Noralou P. Roos

A Population-Based Health Information System

The authors introduce the Population Health Information System, its conceptual framework, and the data elements required to implement such a system in other jurisdictions. Among other innovations, the Population Health Information System distinguishes between indicators of health status (outcomes measures) and indicators of need for health care (socioeconomic measures of risk for poor health). The system also can be used to perform needs-based planning and challenge delivery patterns.

Establishing a Population Data-Based Policy Unit

The Manitoba Centre for Health Policy and Evaluation (MCHPE) developed POPULIS, a population-based health information system, as a vehicle for changing the way we think about the role of health care as a determinant of health. Serving as a bridge between analysts who produce research and politicians and policymakers who use it, MCHPE has developed a research infrastructure that can transform routinely collected administrative data into policy-relevant information. This paper provides a description of Manitoba and its health care system, as well as how MCHPE was started and how it functions. It describes how we at the Centre work with various databases, from the acquisition process through developing concepts and capabilities to the final validity and sensitivity testing of results. We detail the role of a population-based conceptual framework in challenging those who suggest more spending on medical care is self-evidently desirable.

Managing health services: how the Population Health Information System (POPULIS) works for policymakers.

OBJECTIVESnUniversity-based researchers in Manitoba, Canada, have used administrative data routinely collected as part of the national health insurance plan to design an integrated database and population-based health information system. This information system is proving useful to policymakers for answering such questions as: Which populations need more physician services? Which need fewer? Are high-risk populations poorly served? or do they have poor health outcomes despite being well served? Does high utilization represent overuse? or is it related to high need? More specifically, this system provides decision makers with the capability to make critical comparisons across regions and subregions of residents health status, socioeconomic risk characteristics and use of hospitals, nursing homes, and physicians. The system permits analyses of demographic changes, expenditure patterns, and hospital performance in relation to the population served. The integrated database has also facilitated outcomes research across hospitals and countries, utilization review within a single hospital, and longitudinal research on health reform. The discussion highlights the strengths of integrated population-based information in analyzing the health care system and raising important questions about the relationship between health care and health.

From research to policy: what have we learned?

The Manitoba Centre for Health Policy and Evaluation has now had eight years of experience as an academic research unit interfacing with policymakers. Most of our research has focused on the determinants of health and on the delivery of health care from a population perspective. Each project that we have undertaken has made its own contribution and reinforced or built on the contribution of others. By communicating closely with policymakers at all levels, while maintaining an arms-length relationship and the right of publication, MCHPE acts as a knowledgeable non-stakeholder with a commitment to inform the broader public.

A population-based approach to monitoring adverse outcomes of medical care.

&NA; A population‐based approach to monitoring quality of care combining small‐area analysis and outcomes assessment is proposed. While adverse outcomes due to poor surgical technique have long been targeted for quality‐of‐care review, in this study, giving similar attention to adverse outcomes produced by high rates of interventions is proposed. A population‐based approach will strengthen traditional review efforts that currently begin and end at the hospital door. Excluded from these reviews have been questions such as the following: Should the procedure have been performed in the first place? Did the benefits outweigh the risks? Were there other patients not operated on who might have benefited more? Traditional approaches can identify less competent hospitals or practitioners: population‐based approaches can identify the surgical enthusiasts who may pose equal risks to the populations of the areas they serve. Applying a population‐based approach to review of coronary artery bypass graft surgery for Medicare patients in five cities in the United States demonstrates that at least as many deaths could have been prevented by decreasing surgical rates to the U.S. average as by improving the technical quality of care with which the procedure was performed. A similar population‐based analysis of complications (as judged by re‐admissions within 30 days of surgery) associated with hysterectomy across regions of Manitoba, Canada, is presented. In summary, negligent acts in the delivery of health care in institutions are rare and are difficult to detect because medicine is an inexact science and because adverse outcomes are more likely in high‐risk patients, regardless of the quality of care. However, from a population perspective, adverse events are predictable, occur relatively frequently, and are directly related to the frequency of a populations exposure to surgical intervention. Efforts to improve quality of care could be made more effective by including the rates at which populations are exposed to treatments and the technical quality of care delivered.

Population Health and Health Care Use: An Information System for Policy Makers

University-based researchers in Manitoba, Canada, have used administrative data routinely collected as part of the national health insurance plan to design a population-based health information system (POPULIS). Decision-makers can use this system to make critical comparisons across regions of residents health status, socioeconomic risk characteristics, and use of hospitals, nursing homes, and physicians. Policy makers have found this information system useful in providing answers to questions they are often asked: Which populations need more physician services? Which need fewer? Are high-risk populations poorly served or do they have poor health outcomes despite being well served? Does high utilization represent overuse or is it related to high need? Three commentaries follow.

Utilization of hospital resources.

A population-based approach was used to analyze the utilization patterns of hospital care by Manitoba residents during the fiscal year 1991/1992. Patterns were analyzed for eight administrative regions, with use assigned to the patients region of residence, regardless of the location of the hospitalization. Regional boundaries consistent with those used for presentation of data on health status and socioeconomic risk permitted integration of findings across the Population Health Information System. Marked differences in acute hospital use were found. Residents of the urban Winnipeg (“good health”) region had the lowest rates of use of acute care overall, and northern rural (“poor health”) regions had significantly higher rates of use. However, almost one-half of hospital days by Winnipeg residents were used in long-stay care (60+ days), while rural residents were more likely to use short-stay hospital care. Despite a concentration of surgical specialists in Winnipeg, there were only small regional differences in overall rates of surgery.

Needs-based planning for generalist physicians.

OBJECTIVESnThe Manitoba Centre for Health Policy and Evaluation (MCHPE) collaborated with a provincially-appointed Physician Resource Committee in an assessment of provincial physician resources.nnnRESEARCH DESIGNnBeginning with map-based analyses of physician supply and contacts across the province, compared with the health and socioeconomic characteristics of local populations, the study moved to a needs-based, regression-based approach to physician resource planning.nnnRESULTSnThe results challenged the popular belief that Manitoba suffers from an increasing shortage of physicians. A handful of high-need, low-supply and low-use areas are identified, as is the expensive surplus of generalist physicians in Winnipeg. (Generalist physicians include general and family practitioners as well as general internists and pediatricians.) No relationship between physician supply and health characteristics of populations, or between high physician supply and low hospital use patterns were found. Given the Committees interest in what drives high physician contact rates, analyses of visit patterns of hypertensive patients were undertaken. We found that patients who had more complex medical conditions made more contacts, but that after controlling for this and other key patient characteristics, the patients primary care physicians patient recall rate was a strong influence on how frequently visits were made.

Managing health services: how administrative data and population-based analyses can focus the agenda.

University-based researchers in Manitoba, Canada, have used administrative data routinely collected as part of the national health insurance plan to design an integrated database and population-based health information system. This information system is proving useful to policymakers for providing answers to such questions as: which populations need more physician services? Which need fewer? Are high-risk populations poorly served or do they have poor health outcomes despite being well served? Does high utilization represent overuse or utilization related to high need? More specifically, this system provides decision-makers with the capability to make critical comparisons across regions and subregions of residents health status, socioeconomic risk characteristics, and use of hospitals, nursing homes, and physicians. The system permits analyses of demographic changes, expenditure patterns, and hospital performance in relation to the population served. The integrated database has also facilitated outcomes research across hospitals and counties, utilization review within a single hospital, and longitudinal research on health reform. A particularly interesting application to planning physician supply and distribution is discussed. The discussion highlights the strengths of integrated population-based information in analyzing the health care system and raising important questions about the relationship between health care and health.

Issues in planning for specialist physicians.

OBJECTIVESnThe Manitoba Centre for Health Policy and Evaluation worked in support of a provincial Physician Resource Committee to address questions pertinent to assessing Manitobas supply of specialist physicians.nnnRESEARCH DESIGNnBecause there was no direct method of determining whether the provinces supply of specialists was adequate, three types of evidence were reviewed: the supply of specialists relative to recommended population/physician ratios; the supply of specialists relative to other Canadian provinces; and the level of care delivered by specialists in Manitoba relative to other provinces. Four additional questions were addressed: is a problem developing from the aging of Manitobas specialist physicians? and will the supply of specialists be sufficient to keep up with the aging of the population? How well do specialists serve as a provincial resource? and how well do specialists serve high-need populations?