12-$1,755.69 for dislocations. The third manuscript explored the impact of body mass index on recovery from medically attended grade 1 and 2 ankle sprains using the Foot and Ankle Outcome Score. Data came from a randomized controlled trial of a physiotherapy intervention in Kingston, Ontario. At six months, the odds ratio of recovery for participants with obesity was 0.60 (0.37-0.97) before adjustment and 0.74 (0.43-1.29) after adjustment compared to non-overweight participants. The fourth manuscript used trial data to examine the health-related quality of life among ankle sprain patients using the Health Utilities Index version 3 (HUI-3). The greatest improvements in scores were seen at one month post-injury (HUI-3: 0.88, 95% CI: 0.86-0.90). Individuals with grade 2 sprains had significantly lower ambulation scores than those with grade 1 sprains (0.70 vs. 0.84; p<0.05). The final manuscript used trial data to describe the financial burden (direct and indirect costs) of ankle sprains. The overall mean costs were $1,508 (SD: $1,452) at one month and increased to $2,206 (SD: $3,419) at six months. Individuals with more severe injuries at baseline had significantly higher (p<0.001) costs compared to individuals with less severe injuries, after controlling for confounders.

Paternalism and Competent Patient Choice in the Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People

In 2016 physicians in Ontario will be granted the authority to refer patients with gender dysphoria for sex reassignment surgery. In order to be granted this authority physicians must be trained in the World Professional Association for Transgender Health’s Standards of Care, which outlines healthcare procedures for the treatment of gender dysphoria and provides background information concerning transgender health. The Standards of Care require that patients undergo a process of 12 months of continuous living in a gender role that is congruent with their gender identity prior to being given access to sex reassignment surgery. While this requirement can sometimes be helpful it can also cause more harm than benefit. This paper argues that the requirement is strongly paternalistic in its current form and should no longer be mandatory in most cases.

The Affordable Care Act and the Transformation of US Health Care

The neoliberal period was accompanied by a momentous transformation within the US health care system.  As the result of a number of political and historical dynamics, the healthcare law signed by President Barack Obama in 2010 ‑the Affordable Care Act (ACA)‑ drew less on universal models from abroad than it did on earlier conservative healthcare reform proposals. This was in part the result of the influence of powerful corporate healthcare interests. While the ACA expands healthcare coverage, it does so incompletely and unevenly, with persistent uninsurance and disparities in access based on insurance status. Additionally, the law accommodates an overall shift towards a consumerist model of care characterized by high cost sharing at time of use. Finally, the law encourages the further consolidation of the healthcare sector, for instance into units named “Accountable Care Organizations” that closely resemble the health maintenance organizations favored by managed care advocates. The overall effect has been to maintain a fragmented system that is neither equitable nor efficient. A single payer universal system would, in contrast, help transform healthcare into a social right.

Market reforms and privatisation in the English National Health Service

The article examines developments in the marketisation and privatisation of the English National Health Service, primarily since 1997. It explores the use of competition and contracting out in ancillary services and the levering into public services of private finance for capital developments through the Private Finance Initiative. A substantial part of the article examines the repeated restructuring of the health service as a market in clinical services, initially as an internal market but subsequently as a market increasing opened up to private sector involvement. Some of the implications of market processes for NHS staff and for increased privatisation are discussed. The article examines one episode of popular resistance to these developments, namely the movement of opposition to the 2011 health and social care legislative proposals. The article concludes with a discussion of the implications of these system reforms for the founding principles of the NHS and the sustainability of the service.

Economic crisis and national health system

The text analyzes the impact of the economic crisis in some critical aspects of the National Health System: outcomes, health expenditure, remuneration policy and privatization through Private Public Partnership models. Some health outcomes related to social inequalities are worrying. Reducing public health spending has increased the fragility of the health system, reduced wage income of workers in the sector and increased heterogeneity between regions. Finally, the evidence indicates that privatization does not mean more efficiency and better governance. Deep reforms are needed to strengthen the National Health System.

Commodification of health care systems: The Catalan case

Commodification of the public healthcare system has been a growing process in recent decades, especially in universal healthcare systems and in high-income countries like Spain.  There are substantial differences in the healthcare systems of each autonomous region of Spain, among which Catalonia is characterized by having a mixed healthcare system with complex partnerships and interactions between the public and private healthcare sectors.  Using a narrative review approach, this article addresses various aspects of the Catalan healthcare system, characterizing the privatization and commodification of health processes in Catalonia from a historical perspective with particular attention to recent legislative changes and austerity measures.  The article approximates, the eventual effects that commodification and austerity measures will have on the health of the population and on the structure, accessibility, effectiveness, equity and quality of healthcare services.

Health equity in all policies

Public Health England (PHE) worked with the Association of Directors of Public Health (ADPH) and the Local Government Association (LGA) to develop a masterclass to understand what PHE could do to support directors and consultants of public health to embed health and health equity in all policies at a local level. These documents provide a full report and executive summary of 2 pilot masterclasses held on: 25 February 2015 in London 17 March 2015 in Manchester The masterclasses aimed to: frame public health challenges and use appropriate language within the context of overarching local authority priorities effectively position health and wellbeing in the context of competing (and sometimes conflicting) policy agendas engage wider service and policy areas in the pursuit of health and health equity within current economic and funding contexts

Audit report on the County Rural Offices of Social Services Mental Health Region (CROSS) for the year ended June 30, 2015

Audit report on the County Rural Offices of Social Services Mental Health Region (CROSS) for the year ended June 30, 2015

Audit report on the Great River Regional Waste Authority for the year ended June 30, 2015

Audit report on the Great River Regional Waste Authority for the year ended June 30, 2015

Audit report on Mental Health Disability Services of the East Central Region (MHDS-ECR) for the year ended June 30, 2015

Audit report on Mental Health Disability Services of the East Central Region (MHDS-ECR) for the year ended June 30, 2015

Report on the Iowa Department of Public Health for the year ended June 30, 2015

Report on the Iowa Department of Public Health for the year ended June 30, 2015

Audit report on the Iowa State Fair Authority for the year ended October 31, 2015

Audit report on the Iowa State Fair Authority for the year ended October 31, 2015

Agreed-upon procedures report on the Lucky for Life game administered by the Iowa Lottery Authority for the period January 25, 2016 through March 31, 2016

Agreed-upon procedures report on the Lucky for Life game administered by the Iowa Lottery Authority for the period January 25, 2016 through March 31, 2016

Report on the High Quality Jobs Program (HQJP) and the Grow Iowa Values Fund (GIVF), administered by the Iowa Economic Development Authority (IEDA), previously known as the Department of Economic Development, for the period July 1, 2003 through June 30, 2014

Report on the High Quality Jobs Program (HQJP) and the Grow Iowa Values Fund (GIVF), administered by the Iowa Economic Development Authority (IEDA), previously known as the Department of Economic Development, for the period July 1, 2003 through June 30, 2014

Report on the Iowa Economic Development Authority for the year ended June 30, 2015

Report on the Iowa Economic Development Authority for the year ended June 30, 2015