Steve Morgan

Professor

Faculty of Medicine

Research Classification

Health policy

Economics of health care

Health services and systems

Research Interests

Access to medicines

Health care policy

Pharmacare

Pharmaceutical pricing

Prescribing appropriateness

Comparative policy analysis

Health care financing

Relevant Thesis-Based Degree Programs

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Graduate Student Supervision

Doctoral Student Supervision

Dissertations completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest dissertations.

Mapping interorganisational collaboration within biomedicine : collaboration in infection and immunity research (2013)

Background: Collaborations between and within sectors facilitate research and development by transferring knowledge among individuals; but it is often unclear who is involved, with whom they are collaborating, and why they are collaborating. I studied the collaborations of Vancouver-based infection and immunity researchers both with local and non-local collaborators, combining innovation systems with economic geography, neo-institutional theory, Bourdieu’s concept of fields, and a social network perspective. My objectives were to determine how different types of proximity affect collaboration, investigate what motivates collaboration, and to explore how institutions affect collaboration. Methods: I used a mixed methods approach that drew on infection and immunity co-authorships, interviews with infection and immunity researchers, and policy documents. I quantitatively analysed co-authorship trends to explore the impact of institutional and geographic proximity on global co-authorship patterns of Vancouver-based infection and immunity researchers through sociograms, proximity variables, and a quasi-Poisson random effects regression. I investigated collaboration rates between and within sectors through relational contingency table and ANOVA network analysis. I mapped the major organisations and regulative institutions involved in Vancouver’s local infection and immunity network by combining interviews, policy documents, and co-authorship data. Based on interviews, I examined how sectoral and organisational institutions and capital influenced action. Results: I found that Vancouver’s infection and immunity network was dominated by the non-commercial sector, particularly universities. The private sector presence was weak. Geographic and institutional proximity increased the proclivity to co-author papers. Hospitals and universities co-authored more papers together than statistically expected. Vancouver-based infection and immunity researchers collaborated to gain capital to further goals, a process shaped by institutions. Conclusion: This study has important implications for science and innovation theory as well as science policy. For both, my primary contribution is to further the understanding that interactions between non-commercial actors play in knowledge translation and innovation, a role that is often underemphasized in both theory and policy.

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Equity in the use and financing of medicines in British Columbia before and after the move to income-based pharmacare (2011)

Background: In May 2003, the B.C. government introduced an income-based pharmacare program, in which subsidy and private payments for prescription drugs are determined according to household income. Given the limited understanding of the equity implications of this policy, the objectives of my thesis were: to determine the degree of income-related inequity in the use of ACE-inhibitors, beta-blockers and statins before and after the introduction of income-based pharmacare in a population of acute myocardial infarction (AMI) patients; to validate the ability of the Johns Hopkins case-mix adjusters to predict prescription drug expenditures and use, and; to determine the redistributive effect of the move to income-based pharmacare on the overall income distribution in B.C. Methods: Using population-based administrative databases, I identified all AMI patients who survived for at least 120 days after suffering their first AMI between 1999 and 2006. According to their household income level, I examined their odds of initiating on ACE-inhibitors, beta-blockers and statins. Among those who initiated I calculated concentration indices for days of therapy on each of these medicines. I validated the use of the ACG case-mix adjusters to predict both expenditures on and use of prescription drugs using generalized linear models and C-statistics. I performed a redistributive analysis to examine whether, and how, income inequality in the province changed as a result of the differences in prescription drug financing after the introduction of income-based pharmacare. Results: My results reveal that higher income men and women were significantly more likely to initiate on treatment with beta-blockers and statins than those in the lowest income quintile. Higher income men were also more likely to initiate on ACE-inhibitors. Concentration indices reveal that high-income AMI patients received significantly more days of therapy on all three medicines than low-income AMI patients. The ACG case mix system was found to have high predictive ability for both prescription drug expenditures and use. I also found that income-based pharmacare had a redistributive effect that resulted in increased income inequality in B.C. Conclusions: My findings suggest that income-based pharmacare, as it was implemented in B.C., does not meet the health equity standards articulated by Canadians.

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Master's Student Supervision

Theses completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest theses.

Hormonal contraceptive use in Canada: levels, trends, and determinants among reproductive-aged women in British Columbia (2017)

BACKGROUND: Despite widespread use of contraception worldwide, Canadian research on hormonal contraceptive trends is limited. This thesis aims to address this knowledge gap through an investigation of the levels, trends, and determinants of: (1) hormonal contraceptive use in British Columbia (BC) (Study 1), and (2) the use of cyproterone acetate and ethinyl estradiol (CPA-EE), an acne drug that is also known to be prescribed as an oral contraceptive (OC) despite safety concerns (Study 2). METHODS: This thesis consists of two retrospective analyses of de-identified administrative datasets containing health care, pharmaceutical, and sociodemographic information for residents of BC between 2006–2013, inclusive. Study 1 examined incident and prevalent hormonal contraceptive use in a cohort of reproductive-aged women (15–49 years). Study 2 measured incident off-label use of CPA-EE in women aged 15–34. In both studies, logistic regression was used to model relationships between contraceptive use and sociodemographic factors.RESULTS: Study 1 revealed (1) stable prevalence, but declining incidence of overall hormonal contraceptive use, (2) declining rates of OC use, (3) increased rates of hormonal intrauterine device (IUD) use, and (4) decreased odds of hormonal contraceptive use among Chinese and South Asian women. Despite a decline in use, OCs remained the most popular method, accounting for more than 80% of all hormonal contraceptive use. In Study 2, incident use of CPA-EE declined throughout the study period. South Asian women and women with older physicians (65+) were more likely to receive a potentially inappropriate CPA-EE prescription.CONCLUSION: This thesis contributes to a sparse body of literature on hormonal contraceptive use in Canada. While rates of OC use are declining, hormonal IUD use is increasingly widespread, particularly among younger women. Chinese and South Asian women are less likely to be prescribed OCs and may therefore be at greater risk for unintended pregnancy, although this warrants further investigation, as does the influence of provider characteristics on off-label prescribing patterns.

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Disparities in antipsychotic medication use (2011)

Objectives: To examine ethnic and income-related disparities in the use ofantipsychotic medication by conducting a systematic review of the related literatureand a secondary data analysis.Methods: The review was conducted using a protocol developed to systematicallysearch, select and review peer-reviewed articles on ethnic disparities in antipsychoticuse. Study selection and data abstraction were performed by two independentreviewers. The secondary data analysis was conducted to examine income-relateddisparities in antipsychotic use in three cohorts. The first cohort was comprised of 19 to64-year olds who had a recorded schizophrenia diagnosis. Income-related differences inthe essential use of antipsychotics were assessed in this cohort. The second cohort wascomprised of seniors (65 years and older) who had a recorded dementia but notschizophrenia or bipolar disorder diagnosis. The third cohort was of children and youth(18 years and younger) who had no recorded schizophrenia or bipolar disorderdiagnosis. Income-related differences in the potentially inappropriate use ofantipsychotics were studied in these last two cohorts. Disparities in antipsychotic usewere assessed using logistic regression, adjusting for factors that influence medicine use(i.e., age, sex, health status, relevant diagnoses and residence in urban areas).Results: The systematic review found no consistent evidence of ethnic disparities in thereceipt of antipsychotic treatment. However, among those who were treated, ethnicminorities were found to be consistently less likely than non minorities to receive thenewer type of antipsychotics. Results of the secondary data analyses indicate that theodds of essential antipsychotic use were lower in low-income individuals than thosewith higher incomes. Odds of exposure to potentially inappropriate antipsychotic use,on the other hand, were higher among low-income individuals and seniors in long-termcare.Conclusion: There is evidence of persistent disparities in the use of antipsychoticmedication. Periodic examination and studies that identify causal factors and effectiveinterventions are needed to reduce disparities.

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Prescription drug utilization in pregnancy: a systematic review and population-based study in British Columbia, Canada (2010)

Background – There is little evidence on the patterns of prescription drug use during pregnancyin Canada. To address this knowledge gap, the primary objectives of this thesis were to: 1)systematically review published antenatal drug utilization studies, and 2) provide the firstCanadian evidence on prescription drug utilization across the pregnancy period, overall, bytherapeutic category and fetal risk classification, in the province of British Columbia (BC). Methods - This thesis is comprised of two original studies. The first, a systematic review of antenatal drug utilization studies, was conducted according to an a priori protocol and included a double independent review process for the selection of articles and data abstraction. The second, a population-based empirical study in BC, was based on pharmacy claims records linked tomaternal hospital records. The period of pregnancy was constructed from the recorded gestational age and prescriptions filled before, during, and after this period were analyzed. Drugs were classified according to the World Health Organization Anatomical Therapeutic Classification System and US Food and Drug Administration risk categories indicating potential for fetal harm (categories D and X).Results – Published drug utilization studies reveal wide variation in estimates of overallprescription drug use in pregnancy (27% to 93% excluding vitamins and minerals). However,estimates are difficult to compare due to differences in methodology, data sources, classificationof prescription medicines, and inadequate reporting. In BC, the majority of pregnant women(63%) filled at least one prescription in pregnancy and approximately 1 in 12 filled a prescription for a drug with potential risks (category D or X). The most commonly used medicines were antiinfectives, doxylamine, dermatologicals, and drugs acting on the nervous system.Conclusion - A methodological framework and template for reporting exposures in pregnancyshould be developed to improve the quality and comparability of antenatal drug utilizationstudies. Evaluation of medicines with unknown risks that are commonly used in pregnancyshould be a priority for pharmacoepidemiological research. The use of drugs with potential risksshould be targeted by programs to improve appropriate prescribing in pregnancy.

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Program Affiliations

Population and Public Health

Health Sciences

Health Administration

Academic Unit(s)

School of Population and Public Health