Health Care in Canada 2010 December 2010

Health Care in Canada 2010 December 2010
Health Care
in Canada 2010
December 2010
Who We Are
Established in 1994, CIHI is
an independent, not-for-profit
corporation that provides essential
information on Canada’s health
system and the health of Canadians.
Funded by federal, provincial and
territorial governments, we are guided
by a Board of Directors made up
of health leaders across the country.
Our Vision
To help improve Canada’s health
system and the well-being of Canadians
by being a leading source of unbiased,
credible and comparable information
that will enable health leaders to make
better-informed decisions.
Table of Contents
About the Canadian Institute for Health Information . . . . . . . . . . . . . . . . . . . iii
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
About This Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Report Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PART A: The Year in Review
Chapter 1—Emerging Issues in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The H1N1 Pandemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Disruption in the Supply of Medical Isotopes . . . . . . . . . . . . . . . . . . . . . . . .
New Funding Structures: A Focus on Quality and Appropriateness of Care .
In Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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PART B: Aligning Care With Evidence
Chapter 2—Provided Care Leaves Room for Improvement . . . . . . . . . . . . . 21
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Arthroscopic Knee Surgery for Osteoarthritis . . . . .
Vertebroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
When Care Varies: C-Sections and Hysterectomies
In Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Chapter 3—Provided Care Is Not Always Appropriate Care . . . . . . . . . . . . . 41
Introduction . . . . . . . . . . . . . . . . . . . . . . .
Avoidable Hospital Admissions . . . . . . . .
Preventive Care for Diabetes in Canada .
The Challenge of Alternate Level of Care
In Summary . . . . . . . . . . . . . . . . . . . . . . .
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Chapter 4—Substantial Improvement in Care: The Way Forward . . . . . . . . 59
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Heart Disease and Heart Health in Canada . . . . . . . . . . . . . . . . . . . . . .
Measuring Quality of Care: The Hospital Standardized Mortality Ratio
In Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Health Care in Canada 2010
PART C: Health Care System Resources
Chapter 5—An Update on Health Professionals . . . . . . . . . . . . . . . . . . . . . . . 81
Introduction . . . . . . . . . . . . . . . . . . . . . . . . .
Canada’s Health Professionals at a Glance .
International Comparisons . . . . . . . . . . . . .
Changing Scope of Practice . . . . . . . . . . . .
In Summary . . . . . . . . . . . . . . . . . . . . . . . . .
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. 82
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Chapter 6—An Update on Health Expenditures . . . . . . . . . . . . . . . . . . . . . . . 91
Introduction . . . . . . . . . . . . . . . . . . . . . . . .
Comparisons Within Canada and Abroad .
Cost Drivers and Cost Escalators . . . . . . .
In Summary . . . . . . . . . . . . . . . . . . . . . . . .
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Issues on the Horizon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
ii
Health Care in Canada 2010
About the Canadian
Institute for Health
Information
The Canadian Institute for Health Information (CIHI) collects and analyzes information
on health and health care in Canada and makes it publicly available. Canada’s
federal, provincial and territorial governments created CIHI as a not-for-profit,
independent organization dedicated to forging a common approach to Canadian
health information. CIHI’s goal: to provide timely, accurate and comparable
information. CIHI’s data and reports inform health policies, support the effective
delivery of health services and raise awareness among Canadians of the factors that
contribute to good health.
Acknowledgements
CIHI wishes to acknowledge and thank the many individuals and organizations whose
work contributed to the development of this report.
Thank you to the following expert advisors for their review of relevant materials.
For reviewing the vertebroplasty analyses, Chapter 2:
Tracy Merlin, BA (Hons), MPH
Manager, Adelaide Health Technology Assessment
Senior Lecturer, Discipline of Public Health, University of Adelaide
For reviewing the Caesarean section analyses, Chapter 2:
Mark Walker, MD, MSc, FRCSC
Senior Scientist, Ottawa Hospital Research Institute
Associate Professor, Department of Obstetrics and Gynecology
Division of Maternal Fetal Medicine, University of Ottawa
For reviewing the cardiac analyses, Chapter 4:
Jack Tu, MD, MSc, PhD, FRCPC
Senior Scientist, ICES
Canada Research Chair in Health Services Research
Sunnybrook Schulich Heart Centre, University of Toronto
Health Care in Canada 2010
iii
Health Care in Canada 2010 represents the work of many CIHI and contract staff who
did research, conducted literature reviews and environmental scans, compiled and
validated the data, wrote the chapters, contributed to the development of this report
and provided generous and ongoing support to the core team.
The core project team responsible for this report is as follows:
Hani Abushomar, Senior Analyst
Selina Anggawinata, Assistant
Michelle Costa, Senior Analyst
Alexey Dudevich, Analyst
Colleen Dwyer, Senior Analyst
Josh Fagbemi, Program Lead
Cheryl Gula, Manager
Sharon Gushue, Senior Analyst
Joanne Hader, Manager
Hong Ji, Senior Analyst
David Lam, Assistant
Carrie Lee, Analyst
Kira Leeb, Director
Mark McPherson, Analyst
Megan Mueller, Writing Consultant and Editor
Michelle Parker, Senior Program Coordinator
Jeremy Veillard, Vice President
Owen Yun, Senior Analyst
iv
Health Care in Canada 2010
About This Report
Health Care in Canada is CIHI’s annual flagship report on the health care system and
the health of Canadians. Since 2000, it has been a resource that tables fundamental
issues facing the health care system. Addressing questions surrounding patient
safety, wait times, health care spending and analyses on how the system has adapted
over time to meet changing needs has made Health Care in Canada a key source for
the public and policy-makers alike.
This year’s report provides perspective on changes in the health care system and
on current thinking surrounding health care and outcomes of care. As with its
predecessors, Health Care in Canada 2010 draws on both internal and external
information and data and introduces international comparisons where appropriate.
Health Care in Canada 2010 is divided into three sections:
Part A: The Year in Review chronicles some of the substantive, emerging issues
that had an impact on the health care system over the past 12 to 18 months. Among
them were the H1N1 pandemic, the medical isotope supply disruptions and provincial
changes in health care funding models.
Part B: Aligning Care With Evidence focuses on the thematic topic for this report:
appropriateness of care. The first chapter in this section highlights examples
illustrating where there is room for improvement and discusses the impact on the
health system. It also profiles cases where variations in care across Canada point
to underlying questions of appropriateness. Again, impacts on the system and
ways to work toward best practices are explored. The next set of examples focuses
on the aspects of right care and right place for appropriate care by highlighting
examples where the right care is known but is not happening and where care is not
provided in the most appropriate setting. Finally, good news stories—where focused
attention and investments in the system have led to positive changes and sustained
improvements—are explored. These provide examples of the way forward to make
the system better and to make real differences in the lives of patients.
Part C: Health Care System Resources contains updated information on health
human resources and health expenditures. Money and people ultimately run the
health care system. They are inputs to the system and represent system resources.
How they are allocated matters, and keeping track of their availability over time is an
important aspect of monitoring the health of the health care system.
CIHI welcomes comments about this report and would like to know how future
reports can meet your information needs. Please email your comments to
[email protected]
Health Care in Canada 2010
v
Want to Know More?
Please visit the CIHI website (www.cihi.ca) for more specific information about any
area of interest or research involving health care in Canada.
Highlights and the full text of Health Care in Canada 2010 are available free of change
in English and French on the CIHI website.
To order additional print copies of the report, please contact
Order Desk
Canadian Institute for Health Information
495 Richmond Road, Suite 600
Ottawa, Ontario K2A 4H6
Phone: 613-241-7860
Fax: 613-241-8120
A charge will apply to cover printing, shipping and handling costs.
vi
Health Care in Canada 2010
Report Highlights
PART A: The Year in Review
Chapter 1—Emerging Issues in 2010
H1N1
• Where SARS (2004) did not reach pandemic proportions, H1N1 did. In 2009,
Canada had the opportunity to implement lessons learned from the SARS
outbreak. By many accounts it did so effectively and with little disruption overall.
• Almost half (41%) of the Canadian population was vaccinated against H1N1 in 2009.
• All told, 428 Canadians were reported to have died from H1N1 between April 2009
and April 2010. In dollar amounts, Canada spent an estimated $400 million on
vaccines. By November 2009, estimates of the cost of Canada’s response reached
$1.5 billion.
Medical Isotopes
• Up until the closure of the Chalk River reactor in 2009, 40% of the world’s supply
of radioactive medical isotopes was produced by this facility.
• Medical isotopes are used to diagnose and treat a variety of illnesses, such
as cancer. They cannot be stockpiled or stored, so the disruption in the production
of these isotopes required changes in care processes.
• In June 2010, CIHI released the results of a special survey examining the impact
of the supply disruption on the Canadian health care system. The results
suggested that supply disruptions were experienced by health care providers.
But, for the most part, providers were able to implement mitigating strategies, such
as rescheduling and establishing new ways to prioritize patients.
New Funding Structures
• With new and growing financial pressures on the health care system, new funding
structures are evolving across Canada. Many of these funding models are either
activity based—designed to fund volumes of care delivered—or incentive based—
designed to ensure that health care guidelines, among other things, are followed
in the patient care process.
• Provinces are taking somewhat different approaches to introducing new
funding strategies.
Health Care in Canada 2010
vii
PART B: Aligning Care With Evidence
Chapter 2—Provided Care Leaves Room for Improvement
Arthroscopic Knee Surgery for Osteoarthritis
• Despite mounting evidence from randomized controlled trials that this type of
surgery is of little benefit, more than 3,600 therapeutic knee arthroscopies were
carried out in hospitals across Canada in 2008–2009.
• Although the trend in the number of knee arthroscopies is on the decline, there
are still substantial variations in the rates of these surgical procedures across
the country.
Vertebroplasty
• In Canada, about 1,050 vertebroplasties were performed in 2008–2009; a
significant number of these were for patients suffering from osteoporotic
vertebral fractures.
• Recent evidence suggests that these patients are not any better off than those
who undergo placebo procedures.
• The number of vertebroplasties performed in Canada is on the rise, from
approximately 600 in 2006–2007, to about 1,050 in 2008–2009.
Caesarean Section
• Overall Caesarean section (C-section) delivery rates have increased steadily in
Canada since 1995–1996. Primary (that is, first) C-section rates rose dramatically
between 1995–1996 and 2004–2005, and have since stabilized at approximately
19% of deliveries. Repeat C-section rates also rose over this time period, and by
2006–2007 the rate of repeat C-sections stabilized at approximately 82%.
• In 2008–2009, the variation in primary C-section rates was almost double across
the provinces and was triple across the territories. Rates ranged from a high of 23%
of deliveries in Newfoundland and Labrador to a low of 5% in Nunavut. Manitoba
had the lowest rate among the provinces at 14%. Many factors are associated with
variation in C-section rates, at both a patient and a system level.
• Greater understanding of rate variations and better alignment of care with current
recommendations could lead to more appropriate care. If all provinces achieved
the primary C-section rate of Manitoba, an estimated 30% (or 16,200) fewer
C-sections would be performed annually—with a cost savings of more than
$36 million.
viii
Health Care in Canada 2010
Hysterectomy
• Despite the significant decline in the overall hysterectomy rate in Canada between
2000–2001 and 2006–2007, there remains considerable variation across the
country. In 2008–2009, age-standardized hysterectomy rates varied almost
threefold across the provinces and territories, ranging from a high of 512 per
100,000 women (age 20 or older) in Prince Edward Island to a low of 185 per
100,000 in Nunavut. British Columbia had the lowest rate among the provinces, at
311 per 100,000 women. Variations in hysterectomy rates may point to differences
within and between jurisdictions in care provider culture, practice and approaches
to this surgery.
• If all provinces achieved British Columbia’s hysterectomy rate, the difference would
be an estimated 11% (3,700) fewer hysterectomies performed annually—with a cost
savings of more than $19 million.
Chapter 3—Provided Care Is Not Always
Appropriate Care
Preventive Care for Diabetes in Canada
• More than two million Canadians have diabetes.
• Although Canada is doing comparatively well on avoidable hospital admissions for
ambulatory care sensitive conditions such as asthma and congestive heart failure,
the country is not doing as well on avoidable hospital admissions for diabetes.
• Evidence-based guidelines recommend that diabetic patients regularly receive
a variety of tests and exams to help protect their health. However, only 32% of
diabetics reported receiving all four recommended tests and exams in 2007.
• Many jurisdictions across Canada are working toward a model of community teambased care for chronic diseases such as diabetes. So far, some provinces have
instituted incentive billings for providing high-quality chronic disease management.
The Challenge of Alternate Level of Care
• Alternate level of care (ALC) in acute care refers to patients who occupy hospital
beds but no longer need acute care services. In 2008–2009, there were more than
92,000 hospitalizations and more than 2.4 million hospital days involving ALC stays
in Canada. This represented 5% of all hospitalizations and 13% of all hospital days.
• Most ALC patients are classified as ALC at the end of their hospital stay. However,
in 2008–2009, 8% of ALC patients were admitted to acute care as ALC. These
patients accounted for almost 11% of all ALC days. The most common reasons for
patients to be designated ALC upon admission were palliative care (34%), waiting
for admission to another adequate facility (27%) and physical therapy (11%).
• In 2008–2009, 62% of ALC patients had stays of more than one week, and 24%
stayed more than a month in ALC. Five percent of ALC patients stayed more than
100 days.
Health Care in Canada 2010
ix
Chapter 4—Substantial Improvement in Care:
The Way Forward
Cardiac Care
• Coronary artery disease hospitalizations and in-hospital deaths from heart attack,
as well as heart attack readmissions, continue to decline in Canada.
• Over the four-year period examined the rate of hospitalized heart attacks declined
in Canada. In 2004–2005, the age-adjusted rate was 239 per 100,000 population
age 20 and older. In 2008–2009, the rate dropped to 217 per 100,000.
Hospitalizations for angina—a less-severe form of coronary artery disease—
followed suit.
• Thirty-day in-hospital heart attack mortality rates in Canada dropped significantly,
from 10% in 2003–2004 to 9% in 2007–2008. Annual unplanned heart attack
readmission rates also made a significant drop, from 7% to 5%.
• The savings to the system for treating heart attacks would be on the order of a
22% reduction—about 15,480 cases and a savings of approximately $125 million in
hospitalization costs if all provinces had the same number of heart attack episodes
as British Columbia.
Hospital Standardized Mortality Ratio
• Overall, 40% of publicly reportable facilities significantly decreased their
hospital standardized mortality ratios (HSMRs) when 2009–2010 results are
compared to 2004–2005. For this measure, a decrease indicates an improvement
in performance.
• The HSMR results contribute to performance improvement discussions in facilities,
regional health authorities and ministries and departments of health. In many
jurisdictions, the HSMR is one of several measures that are currently part of annual
public reporting.
x
Health Care in Canada 2010
PART C: Health Care System Resources
Chapter 5—An Update on Health Professionals
• Canada experienced a growth rate of 16% in the number of active registered
physicians in the past nine years, from 58,546 in 2001, to 68,101 in 2009.
• In 2009, the provincial supply of active physicians per 100,000 population ranged
from 164 in Saskatchewan to 231 in Nova Scotia. Territorial supply of physicians
per 100,000 population ranged from 37 in Nunavut to 218 in the Yukon. The
nationwide rate was 201. These represent increases over the past decade.
• Similarly, from 2001 to 2009, the number of registered nurses across Canada grew
by 15%. In 2009, there were 266,341 registered nurses in Canada and a combined
total of 348,499 regulated nurses in the nursing workforce as a whole.
• Provincial rates of registered nurses per 100,000 population ranged from 694
in British Columbia to 1,145 in Newfoundland and Labrador.
• From 2004 to 2008, there was also growth in the supply of pharmacists,
physiotherapists, occupational therapists and audiologists. The most rapid
growth was seen among nurse practitioners, increasing by 90% from 2004 to 2008.
• Expanding scopes of practice for some professions may lead to efficiency gains
in the deployment of health human resources.
Chapter 6—An Update on Health Expenditures
• Canada’s health care spending reached an estimated $191.6 billion in 2010.
• Spending on health care is substantial in Canada, but it is not uniform across the
provinces and territories. At a pan-Canadian level, per capita spending was $5,614
in 2010, while provincial per capita spending was estimated to range from a low
of $5,096 in Quebec to a high of $6,266 in Alberta. In the territories, per capita
spending was estimated to range from $7,977 in the Yukon to $12,356 in Nunavut.
Issues on the Horizon
With health care systems—both across Canada and internationally—increasingly
focused on providing quality care, how health care is provided in the not-too-distant
future may be affected by issues such as
• Better alignment of care with evidence, including recognition of the need to
standardize clinical practice guidelines and an increasing focus on regional
variations in care;
• The areas in which government policies and investments are focused, and how
changes in these areas will shape the health system and the care delivered; and
• In 2014, the 10-year Plan to Improve Health Care will have expired and a new health
accord will be negotiated. The provisions of a new accord may have significant
impact on the future direction of health care in Canada.
Health Care in Canada 2010
xi
Introduction
Introduction
If “access” and “wait times” were the buzz words of the first decade of the 21st
century, “value for money,” “appropriateness” and “quality of care” may be the ones
for the second. From 2000 to 2009, some of the most burning questions were about
how dollars spent in the health system could translate into improved access and
reduced wait times for Canadians. In 2010, the questions are about how evidence is
informing patient care and how this translates into improved quality and appropriate
care delivery. In this, CIHI’s 11th edition of Health Care in Canada, we touch on key
emerging issues from the past year, provide an update on health system resources
and expenditures and begin a story about the provision of appropriate care.
The story about appropriateness of care in Health Care in Canada 2010 is limited to
concrete examples where appropriateness can be questioned. The reality remains
that administrative data collected from the millions of interactions people have with
the health care system annually says little about the quality and appropriateness of
care. Although there is a proliferation of clinical practice guidelines and a constantly
evolving pool of evidence from clinical trials and other health research, today’s data
is not enough on which to base conclusions about the quality of health care delivered
or about evidence-based care. But the existing measures, study results and wide rate
variations observed across jurisdictions and population groups together suggest not
all of the care provided is likely appropriate.
This, as with most things in the health system, is changing. And the pace of change
may be accelerating. Countries, including Canada, forecast health care spending that
continues to grow at an uncomfortable pace. Around the globe, policies are being
put in place to ease spending pressures and improve health system performance
by finding efficiencies, improving coordination in care delivery and improving the
quality of care. In Canada a number of policy initiatives support finding efficiencies
and providing a seamless system and care continuum to better serve people in
the community and in their homes. In several provinces, the focus on quality care
provision and evidence-based care continues to gain momentum. The good news
is that in the past decade health system measures have been developed and applied
to ensure that people are safe and not harmed by the care they receive.
The not-so-good news is that questions remain about whether or not people
are receiving care that is appropriate and based on the best available scientific
information. Few will dispute where the system needs to get to. Many know
the challenges.
2
Health Care in Canada 2010
To begin the journey of understanding, measuring and managing appropriateness,
the narratives in this report provide examples of both challenges and successes
pointing the way forward. Their presentation should foster deliberation and generate
discussion about a comprehensive approach to measuring appropriateness and
aligning care and evidence.
For this report, narratives that many are familiar with were selected. Aligning care
with evidence from randomized controlled trials (RCTs) should inform practice, but
the examples profiled here suggest that is not always the case. Substantive rate
variations in service levels should trigger questions of appropriateness where RCT
evidence does not exist. The use of evidence-based practice guidelines should
translate to providing more, less or, more likely, different care and could even initiate
discussion about the setting in which care is provided.
Randomized controlled trials in health care intervention research provide the
strongest level of evidence. Two examples of surgical procedures that have
been evaluated in RCTs are knee arthroscopy for patients with osteoarthritis and
vertebroplasty to treat osteoporotic vertebral fractures. For both procedures there is
strong evidence from more than one RCT of no benefit for certain patient populations.
Yet both procedures are still being carried out.
Substantive rate variations suggest a lack of uniform treatment. They indicate that,
all other things being equal, people in one jurisdiction or patient population are
getting different care than in another. Two well-known examples of substantial rate
variation—Caesarean section delivery and hysterectomy—are discussed. For both
procedures, rates of service vary substantially both within and across jurisdictions.
Like most health care services, agreed-upon benchmarks or optimal levels for these
services do not exist. However, substantive rate variations signal a lack of consistency
in patient treatment and suggest room for improved care.1
Evidence-based guidelines combine research evidence, critically appraise its
quality and make recommendations for clinical practice. 2 They can vary in the
strength of the evidence that is available and brought to bear on a particular issue,
in their development processes and sometimes in their utility (when there is little
research evidence, for example). Not surprising then, uptake can be inconsistent.
Examples are explored from primary health care where available information
suggests that care is both consistent with the guidelines (in the management of
asthma and coronary heart failure) and where it could be better aligned with evidence
and guidelines (in the management of diabetes).
Staying in hospital longer than deemed medically necessary is one example
where patients and providers question the efficiency of care provision and the
appropriateness of the care setting. Alternate level of care (ALC) stays, as they
have been labelled, are the result of complicated issues for which solutions are not
universal. However, it stands to reason that those who do not require the level of
care provided in an acute setting should be discharged to a more appropriate one
(including home, if indicated). This will help ensure that hospital beds are available
for those in need of hospital care and that patients are in the care setting that best
fits their needs. Updated information about the magnitude of ALC stays in Canadian
hospitals is provided where comparable data exists to inform the discussion.
Health Care in Canada 2010
3
Many of the narratives in this report point to waste and inefficiencies in the health
care system. However, the news is not all bad. Certainly, there are areas within the
system where high-quality care exists and measurable improvements are visible.
To that end, included in this report is new information about cardiac care and about
hospital standardized mortality ratios. This information demonstrates the impact of
aligning care with evidence. It also demonstrates the impact of efforts to measure
and monitor how health care is provided.
In the end, this report attempts to feed a multitude of appetites. The beginning of a
story about appropriateness of care is, by necessity, woven within the context of an
evolving health care system with yearly pressures to respond and react, as well as
complex and historical decisions about expenditures and health human resources.
Undoubtedly, not all of these appetites will be satiated. But hopefully, many will have
been whetted for more and better information.
4
Health Care in Canada 2010
References
1.
A. Elshaug et al., “Identifying Existing Health Care Services That Do Not Provide Value for
Money,” Medical Journal of Australia 190, 5 (2009): pp. 269–273.
2.
W. Lim et al., “Evidence-Based Guidelines—An Introduction,” Hematology 2008, 1 (2008):
pp. 26–30.
picture to come later
Health Care in Canada 2010
5
PART A
The Year in Review
Chapter 1
Emerging Issues in 2010
Introduction
Since the release of Health Care in Canada 2009 in October 2009, news stories
about health care have generated headlines across Canada. Among them were the
H1N1 pandemic, the impact of medical isotope supply disruptions and provincial
changes in health care funding models. The first two issues necessitated immediate
systemic reaction. And the system responded. Funding changes will also provoke
systemic responses, but these will be provincial and territorial in nature. This chapter
chronicles some of these stories and their impact on Canada’s health care system
in 2009–2010.
The H1N1 Pandemic
In June 2009, the World Health Organization (WHO) declared the H1N1 influenza
a pandemic.1 Canada underwent a dress rehearsal of pandemic planning in 2003
during the SARS outbreak, although SARS never reached pandemic proportions.
It nevertheless provided the impetus for strategic and focused Canadian pandemic
planning. This included the establishment of the Public Health Agency of Canada and
the Canadian Pandemic Influenza Plan.
H1N1 was first identified in Mexico. Its rapid spread around the world made health
officials in every country take notice. By the time the WHO declared it a pandemic,
74 countries and territories had lab-confirmed infections.1 By June 2010, more than
214 countries and overseas territories had lab-confirmed cases and 18,172 deaths
were attributed to the illness. 2 The pandemic was officially declared over
in August 2010.3
For most people who became ill, H1N1 symptoms lasted one week. While the majority
recovered without medical treatment, there were several quantifiable differences
from seasonal influenza infections. For those hospitalized, H1N1 patients required
more intensive hospital care when compared to typical flu patients.7 There was also
evidence suggesting pregnant women were at greater risk of becoming infected with
H1N1 than seasonal influenza, and healthy youth, not usually severely affected by flu,
succumbed to the illness.8 As well, the WHO reported that “people age 65 and older
are the least likely to be infected with the pandemic flu”—another departure from the
normal flu. The WHO also added that those age 65 and older who did get sick were at
high risk for developing serious complications.9 All told, 428 Canadians were reported
to have died from H1N1 between April 2009 and April 2010.10
8
Health Care in Canada 2010
Influenza Pandemics:
A Historical Perspective
During the last century, three influenza pandemics have occurred.
Due to the high number of deaths caused by the Spanish Flu, it is
the catastrophe against which all modern pandemics are measured.
Estimates say up to 40% of the population worldwide became ill
with this flu and more than 20 million people died.4 Between 1918
and 1919, 50,000 Canadians5 and half a million Americans died
from the Spanish Flu.4 Almost 40 years later, the Asian influenza
pandemic was identified, and vaccine production began within three
months. This pandemic resulted in four million deaths globally;4
2,000 Canadians6 and 69,800 Americans died.4 Only 10 years later,
in early 1968, the Hong Kong influenza pandemic was detected.
By January 1969, the virus had peaked. The Hong Kong influenza
is estimated to have claimed four million lives worldwide.4
Canada’s health system responded swiftly to H1N1. The federal government ordered
more than 50 million doses of vaccine to cover anticipated demand.11 Early in the
outbreak, it was thought that each person would require two doses to be fully
protected. Public health campaigns urged all Canadians to get vaccinated, and
across the country priority groups were identified for immediate inoculation, with
all other non-priority Canadians to follow. Nursing students, contract nurses and
retired nurses were asked to work, and public health workers were retrained and
redeployed to administer the vaccine. Other public health programs were postponed
or suspended; in some jurisdictions, surgical procedures were also postponed.12
Despite this, only 41% of Canadians age 12 and older were actually vaccinated.13
Faced with surplus vaccines, Canada shipped five million to Mexico14 and sent an
additional five million to the WHO.15
In dollar amounts Canada spent an estimated $400 million on vaccines alone.17 By
November 2009, estimates of the cost of Canada’s response reached $1.5 billion.18
Regardless of the expense, most Canadians believed that all levels of government
did at least a fair job of preparing for and dealing with H1N1, despite overreactions
from the media.19 Some provinces have conducted their own cost–benefit analysis
and have concluded that while it may have been a costly campaign it was also costeffective given the number of infections, hospitalizations and workplace disruptions
it prevented. 20
Health Care in Canada 2010
9
1
Figure
H1N1 Pandemic 2009—Countries, Territories and Areas With Lab-Confirmed
Cases and Number of Deaths as Reported to the WHO
Cumulative Deaths
1–10
11–50
51–100
101 and More
Country/Territory/
Area With Confirmed Cases
Source
World Health Organization,
Global Health Observatory
Map Gallery, accessed
on June 30, 2010, from
<http://gamapserver.who.
int/mapLibrary/Files/Maps/
GlobalSubnationalMaster
Gradcolour_20100620_
weekly.png>.
The boundaries and names shown and the designations used on this map do not imply the expression of any
opinion whatsoever on the part of the World Health Organization concerning the legal status of any country,
territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted
lines on maps represent approximate border lines for which there may not yet be full agreement.
Data source: World Health Organization Map Production: Public Health Information and Geographic
Information Systems (GIS) World Health Organization.
© WHO 2010. All rights reserved.
Disruption in the Supply
of Medical Isotopes
Medical isotopes play a vital role every day in diagnosing life-threatening illnesses,
such as cancer and heart disease. While their use has become mainstream in
nuclear medicine, they cannot be stored or stockpiled. In Canada, about one million
procedures using medical isotopes are performed annually, and 25 million are
performed globally. 21 It is estimated that one in three patients entering a hospital
will undergo a procedure involving nuclear medicine. 22
Prior to being shut down in the spring of 2008, the nuclear reactor in Chalk River,
Ontario (near Ottawa), produced 40% of the global radioactive medical isotope
supply. 23 In June 2009, the federal government provided $6 million for research into
alternative, non-nuclear isotopes to replace Tc-99m—a particular type of medical
isotope—and established an expert panel to consider proposals for new sources. 24
Six months later, the panel submitted its report to the Natural Resources Minister.
It concluded that there were no quick fixes and suggested the following:
1) More players should be introduced to the isotope distribution chain, now
dominated by Ottawa-based MDS Nordion;
2) The federal government should work with other countries to better coordinate
worldwide production and distribution of isotopes;
10
Health Care in Canada 2010
The Impact of the H1N1 Pandemic
on Canadian Hospitals
Given the importance of planning for and responding to pandemics,
and given that many parts of Canada’s health system were involved
in responding to the H1N1 pandemic specifically—public health, labs,
pharmacies and primary health care providers—what impact did the
pandemic have on Canadian hospitals? What can be said about the
H1N1 hospitalized patient profile and their use of hospital services?
To help answer these questions, CIHI is investigating the utilization
of hospital and emergency department services by patients with a
diagnosis of either H1N1 or influenza during the pandemic period
(April to December 2009). Preliminary findings indicate the following:16
• During the peak of the second wave in November, H1N1/influenza was
one of the leading causes of hospitalization and represented less than
5% of all acute discharges.
continued on next page
3) Canada should shift to making isotopes with low-enriched uranium targets; and
4) Canada should build a new multi-purpose reactor. 25
The final recommendation was ruled out in March 2010 due to high costs and
long lead times for production. 26 Instead, the federal budget provided $48 million
to encourage the exploration of new avenues for the production and use of
medical isotopes. 27
In June 2010, CIHI released the results of a special survey examining the impact of
the supply disruption on the Canadian health care system. Highlights from the survey
include the following:28
• The number of nuclear medicine exams carried out on Canadian patients
for cardiac, bone and lung diagnostic tests decreased by 22% in October
2009, compared to October 2008; this translated to 12,000 fewer exams
in October 2009 alone.
• Nuclear medicine departments implemented mitigating strategies, such as
rescheduling patient exams and setting up new ways to prioritize patients.
• Two-thirds of the participating nuclear medicine sites reported an increase in the
cost of isotopes. Accordingly, they were managing the increased costs but were
exceeding their budgets.
Health Care in Canada 2010
11
• Between April and December 2009, Ontario emergency
department visits for flu-like symptoms were up by
approximately 140,000 visits compared to historical averages.
• Young children between age 0 and 4 were hospitalized the
most compared to any other age group. As well, hospitalized
H1N1/influenza patients were more likely to be pregnant or have
respiratory comorbidities (such as asthma and chronic lung
diseases) than in a typical flu year.
• H1N1/influenza patients were more likely to need intensive
care units and ventilation than typical flu patients; however,
the extent of this difference was smaller than that estimated
by earlier studies.
New Funding Structures: A Focus on
Quality and Appropriateness of Care
Government leaders are all facing budget deficits and a belt-tightening economy.
In response, some are revising their approach to funding all or aspects of the
health care system. Many of these approaches are linked to both quality and
appropriateness of care. Terms heard across the country to describe new funding
models include “patient focused,” “activity based,” “service based” and “pay for
performance.” While newer in Canada, countries such as the United States, Australia,
the United Kingdom29 and several other European countries30 have also been
experimenting with such funding structures.
Selected Funding Initiatives
Ontario has begun developing a new funding model for local health integration
networks (LHINs) called the health-based allocation model (HBAM). According to
the Ontario Ministry of Health and Long-Term Care,34 HBAM determines each LHIN’s
share of funding based on direct measures of health status; population-based factors
such as age, gender, socio-economic status, rural geography and patient flows;
and provider characteristics relative to their LHIN boundaries. HBAM’s goals include
1) promoting equitable access to services across Ontario; 2) ensuring that money
follows the patient; and 3) promoting innovation through incentives for efficient and
innovative service delivery.
12
Health Care in Canada 2010
Incentives and Activities—
Can They Form the Basis
for Health Care Funding?
Recently, in several jurisdictions, the idea that changing the
way we fund health care can improve not only the quality of
care received but also the value for money spent has been
raised. Several models are being considered and tried, and
there is continued debate as to which of these may best
ensure high-quality, accessible and cost-effective care for
Canadians. Many terms are used to describe these models,
but at the core they can be broken down into two main types:
incentive based and activity based.
continued on next page
Ontario also recently passed its Excellent Care for All Act, 2010.35 The act introduces
pay-for-performance measures for hospitals by linking a portion of CEO salaries to
the achievement of performance targets. It also establishes hospital-based quality
committees that report to hospital boards on quality-related issues, among other
things. The ultimate goals are to provide high-quality, appropriate patient care;
reduce in-hospital infection rates; cut emergency wait times; and speed up access
to procedures like hip replacements.
Finally, Ontario recently implemented reforms to reduce the cost of generic drugs for
the province. The reform took effect July 1, 2010,36 and appears to have had a ripple
effect across the country. British Columbia followed suit shortly after, announcing
its own plans to undertake generic drug reform.37 Quebec also has requirements
currently in place with manufacturers to ensure low pricing for generic drugs.38
More recently, stories have surfaced about provinces and territories pooling their
purchasing power to reduce drug costs across the country.39, 40
British Columbia is focused on reforming its hospital sector through changes in
funding. Its first-year objectives include expanding emergency department patientfocused funding, reducing wait times for selected common surgical procedures and
decreasing the number of overnight stays.41 Its new Health Services Purchasing
Organization, incorporated in January 2010, will distribute $250 million among the
province’s largest hospitals on the basis of patient-focused services,41 effectively
giving available health care dollars to the hospitals offering the lowest price
for surgery.42
Health Care in Canada 2010
13
Incentive-Based Funding: Alternatively known as pay-forperformance and service-based funding, this is the notion
of using payments to achieve results in the quality of patient
care by requiring providers or institutions to reach specific
care goals to receive financial rewards. 31 Pay for performance
provides incentives for how well service is delivered, while
service-based funding provides incentives for the volume
of specific baskets of care delivered. 31
Activity-Based Funding: In contrast to the current block funding
model that provides hospitals with their budgets as a lump sum
at the beginning of a fiscal year, activity-based, patient-focused
or patient-based funding is a model that provides funding
based on the volume and/or complexity of the patients who
are seen and treated.32, 33
Alberta Health Services (AHS) recently introduced activity-based funding. It is
one of the five pillars of the AHS’s new Seniors Care Plan, which is part of the
province’s 2010–2011 budget. In 2006, Alberta began using the Resident Assessment
Instrument (RAI) to support and monitor quality in long-term care. The RAI case mix
system (called Resource Utilization Groups) will support the funding.43 Alberta is also
using RAI instruments in long-term home care programs and plans to expand their
use to supportive living settings.43
Activity-based funding is also used in Quebec. This province’s wait time guarantee
of six months for hip and knee replacement surgery is supported by the federally
funded Patient Wait Time Guarantee Trust (2007). The trust was established to help
jurisdictions introduce guarantees to achieve wait time benchmarks for five priority
areas. In Quebec, if hip and knee replacement operations cannot be performed at a
government-funded hospital within six months, the province will pay for surgery at an
affiliated private clinic in the province.46 In 2010, Quebec, as well as British Columbia
and Ontario, completed 75% of hip and knee replacements within benchmark
time frames.47
With the 2004 Health Accord set to expire in 2014, the federal government, along
with the provincial and territorial governments, will need to renegotiate the terms
of the Canada Health Transfer. The 2004 accord established a number of key
accomplishments to improve the health care system. Arguably the most substantive
change was in wait time reductions for the five areas identified as priorities. Whether
funding flowing from the federal government to the jurisdictions after 2014 will be
conditional in any way remains to be seen. But likely many voices will be heard and
positions solidified over the next three years.
14
Health Care in Canada 2010
About the interRAI Resident
Assessment Instrument–
Home Care
The interRAI Resident Assessment Instrument–Home Care (RAI–HC)©
is a standardized, comprehensive and reliable assessment instrument
designed to evaluate the needs, preferences and strength of people—
generally frail elderly or disabled individuals—receiving care and
services in their homes or community-based settings. Developed by
a not-for-profit network of researchers in more than 30 countries, the
RAI–HC is currently used in eight jurisdictions in Canada and many
countries around the world.44, 45
In Summary
One sign of a healthy system is its ability to respond quickly and effectively when
needed. By many accounts Canada’s health care system responded in exactly this
manner to both the H1N1 pandemic and the medical isotopes supply disruption. In
both cases, processes of care were altered and resources were redeployed, but the
health care system was not systematically disrupted. For many Canadians, these
events marked inconveniences and postponements but not complete reductions in
access to care.
Health care systems need the flexibility to respond to emerging issues. But they
also need to provide resources for ongoing care in the near and distant futures. New
funding models and payment systems within many jurisdictions are being tabled and
discussed. These discussions are reflections of governments looking for new ways
to strike a balance between the demand for care and other competing priorities while
at the same time controlling costs. Governments are looking for value for every dollar
spent; inefficiencies can no longer be afforded. These changes are longer term and
will be further refined over time.
©
interRAI Corporation, 2001. Modified with permission for Canadian use under license to the Canadian
Institute for Health Information.
Health Care in Canada 2010
15
References
1.
World Health Organization, What Is the Pandemic (H1N1) 2009 Virus?, accessed on
May 10, 2010, from <http://www.who.int/csr/disease/swineflu/frequently_asked_questions/
about_disease/en/index.html>.
2.
World Health Organization, Pandemic (H1N1) 2009 Update 105, accessed on
September 29, 2010, from <http://www.who.int/csr/don/2010_06_18/en/print.html>.
3.
World Health Organization, H1N1 in Post-Pandemic Period, accessed from
<http://www.who.int/mediacentre/news/statements/2010/h1n1_vpc_20100810/
en/index.html>.
4.
World Health Organization, “Avian Influenza (Bird Flu): An Introduction,” DCD (Division
of Communicable Diseases Control) Newsletter, 7 (2005).
5.
Collections Canada, Thematic Guides—Unpublished Guides, Spanish Flu Epidemic, last
modified 2008, accessed on April 29, 2010, from <http://www.collectionscanada.gc.ca/
the-public/005-1142.18-e.html>.
6.
Newsmagazine, The Asian Flu Arrives in Canada (CBC digital archives), last modified 2006,
accessed on April 29, 2010, from <http://archives.cbc.ca/health/disease/clips/12707/>.
7.
Canadian Institute for Health Information, H1N1 Patients Required More Intensive Hospital
Care Than Typical Flu Patients (Ottawa, Ont.: CIHI, 2010).
8.
World Health Organization, What Is the Pandemic (H1N1) 2009 Virus?, last modified
February 24, 2010, accessed from <http://www.who.int/csr/disease/swineflu/frequently_
asked_questions/about_disease/en/index.html>.
9.
World Health Organization, Who Is More at Risk of Severe Illness? What About Other
Risks?, accessed from <http://www.who.int/csr/disease/swineflu/frequently_asked_
questions/risk/en/index.html>.
10. Public Health Agency of Canada, FluWatch, last modified 2010, accessed on April 27,
2010, from <http://www.phac-aspc.gc.ca/fluwatch/09-10/w14_10/index-eng.php#t1>.
11. Government of Canada, Government of Canada Announces Intention to Order 50.4 Million
Doses of H1N1 Vaccine, last modified August 6, 2009, accessed on May 14, 2010, from
<http://www.phac-aspc.gc.ca/media/nr-rp/2009/2009_0806-eng.php>.
12. C. Power, Pandemic Preparedness (Halifax, N.S.: Nova Scotia House of Assembly,
Committee on Public Accounts, 2009).
13. Statistics Canada, Canadian Community Health Survey: H1N1 Vaccinations, last modified
July 19, 2010, accessed on September 2, 2010, from <http://www.statcan.gc.ca/dailyquotidien/100719/dq100719b-eng.htm>.
14. Public Health Agency of Canada, News Release: Canada to Bridge Mexico’s H1N1
Vaccine Requirements, last modified January 6, 2010, accessed on April 28, 2010,
from <http://www.phac-aspc.gc.ca/media/nr-rp/2010/2010_0106-eng.php>.
15. Public Health Agency of Canada, News Release: Government of Canada Announces
Significant Contribution to WHO Global Pandemic Relief Efforts, last modified January 28,
2010, accessed on April 28, 2010, from <http://www.phac-aspc.gc.ca/media/nr-rp/
2010/2010_0128-eng.php>.
16
Health Care in Canada 2010
16. Canadian Institute for Health Information, The Impact of the H1N1 Pandemic on Canadian
Hospitals (Ottawa, Ont.: CIHI, 2010).
17. Treasury Board of Canada Secretariat, Supplementary Estimates (B), 2009-10, for the
Fiscal Year Ending March 31st 2010 (Ottawa, Ont.: TBS, 2010).
18. P. Waldie and C. Alphonso, “Cost of Vaccinating Nation Hits $1.5-Billion and Climbing,”
The Globe and Mail, November 12, 2009.
19. Harris-Decima, Majorities Feel Governments Have Performed Adequately on H1N1, but
Media Has Overreacted, last modified November 11, 2009, accessed on May 17, 2010,
from <http://www.harrisdecima.com/sites/default/files/releases/2009/11/12/
hd-2009-11-12-en376.pdf>.
20. B. Sander et al., “Is a Mass Immunization Program for Pandemic (H1N1) 2009 Good
Value for Money? Evidence From the Canadian Experience,” Vaccine 28, 38 (2010):
pp. 6210–6220.
21. Atomic Energy of Canada Limited, Helping to Save Lives Through Nuclear, last
modified 2010, accessed on April 27, 2010, from <http://www.aecl.ca/NewsRoom/
Bulletins/E-060814/E06.htm>.
22. Atomic Energy of Canada Limited, Medical Isotopes, last modified 2010, accessed
on April 28, 2010, from <http://www.aecl.ca/Science/CRL/NRU/Isotopes.htm>.
23. Longwoods Health and Healthcare News, Surviving the Health Care Crisis in Cancer
and Cardiac Testing, last modified June 29, 2009, accessed on February 11, 2010, from
<http://www.longwoods.com/articles/images/news_Surviving_the_Health_jun2909.htm>.
24. Health Canada, Medical Isotopes—Frequently Asked Questions, accessed on
February 17, 2010, from <http://www.hc-sc.gc.ca/dhp-mps/brgtherap/activit/fs-fi/
isotopes-med-faq-eng.php>.
25. R. Collier, “New Direction Recommended for Isotope Production,” CMAJ 182, 2 (2009):
pp. E115–E116.
26. Government of Canada, Government of Canada Response to the Report of the Expert
Review Panel on Medical Isotope Production (Ottawa, Ont.: Government of Canada, 2010).
27. Government of Canada, Canada’s Economic Action Plan, Year 2, Budget 2010: Leading
the Way on Jobs and Growth (Ottawa, Ont.: Government of Canada, 2010), p. 68.
28. Canadian Institute for Health Information, Survey Shows Effects of Isotope Supply
Disruption on Nuclear Medicine Sites in Canada (Ottawa, Ont.: CIHI, 2010).
29. G. H. Pink et al., “Pay-for-Performance in Publicly Financed Health Care: Some
International Experience and Considerations for Canada,” HealthcarePapers 6, 4 (2006):
pp. 8–26.
30. Canadian Doctors for Medicare, Canadian Doctors for Medicare Position on Activity-Based
Funding in Canadian Hospitals and Other Surgical Facilities, last modified 2010, accessed
on July 14, 2010, from <http://www.canadiandoctorsformedicare.ca/>.
31. J. Coutts and J. Thornhill, “Service-Based Funding and Pay for Performance: Will
Incentive Payments Give Canadian Healthcare the Quality Boost It Needs?,” Healthcare
Quarterly 12, 3 (2009): pp. 42–49.
Health Care in Canada 2010
17
32. R. Collier, “Activity-Based Funding: Boon or Boondoggle?,” CMAJ 178, 11 (2008):
pp. 1407–1408.
33. Canadian Agency for Drugs and Technologies in Health, Activity-Based Funding
Models in Canadian Hospitals, last modified 2010, accessed on July 8, 2010, from
<http://www.cadth.ca/index.php/en/hta/reports-publications/health-technology-update/
ht-update-12/activity-based-funding-models-in-canadian-hospitals>.
34. Government of Ontario, Backgrounder: Health-Based Allocation Model (Toronto, Ont.:
Government of Ontario, 2007).
35. Ontario Ministry of Health and Long-Term Care, The Excellent Care for All Act
(Toronto, Ont.: Ontario Ministry of Health and Long-Term Care, 2010).
36. J. S. Graham et al., “Canada: 2010 Ontario Drug System Reforms,” Pharmaceutical,
Healthcare and Life Sciences, accessed from <http://www.mondaq.com/canada/article.
asp?articleid=103668>.
37. British Columbia Ministry of Health Services, Pharmacy Services Agreement (Victoria, B.C.:
Ministry of Health Services, 2010).
38. Competition Bureau of Canada, Benefiting From Generic Drug Competition
in Canada: The Way Forward, last modified November 2008, accessed on
October 13, 2010, from <http://www.competitionbureau.gc.ca/eic/site/cb-bc.nsf/vwapj/
GenDrugStudy-Report-081125-fin-e.pdf/$FILE/GenDrugStudy-Report-081125-fin-e.pdf>.
39. K. Howlett, “Provinces to Team Up on Drug Purchases,” The Globe and Mail, June 8, 2010.
40. Canadian Centre for Policy Alternatives, The Economic Case for Universal Pharmacare
(Ottawa, Ont.: CCPA, 2010).
41. Ministry of Health Services, News Release: B.C. Launches Patient-Focused Funding
Province Wide (Victoria, B.C.: Ministry of Health Services, 2010).
42. J. McFarland, “Hospitals Raise Caution Over Uniform Pay-for-Performance Rules,”
The Globe and Mail, April 9, 2010.
43. S. Duckett, Speaking Notes, Dr. Stephen Duckett, President and Chief Executive Officer,
Alberta Health Services, last modified March 22, 2010, accessed on June 14, 2010, from
<http://www.albertahealthservices.ca/files/org-2010-03-22-senior-citizen-housing.pdf>.
44. interRAI, interRAI HC—Home Care, last modified 2010, accessed from <http://interrai.org/
section/view/?fnode=15>.
45. Canadian Institute for Health Information, Supporting Informal Caregivers—The Heart
of Home Care (Ottawa, Ont.: CIHI, 2010).
46. R. Steinbrook, “Private Health Care in Canada,” New England Journal of Medicine
354, 16 (2006): p. 1661.
47. Canadian Institute for Health Information, Wait Times Tables—A Comparison by Province, 2010
(Ottawa, Ont.: CIHI, 2010).
18
Health Care in Canada 2010
pictures to come later
PART B
Aligning Care With Evidence
Chapter 2
Provided Care Leaves Room for Improvement
Introduction
When presented with three options to control health care spending, almost two out of
three Canadians preferred improving system efficiencies to spending more tax or out-ofpocket dollars.1 One way to do this is to ensure the care provided is appropriate.
The following discussion is about aligning the care provided with evidence of its
appropriateness. Four surgical procedures are highlighted as examples. For two—
therapeutic knee arthroscopies for osteoarthritis and vertebroplasty for osteoporotic
vertebral fracture—research evidence from randomized controlled trials has called into
question the effectiveness of the interventions, yet the procedures continue to be carried
out across Canada.
Although randomized controlled trials provide the strongest level of evidence in testing
whether or not an intervention is beneficial, they are not always feasible or ethical to
undertake. Other levels of evidence, with acknowledgement of the limitations of the
findings, are often brought to bear on the question of appropriateness of care. Findings
of significant differences in rates of an intervention across a population have led to
debate and investigation of what contributes to the variation. Such findings have also
raised questions of the appropriateness of the care in some circumstances. The other
two surgical procedures discussed here are examples of this, as rates of Caesarean
sections and hysterectomies vary significantly across Canada.
Arthroscopic Knee Surgery
for Osteoarthritis
Knee arthroscopy is a minimally invasive surgery used for diagnosing and/or treating
a variety of knee problems. Increasing evidence suggests that, when used to treat
osteoarthritis, this procedure fails to provide additional benefit to improve outcomes
or reduce discomfort compared to physical and medical therapy. 2, 3 Furthermore, there
is some indication that arthroscopic knee surgery is only a temporary measure, with a
substantial number of patients going on to receive a knee replacement within one year
of their arthroscopic surgery.4
Despite this mounting evidence, more than 3,600 i therapeutic knee arthroscopies were
carried out in hospitals across Canada in 2008–2009. By province, age-standardized
rates ranged from a low of 2.8 per 100,000 in Quebec to a high of 36.7 per 100,000 in
Prince Edward Island. ii
Between 2006–2007 and 2008–2009 in Canada, knee arthroscopy rates declined
overall. Part of the decline might illustrate some explicit changes in practice for treating
osteoarthritis of the knee, including better aligning care with the evidence that the
procedure does not improve outcomes for osteoarthritis patients. Although the trend
in the number of knee arthroscopies is on the decline, the more than 3,600 procedures
done in Canada in 2008–2009 suggests there is still room for improvement.
i.
ii.
22
Only therapeutic arthroscopies for osteoarthritis are included. Other exclusions relating to comorbidities
and certain conditions were also applied. Arthroscopies performed outside of hospitals are not included.
Analyses are based on where the facility was located. Few patients travelled out of their home province
to receive the procedure.
Health Care in Canada 2010
Figure
2
Age-Standardized Rates of Therapeutic Knee Arthroscopies by Province,
Canada, 2006–2007 to 2008–2009
Age-Standardized Rate per 100,000
100
80
60
40
20
0
B.C.
Alta.
Sask.
Man.
2006–2007
Ont.
Que.
2007–2008
N.B.
N.S.
P.E.I.
2008–2009
N.L.
Canada
Notes
Numbers for the territories are
suppressed due to small counts but
are included in the Canada rates.
Based on where surgery was
performed, not place of residence
of patients.
Sources
Discharge Abstract Database
and National Ambulatory Care
Reporting System, 2006–2007 to
2008–2009, Canadian Institute
for Health Information; Fichier
des hospitalisations MED-ÉCHO,
2006–2007 to 2008–2009, ministère
de la Santé et des Services sociaux;
Alberta Ambulatory Care Database,
2006–2007 to 2008–2009, Alberta
Health and Wellness.
Vertebroplasty
Vertebroplasty is another example of a surgical procedure with recent evidence
suggesting it may be ineffective in some cases. Vertebroplasty is a spinal surgery
performed percutaneously—that is, through a small hole in the skin. In this procedure
bone cement or synthetic material is infused into a fractured vertebra. Results
of recent randomized controlled trials demonstrated that patients who undergo
vertebroplasty to treat osteoporotic vertebral fractures are not any better off than
those who undergo a placebo procedure where they are anesthetized but no
intervention is performed.5, 6
In Canada, about 1,050 vertebroplasties were performed in 2008–2009. iii Unlike
knee arthroscopy, the volume of vertebroplasty procedures has increased over the
last three years, from approximately 600 in 2006–2007, to 1,050 in 2008–2009. The
increase was evident across most provinces where the procedure was carried out.
Given that osteoporosis is more prevalent among women than men and among
seniors than younger adults,7 it is not surprising that more women than men (65%
versus 35%) underwent this surgery in 2008–2009, and that approximately 71% of
percutaneous vertebroplasties were for people age 65 and older.
Unlike knee arthroscopy, in which 95% of the procedures were done in ambulatory
settings, in 2008–2009, close to 59% of vertebroplasties were carried out in acute
care settings.
iii.
Data coverage issues may exist; thus the actual number of procedures may be significantly higher than
reported here.
Health Care in Canada 2010
23
Figure
3
Number of Percutaneous Vertebroplasty Procedures by Province,
Canada, 2006–2007 to 2008–2009
1,200
Number of Procedures
1,000
800
600
400
200
0
B.C.
Alta.
Sask.
Man.
2006–2007
Ont.
2007–2008
Que.
N.B.
2008–2009
N.S.
Canada
Notes
Numbers for Newfoundland and
Labrador were suppressed but are
included in the Canada totals;
no procedures were reported
for P.E.I. and the territories.
Based on where surgery was
performed, not place of residence
of patients.
Sources
Discharge Abstract Database
and National Ambulatory Care
Reporting System, 2006–2007
to 2008–2009, Canadian Institute
for Health Information; Fichier
des hospitalisations MED-ÉCHO,
2006–2007 to 2008–2009, ministère
de la Santé et des Services sociaux;
Alberta Ambulatory Care Database,
2006–2007 to 2008–2009, Alberta
Health and Wellness.
Impact on the System
The absolute numbers of arthroscopic knee surgery and vertebroplasty procedures
performed in Canada are relatively small; approximately 3,600 and 1,050,
respectively, in 2008–2009. This is especially true in comparison to surgical
procedures such as knee replacement, with more than 47,500 performed in Canada
in 2008–2009. Yet even these small numbers of interventions use system resources
and significantly impact patients. According to an Ontario report, the cost of a knee
arthroscopy performed as an outpatient surgical procedure was $1,150 in 2005.8
Using this figure as the base of estimation, the total cost of knee arthroscopies across
Canada in 2008–2009 would be more than $4.0 million (unadjusted for inflation or
procedural improvements). Estimates of the total cost for professional medical fees
for vertebroplasty in Ontario for 2008–2009 were on the order of $211,000.9
The actual total cost would be even higher if hospital costs were factored in and costs
for these procedures were available across the country. As well, cost is only part of
the equation. Cost does not, for example, reflect the impact on patients’ lives. It also
does not reflect the missed opportunity when valuable health system resources—
such as surgeons, anesthesiologists, nurses, equipment, operating rooms and
hospital beds—are not available to provide other, appropriate, care.
Taken together, when the impact on patients and inefficient resource use are
considered in light of evidence of little benefit, these examples point to opportunities
for improved care. The absolute counts for these procedures may be relatively
small, but the impact on the system of better aligning care with the evidence could
be significant.
24
Health Care in Canada 2010
When Care Varies: C-Sections
and Hysterectomies
Without compelling evidence, choices about the provision of health care are rarely
black and white. When evidence is available, as in the earlier examples, decisions
become clearer. But there are many other examples when the indications are not
as clear. In those cases, care decisions, which in turn affect surgical volumes, are
influenced by system factors (such as access, availability or resources) and patient
factors (such as age, sex or genetic risk).
The first 20 years of health services research in Canada has clearly demonstrated that
when rates of health care services are studied, variations exist. It is well documented
that where people live, their age and their sex, among other factors, influence the
likelihood of having interventions such as hip replacements, knee replacements and
cardiac procedures.10
Generally, variation in rates of services are reported by differences in patient
characteristics (such as age, sex and income), risk factors (such as lifestyle and
genetics) or geography (in Canada by provinces and territories or regional health
authorities). Interactions between these are also reported. Sometimes rate variation
reflects differences in access to services or how services are organized. Sometimes
variation flags differences in practice patterns. Statistical analyses can control for
a number of these factors, such as the differences in the rate of services provided
based on the age of the population or the fact that women experience some health
issues differently than men do. But once these factors are taken into consideration
and sizeable rate variation persists, there are opportunities to dig deeper and ask
why.11 Two examples where rate variations are sizeable across the country are
Caesarean sections and hysterectomies. The discussion below explores some
of the reasons why.
Caesarean Section
Canada, like other countries, has been tracking rates of Caesarean section
(C-section) deliveries for many years. In general the rates have been increasing over
time around the globe12 and have increased dramatically in Canada over the past
two decades.13, 14
C-sections are life-saving in some situations. They are carried out for many reasons,
including, most commonly, to avoid injury to mother and baby in the event of
difficult or non-progressing labour, breech or abnormal fetal position or size, or
non-reassuring fetal heart rate.15 Repeat C-sections are also commonly performed
for women with a previous C-section to prevent tearing the original uterine incision
during labour.16 However, compared with vaginal delivery, women undergoing
C-section delivery are at greater risk of severe morbidity and may face a host of
obstetric complications (including hysterectomy).17 They also face a greater risk
of postpartum readmission to hospital18 and increased risk for complications in
subsequent deliveries.19
Health Care in Canada 2010
25
International Variation
in C-Section Rates
Canada’s overall C-section rate of 26.3 per 100 live births
in 2007 slightly exceeded the Organisation for Economic
Co-operation and Development (OECD) average of 25.7 per
100 live births, placing Canada 17 out of 27 OECD countries
in 2007.12 C-section rates rose in all OECD countries in recent
decades.12 Some research has linked C-section delivery with
increased maternal and infant morbidity, 24 as well as increased
risk of complications in subsequent deliveries.19
In 2008, the Society of Obstetricians and Gynaecologists of Canada and related
Canadian professional organizations released recommendations20, 21 and a joint
policy statement 22 advocating for normal childbirth (that is without interventions such
as C-sections for singleton deliveries). They also recommended that women who
have C-section births attempt a trial of vaginal birth after C-section in subsequent
deliveries, rather than planning for another C-section.23
According to these recommendations and other guidelines from American16 and
British25 medical organizations, C-sections are appropriate only in cases where
vaginal delivery poses medical risk to either the mother or the baby. Because
standardized C-section indications are yet to be determined26, 27 and consensus has
yet to be reached on Canadian and international benchmark rates, the necessary lack
of specificity in these guidelines may contribute to the continued use of C-sections for
discretionary indications and non-medical reasons. 26 Nevertheless, when compared
internationally, Canada’s C-section rate remains high12 and exceeds existing
recommendations. 28–30
26
Health Care in Canada 2010
Country
Figure
4
Caesarean Sections per 100 Live Births, 2007
(or Latest Year Available)
14.0
Netherlands
Norway
Finland
Iceland
Belgium
Czech Republic
Poland
France
Denmark
New Zealand
Slovak Republic
Austria
Ireland
OECD
United Kingdom
Spain
Canada
Germany
Luxembourg
Switzerland
Australia
Hungary
United States
Portugal
Korea
Turkey
Italy
Mexico
15.9
16.0
16.9
17.8
19.6
20.6
20.8
21.4
22.8
23.5
24.4
24.6
25.7
25.8
26.0
26.3
28.5
29.2
30.0
30.3
30.8
31.1
31.2
32.0
36.0
39.7
39.9
0
5
10
15
20
25
30
35
40
45
Rate per 100 Live Births
Source
Organisation for Economic
Co-operation and Development,
OECD Health Data 2009
(Paris, France: OECD, 2009).
Variations in Primary C-Section Rates
Overall C-section delivery rates have increased steadily in Canada since
1995–1996.13, 14 Primary (first) C-section rates rose between 1995–1996 and
2004–2005,14 and have since stabilized at approximately 19% of deliveries.
Repeat C-section rates also rose over this time period,14 and by 2006–2007,
the rate of repeat C-sections stabilized at approximately 82%. This means
8 out of every 10 women who had a C-section in 2008–2009 also had previously
delivered by C-section.
Overall C-section rates (primary plus repeat) and their regional variations have been
reported in detail elsewhere.13 To understand what is driving some of the variations in
the overall C-section rates, new information focusing on primary C-section rates and
risk factors is presented here.
It has been suggested that some C-sections are performed for non-medical
reasons. 26 Variations in rates of primary C-sections across jurisdictions offer an
opportunity to examine this.11 In 2008–2009, the variation in primary C-section rates
was almost double across the provinces and was triple across the territories. Rates
ranged from a high of 23% of deliveries in Newfoundland and Labrador to a low of 5%
in Nunavut. Manitoba had the lowest rate among the provinces at 14%.
Health Care in Canada 2010
27
Appropriate C-Section Rates:
Still a Question
In 1985, the World Health Organization (WHO) recommended that fewer
C-sections be performed and that national C-section rates meet a minimum
of 5% but not exceed a benchmark of 10% to 15%. 28 Subsequently, some
have argued that the recommendations are outdated, inconsistent and
unsafe, as the evidence base for best practices related to C-section births
continues to develop.31, 32 The WHO has since conceded the lack of
evidence supporting its benchmark, stating that “there is no empirical
evidence for an optimum range of percentages, despite a growing body of
research that shows a negative effect of high [C-section] rates.”33 Instead,
the WHO now recommends that nations “continue to use a range of 5-15%
or set their own standards.”33 Despite this, the United States Department of
Health and Human Services still recommends a target C-section rate of 15%
for first-time mothers undergoing low-risk delivery (singleton, full-term,
normal presentation) under its Healthy People 2010 guidelines.30
Many factors are associated with variation in C-section rates, at both patient and
system levels. Patient factors include
• Maternal age;
• Existing conditions like diabetes (gestational or otherwise), obesity
and hypertension;
• Patient choice;
• Previous C-section;
• Baby’s position and size; and
• Multiple births.34, 35
These and other maternal and obstetric conditions are consistently shown to increase
the likelihood of a C-section delivery.15, 36–39
System factors include
• Physician practice patterns;
• Availability of specialists and access to care; and
• The risk tolerance in the health systems delivering the care.40–42
28
Health Care in Canada 2010
Figure
5
Trends in Rates of Primary and Repeat Caesarean Sections,
Canada, 2001–2002 to 2008–2009
100%
Percentage of Deliveries
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2001–2002 2002–2003 2003–2004 2004–2005 2005–2006 2006–2007 2007–2008 2008–2009
Fiscal Year
Repeat: Proportion of C-Section
Deliveries With Previous C-Section
Primary: Proportion of Deliveries
Without Previous C-Section
Notes
Primary C-section rates were
calculated for deliveries without
a previous C-section. Repeat
C-section rates were calculated
for deliveries with a previous
C-section only.
All rates exclude non-residents
of Canada.
Sources
Hospital Morbidity Database,
2001–2002 to 2005–2006 and
Discharge Abstract Database,
2006–2007 to 2008–2009,
Canadian Institute for Health
Information; Fichier des
hospitalisations MED-ÉCHO,
2006–2007 to 2008–2009,
ministère de la Santé et des
Services sociaux.
Across Canada in 2008–2009, approximately 63% of all women with singleton
pregnancies who had not had a previous C-section had at least one risk factor iv
for C-section. The risk factors include several maternal and obstetric conditions
and complications.15, 37–39 Of those at risk for C-section, more than one-quarter (27%)
went on to have a primary C-section delivery. This compares to 2% of deliveries
without risk factors. Primary C-section rates for at-risk deliveries ranged from 10%
in Nunavut to 35% in Newfoundland and Labrador. That C-section rates varied
considerably even among at-risk deliveries points to differences in care provider
culture and practice within and between jurisdictions.
iv.
At-risk deliveries were those having one or more of the following risk factors for C-section delivery:
maternal conditions—heart, liver or renal disease, pre-existing hypertension or diabetes, obesity, asthma,
thrombophilia, systemic lupus, hepatitis B or HIV; obstetric conditions or complications—gestational
hypertension, severe hypertension (eclampsia or severe pre-eclampsia), gestational diabetes, placental
previa, abruption or other placental infection, infant gestational age less than 37 weeks or more
than 41 weeks, breech or other malposition, cephalopelvic or other disproportion, cord prolapse or
other cord disorder, premature membrane rupture, oligohydramnios, fetal distress, asphyxia or nonprogressive labour.
Health Care in Canada 2010
29
Figure
6
Primary Caesarean Section Rates, by Province and Territory,
Canada, 2002–2003, 2005–2006 and 2008–2009
Percentage of All Deliveries
25%
20%
15%
10%
5%
0%
B.C. Alta. Sask. Man. Ont.
Que. N.B.
N.S.
P.E.I. N.L.
Y.T. N.W.T. Nun. Canada
Province/Territory
2002–2003
2005–2006
2008–2009
Notes
Nunavut did not submit to the DAD
in 2002–2003.
Primary C-section rates exclude
abortions and non-residents of Canada
and are calculated for deliveries
without a previous C-section.
Analyses are based on patients’
residences and not on the facility
where they were treated.
Sources
Discharge Abstract Database,
2002–2003, 2005–2006,
2008–2009, Canadian Institute
for Health Information; Fichier
des hospitalisations MED-ÉCHO,
2008–2009, ministère de la Santé
et des Services sociaux.
Impact on the System
Overall, 1 of every 10 dollars spent on inpatient care in Canada is spent on childbirth
and newborn care.43 Compared to vaginal births, C-section deliveries cost hospitals
as much as two times more in obstetric care for both mothers and babies.43 At $4,930
in average hospital inpatient costs per delivery for typical patients, v national estimates
suggest that primary C-sections cost approximately $2,265 more than typical vaginal
deliveries with no other interventions.
In 2008–2009, the total costs for primary C-section hospitalizations were estimated
to be $292 million. vi If primary C-section rates in Canada reached the original range
suggested by the WHO in 1985 (5% to 15%), and vaginal deliveries with no other
interventions were performed instead, the cost savings would be in the order of vi
$97 million
if primary C-section
rates were 5%
in Canada
v.
vi.
30
$61 million
if primary C-section
rates were 10%
in Canada
$25 million
if primary C-section
rates were 15%
in Canada
Typical patients are those who have undergone a normal and expected course of treatment. They exclude
cases involving transfers between acute care facilities, deaths, sign-outs and long-stay cases. Typical
cases made up 94% of all C-section deliveries in 2008–2009.
The estimate is based on the average cost for typical cases and excludes the territories. Cost estimates are
calculated using Cost per Weighted Case, which excludes physician compensation.
Health Care in Canada 2010
Providers are currently operating without an agreed-upon benchmark for C-section
rates. But this does not preclude considering the potential impact reducing rate
variations across the country may have. Of all the provinces, Manitoba has the
lowest, and therefore theoretically achievable, primary C-section rate. If all provinces
achieved Manitoba’s primary C-section rate (14% of all deliveries in 2008–2009), and
vaginal deliveries with no other interventions were performed where C-sections were
not, the overall annual cost difference and reduction in the number of C-sections
performed would be more than $36 million and about 16,200 C-sections in Canada.
Hysterectomy
Hysterectomy is the complete or partial removal of the uterus44 or the removal of
the uterus, fallopian tubes and, sometimes, the ovaries.45 While hysterectomy rates
have steadily declined since the early 1980s for both cancerous and non-cancerous
gynecological conditions, this procedure remains the second-most common surgery
performed on Canadian women, second only to C-section delivery.44 In 2008–2009,
an average of 338 hysterectomies were performed for every 100,000 Canadian
women age 20 or older.44 Similar and even higher hysterectomy rates have also
been reported internationally.46, 47
Evidence-based clinical practice guidelines45 and recommendations 48
for hysterectomy are available in Canada. Despite these, large disparities
in hysterectomy rates exist. In 2008–2009, age-standardized hysterectomy
rates varied threefold across the provinces and territories, ranging from a high
of 512 per 100,000 women age 20 or older in Prince Edward Island to a low
of 185 per 100,000 in Nunavut.44 British Columbia had the lowest rate among
the provinces, at 311 per 100,000. Variations in hysterectomy rates may point
to differences within and between jurisdictions in care provider culture, practice
and approaches to this surgery.44, 49
In addition to significant provincial variation, age-standardized hysterectomy rates
were significantly higher (46%) for women living in rural areas (464 per 100,000)
than for women living in urban areas (318 per 100,000).44 This disparity may be
due to women living in urban areas having greater access to other outpatient
treatment options.44, 50
Where clinical practice does not appear to align with evidence-based guidelines,
questions of appropriateness come into play.11 The analysis above found significant
jurisdictional variation in hysterectomy rates after differences in the patient population
were taken into account. While some of the remaining rate variation was explained
by where women live, urban and rural residence did not explain all variation. Current
guidelines do not provide a benchmark for hysterectomy rates to be evaluated
against; however, the rate variation itself may suggest overuse in some jurisdictions
and underuse in others.
Health Care in Canada 2010
31
Figure
7
Reductions in C-Sections and Estimated Cost Savings
if All Provinces Achieved Manitoba’s C-Section Rate of 14%
of All Deliveries in 2008–2009
Total
16,200
$36,430,000
80
$170,000
P.E.I.
3,210
$6,630,000
B.C.
400
$950,000
N.L.
2,420
$6,170,000
Alta.
Sask.
7,280
1,700
$16,240,000
$3,790,000
Ont.
Que.
320
N.S.
440
$710,000
$1,010,000
N.B.
350
Estimated Reduction in the Number of Primary C-Sections in 2008–2009
Estimated Total Cost Savings in 2008–2009
$760,000
Notes
Cost estimates are based on typical
deliveries and Cost per Weighted
Case, which excludes physician
compensation. They represent savings
where vaginal deliveries with no other
interventions were performed instead
of C-sections. The estimate for Quebec
is calculated using the national
average Resource Intensity Weight
and the national Cost per Weighted
Case. Estimates for the territories
are excluded due to small numbers.
The estimate for Canada excludes
the territories. Analyses are based on
patients’ residences and not on the
facility where they were treated.
Sources
Canadian MIS Database and
Discharge Abstract Database,
2008–2009, 2010 CMG+ Grouping
Methodology, Canadian Institute for
Health Information.
While not setting benchmarks, the current guidelines do provide recommendations
of how to best treat gynecological conditions, with hysterectomy being one of
the options for some conditions. Hysterectomies can be performed vaginally,
laparoscopically or abdominally.48 Current guidelines recommend vaginal
hysterectomy for non-cancerous gynecological conditions, with laparoscopic
hysterectomy as the alternative when vaginal hysterectomy is not possible.45, 48
Abdominal hysterectomy is recommended only when the uterus cannot be removed
by either of the other methods,48 as it is generally more invasive and results in more
recovery time and longer hospital stays.51 Despite the risks, resource implications
associated with longer lengths of stay and guideline recommendations, abdominal
hysterectomy remains the predominate approach used for both cancerous and noncancerous gynecological conditions.13, 52
In 2008–2009, the majority (54%) of hysterectomies performed for non-cancerous
gynecological conditions were abdominal, compared to 32% and 13% performed
using vaginal and laparoscopic approaches, respectively. This pattern persisted
across all jurisdictions except the Northwest Territories. Some research has been
carried out to try to understand why, in light of the recommendations favouring
vaginal hysterectomy, most are still carried out abdominally. Researchers have
suggested that the predominant and continued use of abdominal hysterectomies
may be more influenced by surgeon training, experience and familiarity with the
procedure than by patient characteristics or established and evolving clinical
practice guidelines.13, 53
32
Health Care in Canada 2010
Figure
8
Age-Standardized Hysterectomy Rates by Province and Territory,
Canada, 2008–2009
Age-Standardized Rate per 100,000
600
500
400
300
200
100
0
B.C. Alta. Sask. Man. Ont. Que. N.B.
N.S. P.E.I. N.L.
Province/Territory
Y.T. N.W.T. Nun. Canada
Note
Hysterectomy rates include both
complete and partial hysterectomies.
Analyses are based on patients’
residences and not on the facility
where they were treated.
Sources
Discharge Abstract Database and
National Ambulatory Care Reporting
System, 2008–2009, Canadian
Institute for Health Information;
Alberta Ambulatory Care Database,
2008–2009, Alberta Health and
Wellness; Fichier des hospitalisations
MED-ÉCHO, 2008–2009, ministère de
la Santé et des Services sociaux.
Impact on the System
Researchers have maintained that some hysterectomies are inappropriate54 and, in
some cases, that too many hysterectomies are carried out overall. This is particularly
true for hysterectomy as a first line of treatment where the indication is considered
discretionary (that is, for treating conditions that are neither pre-cancerous nor
cancerous).55 Strategies to reduce hysterectomy rates have been suggested. Based
on physician interviews and expert panel discussions, these include
• Increased medical management of the patient before considering surgery;
• Additional professional education about new techniques (laparoscopy) and
surgical alternatives to hysterectomy (endometrial ablation);
• Improved patient education about treatment options and access to current medical
and surgical therapy; and
• Implementing regular quality assurance checks, such as internal and external chart
review, with feedback on appropriateness of practice.55
In 2008–2009, the total costs for hospitalizations for hysterectomy were estimated
to be $192 million. vii Understanding what rate reduction is possible and quantifying
the impact is challenging. One approach is to look at what has already been
achieved in one jurisdiction and consider the difference—in cost and in number
of procedures—if all jurisdictions achieved the same rate.
vii. The estimate is based on the average cost for typical inpatient and outpatient hysterectomy cases and
excludes the territories. Typical cases made up 96% of all hysterectomy cases in 2008–2009.
Health Care in Canada 2010
33
Figure
9
Proportion of Hysterectomies for Non-Cancerous Conditions by Surgical Approach,
by Province and Territory, Canada, 2008–2009
100%
90%
80%
Proportion
70%
60%
50%
40%
30%
20%
10%
0%
B.C.
Alta. Sask. Man.
Ont.
Que.
N.B.
N.S.
P.E.I. N.L.
Province/Territory
Laparoscopic
Vaginal
Abdominal
Y.T. N.W.T. Canada
Notes
Nunavut was excluded due to
small cell counts.
Hysterectomy rates include both total
and partial hysterectomies. Analyses
are based on patients’ residences
and not on the facility where they
were treated.
Sources
Discharge Abstract Database and
National Ambulatory Care Reporting
System, Canadian Institute for Health
Information; Alberta Ambulatory
Care Database, Alberta Health and
Wellness; Fichier des hospitalisations
MED-ÉCHO, ministère de la Santé et
des Services sociaux.
Despite the significant decline in the overall hysterectomy rate in Canada between
2000–2001 and 2006–2007 (22%),13 there remains considerable variation across the
country. British Columbia had the lowest hysterectomy rate among all the provinces.
Using British Columbia’s rate as an example and applying it to other provinces, the
potential differences can be estimated. That is, if all Canadian women in 2008–2009
had the same rate of hysterectomy as those living in British Columbia (at a rate
of 311 per 100,000 population), there would have been an 11% reduction—about
3,700 cases—in the number of hysterectomies performed nationwide. This would
translate into an estimated savings of more than $19 million in hospitalization costs
for hysterectomies across Canada.
This analysis highlights hysterectomy as an area where greater understanding of the
jurisdictional variations could lead to care more closely aligned with the evidence. It is
important to note that aligning the use of hysterectomy procedures more closely with
the clinical practice guidelines may not ultimately save money in procedural costs.
Guidelines recommend performing more vaginal or laparoscopic hysterectomies
and fewer abdominal hysterectomies.45, 48 Laparoscopic surgical procedures are
longer operations than abdominal procedures, but they cost about the same.48, 51
As well, the comparative costs of vaginal and abdominal surgical procedures are
not reported. If, as some researchers have recommended, some hysterectomies
are replaced with other care,54 the differences above would not represent absolute
savings. The alternatives, such as drug therapy or endometrial ablation to manage
abnormal uterine bleeding or myomectomy to remove uterine fibroids, each have
associated costs. Likely some savings would be achieved in shorter hospital stays
and reduced overall patient morbidity.48 These are good reasons to work toward
ensuring best practices are at the centre of care decisions for all women who are
at risk for hysterectomy in Canada.
34
Health Care in Canada 2010
10
Figure
Reductions in Hysterectomies and Estimated Cost Savings
if All Provinces Achieved British Columbia’s Age-Standardized
Hysterectomy Rate of 311 per 100,000 Population in 2008–2009
Total
3,700
$19,270,000
90
$460,000
210
P.E.I.
$1,110,000
N.L.
720
390
$4,380,000
$1,520,000
1,120
Alta.
Sask.
Man.
340
$5,800,000
Ont.
330
$1,720,000
N.S.
Que.
350
$1,690,000
$1,830,000
N.B.
Estimated Reduction in the Number of Hysterectomies in 2008–2009
Estimated Total Cost Savings in 2008–2009
150
$760,000
Notes
Cost estimates are based on typical
inpatient/outpatient cases and Cost
per Weighted Case, which excludes
physician compensation. The estimate
for Quebec is calculated using the
national average Resource Intensity
Weight and the national Cost per
Weighted Case. Estimates for the
territories are excluded due to small
numbers. The estimate for Canada
excludes the territories. Analyses are
based on patients’ residences and not
on the facility where they were treated.
Sources
Canadian MIS Database, Discharge
Abstract Database and National
Ambulatory Care Reporting System,
2008–2009, 2010 CMG+ and CACS
Grouping Methodology, Canadian
Institute for Health Information.
In Summary
This chapter explored how specific examples of surgical care aligned with different
types of evidence about the appropriateness of their use. In the first two examples—
therapeutic knee arthroscopies for osteoarthritis and vertebroplasty for vertebral
fracture—despite the results of research studies suggesting these procedures have
limited clinical effectiveness, hospitalization data from across Canada showed that
they continue to be performed. Next, in the absence of agreed-upon benchmarks
for rates of the two most common surgical procedures for women, achieved rates in
one jurisdiction were used to estimate potential overall savings for others. Discussion
of these rate variations also suggested that underlying differences in how care is
provided may affect patient outcomes and system efficiencies.
Knowing the costs and the impact on patients, efficient health care systems continue
to look for opportunities to reduce the number of ineffective interventions, for
example, by shifting to more effective but similar procedures when the evidence
suggests this is appropriate. These types of shifts likely result not only in cost
savings, but also—and perhaps more importantly—in more appropriate care
for patients.
Health Care in Canada 2010
35
References
1.
Ipsos, To Deal With Rising Costs of Healthcare, Canadians Prefer Finding Efficiences
(61%) Over Investing More Tax Dollars (28%) or Providing Greater Opportunities
to Pay Out of Pocket (11%) (press release), last modified 2010, accessed from
<http://www.ipsos-na.com/news-polls/pressrelease.aspx?id=4910>.
2.
A. Kirkley et al., “A Randomized Trial of Arthroscopic Surgery for Osteoarthritis
of the Knee,” New England Journal of Medicine 359, 11 (2008): pp. 1097–1108.
3.
J. B. Moseley et al., “A Controlled Trial of Arthroscopic Surgery for Osteoarthritis
of the Knee,” New England Journal of Medicine 347, 2 (2002): pp. 1–8.
4.
G. Hawker et al., “Knee Arthroscopy in England and Ontario: Patterns of Use, Changes
Over Time, and Relationship to Total Knee Replacement,” The Journal of Bone and Joint
Surgery 90 (2008): pp. 2337–2345.
5.
R. Buchbinder et al., “A Randomized Trial of Vertebroplasty for Painful Osteoporotic
Vertebral Fractures,” New England Journal of Medicine 361, 6 (2009): pp. 557–568.
6.
D. F. Kallmes et al., “A Randomized Trial of Vertebroplasty for Osteoporotic Spinal
Fractures,” New England Journal of Medicine 361 (2009): pp. 596–579.
7.
Osteoporosis Canada, What Is Osteoporosis?, last modified 2010, accessed on
July 20, 2010, from <http://www.osteoporosis.ca/index.php/ci_id/5526/la_id/1.htm>.
8.
Medical Advisory Secretariat, “Arthroscopic Lavage and Debridement for Osteoarthritis
of the Knee: An Evidence-Based Analysis,” Ontario Health Technology Assessment
Series 5, 12 (2005).
9.
Medical Advisory Secretariat, “Percutaneous Vertebroplasty for Treatment of Painful
Osteoporotic Vertebral Compression Fractures: An Evidence Update,” Ontario Health
Technology Assessment Series 10 (2010).
10. Institute for Clinical Evaluative Sciences, Access to Health Services in Ontario
(Toronto, Ont.: ICES, 2005).
11. A. Elshaug et al., “Identifying Existing Health Care Services That Do Not Provide Value
for Money,” Medical Journal of Australia 190, 5 (2009): pp. 269–273.
12. Organisation for Economic Co-operation and Development, Health at a Glance 2009:
OECD Indicators (Paris, France: OECD, 2009).
13. Canadian Institute for Health Information, Health Indicators 2009 (Ottawa, Ont.:
CIHI, 2009).
14. Public Health Agency of Canada, Canadian Perinatal Health Report: 2008 Edition
(Ottawa, Ont.: PHAC, 2003).
15. G. E. Hanley et al., “Regional Variation in Caesarean Delivery and Assisted Vaginal
Delivery Rates,” Obstetrics and Gynaecology 115, 6 (2010): pp. 1201–1208.
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Health Care in Canada 2010
16. American College of Obstetricians and Gynaecologists, Practice Bulletin: Vaginal Birth
After Previous Caesarean Delivery (Washington, D.C.: ACOG, 2010).
17. S. Liu et al., “Maternal Mortality and Severe Morbidity Associated With Low-Risk Planned
Caesarean Delivery Versus Planned Vaginal Delivery at Term,” CMAJ 176 (2007):
pp. 455–460.
18. S. Liu et al., “Risk of Maternal Postpartum Readmission Associated With Mode of
Delivery,” Obstetrics and Gynaecology 105 (2005): pp. 836–842.
19. A. M. Galyean et al., “Previous Caesarean Section and the Risk of Postpartum Maternal
Complications and Adverse Neonatal Outcomes in Future Pregnancies,” Journal of
Perinatology 29, 11 (2009): pp. 726–730.
20. Society of Obstetricians and Gynaecologists of Canada, Rising C-Section Rates and
Risks During Childbirth Place Excess Strain on the Healthcare System, Warn Canadian
Obstetricians (Ottawa, Ont.: SOGC, 2008).
21. Canadian Association of Midwives, Midwifery Care and Normal Birth (Montréal, Que.:
CAM, 2010).
22. Society of Obstetricians and Gynaecologists of Canada, “Joint Policy Statement on
Normal Childbirth,” Journal of Gynaecology in Canada 30, 12 (2008): pp. 1163–1165.
23. Society of Obstetricians and Gynaecologists of Canada, “Guidelines for Vaginal Birth
After Previous Caesarean Birth,” Journal of Gynaecology in Canada 30, 12 (2008):
pp. 1163–1165.
24. J. Villar, “Caesarean Delivery Rates and Pregnancy Outcomes: The 2005 WHO Global
Survey on Maternal and Perinatal Health in Latin America,” Lancet 367 (2006):
pp. 1819–1829.
25. Royal College of Obstetricians and Gynaecologists, Clinical Guideline: Caesarean Section
(London, U.K.: RCOG, 2010).
26. T. Lavender et al., “Caesarean Section for Non-Medical Reasons at Term,” Cochrane
Database of Systematic Reviews 3, CD004660 (2006).
27. M. Fourer, “Inconsistent Evidence: Analysis of Six National Guidelines for Vaginal Birth
After Caesarean Section,” Birth 37, 1 (2010): pp. 3–10.
28. World Health Organization, “Appropriate Technology for Birth,” Lancet 2 (1985):
pp. 436–437.
29. B. Chalmers, “WHO Appropriate Technology for Birth Revisited,” British Journal
of Obstetrics and Gynaecology 99, 9 (1992): pp. 709–710.
30. U.S. Department of Health and Human Services, Maternal, Infant, and Child Health
(Washington, D.C.: U.S. Government Printing Office, 2000).
31. L. Dosa, Bulletin of the World Health Organization (Geneva, Switzerland: WHO, 2001).
32. Coalition for Childbirth Autonomy, Challenging the WHO Rate (press release), accessed
from <http://www.mmdnewswire.com/birth-group-cca-calls-on-who-to-re-examineoutdated-and-unsafe-10-15-recommended-cesarean-rate-4073.html>.
Health Care in Canada 2010
37
33. World Health Organization, Monitoring Emergency Obstetric Care: A Handbook (Geneva,
Switzerland: WHO, 2009).
34. E. Declercq et al., “Maternal Risk Profiles and the Primary Caesarean Rate in the United
States, 1991–2002,” American Journal of Public Health 96 (2006): pp. 867–872.
35. C. McCourt et al., “Elective Caesarean Section and Decision-Making: A Critical Review
of the Literature,” Birth 34 (2010): pp. 65–69.
36. M. Neumann and C. Graf, “Pregnancy After Age 35. Are These Women at High Risk?,”
AWHONN Lifelines 7, 5 (2003): pp. 422–430.
37. L. M. Korst, “Rethinking the Cesarean Rate: How Pregnancy Complications May Affect
Interhospital Comparisons,” Medical Care 43, 3 (2005): pp. 237–245.
38. K. D. Gregory, “Using Administrative Data to Identify Indications for Elective Primary
Caesarean Delivery,” Health Services Research 37, 5 (2002): pp. 1387–1401.
39. R. R. Patel et al., “Prenatal Risk Factors for Caesarean Section. Analyses of the ALSPAC
Cohort of 12 944 Women in England,” International Journal of Epidemiology 34 (2005):
pp. 353–367.
40. Society of Obstetricians and Gynaecologists of Canada, Health Human Resource Project
on Intrapartum Emergency Obstetrical Care (Ottawa, Ont.: SOGC, 2008).
41. R. A. Rosenblatt et al., “Interspecialty Differences in the Care of Low-Risk Women,”
American Journal of Public Health 87, 3 (1997): pp. 344–350.
42. T. J. Benedetti et al., “Professional Liability Issues and Practice Patterns of Obstetric
Providers in Washington State,” Obstetrics and Gynaecology 107, 6 (2010): pp. 1238–1246.
43. Canadian Institute for Health Information, Giving Birth in Canada: The Costs (Ottawa, Ont.:
CIHI, 2006).
44. Canadian Institute for Health Information, Health Indicators 2010 (Ottawa, Ont.:
CIHI, 2010).
45. Society of Obstetricians and Gynaecologists of Canada, SOGC Clinical Practice
Guidelines: Hysterectomy (Ottawa, Ont.: SOGC, 2002).
46. K. Whiteman et al., “Inpatient Hysterectomy Surveillance in the United States, 2000–2004,”
American Journal of Obstetrics and Gynaecology 198, 1 (2008): pp. e1–7.
47. E. Hill et al., “Hysterectomy Trends in Australia Between 2000–2001 and 2004–2005,”
Australian and New Zealand Journal of Obstetrics and Gynaecology 50, 2 (2009):
pp. 153–158.
48. T. E. Nieber et al., “Surgical Approach to Hysterectomy for Benign Gynaecological
Disease (Review),” Cochrane Database of Systematic Reviews 3 (2009): accessed from
<http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003677/frame.html>.
49. R. E. Hall and M. M. Cohen, “Variations in Hysterectomy Rates in Ontario: Does the
Indication Matter?,” CMAJ 151, 12 (1994): pp. 1713–1719.
50. G. Santow and M. Bracher, “Correlates of Hysterectomy in Australia,” Social Sciences
& Medicine 34, 8 (1992): pp. 929–942.
38
Health Care in Canada 2010
51. C. B. M. Bijen et al., “Costs and Effects of Abdominal Versus Laparoscopic Hysterectomy:
Systematic Review of Controlled Trials,” Systematic Review of Controlled Trials. PLoS ONE
4, 10 (2009): p. e7340.
52. G. McCracken and G. G. Lefebvre, “Vaginal Hysterectomy: Dispelling the Myths,” Journal
of Obstetrics and Gynaecology Canada 29, 5 (2007): pp. 424–428.
53. S. R. Kovac, “Clinical Opinion: Guidelines for Hysterectomy,” American Journal of
Obstetrics and Gynaecology 191, 2 (2004): pp. 635–640.
54. M. S. Broder et al., “The Appropriateness of Recommendations for Hysterectomy,”
Obstetrics and Gynaecology 95, 2 (2000): pp. 199–205.
55. Ontario Women’s Health Council, Achieving Best Practices in the Use of Hysterectomy:
Report of Ontario’s Expert Panel on Best Practices in the Use of Hysterectomy (Ottawa,
Ont.: OWHC, 2002).
Health Care in Canada 2010
39
Chapter 3
Provided Care Is Not Always Appropriate Care
Introduction
By definition, appropriate care is about providing the right care, to the right person,
in the right setting, at the right time. Sometimes, as highlighted in the last chapter,
providing appropriate care will mean doing less. At other times, as highlighted in
this chapter, it means doing more or doing the same but in a different care setting.
The following discussion looks at three examples—avoidable hospital admissions,
preventive care and monitoring for those with diabetes and unnecessary acute care
hospital stays. For all three, the right care is known, but for a variety of reasons
patients are not getting the best care possible.
Avoidable Hospital Admissions
As defined by the World Health Organization, chronic diseases are of long duration
and slow progression.1 Many people cope every day with lifelong conditions such as
asthma, diabetes, epilepsy and heart disease. Complications associated with these
chronic conditions can potentially be prevented by managing symptoms through
regular monitoring, drug therapies, healthy lifestyles and regular visits with primary
care providers. These conditions are sometimes labelled ambulatory care sensitive
conditions (ACSCs) because many hospitalizations and complications can be
avoided or delayed through appropriate delivery of primary care in the community
and specialty clinics.
One common measure of health system performance is the rate of hospitalizations for
specific ACSCs. CIHI developed an ACSC indicator and has reported on it for many
years. The composite CIHI measure includes several chronic conditions: angina,
asthma, chronic obstructive pulmonary disease, diabetes, epilepsy, heart failure and
pulmonary edema, and hypertension. Since 2001–2002, health system performance
based on this measure has been improving. In fact, the hospitalization rate for ACSCs
in Canada decreased by 30%, from 459 per 100,000 population to 320 per 100,000,
between 2001–2002 and 2008–2009.2
Canada is not the only country to use hospitalizations for ACSCs as a measure
of health system performance. The Organisation for Economic Co-operation and
Development (OECD) publishes international comparisons on avoidable hospital
admissions for condition-specific ACSCs, including asthma, congestive heart failure
and diabetes.
42
Health Care in Canada 2010
Figure
11
Asthma Hospital Admission Rates,
Age 15 and Older, 2007
140
122
120
97
100
92
75
80
73
62
60
58
55
54
52
52
44
40
43
43
42
34
32
26
20
25
21
18
17
ite
d
St
ate
s(
La
tvi
a
20
06
)
Ko
re
a
Un
F
ite inla
n
d
Ki d
n
Ne gdo
m
w
Po Zeal
lan an
d
d
Ja (200
pa
6
)
n
OE (20
CD 05
)
A
Au vera
str
ge
ia
(2
00
6
Be
Ir )
lgi elan
um
d
(2
00
6)
Sp
ain
Fra
nc
De e
nm
ar
k
No
rw
ay
Sw
I
itz
er cela
Ne land nd
th
(2
er
lan 006
ds
)
(2
00
5
Sw )
ed
Ge en
rm
an
Ca y
na
da
Ita
ly
(2
00
6)
0
Un
Rate per 100,000
120
Notes
Data does not fully exclude day cases.
Data includes transfers from other
hospitals and/or other units within
the same hospitals, which marginally
elevates the rates.
Canadian data does not
include Quebec.
The total rates were age–sex
standardized to the 2005 population.
Source
OECD Health Care Quality Indicators
Database, 2009, Organisation
for Economic Co-operation
and Development.
Compared to other countries, Canada i has one of the lowest rates of asthma
admissions (18 per 100,000 population), well below the OECD average (55 per
100,000 population) and second only to Italy (17 per 100,000). Canada also is
doing comparatively well with rates of hospitalization for congestive heart failure (146
per 100,000 population), again below the OECD average (230 per 100,000 population)
and just behind Korea, the U.K. and Japan (with 110, 117 and 134 per
100,000, respectively).
Canada has done well compared to other OECD countries for some avoidable
hospitalization measures. This suggests that primary care providers are appropriately
managing a variety of chronic ACSCs within the community and that hospital
admissions are being avoided.
Canada does not fare equally well for all chronic conditions. Hospitalizations per
100,000 for diabetes in Canada, for example, are above the OECD average (23 versus
21 per 100,000, respectively). The good news is that appropriate care for Canadians
with diabetes is clearly articulated in clinical practice guidelines. The not-so-good
news is that a notable gap exists between expert, evidence-based recommendations
for diabetes prevention and care and the care Canadians living with diabetes
report receiving.
i.
OECD results for Canada do not include Quebec.
Health Care in Canada 2010
43
12
Figure
500
450
Heart Failure Hospital Admission Rates,
Age 15 and Older, 2007
474
441
400
Rate per 100,000
352
350
331
308 306
300
250
289
276
252
234 230
206
200
202 192
188
176 171 169
165 155
150
146 134
117 117 110
100
50
Un
Po
l
ite and
d
St (200
ate
6
s( )
20
06
Ge )
Au rm
an
str
y
ia
(2
0
06
Ita
)
ly
(2
00
6)
Fin
lan
Sw d
ed
en
Fra
Si nce
ng
ap
or
e
OE
S
CD pain
Av
Ne erag
w
e
Ze
ala
nd
Ice
lan
d
Ire
lan
No d
rw
a
Ne
Po y
th
r tu
er
lan
ga
ds
l
(2
Be
0
lgi
um 05)
(2
00
Sw
6
itz Den )
er
m
lan ar
k
d
(2
00
6)
C
Ja ana
pa
da
n
Un
(
ite 200
d
Ki 5)
ng
do
m
La
tvi
a
Ko
re
a
0
Notes
Data does not fully exclude day cases.
Data includes transfers from other
hospitals and/or other units within
the same hospitals, which marginally
elevates the rates.
Canadian data does not
include Quebec.
The total rates were age–sex
standardized to the 2005 population.
Source
OECD Health Care Quality Indicators
Database, 2009, Organisation
for Economic Co-operation
and Development.
Preventive Care for Diabetes in Canada
Diabetes is a serious, chronic condition that affects the body’s ability to produce
or effectively use insulin.3, 4 More than two million Canadians have diabetes, with
thousands of new cases diagnosed each year.4 If not managed, diabetes can lead to
disabling and life-threatening complications.3, 5, 6 For example, diabetes is the single
largest cause of blindness in Canada and is a leading cause of kidney failure, lower
limb amputations and cardiovascular complications such as heart disease.7
When compared to people who do not have diabetes, adults with diabetes are more
likely to be admitted to hospital for serious, sometimes life-threatening, complications
and conditions:
• Four times more likely for heart failure;
• Six times more likely for chronic kidney disease;
• Three times more likely for stroke; and
• Nineteen times more likely for lower limb amputations.4
Once hospitalized, adults with diabetes also tend to have longer lengths of stay.4
44
Health Care in Canada 2010
Figure
13
Diabetes Hospital Admission Rates,
Age 15 and Older, 2007
70
57
60
Rate per 100,000
50
44
40
32
31
30
24
20
23
22
22
21
20
20
19
18
18
17
14
12
11
10
10
8
1
Fin
m
do
ng
Ki
lan
d
Un
ite
d
Ire
Po
l
lan and
d
(2
00
6)
Ca
Be
na
lgi
d
a
um
(2
Au
00
str
6)
ia
(
OE 200
CD
6)
Av
er
ag
e
No
rw
ay
De
nm
ar
k
Sw
ed
en
Sp
ain
Si
ng
ap
or
e
Ko
re
a
Ge
Sw
rm
itz
an
er
lan
y
d
(2
00
6)
Ita
ly
(2
00
6)
Ne
Ice
th
er
lan land
ds
(2
00
Ne
5)
w
Ze
ala
nd
Un
ite
d
St
ate
s(
20
06
)
0
Notes
Data does not fully exclude day cases.
Data includes transfers from other
hospitals and/or other units within
the same hospitals, which marginally
elevates the rates.
Canadian data does not
include Quebec.
The total rates were age–sex
standardized to the 2005 population.
Source
OECD Health Care Quality Indicators
Database, 2009, Organisation
for Economic Co-operation
and Development.
Recommended Care for Diabetes
Originally published in 1998, the Canadian evidence-based clinical practice
guidelines for the management of diabetes recommend a variety of tests and exams
to help protect the health of people with diabetes. Recommendations for preventive
measures were introduced in the 2003 guideline update. They were updated again
in 2008. In addition to generally guiding diabetes prevention and care, the 2008
guidelines recommend annual and biannual testing, including
• Annual (if not more frequent) hemoglobin A1c (HbA1c) tests to monitor control
of blood glucose;
• Annual urine tests to monitor protein levels;
• A dilated eye exam every two years to monitor changes in the retinas’ blood
vessels; and
• An annual foot exam for sores or irritation by a health care professional.9
Despite the availability of these guidelines, only 32% of adult diabetics who
responded to the Canadian Community Health Survey in 2007 reported receiving all
four tests from a health care professional.10 A higher percentage reported receiving
at least one. Four out of five (81%) reported receiving at least one hemoglobin
test. Three-quarters (74%) reported receiving a urine protein test. Two-thirds (66%)
reported having a dilated eye exam in the previous two years, and half (51%) reported
having had their feet checked.
Health Care in Canada 2010
45
Type I and Type II Diabetes
There are two main types of diabetes. In type I diabetes, the pancreas is
unable to produce insulin—a hormone used to regulate glucose (sugar) levels
in the blood and body’s cells. Sometimes called juvenile diabetes, type I is
typically diagnosed among children and adolescents and accounts for
approximately 10% of people with diabetes. In type II diabetes, the pancreas
produces an insufficient amount of insulin or the body is unable to effectively
use the insulin it produces. Sometimes called adult-onset diabetes, it usually
occurs in adults age 40 and older and represents about 90% of people
with diabetes.3, 8
Type II diabetes can be prevented in some cases by making lifestyle changes,
including engaging in regular physical activity, eating a well-balanced diet and
maintaining a healthy body weight.8 Treatment for both types of diabetes may
include drug therapy, insulin injections and lifestyle management. 3
Some diabetic patients were more likely than others to receive all four of the tests.
Those who used insulin—mostly type I diabetics—were more likely to receive all the
recommended tests than those who did not use insulin (50% versus 28%).10 Income
level was also a factor. More patients with comparatively higher household incomes
reported they received all the recommended tests than those with lower incomes.
Forty-two percent of those earning $60,000 or more annually reported receiving
all of the recommended tests in the last year, compared to 32% of those earning
$20,000 to $59,999.10 Of those earning less than $20,000, only 21% received all the
recommended tests in the previous year.
Impact on the System
Health care expenditures for diabetes—including hospitalizations, emergency room
visits, costs of visits to health care professionals and costs of diabetes supplies and
medication—are increasing.6 This is due to increases in the prevalence and incidence
of diabetes as well as associated risk factors. It is also because of complications
diabetics experience once diagnosed.6, 20
46
Health Care in Canada 2010
Figure
100%
90%
14
Percentage of Adults 18 and Older With Diabetes
Who Received Recommended Care Components,
Canada, 2007
81
74
80%
66
70%
60%
51
50%
40%
32
30%
20%
10%
0%
HbA1c Test
Urine Protein
Test
Dilated Eye Exam
Feet Checked
Recommended Care Component
All Four
Recommended
Care Components
Notes
Unknown responses (missing
responses, refused to answer or
“don’t know”) were excluded from
the analysis. Unknown responses
account for less than 5% of responses
for each question individually and for
about 10% for all recommended care
components combined.
Age-standardized to the 2007
Canadian population 18 and older with
non-gestational diabetes.
Excludes gestational diabetes.
Source
Canadian Community Health Survey,
2007, Statistics Canada.
Preventing the onset of diabetes, effectively managing the disease once diagnosed
and following recommended care guidelines all contribute to reducing the burden
of disease on patients, the health care system and communities.9 In a recent study,
a 2% annual reduction in new diabetes cases in Canada translated to a 0.5% annual
reduction in specialist and doctor visits. In turn, costs of diabetes were estimated
to fall by $1.3 billion annually.6 Other researchers have estimated the cost of newly
diagnosed diabetes patients and the cost implications of related complications. 20
An Ontario study found the average cost per new diabetes patient per year was
$5,104. This compares to $2,174 per patient per year for the average annual total
health care cost for non-diabetic patients in Ontario. 20 When costs of complications
are compared between new diabetes patients and those without diabetes who
experienced the same complications, the additional costs associated with diabetes
were $5,133 for amputations, $4,117 for nephropathy and $3,965 for stroke. 20
Preventing the onset of diabetes and other chronic conditions is the most effective
way to reduce the burden of disease on patients and the health care system. Not
all diabetes can be prevented. However, there is good evidence that following the
recommended care guidelines would facilitate diabetes management and help
reduce associated complications and hospitalizations.
Health Care in Canada 2010
47
Preventive Care for Diabetes:
How Does Canada Compare?
In 2007, the U.S. Centers for Disease Control and Prevention reported that 69%
of American diabetics age 18 and older had an annual foot examination and
66% of them had an annual dilated eye exam.11, 12 In comparison, 51% of adult
diabetics in Canada had their feet checked annually and 66% had a dilated
eye exam every two years. While 8 out of 10 Canadian diabetics received
one or more hemoglobin tests in the past year, 7 out of 10 of their American
counterparts received two or more hemoglobin tests in the same time period.
In the U.K., as of September 2009, more than 96% of adult diabetics age 18 and
older were offered eye examinations in the previous year.13 In 2008–2009, more
than 95% of them had a documented hemoglobin test, a blood pressure test
and/or a total cholesterol test.13
Despite the presence of clinical practice guidelines that should facilitate the
integration of the most current evidence into clinical practice, variation in practice
still exists. 21–23 Several studies have explored the barriers to implementing clinical
practice guidelines. 21, 24 Examples of barriers specific to care providers include
• Degree of clinical skill;25
• Educational barriers;26
• Inadequate reimbursement;27
• Time constraints;22 and
• Disagreement with aspects of the clinical practice guidelines. 28
There are also barriers that go beyond individual providers, including patient needs, 25
a system considered limited in supporting chronic disease management 29 and
potential poor adherence by patients to diabetes treatment.30, 31
The current guidelines for diabetes prevention and management recommend a
multidisciplinary team approach to effective diabetes care.9 This would include
primary care physicians, nurses, pharmacists and diabetes educators, among others,
who work with the diabetic individual to achieve optimal care. Today, most diabetics
still rely solely on their family physician to manage their diabetes care.21, 32
When evidence-based recommendations and the care provided are not aligned,
patients and the system are both affected. In Canada there is room to improve
care for diabetes patients. Working to remove the barriers to providing high-quality
care as per the guidelines is the next step.
48
Health Care in Canada 2010
Incentive Billing for Diabetes Care
Across Canada
Provinces and territories across Canada are working toward a model of
community team-based care for chronic diseases such as diabetes. Many
have introduced incentive billing for primary care practitioners to support
the provision of high-quality chronic disease management.
There are several examples specific to diabetes care, including
the following:
• In 2003, British Columbia introduced the Full Service Family Practice
Condition Payment, which is aimed at supporting high-quality
management of congestive heart failure, diabetes and hypertension.
Eligible physicians receive an annual payment of $125 for each
patient with diabetes and/or congestive heart failure whose clinical
management is consistent with recommendations in the B.C. Clinical
Practice Guidelines.14
continued on next page
The Challenge of Alternate Level of Care
In 2007, Pam, a 78-year-old woman who lived alone, became ill with the flu. She was
an independent woman and was usually the one spearheading community initiatives
to provide home care for others. But this time, despite trying hard to manage her
symptoms, she became severely ill. By the time her neighbours checked in on her,
she was so dehydrated she was delusional. After several days in hospital, Pam
regained her strength and her mental clarity. She no longer needed the intense
care provided by her local acute care hospital. However, Pam had not completely
recovered. She was still weak and needed help to wash and cook meals. But she
lived alone and none of her family members lived close enough to help. So Pam had to
stay in hospital an extra five days, occupying an acute care bed, before arrangements
could be made to get her the care she needed at home.
The above story is fictitious, but many Canadians have similar experiences every day.
In defining appropriate care, researchers have described it as a partnership between
patients and providers, wherein the right care is provided in “the right place, at the
right time, to the right person, in the most efficacious way possible.”33 As discussed
in the previous section, for Canadians living with diabetes, the right care is not always
being provided at the right time. Pam’s story illustrates that at other times the place
is not right. Sometimes people need non-acute care, outside of hospitals, but are
unable to access it when needed. When this happens, patients remain in hospital
for longer than may be medically necessary. Hospitals call these stays alternate
level of care (ALC) stays.
Health Care in Canada 2010
49
• In 2006, Ontario introduced the Diabetes Management Incentive,
which is a $60 per patient annual payment available to eligible
physicians for coordinating, providing and documenting all required
elements of care for enrolled diabetic patients.15 According to the
Ontario Medical Association, $11.7 million in incentives was paid
to about 3,900 physicians who followed diabetes management
protocols.16 Ontario is currently building a diabetes patient registry
that will result in faster diagnoses and treatment and improved
management for Ontarians living with diabetes.17
• Manitoba’s Quality Based Incentive Funding provides funding
to clinics for meeting quality targets on selected clinical process
indicators. One indicator related to management of diabetes is
the percentage of diabetic patients who have had an HbA1c test
in the last 12 months.18
continued on next page
In 2006, CIHI published a first attempt to quantify bed days in Canadian hospitals
that were designated ALC. At that time, comparable data was not readily available
for all jurisdictions. In 2010, these patients can be better described. Further, the
impact of patients remaining in hospital when not medically necessary can be
better determined.
Impact on the System
In 2008–2009, there were more than 92,000 hospitalizations and more than
2.4 million hospital days involving ALC stays in Canada. This represents 5% of all
hospitalizations and 13% of all hospital days. In addition, a significant number of
these cases involved long stays. In 2008–2009, 62% of ALC patients had stays of
more than a week, and 24% stayed more than a month in ALC. Five percent of ALC
patients stayed more than 100 days. On any given day, ALC patients occupy the
equivalent of approximately 7,550 beds in acute care hospitals across Canada.
ALC days in acute care facilities often have a domino effect on the health care
system. Because beds being used for ALC patients are not available for patients
needing to be admitted from emergency departments, this may result in prolonged
wait times for in-hospital admissions.34 There is growing concern that over time
there are more ALC stays, and these are increasingly affecting the ability of hospitals
to provide services to those requiring hospital-based care.35–37
50
Health Care in Canada 2010
• Starting in April 2010, eligible family physicians in New Brunswick are paid a base
incentive (about $84 per patient) annually for providing guideline-based care to
diabetic patients. The provincial chronic disease management incentive program
has funding of $1.5 million and $2.0 million for 2010–2011 and 2011–2012,
respectively, and will initially target diabetes.
• In 2005, the Saskatchewan Health Quality Council launched the first Chronic
Disease Management Collaborative, which aims to improve access to family
physicians and care and health of people living with diabetes and/or coronary
artery disease. Participation of physicians is encouraged, as eligible physicians
can receive a payment of $60 or more (if patients have multiple chronic
conditions) per patient visit each quarter.19
Similar financial assistance programs exist, are being established or are under
consideration in other jurisdictions such as Nova Scotia, the Yukon and Alberta.
To date, however, there is no indication that Quebec, Newfoundland and Labrador
and P.E.I. are pursuing such models.
For those provinces where data was comparable, in 2008–2009, Saskatchewan and
Quebec had the lowest ALC rates (2%). Ontario and Newfoundland and Labrador
had the highest, with almost 7% of hospitalizations in those provinces involving
ALC stays. Differences in ALC rates across the provinces may be partially due to
ongoing differences in how ALC days are defined and captured. They may also reflect
differences in funding, the availability of long-term care beds and community care in
different jurisdictions, or differences in targeted strategies to minimize unnecessary
hospital stays.38
ALC Patients Awaiting Discharge
In 2008–2009, the main discharge destination of ALC patients was a long-term care
facility (46%). More than one in four (26%) ALC patients were discharged home and
12% died in hospital. The majority of ALC patients ii who died in hospital were waiting
for either palliative care (46%) or admission to another facility (43%).
The above speaks to ALC patients’ destinations after leaving the hospital. But
why was some portion of their total stay designated ALC to begin with? The most
common reason patients were designated ALC was waiting for admission to another
facility. This was the case for 64% of ALC patients. Of the 64% who were waiting for
placement, 16% were ultimately discharged home. Others were initially designated
ALC because they were waiting for convalescence care (11%) or palliative care
(9%) or because needed medical services—such as chemotherapy—could not be
provided in their homes (5%).38–40
ii.
This and the remaining ALC analyses exclude Quebec due to differences in data reporting.
Health Care in Canada 2010
51
Figure
15
Scope of Alternate Level of Care by Province,
Canada, 2008–2009
Canada
7,540
5%
30
3%
P.E.I.
180
7%
N.L.
950
5%
B.C.
630
3%
Alta.
170
2%
Sask.
540
5%
Man.
3,060
7%
Ont.
1,150
2%
Que.
N.S.
N.B.
Number of hospital bed equivalents used for ALC,
assuming 90% occupancy, rounded to the nearest 10 beds
Percentage of hospitalizations that were ALC related
390
6%
440
4%
Notes
ALC may be defined and recorded
differently in different provinces.
Excludes abstracts from obstetric
and pediatric patients.
Canada data excludes the territories.
Source
Discharge Abstract Database
and Hospital Morbidity Database,
2008–2009, Canadian Institute for
Health Information.
Most patients are classified as ALC at the end of their hospital stay. However, in
2008–2009, 8% of ALC patients were admitted to acute care as ALC. These patients
accounted for almost 11% of all ALC days. The most common reasons for patients to
be designated ALC upon admission were waiting for palliative care (34%), admission
to another adequate facility (27%) or physical therapy (11%).
ALC stays are not limited to acute care settings. According to a recent report on
ALC stays in Ontario’s Greater Toronto Area, ALC patients are occupying up to 4%
of rehabilitation beds and close to 15% of complex continuing care beds used for
a specific type of rehabilitation, called low-tolerance long-duration.41
52
Health Care in Canada 2010
Figure
16
Discharge Destinations for ALC Patients,
Canada, 2008–2009
Other
4%
Rehabilitation Facility
12%
Died
12%
Home
(With/Without Support)
26%
Long-Term Care
46%
Note
Excludes abstracts from obstetric
and pediatric patients.
Sources
Discharge Abstract Database
and Hospital Morbidity Database,
2008–2009, Canadian Institute for
Health Information.
Recognizing the significant impact of ALC on delivery and quality of patient care,
some jurisdictions have taken action to try to address the issue of ACL stays. For
example, the Ontario Ministry of Health and Long-Term Care established several
strategies over the years to reduce pressure related to prolonged waits. Initiatives
such as the Wait Times Strategy, Emergency Room Strategy, Critical Care Strategy
and Aging at Home Strategy among others were introduced. While each addresses
different components of the continuum of care individually, combined these initiatives
target improved access to care, the efficiency of delivering care and the appropriate
setting for care.
The challenge of ALC stays is about addressing questions of availability of services,
access and equity, and patient and family preferences. It is also about maximizing
care settings. Replacing ALC patients with those requiring higher levels of care in
hospital, for example, will likely increase, not decrease, costs. However, it will also
ensure that patients not in need of acute care are receiving the care they do need
and that those needing acute care have beds available.
Health Care in Canada 2010
53
Ontario’s Strategies to Combat
ALC Problems
On August 31, 2010, the Ontario Ministry of Health and Long-Term Care
announced $330.6 million in funding to expand the Aging at Home Strategy.
Initially launched in August 2007, the Aging at Home Strategy is a four-year,
$1.1 billion program aimed at providing support to seniors to continue living
independently in their homes. The strategy is also designed to reduce
number of ALC patients by
• Increasing community beds to help patient transitions;
• Ensuring high-quality care delivered both inside and outside the hospital
to avoid unnecessary readmissions;
• Enhancing home care; and
• Providing nursing outreach teams for high-risk seniors living in long-term
care homes and in the community.42
In Summary
This chapter asked questions about appropriateness of care by examining instances
where the right care and right place were called into question. In comparison to other
developed countries, Canadians are hospitalized less often for some ambulatory
care sensitive conditions, including heart failure and asthma. Not so, however, for
diabetes. Canadian diabetics are hospitalized more often than those living in other
countries. The data in this chapter points to significant gaps between recommended
care and the care Canadians living with diabetes report getting. The data on ALC
stays is also about providing appropriate levels of care but focuses on how care is
organized rather than the number of tests being done. In both cases, the evidence
shows there is room for improvement, as some care is not optimized and some
patients are not getting what they need where they need it.
54
Health Care in Canada 2010
References
1.
World Health Organization, Chronic Diseases, last modified 2010, accessed on
August 12, 2010, from <http://www.who.int/topics/chronic_diseases/en/>.
2.
Canadian Institute for Health Information, Health Indicators 2010 (Ottawa, Ont.:
CIHI, 2010), pp. 35–80.
3.
Canadian Diabetes Association, Diabetes Facts, last modified 2010, accessed
on July 20, 2010, from <http://www.diabetes.ca/diabetes-and-you/what/facts/>.
4.
Public Health Agency of Canada, Report From the National Diabetes Surveillance System:
Diabetes in Canada, 2009 (Ottawa, Ont.: PHAC, 2009).
5.
Public Health Agency of Canada, Complications of Diabetes, last modified 2008, accessed
on July 20, 2010, from <http://www.phac-aspc.gc.ca/cd-mc/diabetes-diabete/diabetes_
complications-diabete_complications-eng.php>.
6.
Canadian Diabetes Association, An Economic Tsunami: The Cost of Diabetes in Canada
(Toronto, Ont.: CDA, 2009).
7.
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August 6, 2010, from <http://www.phac-aspc.gc.ca/publicat/dic-dac99/index-eng.php>.
8.
Ontario Ministry of Health and Long-Term Care, Stand up to Diabetes: Preventing
Diabetes, last modified September 29, 2009, accessed on September 9, 2010, from
<http://www.health.gov.on.ca/en/ms/diabetes/en/preventing_diabetes.html>.
9.
Canadian Diabetes Association, “Canadian Diabetes Association 2008 Clinical Practice
Guidelines for the Prevention and Management of Diabetes in Canada,” Canadian Journal
of Diabetes 32, 1 (2008): pp. 1–215.
10. Canadian Institute for Health Information, Diabetes Care Gaps and Disparities in Canada
(Ottawa, Ont.: CIHI, 2009).
11. Centers for Disease Control and Prevention, 2007 National Diabetes Fact Sheet, last
modified 2007, accessed on July 20, 2010, from <http://www.cdc.gov/diabetes/pubs/
factsheet07.htm#contents>.
12. Centers for Disease Control and Prevention, Diabetes Data & Trends, last modified 2009,
accessed from <http://www.cdc.gov/diabetes/statistics/preventive/mUSTableMenu.htm>.
13. Department of Health, Six Years On: Delivering the Diabetes National Service Framework
(London, U.K.: Department of Health, 2010).
14. Government of British Columbia, Full Service Family Practice Incentive Program,
last modified April 13, 2007, accessed on September 10, 2010, from
<http://www.health.gov.bc.ca/cdm/practitioners/fullservice.html>.
15. Ontario Ministry of Health and Long-Term Care, Fact Sheet: Diabetes Management
Incentive (2006), accessed on September 10, 2010, from <http://www.anl.com/
MOHGUIDE/00%20Diabetes%20Management%20Incentive%20-%20April%202006.pdf>.
16. Ontario Medical Association, “OMA Policy on Accountability in the Health-Care Sector,”
Ontario Medical Review July/August (2009): pp. 17–29.
Health Care in Canada 2010
55
17. Ministry of Health and Long-Term Care, Guide to Chronic Disease Management and
Prevention (Toronto, Ont.: MOHLTC, 2005).
18. Program Evaluation and Economic Konsulting, Quality Incentive Payments: International
Experiences, Lessons for Canada (Winnipeg, Man.: Government of Manitoba, 2007).
19. Health Quality Council, Reports From CDMC I (2010), accessed from <http://www.hqc.
sk.ca/portal.jsp?IPsxAygNYpdjpTuPbFF+UDBIzBf0QfLQkUwK4QBZaJtn0S0v2G9CT1VvI5
thiwzu>.
20. R. Goeree et al., “Prevalence, Total and Excess Costs of Diabetes and Related
Complications in Ontario, Canada,” Canadian Journal of Diabetes 33, 1 (2009): pp. 35–45.
21. S. B. Harris et al., “Type 2 Diabetes in Family Practice. Room for Improvement,” Canadian
Family Physician 49, 6 (2003): p. 778.
22. S. B. Harris et al., “Lifestyle Management for Type 2 Diabetes,” Canadian Family Physician
50 (2004): pp. 1235–1243.
23. S. Vachhrajani et al., “Clinical Practice Guidelines,” Journal of Neurosurgery: Pediatrics 3,
4 (2009): pp. 249–256.
24. M. J. Irving et al., “Nephrologists’ Perspectives on the Effect of Guidelines on Clinical
Practice: A Semistructured Interview Study,” American Journal of Kidney Diseases 55, 2
(2010): pp. 241–249.
25. K. A. Peterson and F. Vinicor, “Strategies to Improve Diabetes Care Delivery,” Journal
of Family Practice 47, 5 (1998): pp. S55–62.
26. R. B. Haynes, “Some Problems in Applying Evidence in Clinical Practice,” Annals of the
New York Academy of Sciences 703 (1993): p. 210.
27. J. N. Lavis et al., Evidence Brief: Optimizing Diabetes Management in Ontario
(Hamilton, Ont.: McMaster Health Forum, 2009).
28. M. D. Cabana et al., “Why Don’t Physicians Follow Clinical Practice Guidelines?:
A Framework for Improvement,” JAMA 282, 15 (1999): p. 1458.
29. Health Council of Canada, Why Health Care Renewal Matters: Lessons From Diabetes
(Toronto, Ont.: HCC, 2007).
30. A. C. Larme and J. A. Pugh, “Attitudes of Primary Care Providers Toward Diabetes:
Barriers to Guideline Implementation,” Diabetes Care 21, 9 (1998): p. 1391.
31. E. Vermeire et al., “Interventions for Improving Adherence to Treatment Recommendations
in People With Type 2 Diabetes Mellitus,” Cochrane Database of Systematic Reviews 2,
CD003638 (2005).
32. L. Jaakkimainen et al., Sources of Physician Care for People With Diabetes in Ontario:
An ICES Practice Atlas (Toronto, Ont.: Institute for Clinical Evaluative Sciences, 2003),
pp. 181–191.
33. B. A. Liang, “A System of Medical Error Disclosure,” Quality and Safety in Health Care 11, 1
(2002): pp. 64–68.
56
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34. Ontario Health Quality Council, 2010 Report on Ontario’s Health System (Toronto, Ont.:
OHQC, 2010).
35. Ontario Association for Community Care Access Centres et al., Alternate Level of Care—
Challenges and Opportunities. A Collaborative Position Paper (Toronto, Ont.: OHA, 2006).
36. A. Yassi et al., Caring for the Caregivers of “Alternate Level Care” (ALC) Patients: The
Impact of Healthcare Organizational Factors in Nurse Health, Well Being, Recruitment
and Retention in the South Fraser Health Region of British Columbia (Vancouver, B.C.:
Occupational and Safety Agency for Healthcare in B.C., 2008).
37. Centre for Healthcare Quality Improvement, The Flo Collaborative: Quality Transitions
for Better Care (Toronto, Ont.: Ministry of Health and Long-Term Care, 2009).
38. Canadian Institute for Health Information, Alternate Level of Care in Canada (Ottawa, Ont.:
CIHI, 2008).
39. S. Lewis and J. Hader, Barriers to Community Care (Regina, Sask.: Saskatchewan Health
Services Utilization and Research Commission, 1993).
40. Manitoba Centre for Health Policy and Evaluation, Alternative to Acute Care
(Winnipeg, Man.: MCHPE, 1996).
41. GTA Rehab Network, Beyond Acute Care: Next Steps in Understanding ALC Days
(Toronto, Ont.: GTA Rehab Network, 2008).
42. Ministry of Health and Long-Term Care, Aging at Home Strategy, last modified
2010, accessed from <http://www.news.ontario.ca/mohltc/en/2010/08/
aging-at-home-strategy.html>.
Health Care in Canada 2010
57
Chapter 4
Substantial Improvement in Care:
The Way Forward
Introduction
When Canadians are asked how satisfied they are with the care they receive, an
overwhelming majority inevitably say “very.”1–3 Despite this, Part 2 of Health Care in
Canada 2010 highlighted areas where clear opportunities exist to improve the care
provided by better aligning it with the evidence. Reduce the number of ineffective
surgical procedures. Ask questions about appropriateness of care when rates of
procedures vary two- and threefold across the country. Ensure patients get the
services recommended by care guidelines to improve their outcomes and reduce
demands on the health care system. When hospital care is not required, investigate
how care can be better organized to minimize unnecessary hospital stays.
It is difficult to fully quantify savings related to these measures or to know directly
whether they will reduce overall health care costs. It is harder to argue that patient
outcomes would not be improved. The way forward is about improving care in the
future. More specifically, it is about learning from examples where focus, attention
and data have all contributed to improving care, improving patient outcomes and,
in turn, reducing demands on the health care system. The examples highlighted in
this section relate to cardiac care in Canada and updated results from CIHI’s hospital
standardized mortality ratio (HSMR).
Heart Disease and Heart Health
in Canada
The most common form of heart disease is coronary artery disease.4 Coronary artery
disease occurs when blood flow to the heart tissue is interrupted by blockage in the
coronary arteries. This blockage in the heart’s arteries either fully or partially deprives
it of oxygen. This in turn can cause chest pain—called angina—or, in more severe
cases, acute myocardial infarction (AMI), also called heart attack.4
Outcomes for patients with coronary artery disease are improving. Targeted efforts by
researchers and health care providers—networks such as the Cardiac Care Network,
the Heart and Stroke Foundation and others—have all contributed to improving our
understanding of the factors that influence cardiac health. This knowledge leads to
efficiencies in how cardiac care is delivered, such as centralizing treatment, refining
surgical procedures and moving to less invasive procedures or drug therapies when
warranted and indicated. Over the past 40 years, mortality rates for coronary artery
disease have decreased, and the disease has dropped from the leading cause of
death to the second leading cause in Canada, behind deaths due to all types of
cancers.5, 6 Coronary artery disease hospitalizations and in-hospital deaths from heart
attack, as well as heart attack readmissions, continue to decline in Canada, despite
recent evidence of rising rates of risk factors such as obesity, diabetes and high
blood pressure.6, 7
60
Health Care in Canada 2010
The Early Impacts of Smoking Bans
Many of the risk factors for heart disease such as obesity, diabetes and
hypertension continue to increase. The good news is that rates of cigarette
smoking are decreasing while physical activity and consumption of fruits and
vegetables are increasing.6, 7 Campaigns urging smokers to quit and laws
restricting where people can smoke represent true success in dealing with
a key risk factor for cardiovascular diseases.
Within the last decade, all provinces and territories in Canada have enacted
legislation banning smoking in public spaces, with some variation in what
constitutes a public space.8 For example, ventilated smoking rooms are permitted
in some jurisdictions. In others, smoking is not allowed even in private vehicles
when children are present.8 Overall, these laws, along with their substantial fines
and other consequences, have severely restricted smokers’ options.
continued on next page
Hospitalizations for Cardiac Care
Over the four-year period examined, hospitalizations for new heart attacks declined
in Canada. In 2004–2005, the age-adjusted rate was 239 per 100,000 population
age 20 and older. In 2008–2009, the rate dropped to 217 per 100,000. However, not
all jurisdictions saw similar declines. While the rate declined in Ontario and Alberta,
for example, it remained on the rise in Newfoundland and Labrador.
Hospitalizations for angina—a less severe form of coronary artery disease—have
followed suit. That is, rates have declined in almost all jurisdictions over the same
four-year period, meaning fewer Canadians were hospitalized with angina. This
could be due to increased prevention and outpatient treatment in the community,
among other factors. In absolute terms, declines in angina hospitalizations are
greater than the declines in AMI hospitalizations. But as with heart attacks, regional
variations persist.
Health Care in Canada 2010
61
In addition to the direct health benefits of reduced smoking, banning smoking
in public places appears to have contributed to declining rates of hospitalization
for cardiovascular diseases. Reductions in emergency department visits, hospital
admissions and even deaths from AMI after public smoking was banned have
been noted. For example, a recent study following Toronto, Ontario’s, 2001 ban
on smoking in public spaces found a 17% decrease in AMI hospitalization rates
and a 39% decrease in hospital admissions due to cardiovascular conditions.9
These decreases were significant when compared to those found in other cities
without smoking bans or restrictions. Meta-studies that combined findings from
different studies around the globe also recorded reductions of 17% to 19% in AMI
hospital admissions associated with smoking restriction laws.10, 11
The impacts on heart health go beyond personal choices to smoke. Evidence
suggests that second-hand smoking also increases the risk of AMI, as well as
other cardiovascular conditions.12, 13 Despite obvious successes, smoking remains
an important risk factor for cardiovascular disease.14 Sustained efforts to reduce
smoking are no doubt needed to maintain these successes into the future.15
Outcomes of Care for Heart Attack
CIHI data can be used to measure two outcomes of care for AMI patients: 30-day
in-hospital mortality and unplanned readmissions. i The importance of mortality as
an outcome measure is perhaps more immediately obvious. Unplanned readmissions
for AMI patients speak to the management of cases prior to discharge and the followup care received afterward.18, 19 Readmissions are not only preventable in some
cases, they are also costly in their impact on the system and on patients.19
Thirty-day AMI in-hospital mortality rates in Canada dropped, from 10% to 9%
from 2003–2004 to 2007–2008. Annual unplanned AMI readmission rates also
made a drop, from 7% to 5%. As seen with hospitalizations, there remains room
for improvement in both mortality and readmission outcome measures when
comparing the different jurisdictions.
Prince Edward Island, for example, had 30-day AMI in-hospital mortality rates of
9.8%, compared to 7.3% in Alberta. Heart attack readmission rates are highest in
the eastern provinces, at 6% in both Prince Edward Island and Newfoundland and
Labrador, and lowest in Alberta at 4% (results pooled for 2006–2007 to 2008–2009).20
The decrease in heart attack mortality rates is not unique to Canada. The U.S.,
Sweden, the U.K. and Australia have all reported similar trends in the past six years. 21
i.
62
Readmission to any acute care facility.
Health Care in Canada 2010
Distinguishing Types of Heart Attack
Being able to distinguish specific types of heart attacks is vital to subsequent
treatment decisions and patient outcomes.16 Electrocardiography is the diagnostic
test used to classify heart attacks as either ST-segment elevated myocardial
infarction (STEMI) or non-ST-segment elevated myocardial infarction (NSTEMI).16
STEMI cases are more serious, involve full blockage of the coronary artery and
require immediate invasive intervention, including PCI or fibrinolytic therapy.
In NSTEMI cases, the blockage is only partial and intervention need not be
as invasive.15, 17
Distinguishing STEMI from NSTEMI cases is one of the steps in assessing the
seriousness of AMI. Other diagnostic tests are important in distinguishing AMI
from angina.17
Targeting Appropriate Care to Specific Types
of Heart Attack
Overall declines in hospitalizations and in-hospital deaths are the result of many
contributing factors. Reduced smoking and improved medical interventions
are perhaps the most influential. Drug therapies such as statins, aspirin,
angiotensin converting enzyme inhibitors (ACE inhibitors) and beta blockers
are being used more intensively to treat risk factors, such as hypertension and
hypercholesterolemia. 22 The increasing use of diagnostic and revascularization
procedures, such as catheterization for diagnosis and percutaneous coronary
intervention (PCI) when heart attack is diagnosed, have also contributed to
overall declines. 23
As the more serious type of heart attack and according to practice guidelines, STEMI
cases require immediate intervention. This could include fibrinolytic therapy and/or
revascularization procedures such as PCI or CABG. 24 For the less serious NSTEMI
cases, guidelines indicate treatment should rely on further risk assessments based
on the progression of signs and symptoms.16, 17, 25
Health Care in Canada 2010
63
Figure
17
AMI Hospitalization Rates, by Province and Territory,
Canada, 2004–2005 to 2008–2009
Hospitalizations per 100,000
(Age-Standardized)
350
300
250
200
150
100
50
B.C.
Alta.
Sask.
Man.
Ont.
Que.
N.B.
N.S.
Province/Territory
Total
Other and Not Classified
NSTEMI Classified
STEMI Classified
Prior to 2007–2008, it could not reliably be determined from CIHI data which heart
attacks in Canada were STEMI and which were NSTEMI. In 2007–2008, changes
to the Canadian Coding Standards were made so that these distinctions could be
tracked. In 2008–2009, the changes were refined, and now due to improved data
capture the ways different types of heart attacks are treated can be investigated.
In 2008–2009, approximately one-third of heart attacks in Canada were classified as
STEMI. Newfoundland and Labrador had the lowest proportion of STEMI-classified
heart attacks (22%) while Saskatchewan had the highest (36%). Patients with heart
attacks classified as STEMI had a 68% chance of receiving a revascularization
procedure within 30 days, compared to 39% among NSTEMI-classified patients
in 2008–2009.
In addition, STEMI-classified patients were about five times more likely than NSTEMIclassified patients to receive a revascularization procedure within 48 hours of
being hospitalized. Approximately 46% of STEMI-classified patients, compared
to only about 9% of NSTEMI-classified patients, received any revascularization
procedure (PCI or CABG) within 48 hours of being hospitalized with a new heart
attack in 2008–2009.
Looking at PCI only, STEMI-classified patients were six times more likely to receive
PCI within 48 hours than NSTEMI-classified patients in 2008–2009. Researchers who
analyzed similar data for Quebec from 1996–1997 to 2006–2007 found rates of PCI in
the first 48 hours increased throughout the study period, notwithstanding the finding
that PCI rates overall plateaued in 2005–2006.26 This could be due to changes in
medical decisions to carry out early PCIs or improvements in wait times.26
64
Health Care in Canada 2010
P.E.I.
2008–2009
2007–2008
2006–2007
2005–2006
2004–2005
2008–2009
2007–2008
2006–2007
2005–2006
2004–2005
2008–2009
2007–2008
2006–2007
2005–2006
2004–2005
2008–2009
2007–2008
2006–2007
2005–2006
2004–2005
2008–2009
2007–2008
2006–2007
2005–2006
2004–2005
2008–2009
2007–2008
2006–2007
2005–2006
2004–2005
2008–2009
2007–2008
2006–2007
2005–2006
2004–2005
2008–2009
2007–2008
2006–2007
2005–2006
2004–2005
2008–2009
2007–2008
2006–2007
2005–2006
2004–2005
0
17
AMI Hospitalization Rates, by Province and Territory,
Canada, 2004–2005 to 2008–2009 (cont’d)
350
300
250
200
150
100
50
N.L.
Y.T.
N.W.T.
Nun.
2008–2009
2007–2008
2006–2007
2005–2006
2004–2005
2008–2009
2007–2008
2006–2007
2005–2006
2004–2005
2008–2009
2007–2008
2006–2007
2005–2006
2004–2005
2008–2009
2007–2008
2006–2007
2005–2006
2004–2005
2008–2009
2007–2008
2006–2007
2005–2006
0
2004–2005
Hospitalizations per 100,000
(Age-Standardized)
Figure
Canada
Province/Territory
Total
Other and Not Classified
NSTEMI Classified
STEMI Classified
Notes
Includes all adults age 20 and older.
Quebec data before 2007 was
not included due to differences in
data reporting.
Total Canadian estimates do not
include Quebec.
A coding directive in Quebec that
mandates the coding of STEMIclassified cases but allows for optional
coding of NSTEMI-classified cases
negates full comparison of Quebec to
other provinces and territories.
Sources
Discharge Abstract Database,
Canadian Institute for Health
Information; Fichier des
hospitalisations MED-ÉCHO, ministère
de la Santé et des Services sociaux.
This suggests that care for these patients is beginning to align with the evidence, as
the care guidelines for treatment of AMI recommend immediate treatment (such as
PCI) for STEMI patients.17
This data reveals new information about heart attack care in Canada by showing
differences in treatment with revascularization for STEMI-classified and NSTEMIclassified heart attacks:
• STEMI-classified patients were overall more likely to undergo any type of
revascularization within 30 days than those with less severe heart attacks.
• A higher proportion of STEMI-classified patients were treated with PCI versus
CABG, compared to those with less severe heart attacks.
The pattern of results also shows some similarities:
• When revascularization was required, PCI was consistently used over CABG
to treat both STEMI-classified and NSTEMI-classified cases.
• Among both STEMI-classified and NSTEMI-classified cases, there were
differences across jurisdictions in the proportion who underwent either type
of revascularization within 30 days.
• Among both STEMI-classified and NSTEMI-classified cases, the differences across
jurisdictions in the use of PCI appeared to be greater than the differences across
jurisdictions in the use of CABG.
Health Care in Canada 2010
65
CIHI–CCN Cardiac Care Quality Indicators
Pilot Project
CIHI and the Cardiac Care Network of Ontario (CCN) have developed a set of cardiac care
quality indicators in consultation with a national cardiac expert panel. The purpose of these
comparative performance indicators support cardiac care centres with routine monitoring of
their quality of care and foster an environment of quality improvement. Using data from CIHI’s
Discharge Abstract Database and National Ambulatory Care Reporting System, 14 indicators
provide new information to hospitals on outcomes related to select cardiac
interventions, including
•
•
•
•
•
Diagnostic cardiac catheterization;
Percutaneous coronary intervention;
Isolated coronary artery bypass graft (CABG) surgery;
Isolated valve surgery; and
Combined CABG and valve surgery.
Additionally, the indicators provide hospitals with information on outcomes occurring outside
of their walls—such as transfers or readmissions to other facilities—for a more complete
picture of patient care. Cardiac centres from Ontario and British Columbia participated
in this pilot project. For more detailed information, contact us at [email protected]
Indicators of patient outcomes following treatment for STEMI versus NSTEMI heart
attacks have yet to be developed. Nevertheless, more is now known about the care
and treatment of patients with heart attacks in Canada than only a few years ago.
This is good news and a first step on the way forward to learning more about care
for STEMI and NSTEMI patients specifically.
Impact on the System
Cardiac care is costly in Canada. Overall hospitalization costs for each heart attack
treated nationally ii are approximately $9,400. iii And the cost of cardiac care is rising.
Researchers have suggested that two of the main cost drivers are the increase in
the use of both invasive and non-invasive technologies and the proliferation of other
cardiac treatments, such as drug-eluting stents. 27
The cost of drug therapies is also rising. Between 1996 and 2006, the cost of drug
therapies to treat cardiovascular diseases increased by 200% in Canada. Statins,
ACE inhibitors and calcium agonists account for most of the expenditure on
cardiovascular medications. 28 Western provinces and the territories spent less per
capita on medications for cardiovascular diseases during this period than did the
rest of Canada. 28 This may not be surprising given the lower risk of cardiovascular
diseases and lower rates of heart attack hospitalizations, in British Columbia in
particular. In addition, British Columbians are more likely to be prescribed lowercost therapeutic alternatives than Canadians in other jurisdictions. 29 It also begs the
question of what could be achieved if all provinces and territories were to lower their
heart attack hospitalization rates to that of British Columbia’s. Following, a high-level
calculation serves to estimate what that might look like for each jurisdiction.
ii.
iii.
66
The estimate does not include Quebec and is based on all heart attack hospitalizations.
All cost data presented in this section is calculated using Cost per Weighted Case, which excludes
physician compensation.
Health Care in Canada 2010
Figure
18
Angina Hospitalization Rates, by Province and Territory,
Canada, 2004–2005 to 2008–2009
Hospitalizations per 100,000
(Age-Standardized)
350
300
250
200
150
100
50
0
B.C.
Alta.
Sask.
Man.
Ont.
Que.
N.B.
N.S.
P.E.I.
N.L.
Y.T.
N.W.T.
Nun.
Canada
Province/Territory
2004–2005
2007–2008
2005–2006
2008–2009
2006–2007
Note
Includes all adults age 20 and older.
Sources
Discharge Abstract Database, Canadian Institute for
Health Information; Fichier des hospitalisations MEDÉCHO, ministère de la Santé et des Services sociaux.
British Columbia has the lowest rates of coronary artery disease in the country.
People in B.C. also have the healthiest lifestyles. British Columbians smoke less, are
more physically active, eat more fruits and vegetables (second only to Quebecers)
and have lower obesity rates than people in other provinces and territories.7, 30 Their
healthy lifestyles contribute to their overall low rates of heart attack hospitalizations.
Forty-two percent of the regional variation in coronary artery disease mortality in
Canada has been attributed to differences in healthy lifestyle factors.31
Reducing heart attack hospitalization rates in other provinces to the level achieved in
British Columbia would likely include both health promotion and disease prevention
efforts. If achieved, however, the savings to the system for treating heart attacks
would be on the order of a 22% reduction—about 15,480 cases—and a savings
of approximately $125 million in hospitalization costs. Savings and reduced
hospitalizations would vary depending on the existing rates per jurisdiction.
Such hospitalization reductions would not represent an absolute reduction in costs
to the system. Likely some of these savings would be replaced, appropriately so, with
other care, which has its own associated costs.
Health Care in Canada 2010
67
Figure
19
Annual 30-Day AMI In-Hospital Mortality
and Unplanned AMI Readmission Rates,
Canada, 2003–2004 to 2007–2008
12%
Risk-Adjusted Rate
10%
10.2
10.0
9.9
9.7
9.1
5.1
4.7
8%
6%
6.8
6.1
5.5
4%
2%
0%
2003–2004
2004–2005
2005–2006
30-Day In-Hospital Mortality Rate
2006–2007
2007–2008
Acute Readmission
Notes
Readmission: Rates do not include
Quebec due to differences in data
collection. The rate for 2003–2004
does not include Manitoba due
to differences in data collection.
To obtain annual results the rates
were risk-adjusted using data from
2003–2004 to 2007–2008. The trend
is statistically significant (p<0.05).
Readmissions are unplanned
readmissions for reasons related to
the initial AMI episode.
Mortality: Rates do not include Quebec
due to differences in data collection.
To obtain annual results the rates
were risk-adjusted using data from
2003–2004 to 2007–2008. The trend
is statistically significant (p<0.05).
Sources
Hospital Morbidity Database,
Discharge Abstract Database and
National Ambulatory Care Reporting
System, Canadian Institute for Health
Information; Alberta Ambulatory
Care Database, Alberta Health
and Wellness.
Measuring Quality of Care: The
Hospital Standardized Mortality Ratio
The cardiac care example is one illustration of the gains made when multifaceted
efforts are put in place targeting improvements in a specific patient outcome. A
second example of when focus, attention and data have all contributed to improving
care, patient outcomes and, in turn, reducing demands on the health care system is
the hospital standardized mortality ratio (HSMR). Improvements over time, inclusion
in formal reporting structures and success stories detailing specific changes made
in facilities all demonstrate that providing such results can inform continuous
improvement efforts in facilities, health regions and ministries of health.
Improving Health System Performance
Researchers have linked health system performance measurement and reporting to
resulting improvements in the system. Berwick et al.32 identified two distinct pathways
through which quality measurement can lead to improvement in health care settings.
The first is called selection and the second is called change.
Selection improves performance by influencing choices that in turn shift where and
by whom care is delivered.32 For example, information on volumes of care for specific
interventions can be collected and reported on at the level of facilities or of individual
providers. This allows primary care physicians—or individual patients—to select
specific facilities or providers with, for example, higher volumes. For interventions
where higher volumes are associated with better outcomes, this can result in better
outcomes for patients.
68
Health Care in Canada 2010
Figure
20
Management of STEMI-Classified Hospitalizations
by Type of Revascularization Procedure, by Province,
Canada, 2008–2009
100%
90%
Percentage of Hospitalizations
80%
70%
60%
50%
40%
30%
20%
10%
0%
B.C.
Alta.
PCI
Sask.
Man.
Ont.
CABG
N.B.
N.S.
P.E.I.
N.L. Canada
No Revascularization
Notes
Includes all adults age 20 and older,
excluding Quebec due to differences
in data reporting.
Procedures were identified within 30 days
after the AMI episode, including those carried
out in day surgery institutions.
Rates for the territories are not presented
due to small numbers. The total Canada
estimates include numbers from
the territories.
The analysis includes those who died;
this might have slightly underestimated
the real percentages of those who
received revascularization.
The percentages of those who received
revascularization for New Brunswick are
slightly underestimated due to the exclusion
of patients from New Brunswick who had
their procedures done in Quebec.
Sources
Discharge Abstract Database and National
Ambulatory Care Reporting System,
Canadian Institute for Health Information;
Alberta Ambulatory Care Database, Alberta
Health and Wellness.
In contrast, the change pathway improves performance by shifting or modifying what
or how care is provided.32 For example, after measuring and reporting on nosocomial
infections, those sites with poorer performance may investigate to determine why
they are doing relatively poorly. If the investigation reveals a hand-hygiene issue, a
new hand-washing campaign may be introduced as a targeted response to change
practice and reduce the future spread of in-hospital infection.
Often measurement facilitates performance improvements through both pathways
at once. CIHI’s HSMR is a measure of quality of care that is available not only to the
general public, but is also reportable to and by ministries of health and health regions
across Canada. As such, it is tempting to view the HSMR as an example of a measure
that can lead to quality improvements through selection. Given the HSMR is only
one of a number of quality measures, and that it speaks to only a specific aspect
of hospital performance, many suggest it is more appropriate to examine the HSMR’s
impact as a tool of change.
The HSMR is most useful to individual hospitals to track trends over time in their
own performance. While the HSMR takes into consideration many of the factors
associated with the risk of dying, it is not designed for comparisons between
hospitals as it cannot adjust for every factor that may impact mortality.
Health Care in Canada 2010
69
Figure
21
Management of NSTEMI-Classified Hospitalizations
by Type of Revascularization Procedure, by Province,
Canada, 2008–2009
100%
Percentage of Hospitalizations
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
B.C.
Alta.
PCI
Sask.
Man.
Ont.
CABG
N.B.
N.S.
P.E.I.
No Revascularization
N.L.
Canada
Notes
Includes all adults age 20 and older,
excluding Quebec due to differences
in data reporting.
Procedures were identified within 30 days
after the AMI episode, including those
carried out in day surgery institutions.
Rates for the territories are not presented due
to small numbers. The total Canada estimates
include numbers from the territories.
The analysis includes those who died;
this might have slightly underestimated
the real percentages of those who
received revascularization.
The percentages of those who received
revascularization for New Brunswick are
slightly underestimated due to the exclusion
of patients from New Brunswick who had their
procedures done in Quebec.
Sources
Discharge Abstract Database and National
Ambulatory Care Reporting System,
Canadian Institute for Health Information;
Alberta Ambulatory Care Database, Alberta
Health and Wellness.
Improvements in HSMR Over Time
It takes time and sustained effort for system changes to be implemented and to
have an effect on hospital mortality. The value of providing HSMR data over time
is that it allows organizations to monitor and compare trends. In this way, they can
measure the impact on the rate of targeted improvement efforts, including changes
to practices, processes and delivery of care.
CIHI has calculated HSMR results using data from 2004–2005 forward. Over
time, an increasing proportion of facilities’ HSMRs has significantly decreased
compared to the previous year. For the HSMR, a decrease in the measure indicates
an improvement in performance. Overall, 40% of publicly reportable facilities
significantly decreased their HSMRs when 2009–2010 results are compared with
those of 2004–2005.
The HSMR results contribute to performance improvement discussions in facilities,
regional health authorities and ministries and departments of health in several ways.
In many organizations, quality measures are increasingly top items on board meeting
agendas. The HSMR results are regularly included. By design the HSMR is to be used
in conjunction with other macro- and micro-level process and outcome measures
to help provide a complete perspective on hospital performance. As well, in many
provinces the HSMR is one of several measures that are currently part of annual
public reporting.
70
Health Care in Canada 2010
Figure
22
Estimated Reduction in Heart Attack Hospitalization and Cost Savings
if All Jurisdictions Had British Columbia’s Rate, 2008–2009
Total
15,480
$125,200,000
180
$1,250,000
P.E.I.
900
$8,270,000
N.L.
1,050
980
$9,530,000
$7,940,000
4,240
5,900
Alta.
Sask.
Man.
550
$48,490,000
$34,210,000
Que.
Ont.
N.S.
$3,460,000
910
N.B.
Estimated Episodes Prevented
Estimated Total Cost Savings, 2008–2009
770
$4,890,000
$7,160,000
Notes
Includes all adults age 20 and older.
Estimates for the territories are excluded
due to small numbers.
The estimate for Canada excludes the
territories.
Estimates are based on the average cost for
hospitalizations for AMI patients who did not
receive revascularization procedures. The
real savings could be significantly higher
if the costs for these procedures were
factored into the estimates.
All cost data presented in this section is
calculated using Cost per Weighted Case,
which excludes physician compensation.
The estimated cost savings for Quebec
were calculated using the national average
Resource Intensity Weight and the national
Cost per Weighted Case.
Sources
Canadian MIS Database and Discharge
Abstract Database, 2008–2009, 2010 CMG+
Grouping Methodology, Canadian Institute
for Health Information.
What Do Lower HSMR Results Mean for Patient Care?
Since CIHI started to calculate and publish HSMR results, there have been
significant and sustained reductions in HSMRs in many jurisdictions and for many
facilities. Also, facilities have moved beyond solely monitoring their HSMR results.
Organizations across Canada regularly examine their HSMR data with the goal of
linking findings to targeted quality improvement initiatives and continued reductions
in in-hospital mortality.
The success stories presented below illustrate how organizations can achieve
sustained performance improvement, guided by measurement, through changes
to their actual work processes and underscore how the HSMR informs actions that
in turn improve outcomes of care for Canadian patients.
Health Care in Canada 2010
71
HSMR Defined
The HSMR is the ratio of actual (observed) deaths to expected deaths. It focuses
on the diagnosis groups that account for the majority of in-hospital deaths. Using
a logistic regression model, it is adjusted for several factors that affect in-hospital
mortality, including age, sex, length of stay, admission category, diagnosis group,
comorbidity and transfer from another acute care institution. An HSMR equal to
100 suggests that there is no difference between a local mortality rate and the
average national experience, given the types of patients cared for. An HSMR
greater or less than 100 suggests that a local mortality rate is higher or lower
than the national experience, respectively.
CIHI developed and validated the HSMR measure for use in Canada and has
publicly released results annually (for larger institutions and health regions outside
of Quebec) since 2007. The HSMR can be used by hospitals to track progress
in reducing mortality related to quality of care improvements. It does not provide
a specific measure of preventable deaths.
Trillium Health Centre Uses HSMR eReports to Drill Deeper
For the past decade, patient safety and quality of care have been a priority at Trillium
Health Centre in Mississauga.
An early adopter of the HSMR, the centre monitors its score monthly and has
seen a substantial improvement in it over the last year. Gary Spencer, Director of
Decision Support, says it is a matter of a number of interventions and initiatives
coming together.
Driven by the philosophy of providing care to the right patient, at the right time, in
the right place, by the right people, with the right information, Trillium has introduced
rapid response teams, Safer Healthcare Now! practices and frameworks that enhance
teamwork and communication. These in turn expedite care and ensure a smooth
transfer of accountability between team members. To date, Trillium has adopted more
than 400 order sets for various diagnoses, ensuring every patient gets the same
evidence-based care for the same condition, while optimizing patient outcomes and
lengths of stay. The centre also created a strategy of care for high-risk populations
and worked on sepsis recognition and protocols, as this is a leading contributor
to mortality.
72
Health Care in Canada 2010
CIHI’s HSMR Reporting:
Want to Know More?
CIHI releases HSMR results through three distinct products:
the HSMR eReporting Service, the electronic hospital-specific
cumulative eHSMR report and the HSMR public release.
• The HSMR eReporting Service is a secure, web-based
tool that provides clients with detailed, confidential HSMR
reports. Registered organizations can review results that
span fiscal years and patient groups and encompass
regions or individual facilities. The tool is designed to
provide current data and drill-down capability to assist with
interpreting HSMR results and trends. For more information
or to register, contact us at [email protected]
continued on next page
Most recently, the centre embraced CIHI’s new, customizable HSMR eReporting tool.
It offers enhanced reporting around the HSMR and identifies, by diagnosis group,
where observed deaths have been greater than expected deaths. Trillium is using the
e-tool to drill down further into its HSMR cases and identify patient populations that
can be targeted for improved care processes, such as creating and/or revising order
sets for those patient populations. In this way, the e-tool is used to identify specific
patient populations for targeted improvement efforts.
Spencer says their efforts can now be taken to the next level, as the reports allow
specific program areas to pull patient records that might have contributed to the
higher rate. They can then conduct a chart review to determine if there are quality-ofcare issues to be addressed.
“You can really focus your attention on what’s going to have the greatest impact in
terms of improving your HSMR,” Spencer says. “If anything, you can fault us as an
organization for trying to do too much. We’ve learned we have to focus our attention
and resources, and these eReports have allowed us to do that.”
Health Care in Canada 2010
73
• One in the suite of electronic Hospital Specific Reports, the
cumulative eHSMR report provides monthly and year-to-date HSMR
results within five business days of data submission to CIHI. These
facility-specific PDF reports allow timely and actionable monitoring
and are available to acute care facilities that submit data to the
Discharge Abstract Database. For more information or to register,
contact us at [email protected]
• The HSMR public release provides annual HSMR results for all
facilities, hospital corporations and health regions with at least
2,500 HSMR qualifying cases. The results for 2004–2005 to
2009–2010 are now available free of charge to both health system
stakeholders and the general public at www.cihi.ca. For more
information, contact us at [email protected]
As part of the process, opportunities for improvement in documentation that may
impact patient care were also identified. In addressing the documentation issues,
Dr. Amir Ginzburg, a general internist and hospitalist, says their focus is on improving
communication to ensure patients receive the most appropriate care. “We’re still
gleaning from chart reviews what system changes we can put in place,” Ginzburg
says. “But eReports give us another tool to look at ourselves critically.”
74
Health Care in Canada 2010
Figure
23
Quantifying the Improvements in HSMR Results Over Time
The timeline below illustrates the number
and percentage of hospitals whose HSMRs
significantly decreased over the years compared (total N = 75).
4 hospitals
5 hospitals
10 hospitals
10 hospitals
13 hospitals
5.3%
6.7%
13.3%
13.3%
17.3%
2004–2005
2005–2006
2006–2007
2007–2008
2008–2009
2009–2010
40%
30 hospitals
Note
Results are presented
for reportable
hospitals only.
Source
Discharge Abstract
Database, Canadian
Institute for
Health Information.
New Brunswick Health Council Uses HSMR as
a Performance Indicator
When the New Brunswick Health Council was formed in 2008, there was only one
quality of care indicator related to patient safety that members felt comfortable
using in its provincial performance index—the HSMR. The council chose CIHI’s
measure as a starting point for measuring and monitoring patient safety because
it was standardized.
“Being a death rate, you want it to be accurate,” says Michelina Mancuso, the
council’s executive director of performance measurement. “Because of the rigor in
the HSMR methodology, we felt it was reliable and valid enough to show up on our
index.” Since that time, the council and its health system partners have selected and
worked on 10 additional safety indicators for the next report card.
Earlier this year, the council started a special project that included a patient survey of
acute care experiences. This marked the first time safety information had come from
patients. The questions included the following: Was your arm band checked before
receiving medication? Did staff wash their hands? Did you experience harm? Do you
think this hospital takes your safety seriously?
“People are talking about these things, but are they really being done? This was
a way to check on them,” says Mancuso. “We wanted to look at the relationship
between the HSMR scores for each of the hospitals and the results we’re seeing
from the patient safety questions and rates of errors or harm.”
Health Care in Canada 2010
75
Figure
24
HSMR in Quality of Care Public Reporting Across Canada
British Columbia
Alberta
Saskatchewan
Health authorities
routinely monitor
HSMR results
and trends.
In September 2010, Alberta Health
and Wellness introduced a Patient
Safety Framework to support the
continuous and measureable
improvement of patient safety
in Alberta. The HSMR is among
the measures which are being
considered for possible use in the
safety domain of this framework in
the future.
The Ministry Plan,
Ministry of Health for
2010–2011 includes
annual public reporting
for selected performance
measures; an aggregated
HSMR for all Saskatchewan
hospitals is among
the measures that are
monitored and reported.
Manitoba
Regional health
authorities routinely
monitor HSMR results
and trends.
The council found that the error rate and the harm patients reported were not
necessarily linked to the hospital’s HSMR. Next it plans to investigate further by
looking at patients’ perceptions of whether the hospital takes their safety seriously
and to see if there is a relationship with the HSMR. The initial survey results will serve
as a baseline for monitoring dimensions of quality. They will also become a part of
the council’s care experience indicator and possibly its performance index to show
hospitals where they are under- or over-performing and, ultimately, where to focus
their attention.
“It’s a flag to go into things a little deeper,” Mancuso says. “We’re giving them
information to help improve those particular components that may enhance the
quality of care, which could ultimately influence their HSMR.”
The survey is the latest initiative in the province’s system-wide use of the HSMR.
Hospitals and the Department of Health have used the indicator for years to identify
opportunities to improve care.
“With this survey, we’re using the HSMR quite uniquely,” Mancuso says. “It was a
catalyst to getting our discussions started and work done around the quality of care.”
76
Health Care in Canada 2010
Figure
24
HSMR in Quality of Care Public Reporting Across Canada (cont’d)
Ontario
New Brunswick
Nova Scotia
As of September
2008, the Ministry of
Health and Long-Term
Care introduced full
public reporting of
selected patient safety
indicators, including
the HSMR. The HSMR
is reported annually on
December 30.
The New Brunswick
Health Council’s
Health System
Report Card,
published annually,
includes the
HSMR as one of
the indicators in the
Safety Dimension.
Regional health
authorities
routinely
monitor HSMR
results and
trends.
Prince Edward
Island
Newfoundland
and Labrador
To support the
strategic direction
of Health P.E.I., the
HSMR is routinely
monitored as
one of the quality
indicators to
ensure appropriate
safety standards
are met.
Regional health
authorities
routinely monitor
HSMR results
and trends.
Note
The HSMR is not
calculated for Quebec
and is not publicly
reported for the
Yukon, the Northwest
Territories or Nunavut.
Source
Compiled by CIHI.
In Summary
The gains made in cardiac care in Canada are not new. Focused efforts
by researchers and health care providers have all contributed to improved
understanding of what affects cardiac health. Activities such as centralizing
treatment, refining surgical procedures, moving to less-invasive or drug therapies
and targeting health promotion activities are all informed by this. Improving data
collection and ensuring data quality for monitoring and measuring also contributed
to understanding how to treat cardiac patients most appropriately. And there is still
room for improvement.
The HSMR is a high-level indicator that provinces, health regions and hospitals use
as one measure of the quality of care they are providing. The sustained improvement
in performance using this measure over the years, how the jurisdictions are using the
results for public reporting and specific case studies of on-the-ground change show
how the HSMR continues to be used to measure, monitor and improve care.
Improvements in both cardiac care and hospital processes and policies in reaction
to HSMR results are examples of what is possible when targeted efforts to improve
the health of Canadians meet head on with targeted efforts to improve quality of care.
There remains a way to go. But these examples provide a way forward in considering
ongoing efforts to better align care with the evidence and to make improvements in
the health care system overall.
Health Care in Canada 2010
77
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Uptake With Coronary Heart Disease Mortality, 1994–2005,” JAMA 303, 18 (2010):
pp. 1841–1847.
24. F. G. Kushner et al., “2009 Focused Updates: ACC/AHA Guidelines for the Management
of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007
Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention
(Updating the 2005 Guideline and 2007 Focused Update): A Report of the American
College of Cardiology Foundation/American Heart Association Task Force on Practice
Guidelines,” Journal of the American College of Cardiology 54, 23 (2009): pp. 2205–2241.
25. K. A. Fox et al., “Decline in Rates of Death and Heart Failure in Acute Coronary
Syndromes, 1999–2006,” JAMA 297, 17 (2007): pp. 1892–1900.
26. M. Page et al., “Temporal Trends in Revascularization and Outcomes After Acute
Myocardial Infarction Among the Very Elderly,” CMAJ (2010): accessed from
<http://www.ecmaj.ca/cgi/rapidpdf/cmaj.092053v1>.
27. D. A. Alter et al., “Proliferation of Cardiac Technology in Canada,” Journal of the American
Heart Association 113 (2005): pp. 380–387.
28. C. A. Jackevicius et al., “Long-Term Trends in Use of and Expenditures for Cardiovascular
Medications in Canada,” CMAJ 181 (2009): pp. E19–E28.
29. S. Morgan, “Sources of Variation in Provincial Drug Spending,” CMAJ 170, 3 (2004):
pp. 329–330.
30. Canada’s Health Newsweekly, S urvey Puts B.C. Lifestyle in Favourable Light, last
modified 2010, accessed on June 18, 2010, from <http://www.healthedition.com/
printIssue.cfm?issueID=717>.
31. W. A. Filate et al., “Regional Variations in Cardiovascular Mortality in Canada,”
The Canadian Journal of Cardiology 19, 11 (2003): pp. 1241–1248.
32. D. M. Berwick et al., “Connections Between Quality Measurement and Improvement,”
Medical Care 41, 1 (2003): pp. I30–I38.
Health Care in Canada 2010
79
PART C
Health Care System Resources
Chapter 5
An Update on Health Professionals
Figure
25
Physicians and Registered Nurses per 100,000 Population,
by Province and Territory, Canada, 2009
Registered Nurses per 100,000 Population
1,600
N.W.T.
1,400
Nun.
1,200
N.L.
P.E.I.
1,000
N.B.
Y.T. N.S.
Man.
Sask.
800
Canada Alta.
Ont.
600
Que.
B.C.
400
200
0
0
50
100
150
200
250
Physicians per 100,000 Population
Introduction
The supply and distribution of health professionals continue to be discussed nationally and
internationally. In 2006, the World Health Organization estimated there was a shortage of
more than 4.3 million health personnel worldwide.1 The issues at the heart of this discussion
are the number of health professionals and their distribution. Projections of the availability
of health care professionals have been particularly salient for physicians and nurses,1
leading some to officially declare a Canada-wide physician shortage. 2 However, where
evidence of growth in the number of health professionals meets continued declarations of
shortages, there are obviously opposing opinions.
Understanding these opposing opinions is challenging because there is no agreement
about the optimal number of health care professionals and how and where they can and
should be best utilized to deliver the most appropriate care. At the centre of the discussion,
then, is the need to ensure that Canada has a sufficient supply of health care professionals
to deliver high-quality care.
Canada’s Health Professionals at a Glance
Canada experienced a growth rate of 16% in the number of active registered physicians in
the past nine years, growing from 58,546 in 2001, to 68,101 in 2009.3 In 2009, the provincial
supply of active physicians per 100,000 population ranged from 164 in Saskatchewan to
231 in Nova Scotia. Territorial supply of physicians per 100,000 population ranged from
37 in Nunavut to 218 in the Yukon. The nationwide rate was 201. Each of these numbers
represents increases over the past decade.
82
Health Care in Canada 2010
Figure
25
Physicians and Registered Nurses per 100,000 Population,
by Province and Territory, Canada, 2009: Notes and Sources
Notes
Physician Data
Includes active physicians in clinical and non-clinical practice (for example, research and academia) who have an MD,
are registered with a jurisdictional medical college and have a valid mailing address (mail sent to the physician by Scott’s
Directories is not returned).
Excludes residents, physicians in the military as well as semi-retired and retired physicians.
Excludes non-licensed physicians who requested that their information not be published as of December 31 of the
reference year.
Data as of December 31 of the reference year.
The physician-per-population ratio is calculated annually using the most recent Statistics Canada population estimates.
Registered Nurse Data
See Chapter 5 (Methodological Notes) in Regulated Nurses: Canadian Trends, 2005 to 2009 for more information
regarding collection and comparability of data.
Registered nurses include nurse practitioners.
Registered nurses employed in a jurisdiction different from their jurisdiction of registration are excluded to avoid
duplication. However, Northern territories data may include inter-jurisdictional duplicates. Additionally, registered nurses
living abroad are not included in workforce counts.
The registered nursing workforce includes registered nurses who indicated an Employment Status of full time, part time,
casual or employed—status unknown. Not stated (non-response) for Employment Status (percentage of supply) 2009:
n = 5,066 (1.8%).
Sources
Physician Data
Scott’s Medical Database, 2009, Canadian Institute for Health Information; Statistics Canada, Quarterly Demographic
Estimates 23, 4 (March 2010), catalogue no. 91-002-X.
Registered Nurse Data
Nursing Database, 2009, Canadian Institute for Health Information; Statistics Canada, Canadian Demographic Estimates
(July 2009), catalogue no. 91C0029, 2008/2009.
Data on the nursing workforce shows a similar trend. From 2001 to 2009,
the number of registered nurses across Canada grew by 15%.4 In 2009,
there were 266,341 registered nurses in Canada and a combined total of
348,499 regulated nurses in the nursing workforce as a whole (including
licensed practical nurses and registered psychiatric nurses).4 The number
of registered nurses per 100,000 population ranged from 694 in British
Columbia to 1,145 in Newfoundland and Labrador and averaged 1,091 in
the Yukon and 1,351 in Nunavut and the Northwest Territories. Nationally,
there were 789 registered nurses per 100,000 population. Again, the rates
consistently increased over the past several years.4
In the past decade, the number of seats in Canadian universities for physicians
and registered nurses has increased substantially to serve the needs of Canada’s
growing population. The number of physician graduates in Canada increased
from 1,594 in 1999 to an estimated 2,344 in 2009—an increase of nearly 50%.5
The number of nurses graduating from Canadian colleges and universities has
also increased. The number of graduates from entry-to-practice programs i nearly
doubled, from 4,833 in 1999 to 9,662 in 2009.6
A recent report from the Organisation for Economic Co-operation and Development
(OECD) suggested that one of the factors contributing to what it sees as a global
shortage of health care professionals is international migration.1 In Canada in 2009,
approximately 24% of physicians3 and 8% of registered nurses 4 were graduates
of international schools. Some researchers have criticized this, asserting there
is a greater need for these health professionals in their mother countries.1, 7
i.
Entry-to-practice programs (ETPs) entitle the successful graduate to apply for initial licensure/registration
as a registered nurse. As of January 2009, there were 135 schools in Canada offering ETPs.
Health Care in Canada 2010
83
International Policies Restricting Migration
of Foreign Health Workers
The migration and recruitment of foreign health workers can help alleviate health personnel
shortages and reduce the cost of acquiring trained practitioners in the receiving country.7
However, there is growing global concern that this practice is exacerbating shortages in some
developing countries,1 as the majority of health workers migrating to OECD countries originate
from comparatively less-affluent countries—those nations experiencing health personnel
shortages themselves.1, 8
To address these concerns, in May 2010, the WHO Global Code of Practice on the International
Recruitment of Health Personnel 9 was adopted unanimously by all member states. The code is
voluntary in nature but global in scope. It serves as an ethical framework for guiding member states
in their recruitment practices and the treatment of internationally educated health care workers.
Specifically, the code encourages destination countries to collaborate with source countries
to sustain and promote health human resource development and training where appropriate. It
discourages the active recruitment of health personnel from developing countries facing critical
health care shortages. The code also supports “circular migration” of health personnel so that
both source and destination countries mutually benefit from the skills and knowledge attained.10
Within Canada, there is also concern about shortages resulting from an aging
workforce, with some provinces increasing their medical school enrolments to
compensate for those retiring.11 From 2004 to 2009, the average age of physicians
increased by 1.2 years.3 In 2009, the proportion of the physician workforce younger
than age 40 was equal to the proportion older than age 60—23% and 22%,
respectively.3 Older workers (age 40 to 60) also dominated the nursing professions,
accounting for 57% of the registered nurse workforce in 2009.4
Achieving a balance in supply, mix and distribution of health care providers to meet
current and future needs is complex.11 Past trends and future directions of this
supply—whether perceived as a shortage or a potential surplus—continue to be
of interest.12–15 For example, some researchers suggest that the potential impact of
increased medical school enrolments over the past decade may place increased
pressure on future medicare budgets13 and that careful monitoring, coordination
and collaboration are needed to optimize and plan future workforce supply targets.15
How best to estimate future requirements and efficiently provide them remains
uncertain. Pressures such as funding,16 workforce demographics, changing patterns
in labour supply, the adoption of new technologies, the effects of policy decisions
and changes in health care delivery12 and practice environment14 are important
factors in these decisions.
While the majority of Canada’s health professionals are physicians and nurses, there
are many other health professionals providing important care to Canadians. Growth
similar to that for physicians and nurses was found in several other health professions
over the past five years. From 2004 to 2008, there was substantial growth in the
supply of pharmacists, physiotherapists, occupational therapists and audiologists.
The most rapid growth was seen among nurse practitioners, increasing by 90%
from 2004 to 2008. This increase is likely due to recent developments in legislation
supporting the evolving and autonomous nature of the nurse practitioner role.17
84
Health Care in Canada 2010
Figure
26
Growth in Selected Health Professions,
Canada, 2004 to 2008
90%
80%
70%
Percent Growth
60%
50%
40%
30%
20%
10%
rs
es
s
ist
ter
ed
Nu
nt
De
Re
gis
HI
M
Nu
rs
eP
ra
cti
ti
on
er
Pr
s
of
es
sio
De
na
nt
ls †
al
Re
Hy
sp
gie
ira
nis
to
ry
ts
Th
e
ra
M
pis
ed
ica
ts*
lP
hy
sic
ist
s†
Op
to
m
etr
ist
Ch
s
iro
pr
ac
to
rs
Ph
ys
ici
an
Ps
s
yc
ho
log
ist
s
0%
Notes
* Profession is not regulated in all
provinces. The Canada total for each
profession includes some provincial
data in which registration with a
regulatory authority may not be a
condition of practice.
† Data was submitted to CIHI from
an organization in which membership
is voluntary.
HIM: health information management.
Source
Canadian Institute for Health
Information, Canada’s Health Care
Providers—2008 Provincial Profiles:
A Look at 24 Health Occupations
(Ottawa, Ont.: CIHI, 2010).
International Comparisons
According to the most recent data available from the OECD, Canada’s supply of
health professionals for its population ranks near the middle when compared to other
countries. For example, in 2008 Canada had 2.3 practising physicians ii per 1,000
population and 9.2 practising nurses; this was similar to Japan (2.2 physicians per
1,000 and 9.5 nurses) and New Zealand (2.5 practising physicians and 9.7 nurses)
but different from both Finland (2.7 physicians and 15.5 nurses) and Turkey
(1.51 physicians and 1.34 nurses iii). The variation observed in nurse-to-physician
ratios may reflect varying models of health care between these countries.
Canada also differs significantly from several of its international comparators in
supply growth trends. Since 1990, 24 OECD countries increased their physicianto-patient ratios by at least 10%.18 In contrast, Canada’s ratio increased by 5%.18
Because the supply of health professionals is somewhat unrelated to the health of
populations,19 it is difficult to determine the impact of supply differences on health.
However, these differences may lend insight into why Canadians continue to report
difficulties in accessing health care when compared to other countries. 20
ii.
iii.
Data represents professionally active physicians.
Data represents professionally active nurses.
Health Care in Canada 2010
85
Figure
27
Practising Physicians and Nurses per 1,000 Population,
25 Selected OECD Countries
18
Practising Nuses per 1,000 Population
16
FIN‡
ISL‡ CHE§
DNK†
14
NOR‡
12
LUX†
USA‡
10
JPN‡
CAN‡
8
UK§
SWE*
AUS†
NZL‡
FRA‡
DEU‡
CSK‡
AUT§
SVK†
6
POL‡
HUN‡
ESP§
KOR§
GRC‡
4
MEX‡
2
TUR‡
0
0
1
2
3
4
5
6
Practising Physicians per 1,000 Population
7
Notes
* Data for 2006.
† Data for 2007.
‡ Data for 2008.
§ Data for 2009.
All physician data is for “practising”
status, with the exception of Canada,
Finland, Germany, Greece, Italy and
Switzerland, which have “professionally
active” status.
All nurse data is for “practising”
status, with the exception of France,
Portugal, the Slovak Republic, Turkey
and the United States, which have
“professionally active” status.
Source
Organisation for Economic Cooperation and Development, OECD
Health Data 2009—Frequently
Requested Data, accessed June 30,
2010, from <http://www.oecd.org/
document/16/0,3343,en_2649_34631_
2085200_1_1_1_1,00.html.>
Changing Scope of Practice
As stated at the outset of this chapter, there remain questions not only about the
optimal number of health care professionals but also about how and where they can
be best utilized to deliver the most appropriate care. In addition to continuing to train
an increasing number of physicians and nurses, expanding scopes of practice may
also lead to efficiency gains in the deployment of health human resources.
For example, over the past 15 years in Canada, midwives have become autonomous
health professionals, providing primary maternity and newborn care during
pregnancy, labour and delivery, and the postpartum period.21 In other industrialized
nations, midwifery care is an integral part of maternity services, playing a key role
in lowering intervention rates and strengthening maternity care. 22 Its growth in
Canada could deliver similar benefits. However, the profession is still not regulated
in all jurisdictions. 21
Another example is the evolving scope of practice for pharmacists in Canada. 23
In several jurisdictions across the country, pharmacists are now able to adapt
prescriptions to optimize therapeutic outcomes and to prescribe in emergency
situations. This change in scope of practice is primarily designed to help alleviate the
burden on physicians of prescription renewal and modification. To date, provinces
such as British Columbia, Alberta, Saskatchewan, New Brunswick and Nova Scotia
have all implemented changes in legislation to broaden pharmacists’ scope of
practice, and Ontario has legislation pending. 23, 24 Although not precedent-setting
internationally—pharmacists were given similar authority in the United States
more than three decades ago25 —this type of legislation represents a significant
step forward.
86
Health Care in Canada 2010
Canada’s Nurse Practitioners
First regulated in Alberta in 1996, nurse practitioners are now gaining
ground within Canada. With a growth rate of more than 90% from 2004 to
2008, there were 5.0 nurse practitioners per 100,000 population in Canada
in 2008, compared with only 2.7 in 2004. Nurse practitioners are advanced
practice registered nurses, with additional education in health assessment,
diagnosis and management of illness and injuries. Their scope of practice
includes ordering tests and prescribing drugs. 26 The Canadian Nurses
Association asserts that nurse practitioners are making a real difference
in some of the issues currently facing the health care system, including
contributing to improvements in access to care, coordination and delivery
of services, and health outcomes. 26
Despite this, the nurse practitioner role is not uniformly accepted. In
2010, the Canadian Medical Association released a report calling for
transformational change to Canada’s health care system. 27 There was
no mention of what role nurse practitioners would play in the report.
In Summary
When the current health human resources are managed effectively, room can be
made for new investments that will inevitably come. To ensure this, some believe the
health care workforce needs to be better employed and better deployed. 28, 29 There
have been continuing increases in the numbers of physicians and nurses in Canada,
which may offset some of the impact of the aging workforce. Numbers of other health
professionals continue to increase as well. In addition, evolving scopes of practice
may emerge as a key component in using the resources available most efficiently.
Health Care in Canada 2010
87
References
1.
Organisation for Economic Co-operation and Development, Policy Brief: International
Migration of Health Workers (Paris, France: OECD, 2010).
2.
R. L. Phillips Jr. et al., “The Canadian Contribution to the US Physician Workforce,”
CMAJ 176, 8 (2007): pp. 1083–1087.
3.
Canadian Institute for Health Information, Supply, Distribution and Migration of Canadian
Physicians, 2009 (Ottawa, Ont.: CIHI, 2010).
4.
Canadian Institute for Health Information, Regulated Nurses: Canadian Trends, 2005 to
2009 (Ottawa, Ont.: CIHI, 2010).
5.
Association of Faculties of Medicine of Canada, Canadian Medical Education Statistics
2009 (Ottawa, Ont.: AFMC, 2010).
6.
Canadian Nurses Association and Canadian Association of Schools of Nursing, Nursing
Education in Canada Statistics, 2008–2009 (Ottawa, Ont.: CNA and CASN, 2010).
7.
H. Hoag, “Canada Increasingly Reliant on Foreign-Trained Health Professionals,”
CMAJ 178, 3 (2010): pp. 270–271.
8.
S. Simoens and J. Hurst, The Supply of Physician Services in OECD Countries (Paris,
France: OECD, 2006).
9.
World Health Organization, Managing Health Workforce Migration—The Global Code of
Practice, last modified 2010, accessed on October 22, 2010, from <http://www.who.int/
hrh/migration/code/practice/en/index.html>.
10. World Health Organization, WHO Global Code of Practice on the International Recruitment
of Health Personnel (Geneva, Switzerland: WHO, 2010).
11. D. Chew et al., “International Medical Graduates: The BC Doctor Shortage Solution,”
University of British Columbia Medical Journal 1, 2 (2010): pp. 40–41.
12. Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human
Resources, How Many Are Enough? Redefining Self-Sufficiency for the Health
Workforce—A Discussion Paper (Ottawa, Ont.: ACHDHR, 2009).
13. R. G. Evans and K. M. McGrail, “Richard III, Barer–Stoddart and the Daughter of Time,”
Healthcare Policy 3, 3 (2008): pp. 18–28.
14. T. F. Crossley et al., “Physician Labour Supply in Canada: A Cohort Analysis,” Health
Economics 18, 4 (2009): pp. 437–456.
15. W. D. Dauphinee and L. Buske, “Medical Workforce Policy-Making in Canada, 1993–2003:
Reconnecting the Disconnected,” Academic Medicine 81, 9 (2006): pp. 830–836.
16. L. O’Brien-Pallas et al., “Integrating Workforce Planning, Human Resources, and Service
Planning,” Human Resources for Health Development Journal 5, 1–3 (2001): pp. 2–16.
88
Health Care in Canada 2010
17. Canadian Institute for Health Information, The Regulation and Supply of Nurse Practitioners
in Canada (Ottawa, Ont.: CIHI, 2005).
18. M. Milke, Canada’s Doctor Shortage. Comparing Canada With the World (Winnipeg, Man.:
Frontier Centre for Public Policy, 2008).
19. D. E. Watson and K. M. McGrail, “More Doctors or Better Care?,” Healthcare Policy 5, 1
(2009): pp. 26–31.
20. K. Davis et al., Mirror, Mirror on the Wall: An International Update on the Comparative
Performance of American Healthcare (New York, New York: The Commonwealth
Fund, 2007).
21. Canadian Association of Midwives, Midwifery Regulation in Canada: Fact Sheet
(Montréal, Que.: CAM, 2010).
22. A. M. Malott et al., “Midwifery Care in Eight Industrialized Countries: How Does Canadian
Midwifery Compare?,” Journal of Obstetrics and Gynaecology Canada 31, 10 (2009):
pp. 974–979.
23. Canadian Pharmacists Association, Summary: Pharmacist Prescribing Authority Status
Across Canada (Ottawa, Ont.: Canadian Pharmacists Association, 2009).
24. Government of Saskatchewan, Putting Patients First: Improving Access to Health
Care by Enhancing Pharmacists’ Prescribing Authority (Regina, Sask.: Government
of Saskatchewan, 2010).
25. J. M. Carmichael et al., “Collaborative Drug Therapy Management by Pharmacists,”
Pharmacotherapy 17, 5 (1997): pp. 1050–1061.
26. Canadian Nurses Association, Position Statement: The Nurse Practitioner (Ottawa, Ont.:
CNA, 2003).
27. Canadian Medical Association, Health Care Transformation in Canada (Ottawa, Ont.:
CMA, 2010).
28. New Brunswick Health Council, Understanding New Brunswick’s Health Care Costs and
Capacity to Deliver Health Care: Relationship Between Health Care and Sustainability
(Moncton, N.B.: New Brunswick Health Council, 2010).
29. Health Council of Canada, Sustainability in Public Health Care: What Does It Mean?
A Panel Discussion Report (Toronto, Ont.: HCC, 2008).
Health Care in Canada 2010
89
Chapter 6
An Update on Health Expenditures
Introduction
Health care spending in Canada is considerable, as it is in many countries. Yet there
remains no consensus on the right amount of money to spend or the right distribution
of resources within the system. As well, the complex question of fiscal sustainability
arises frequently. In 2002, Roy Romanow declared, “Medicare is as sustainable as
Canadians want it to be.”1 It is a system funded by tax dollars; as long as Canadians
are willing to pay, the system will be there. 2, 3 And Canadians seem not only willing to
pay, but also to pay at increasing rates.
With an annual increase of anywhere from 1% to 18% over the past 35 years,
Canada’s health care spending will have reached an estimated $191.6 billion in
2010 (see Figure 28). Spending as a percentage of gross domestic product (GDP)
increased from 10.0% in 2002 to a forecasted 11.7% in 2010. Although health
spending in 2010 continued to increase, the estimated increase in health care
spending from 2009 to 2010 was the smallest observed since 1997. The proportion
of the provincial/territorial budgets spent on health care has remained stable
since 2004.
Both the public and private sectors finance Canada’s health care system. Publicsector funding includes payments by governments at the federal, provincial/territorial
and municipal levels and by workers’ compensation boards and other social
security systems. Private-sector funding consists primarily of health expenditures
by households and private insurance firms.4 Of the $191.6 billion spent in 2010 on
health care, approximately 65.3% was expected to come from provincial/territorial
governments, 3.5% from the federal government, 0.5% from municipal governments
and 1.3% from social security funds.4 Overall, 70% of health funding is from the
public sector and 30% is from the private sector.4 This 70/30 split has been the
reality of health care spending in Canada since 19974 and compares with the public/
private split in health care spending among several countries in the Organisation for
Economic Co-operation and Development (OECD) (Figure 29).
92
Health Care in Canada 2010
Figure
28
Total Health Expenditure, Canada, in Current Dollars,
1975 to 2010
250
12%
200
10%
150
8%
6%
100
4%
50
2%
0
Percentage of GDP
2007
2009*
2010*
2003
2005
2001
1999
1997
1995
1991
Total Expenditure
1993
1989
1987
1985
1983
1981
1979
1977
1975
0%
Health Expenditure in Billions of Dollars
Percentage of Total GDP Spent on Health
14%
Note
* Forecast.
Source
Canadian Institute for Health
Information, National Health
Expenditure Trends, 1975 to 2010
(Ottawa, Ont.: CIHI, 2010).
Comparisons Within Canada and Abroad
Internationally, Canada’s per capita spending is among the highest when compared
with other OECD countries. In 2008, Canada ranked fourth out of 24 OECD countries
with comparable data.5 Canada also ranked ninth out of 33 OECD countries for life
expectancy.5 Health care spending and life expectancy are often plotted against each
other, while acknowledging the limitation that the two are only partially linked. For the
most part, health care spending is not highly correlated with life expectancy past a
threshold of about US$3,000 to US$3,500 per capita. i, 5 With Canada’s current per capita
spending at US$4,079 in 2008, it could be argued that gains thereafter would be minimal.
Spending on health care is substantial in Canada, but it is not uniform across the
provinces and territories. At a pan-Canadian level, per capita spending in 2010 is
expected to be $5,614 per person; total per capita spending is forecast to range from
a low of $5,096 in Quebec to a high of $6,266 in Alberta at the provincial level.4 In the
territories, total per capita spending was estimated to range from $7,977 in the Yukon
to $12,356 in Nunavut in 2010.4 Likely, the higher per capita spending in the territories
is due in part to costs associated with travel to receive certain types of care. Several
factors may have contributed to the spending variations among provinces and territories,
including differences in populations and their health status, patterns of health service
delivery and coverage, geography and population density, and the costs of providing care.
i.
Health expenditure per capita was converted to U.S. dollars using purchasing power parities (PPPs) for GDP,
which are the rates of currency conversion that eliminate the differences in price levels between countries. That
is, PPPs equalize the purchasing power of different currencies.
Health Care in Canada 2010
93
Figure
29
International Health Spending by Public Sector,
30 Select OECD Countries, 2008
Percentage of Public Health Expenditure
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
Luxembourg*
Denmark†
Norway
United Kingdom
Czech Republic
Japan†
Sweden
New Zealand
France
Estonia
Italy§
Austria
Ireland
Germany
Finland
Spain
Slovenia
Poland
Portugal*
Hungary
Canada§
Slovak Republic
Turkey†
Australia†
Greece†
Switzerland
Chile
Israel
Korea
United States
0%
Notes
* Data for 2006.
† Data for 2007.
§ Data for 2009.
Source
Organisation for Economic Cooperation and Development, OECD
Health Data 2010 (June Edition)
(Paris, France: OECD, 2010).
Similarly, there is variation across the country in life expectancy at birth, but the
variation in the two measures does not appear to be highly correlated. That is,
jurisdictions that have higher per capita health care spending do not appear to have
similarly higher life expectancy. The converse is also true: jurisdictions with lower
per capita health care spending do not necessarily have lower life expectancy. For
example, British Columbia and Quebec spend the least per person compared to the
other provinces ($5,355 in B.C. and $5,096 in Quebec), yet they both fall in the top
three for average life expectancy (81.2 years in B.C. and 80.7 in Quebec) in Canada.
The United States is another example. Despite having the highest per capita spending
of 33 OECD countries, life expectancy in the U.S. is among the lowest (77.9 years).
94
Health Care in Canada 2010
Figure
30
Health Expenditures per Capita, by Province and Territory,
Canada, 2010†
Life Expectancy at Birth (Years)*
82
B.C.
Ont.
Canada
Que.
Alta.
P.E.I.
N.B.
N.S.
Sask.
Man.
81
80
79
N.L.
78
77
76
Y.T.
N.T.
Nun.
75
0
2,000
4,000
6,000
8,000
10,000
Per Capita Total Expenditure on Health
12,000
14,000
Notes
* Life expectancy at birth; data from
2005 to 2007.
† Forecast.
Sources
National Health Expenditure Database,
2010, Canadian Institute for Health
Information; Statistics Canada, Table
102-0512—Life Expectancy at Birth and
at Age 65, by Sex, Canada, Provinces
and Territories, Annual (2005/2007)
(CANSIM—Birth Database; Death
Database), last modified June 21,
2010, accessed on July 12, 2010, from
<http://www40.statcan.ca/l01/cst01/
health26-eng.htm>.
Analysis of regional variations in spending and health outcomes in the United
States also concluded that higher spending does not equal better health. Increased
investments in greater availability of physicians, hospital beds and more inpatientbased and specialist-oriented patterns of practice were not associated with improved
access to care, better quality of care 8 or better health outcomes or satisfaction.9
Further, these studies concluded that additional growth in health care spending may
not be explained primarily by advances in science and technology, and increased
spending may not result in greater quality of care or better health.8, 9
Without obvious links to improved health it is hard to understand why health care
expenses continue to rise. The following section examines some of the cost drivers.
Health Care in Canada 2010
95
Figure
31
Health Spending per Capita and Life Expectancy
in 33 Selected OECD Countries, 2008
84
JPN†
Life Expectancy at Birth (Years)
CHE
82
ITA § AUS ISL§
FRA
CAN§
SWE†
ESP
AUT†
NZL
DEU
KOR
LUX*
UK
NLD
BEL
PRT†
GRC† FIN
IRE
DNK†
ISR
80
NOR
SLO
78
USA
CSK
POL
76
MEX
HUN
TUR
74
SVK
EST
72
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
Per Capita Total Expenditure on Health ($US PPP)
Notes
* Data for 2006.
† Data for 2007.
§ Data for 2009.
PPP: purchasing power parity.
Source
Organisation for Economic
Co-operation and Development,
OECD Health Data 2010—Frequently
Requested Data, accessed on June
30, 2010, from <http://www.oecd.org/
document/16/0,3343,en_2649_34631_
2085200_1_1_1_1,00.html>.
Cost Drivers and Cost Escalators
A common misconception is that the aging baby-boomer population is driving health
care spending and that this will continue into the future.10 This does not tell the
complete story. In reality, the aging population is responsible for 0.8% of spending
growth per year, which is less than overall population growth (1%) and the rate of
inflationary growth (2.5%).11, 12 The biggest cost increases in the system are spending
on new drugs, medical technology, medical imaging, costly interventions and
community services.11–15 Simply put, more care is being provided.
96
Health Care in Canada 2010
Health Care Reform in
the United States
Many factors influenced the health care reform undertaken
by the U.S. in 2010. One factor was that, despite higher per
capita health spending than any other developed country, such
spending was not contributing to better health or longer life
expectancies for Americans. The current round of reform has
been compared to that country’s creation of Social Security
(1935) and the advent of Medicare (1965).
President Obama’s health reform plan for the U.S. as currently
put forth has promised to
• Control the insurance industry with new consumer protections
and ensure that premiums will be kept down and coverage will
not be denied (including for pre-existing conditions);
continued on next page
The Conference Board of Canada separates these areas into two categories: cost
drivers and cost escalators.11 Cost drivers are the underlying structural forces
and include factors such as population aging, demand, inflation and increased
chronic disease prevalence.11 Cost escalators are short- and medium-term issues,
meaning that once introduced, their impact is felt far more quickly. The escalators
include pharmaceuticals, new technologies, home and community services, and
health human resources.11 Drugs are one of the fastest-growing expenditure items
in our system and have been for the past 25 years.11 These increased costs may be
subsiding, however, as spending on prescription drugs was expected to increase
by 4.6% in 2010, the smallest increase in 14 years. As new drugs hit the market and
costs continue to climb, this area remains one of the most challenging for health
policy in the coming years.11
Health Care in Canada 2010
97
• Make health insurance affordable for middle-class families
and small business owners and provide improved security
to those who have lost their jobs;
• Strengthen Medicare benefits, with lower prescription
drug costs for vulnerable groups; and
• Reduce the deficit by more than $100 billion over the
next decade.6
Some of these reforms began immediately, but many may
not begin until 2014.7 Both nationally and internationally,
eyes will be on the U.S. to assess both the positive and
negative impacts of these changes.
With respect to health human resources, current models of physician compensation
in Canada have been identified as a potential cost escalator. According to a recently
released OECD report, physician income in Canada is higher than the OECD
average.16 Physician payment recommendations coming from the report that might
aid overall cost containment include
• Considering alternative payment models, such as paying doctors partially by
capitation or salary instead of solely by fee-for-service. In Canada this already
exists and continues to increase over time. Based on data collected by CIHI, in
2008–2009, approximately 27% of total clinical payments to Canadian physicians
were made through alternative payment methods. The proportion ranged from
49% in Nova Scotia to 15% in Alberta and up to 96% in the Northwest Territories.17
This may reflect each province’s and territory’s decision-making toward a variety
of goals such as physician recruitment and retention in rural/remote areas,
increasing collaboration between providers, and continuity of care, prevention
and health promotion;18
• Having fees regulated from the provincial level to the regional level;16 and
• Implementing cost-sharing arrangements among physicians (such as
specialist referrals).16
New medical technologies are also major cost escalators. Advances in biomedical
imaging have already affected diagnostic imaging, medical treatment and surgical
procedures.19 In addition, genetic sciences and biotech research—though still
emerging fields—have begun to inform medical advancements, particularly through
pharmaceutical research activity.11
98
Health Care in Canada 2010
Figure
32
Health Expenditures by Use of Funds,
Canada, 1975 and 2010*
1975
2010*
Other
16%
Other
24%
Drugs
9%
Dental
Services
6%
Hospitals
29%
Hospitals
45%
Drugs
16%
Physicians
15%
Other
Institutions
9%
Dental
Services
7%
Other
Institutions
10%
Physicians
14%
Note
* Forecast.
Source
National Health Expenditure
Database, Canadian Institute
for Health Information.
In Summary
CIHI has been collecting data and reporting on health expenditures in Canada for
many years. Over the past 30 years steady growth in health expenditures—both at the
pan-Canadian and jurisdictional levels—was documented. While health expenditures
in 2010 are estimated to be $191.6 billion, as a percentage of gross domestic
product the growth in spending has changed by just one or two percentage points
(from 10.0% in 2002 to 11.9% of GDP in 2010)4 over the last several years. Canada’s
health care spending and life expectancy are among the highest of 33 comparable
developed countries, although considerable variation in both measures exists across
provinces and territories. Efforts, including new funding initiatives, are under way to
bend the cost curve. The success of these efforts will be reflected in data collected
and reported on in the years to come.
Health Care in Canada 2010
99
References
1.
R. J. Romanow, Building on Values: The Future of Health Care in Canada (Ottawa, Ont.:
Commission on the Future of Health Care in Canada, 2002).
2.
Health Council of Canada, Sustainability in Public Health Care: What Does It Mean? A Panel
Discussion Report (Toronto, Ont.: HCC, 2008).
3.
I. Dhalla, “Canada’s Health Care System and the Sustainability Paradox,” CMAJ 177, 1
(2007): pp. 51–53.
4.
Canadian Institute for Health Information, National Health Expenditure Trends, 1975 to 2010
(Ottawa, Ont.: CIHI, 2010).
5.
Organisation for Economic Co-operation and Development, OECD Health Data 2010—
Frequently Requested Data, last modified 2009, accessed on June 30, 2010, from
<http://www.oecd.org/document/16/0,3343,en_2649_34631_2085200_1_1_1_1,00.html>.
6.
Department of Health and Human Services, Health Care Reform, accessed on
May 14, 2010, from <http://www.healthreform.gov/about/index.html>.
7.
United States Congress, H.R. 3590. Patient Protection and Affordable Care Act
(Washington, D.C.: United States Congress, 2010).
8.
E. S. Fisher et al., “The Implications of Regional Variations in Medicare Spending. Part 1:
The Content, Quality, and Accessibility of Care,” Annals of Internal Medicine 138, 4 (2003):
pp. 273–287.
9.
E. S. Fisher et al., “The Implications of Regional Variations in Medicare Spending. Part 2:
Health Outcomes and Satisfaction With Care,” Annals of Internal Medicine 138, 4 (2003):
pp. 288–322.
10. Canadian Health Services Research Foundation, “Myth: The Aging Population Will
Overwhelm the Healthcare System,” Mythbusters (Ottawa, Ont.: CHSRF, 2001).
11. The Conference Board of Canada, Understanding Health Care Cost Drivers and Escalators
(Ottawa, Ont.: The Conference Board of Canada, 2004).
12. Canadian Health Coalition, Sustainability of Health Care: Myths and Facts, last modified
June 1, 2010, accessed from <http://www.medicare.ca/>.
13. Canadian Health Services Research Foundation, “Myth: Canada’s System of Healthcare
Financing Is Unsustainable,” Mythbusters (Ottawa, Ont.: CHSRF, 2007).
14. New Brunswick Health Council, Understanding New Brunswick’s Health Care Costs and
Capacity to Deliver Health Care: Relationship Between Health Care and Sustainability
(Moncton, N.B.: New Brunswick Health Council, 2010).
15. S. Morgan and J. Hurley, Influences on the “Health Care Technology Cost-Driver.”
Discussion Paper No. 14 (Ottawa, Ont.: Commission on the Future of Health Care
in Canada, 2002).
16. Organisation for Economic Co-operation and Development, OECD Economic Surveys:
Canada 2010 (Paris, France: OECD, 2010), pp. 105–157.
100
Health Care in Canada 2010
17. Canadian Institute for Health Information, National Physician Database 2008–2009 Data
Release (Ottawa, Ont.: CIHI, 2010).
18. D. W. Wranik and M. Durier-Copp, “Physician Remuneration Methods for Family
Physicians in Canada: Expected Outcomes and Lessons Learned,” Health Care
Analysis 18, 1 (2010): pp. 35–59.
19. C. M. Tempany and B. J. McNeil, “Advances in Biomedical Imaging,” JAMA 285, 5 (2001):
pp. 562–567.
Health Care in Canada 2010
101
Issues on the Horizon
Issues on the Horizon
Managing health system performance is about measuring and assessing, questioning
the results and translating them into actions for improvement.1 To be successful
at this requires an understanding of the current state. Success also requires the
implementation of targeted improvement initiatives to maintain good performance or
improve performance where necessary.
Health Care in Canada 2010 highlights some specific areas where there have been
successes, where there is room for improvement and where further investigation
is needed to better understand the underlying issues.
This publication also demonstrates how sustained effort and focused attention
can facilitate lasting improvements. During times of economic uncertainty, where
sustainability and health care share many headlines, it is particularly important to
focus efforts and demonstrate successes. Canadians should be receiving care in
the right place, at the right time, by the right person and in the most effictive way;2
in other words, they should be getting the most appropriate care possible.
In Part A: The Year in Review of this report, three health care stories that captured
headlines over the last year were highlighted. These issues will have both immediate
and longer-term effects. The H1N1 pandemic and disruptions in the supply of medical
isotopes required the redeployment of personnel and other resources; prompt,
coordinated, local and system responses; and modification of some processes.
Significant changes in funding models were announced and discussed. Some, like
the funding for generic pharmaceuticals, were implemented rapidly. Other funding
changes are still in development and their impact is yet to be seen.
Part B: Aligning Care With Evidence of this report focused on appropriateness of
care. The first set of examples looked at procedures that research evidence suggests
should not be carried out in some circumstances. It also looked at procedures that
had significant rate variations across the country, thereby calling into question the
appropriateness of care. Potential savings—at both the patient and system levels—
through better care alignment were estimated, where possible.
In cases when appropriate care is not the provided care, both the system and the
patients are affected. The examples of avoidable hospital admissions, preventive care
for diabetes patients and the extent of alternate level of care (ALC) days all spoke to
what can happen when, despite knowing what the right care is, it is not provided for
a variety of reasons. These examples suggest gaps where care could be optimized.
104
Health Care in Canada 2010
Finally, in the discussion of appropriateness, two of the system’s success stories
were highlighted to show that, with focused effort, there can be sustained
improvement. This was exemplified by noted improvements in cardiac care: rates
of hospitalizations, mortality and readmissions all continue to decline. Yet, even
here, room for improvement was indicated by rate variations across the country.
To this end, potential savings for patients and the system if heart attack rates were
more similar across the country were estimated. Health system performance was
also explored at a high level by examining the hospital standardized mortality ratio
(HSMR)—a measure of system performance that has seen continued improvements
across Canada since it was first calculated by CIHI in 2004.
In addition to the new and updated analyses and focused discussion of
appropriateness, Part C: Health Care System Resources of Health Care in
Canada 2010 provided updated information on health human resources and
health expenditures. Counts of physicians and nurses, as well as growth in
other health professions, were presented along with international comparators
to situate Canada within a global context. Similarly, updated per capita health
spending for Canada was provided alongside international information on
spending and life expectancy.
In providing the information and analyses in this report, the goal of Health Care
in Canada 2010 was to initiate discussion.
With health care systems—both across Canada and internationally—increasingly
focused on providing quality care, how health care is provided in the not-too-distant
future may be affected by issues such as the following:
• Recognition of the need to standardize clinical practice guidelines for the care
and treatment of many more patient populations than are covered currently. This
effort would help improve health care quality and outcomes, and ensure maximum
value for health care dollars spent.
• Increasing focus on regional variations of the cost of care, coupled with
evidence suggesting that high costs do not necessarily lead to improved patient
outcomes or higher levels of care. These types of analyses have contributed to
substantial learnings in the U.S. and will continue to influence how care is provided
and distributed in the U.S., Canada and elsewhere.
• Increasing attention on where government policies and investments are
focused. Where investments are made affects the care that is delivered. In
2003–2004, wait times for care were identified as problematic. In response, the
first ministers signed the 2004 Health Accord, which directed funding to reducing
wait times for care in five priority areas. In 2010, some governments tested the
idea of focused funding to physicians to ensure that care is aligned with evidence.
(Diabetic patients are at the centre of some of these funding incentives.) There are
mixed international reviews on whether incentive payments ensure optimal care for
patients.3 Canada might have to go through its own learning curve to understand
what works and what does not for ensuring optimal care in the Canadian context.
Health Care in Canada 2010
105
• Where care takes place matters. Many ALC stays occur because patients do
not have access to home care or are unable to transition readily into long-term
care settings at the end of their hospital stay. Recently, the Canadian Medical
Association advocated for increased numbers of long-term care facilities across the
country.4 This was largely directed at mitigating the impact of an aging population
on the health care system. Others, however, have advocated for improved access
to home care, and not just medical services in the home.5 Improving access to
home care was also a focus of the 2004 Health Accord. Reducing the impact of
ALC stays on the health care system and patients is probably not a one-size-fits-all
solution. Understanding who these patients are, what their specific care needs are
and what the magnitude of the impact of ALC days on the system is may all help
to improve and focus care decisions for these patients.
• Renewal of the 2004 Health Accord. In 2014, the 10-year plan to improve health
care will have expired and a new health accord will be negotiated. The provisions
of a new accord may have a significant impact on the future direction of health care
in Canada.
• The potential impact of the rising rates of obesity, high blood pressure and
other risk factors on the health of Canadians, especially in light of an aging
population. What mechanisms might exist to bend the curve of these rising rates?
106
Health Care in Canada 2010
References
1.
J. Veillard et al., “A Performance Assessment Framework for Hospitals: The WHO Regional
Office for Europe PATH Project,” International Journal for Quality in Health Care 17, 6
(2005): pp. 487–496.
2.
B. A. Liang, “A System of Medical Error Disclosure,” Quality and Safety in Health Care 11, 1
(2002): pp. 64–68.
3.
National Health Care Purchasing Institute, The Growing Case for Using Physician
Incentives to Improve Health Care Quality (Washington, D.C.: NHCPI, 2001).
4.
Canadian Medical Association, Health Care Transformation in Canada (Ottawa, Ont.:
CMA, 2010).
5.
Health Council of Canada, Fixing the Foundation: An Update on Primary Health Care and
Home Care Renewal in Canada (Toronto, Ont.: HCC, 2008).
Health Care in Canada 2010
107
Index
Note: The lower-case letter “f” preceding a page number
indicates that the information is in a figure, table or sidebar.
A
activity-based health care funding,
f-13–14
admissions, avoidable, 42–43, f-44
age
and Caesarean section rates, 28
and hysterectomy rates, 31
and knee arthroscopies, f-23
and vertebroplasties, 23, f-24
of nurses, 84
of physicians, 84
Alberta
alternate level of care rates, f-52
angina hospitalization rates, f-67
Caesarean sections, f-30
Caesarean sections, potential cost
savings, f-32
diabetes funding, f-51
funding initiative, activity-based, 14
health care spending, 93, f-95
heart attack hospitalization rates, f-64
heart attack in-hospital mortality
rates, 62
heart attacks, potential cost
savings, f-71
hysterectomies, f-33, f-34
hysterectomies, potential cost
savings, f-35
knee arthroscopies, f-23
pharmacists, 86
physicians, f-82–83
use of HSMR, f-76
vertebroplasties, f-24
alternate level of care (ALC)
deaths during, 51
defined, 3, 49
discharges, 51, f-53
impacts on the system, 50–51
proportion of hospitalizations, 50–51
108
Health Care in Canada 2010
reasons for, 51–52
ambulatory care sensitive conditions
(ACSCs), 42
angina
cause, 60
hospitalization rates, 61, f-67
appropriateness of care
and alternate levels of care, 50–52
and care setting, 3, 49–53, f-54, 106
defined, 49
difficulty of measuring, 2
of Caesarean sections, 25–31
of hysterectomies, 31–34, f-35
of knee arthroscopy for
osteoarthritis, 22, f-23, 24
of vertebroplasty for osteoporotic
vertebral fracture, 23–24
arthroscopies
in knee, for osteoarthritis, evidence
against, 22
in knee, for osteoarthritis, impact
on system, 24
in knee, for osteoarthritis, rates
of, 22, f-24
asthma, hospitalizations, international
comparisons, 43
audiologists, 84
B
British Columbia
alternate level of care rates, f-52
angina hospitalization rates, f-67
Caesarean sections, f-30
Caesarean sections, potential cost
savings, f-32
chronic illness funding, f-49
drug expenditures, cardiovascular
diseases, 66
drug reform measures, 13
health care spending, 94, f-95
heart attack hospitalization
rates, f-64, 66–67
hospital funding, 13
hysterectomies, 31, f-33, f-34
knee arthroscopies, f-23
pharmacists, 86
physicians, f-82–83
registered nurses, 83
use of HSMR, f-76
vertebroplasties, f-24
wait times for joint replacements, 14
C
Caesarean sections
impacts on the system, 30–31
indications for, 25–26, 29
international comparisons, f-26, f-27
rate variations, 27–29
risks, 25
Canada Health Transfer, 14
Canadian Pandemic Influenza Plan, 8
cardiac care
hospitalization rates, 61
impacts on the system, 66–67, f-71
improvements, 60, 63–66
quality indicators, f-66
cardiovascular health, benefits of
smoking bans, f-61–62
care
appropriateness—see appropriateness
of care
evidence-based—see evidencebased care
measuring, 4
quality of—see quality of care
care providers
aging of, 84
graduates in, 83
migration and immigration, 83, f-84
numbers and population ratios, 82–83
shortages, 82
Chalk River (Ontario) National Research
Universal (NRU) reactor, 10
children
and H1N1 pandemic, 8, f-11
chiropractors, f-85
chronic illness, management and
prevention, 42
congestive heart failure, hospitalizations,
international comparisons, 43, f-44
coronary artery disease, 60
D
deaths
from influenza, H1N1, 8, f-10
dental hygienists, f-85
dentists, f-85
developing countries, care provider
migration from, f-84
diabetes
and comorbidity, 44
barriers to care, 48
care, preventive, 44–46, f-47, f-48
hospitalizations, international
comparisons, 43
impacts on the system, 46–48
incentive billing, f-49
prevalence, 44
types, f-46
drug expenditures
and generic drug reforms, 13
as health care cost escalators, 97
cardiovascular diseases, 66
E
electrocardiography, f-63
emergency departments and H1N1
pandemic, f-11
evidence-based care and practice
guidelines, 3, 105
G
gender factors, vertebroplasties, 23
Health Care in Canada 2010
109
H
H1N1—see influenza A virus,
H1N1 subtype
health accord (2004), 14, 106
health-based allocation model
of funding, Ontario, 12
health care reform, in
United States, f-97–98
health care spending
1975 to 2010, f-93
as percentage of GDP, f-93
by use of funds, f-99
cost drivers, 96–98
cost escalators, 96–98
funding initiatives, 12–14
international comparisons,
93, 94–95, f-94, f-96
no correlation with life expectancy,
94–95, f-96
on H1N1 pandemic, 9
public/private mix, 92
regional variations, 93–94, 105
health human resources
compensation, 98
international comparisons, 85, f-86
planning, 84
health information management
professionals, f-85
health system performance,
measuring, 68–69
heart attacks
appropriate care, 63–66
care improvements, 63
cause, 60
death rates, in-hospital, 60, 62, f-68
hospitalization rates, 61, f-69, f-70
outcomes, 62
readmission rates, 61–62, f-67
risk factors, 60
types, f-63
hip replacements, wait time
improvements, 14
hospitalizations
alternate level of care, 49–53, f-54
for ACSCs, 42–43
for angina, 61, f-67
for asthma, 43
for chronic illness, 42
110
Health Care in Canada 2010
for coronary artery disease, 60
for diabetes, 43, 44, f-45
for H1N1 influenza, 8, f-10–11
for heart attacks, 61, 62, 66–67,
f-69, f-70
for heart failure, 43, f-44
hospitals
admissions, avoidable, 42–43, f-44
funding initiatives, 13
H1N1 impact, f-11–12
quality-of-care initiatives, 13
hospital standardized mortality
ratio (HSMR)
defined, f-72
examples of uses, 72–76, f-76–77
improvements, 70, 71, f-75
purpose, 69–70
reporting service, f-73–74
hysterectomies
costs and procedure types, 34
defined, 31
impacts on the system, 33–34
rate variations, 31–32, f-33
I
incentive-based health care funding,
12, f-13–14
income and diabetes testing, 46
influenza A virus, H1N1 subtype
2009–2010 pandemic, 8–9, f-10, f-11
Canadian health system response to, 9
death rates, 8, f-10
impact on Canadian hospitals, f-11–12
symptoms of illness, 8
international comparisons
ACSC hospitalizations, 42–43
asthma hospitalizations, 43
Caesarean sections, f-26, f-27
congestive heart failure
hospitalizations, 43, f-44
diabetes prevention, f-48
health care spending,
93, 94–95, f-94, f-96
health human resources, 85, f-86
heart attack in-hospital mortality
rates, 62
life expectancy, f-96
J
joint replacements, wait time
improvements, 14
K
knee replacements, wait time
improvements, 14
knee surgery, arthroscopic
for osteoarthritis, evidence against, 22
for osteoarthritis, impact on
system, f-24
for osteoarthritis, rates of, 22, f-23
L
life expectancy
international comparisons, f-96
no correlation with health care
spending, 94–95, f-96
regional variations, 94
local health integration networks,
funding, 12
long-term care, quality-of-care
initiatives, 14
M
Manitoba
alternate level of care rates, f-52
angina hospitalization rates, f-67
Caesarean sections, 27, f-30, 31
diabetes funding, f-50
heart attack hospitalization rates, f-64
heart attacks, potential cost
savings, f-71
hysterectomies, f-33, f-34
hysterectomies, potential cost
savings, f-35
knee arthroscopies, f-23
physicians, f-82–83
use of HSMR, f-76
vertebroplasties, f-24
medical isotopes, supply
disruption, 10–11
medical physicists, f-85
midwives, 86
N
New Brunswick
alternate level of care rates, f-52
angina hospitalization rates, f-67
Caesarean sections, f-30
Caesarean sections, potential cost
savings, f-32
diabetes funding, f-51
health care spending, f-95
heart attack hospitalization rates, f-64
heart attacks, potential cost
savings, f-71
hysterectomies, f-33, f-34
hysterectomies, potential cost
savings, f-35
knee arthroscopies, f-23
pharmacists, 86
physicians, f-82–83
use of HSMR, 75–76, f-76, f-77
vertebroplasties, f-24
Newfoundland and Labrador
alternate level of care rates, 51, f-52
angina hospitalization rates, f-67
Caesarean sections, 27, 29, f-30
Caesarean sections, potential cost
savings, f-32
health care spending, f-95
heart attack hospitalization rates, f-65
heart attack in-hospital mortality
rates, 62
heart attacks, potential cost
savings, f-71
hysterectomies, f-33, f-34
hysterectomies, potential cost
savings, f-35
knee arthroscopies, f-23
physicians, f-82–83
registered nurses, 83
use of HSMR, f-77
Health Care in Canada 2010
111
non-ST-segment elevated myocardial
infarction (NSTEMI)
appropriate care, 63–66
defined, f-63
hospitalization rates, f-70
Northwest Territories
angina hospitalization rates, f-67
Caesarean sections, f-30
health care spending, f-95
heart attack hospitalization rates, f-65
hysterectomies, f-33, f-34
physicians, f-82–83
registered nurses, 83
Nova Scotia
alternate level of care rates, f-52
angina hospitalization rates, f-67
Caesarean sections, f-30
Caesarean sections, potential cost
savings, f-32
diabetes funding, f-51
health care spending, f-95
heart attack hospitalization rates, f-64
heart attacks, potential cost
savings, f-71
hysterectomies, f-33, f-34
hysterectomies, potential cost
savings, f-35
knee arthroscopies, f-23
pharmacists, 86
physicians, f-82–83
use of HSMR, f-77
vertebroplasties, f-24
nuclear medicine examinations, 10
Nunavut
angina hospitalization rates, f-67
Caesarean sections, 27, 29, f-30
health care spending, 93, f-95
heart attack hospitalization rates, f-65
hysterectomies, 31, f-33, f-34
physicians, 82, f-82–83
registered nurses, 83
nurse practitioners, 84, f-85, f-87
nurses, 83–84
112
Health Care in Canada 2010
O
occupational therapists, 84
Ontario
alternate level of care
measures, 53, f-54
alternate level of care rates, 51, f-52
angina hospitalization rates, f-67
Caesarean sections, f-30
Caesarean sections, potential cost
savings, f-32
diabetes funding, f-50
drug reform measures, 13
Excellent Care for All Act, 2010, 13
H1N1 emergency room visits, f-12
health-based allocation model of
funding, 12–13
health care spending, f-95
heart attack hospitalization rates, f-64
heart attacks, potential cost
savings, f-71
hysterectomies, f-33, f-34
hysterectomies, potential cost
savings, f-35
knee arthroscopies, f-23
pharmacists, 86
physicians, f-82–83
use of HSMR, f-77
vertebroplasties, f-24
wait times for joint replacements, 14
optometrists, f-85
osteoarthritis, knee arthroscopy for,
evidence against, 22
osteoporotic vertebral fractures,
vertebroplasty for, evidence against, 23
P
pandemics
H1N1, 8–9, f-10, f-11
influenza, history of, f-9
pharmacists
numbers and population ratios, 84
scope of practice, 86
physicians
aging, 84
Canadian medical graduates, 83
international medical graduates, 83
numbers and population ratios,
82, f-82–83, f-85
physiotherapists, 84
policies and programs, and investment
priorities, 105
pregnancy and childbirth
and H1N1 influenza, 8, f-11
Caesarean sections, 28
Prince Edward Island
alternate level of care rates, f-52
angina hospitalization rates, f-67
Caesarean sections, f-30
Caesarean sections, potential cost
savings, f-32
health care spending, f-95
heart attack hospitalization rates, f-64
heart attack in-hospital mortality
rates, 62
heart attacks, potential cost
savings, f-71
hysterectomies, 31, f-33, f-34
hysterectomies, potential cost
savings, f-35
knee arthroscopies, 22, f-23
physicians, f-82–83
use of HSMR, f-77
private-sector funding, defined, 92
provinces
alternate level of care rates, 51, f-52
angina hospitalization rates, f-67
Caesarean section rate variations,
27, 29, f-30, 31
Caesarean sections, potential cost
savings, f-32
chronic illness management, f-49–51
drug expenditures, 13
drug expenditures, cardiovascular
diseases, 66
drug reform measures, 13
funding initiatives, 12–14
health care spending, 93–94, f-95
heart attack hospitalization rates,
f-64–65, 66–67
heart attack in-hospital mortality
rates, 62
heart attacks, potential cost
savings, f-71
hysterectomies, potential cost
savings, f-35
hysterectomy rate variations,
31–32, f-33, f-34
knee arthroscopies, 22, f-23
pharmacists, 86
physicians, 82, f-82–83
registered nurses, 83
uses of HSMR, 75–76, f-76–77
vertebroplasties, f-24
wait times for joint replacements, 14
psychologists, f-85
Public Health Agency of Canada,
established, 8
public-sector funding, defined, 92
Q
quality of care
difficulty of measuring, 2
in hospitals and funding models, 13
in long-term care and funding
models, 14
measuring, using HSMR, 68–69
Quebec
alternate level of care rates, 51, f-52
angina hospitalization rates, f-67
Caesarean sections, f-30
Caesarean sections, potential cost
savings, f-32
drug reform measures, 13
funding initiative, activity-based, 14
health care spending, 93, 94, f-95
heart attack hospitalization rates, f-64
heart attacks, potential cost
savings, f-71
hysterectomies, f-33, f-34
hysterectomies, potential cost
savings, f-35
knee arthroscopies, 22, f-23
physicians, 82, f-82–83
vertebroplasties, f-24
wait times for joint replacements, 14
Health Care in Canada 2010
113
R
randomized controlled trials (RCTs)
feasibility, 22
value as evidence basis, 3
registered nurses, 83, f-85
Resident Assessment Instrument (RAI)
for home care, f-15
for long-term care, 14
respiratory therapists, f-85
rural and remote areas, hysterectomy
rates, 31
S
SARS (severe acute respiratory
syndrome), as impetus for pandemic
planning, 8
Saskatchewan
alternate level of care rates, 51, f-52
angina hospitalization rates, f-67
Caesarean sections, f-30
Caesarean sections, potential cost
savings, f-32
diabetes funding, f-51
heart attack hospitalization rates, f-64
heart attacks, potential cost
savings, f-71
hysterectomies, f-33, f-34
hysterectomies, potential cost
savings, f-35
knee arthroscopies, f-23
pharmacists, 86
physicians, 82, f-82–83
use of HSMR, f-76
vertebroplasties, f-24
scopes of practice, expanding, 86
seniors
and H1N1 pandemic, 8
vertebroplasties, 23
smoking bans and cardiac
health, f-61–62
Society of Obstetricians and
Gynaecologists of Canada,
recommendations for Caesarean
sections, 26
114
Health Care in Canada 2010
ST-segment elevated myocardial
infarction (STEMI)
appropriate care, 63–66
defined, f-63
hospitalization rates, f-69
substantive rate variations
as indicator of lack of uniform
treatment, 3
cardiac care, 61–62
factors affecting, 25
T
technetium-99m (Tc-99m), 10–11
technologies, health care
spending on, 98
territories
angina hospitalization rates, f-67
Caesarean section rate variations,
27, 29, f-30
drug expenditures, 13
drug expenditures, cardiovascular
diseases, 66
health care spending, 93–94, f-95
heart attack hospitalization rates, f-65
hysterectomy rate variations,
31–32, f-33, f-34
physicians, 82, f-82–83
registered nurses, 83
Trillium Health Centre, Mississauga,
Ontario, 72–74
U
urban areas, hysterectomy rates, 31
V
vertebroplasties
for osteoporotic vertebral fractures,
evidence against, 23
for osteoporotic vertebral fractures,
impact on system, 24
for osteoporotic vertebral fractures,
rates of, 23, f-24
W
women, vertebroplasties, 23
World Health Organization
and H1N1 pandemic, 8
on Caesarean sections, f-28
on international recruitment of health
personnel, f-84
Y
Yukon
angina hospitalization rates, f-67
Caesarean sections, f-30
diabetes funding, f-51
health care spending, 93, f-95
heart attack hospitalization rates, f-65
hysterectomies, f-33, f-34
physicians, 82, f-82–83
registered nurses, 83
Health Care in Canada 2010
115
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given to the Canadian Institute for Health Information.
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Canadian Institute for Health Information, Health Care in Canada 2010
(Ottawa, Ont.: CIHI, 2010).
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