Sandra Peterson

Waiting times for surgical procedures.

OBJECTIVES Polls show that nearly two thirds of Canadians believe that waiting times prior to surgery have increased in recent years. A study was undertaken in Manitoba to determine whether public perceptions about long and increasing waits were valid. RESEARCH DESIGN Using administrative data, waiting times for 10 types of surgery-ranging from coronary artery bypass surgery and mastectomy to cataract surgery and hernia repairs-were studied over a 5-year period. RESULTS Using each patients preoperative visit to the surgeon as the beginning of the waiting time, median waiting times for most of the procedures studied were found to have, in fact, remained stable or fallen slightly over the period studied. CONCLUSIONS Further, an examination of waiting times for cataract surgery demonstrated that allowing surgeons to practice in both public and private arenas seems to be counterproductive to providing good public service.

Patient activation in primary healthcare: a comparison between healthier individuals and those with a chronic illness.

Background and ObjectiveCurrent policy directions place increasing expectations on patients to actively engage in their care, especially in chronic disease management. We examined relationships between patient activation and multiple dimensions of primary healthcare (PHC), including access, utilization, responsiveness, interpersonal communication, and satisfaction for patients with and without chronic illness. Research DesignCross-sectional, random digit dial survey conducted in British Columbia (BC), Canada. SubjectsStratified sample of adults (n=504), aged 19 to 90 years, who had visited their regular provider within the past 24 months. All data were weighted to represent residents living in BC. MeasuresPatient activation and PHC experiences include accessibility, continuity, whole-person care, interpersonal communication, responsiveness, chronic disease management, and satisfaction. ResultsThe multivariate models provide evidence that both quantity of time and quality of interactions with ones regular provider are associated with higher patient activation. Those with no chronic illness had higher activation scores when they spent more time talking with their regular provider, experienced less hurried communication, or if their test results were explained. The more time people with chronic illness are able to spend with their physician, the more activated they were. Chronic illness respondents also had higher activation scores if they reported higher whole-person care or if they were more satisfied. ConclusionsPositive interactions between the patient and the provider can influence the patients abilities to engage in and be confident in maintaining/improving his/her health. Supporting patients in becoming actively engaged, in ways that work for them, is essential to providing high quality care, especially among those with a chronic condition.

Assessing the extent to which hospitals are used for acute care purposes.

OBJECTIVES The degree to which Manitobans were appropriately hospitalized for medical conditions was assessed using a retrospective chart review of a sample of patients in 26 hospitals. RESEARCH DESIGN A standardized set of object-based, nondiagnostic criteria (Inter-Qual) was used by trained abstractors to assess the patient at admission and for each day of stay. RESULTS A high percentage of admissions and days of care were inappropriate. Overall, 49.5% of medical patients were acute at the time of admission, 1.6% required no health care services, and 48.9% could have received care through alternate methods or facilities. Only 33.4% of the subsequent days of stay were appropriate. For patients assessed as acute at the time of admission, by the 8th day of stay, only 47% were still acute and by day 30, only 27% were acute. Patients aged 75 years or older were just as likely to be acute at the time of admission as were younger patients; however, they accounted for 54% of the days in the study, and fewer than 30% of these days were acute. Our data suggest that despite their high use of hospitals, disadvantaged groups (the poor, aboriginal Manitobans), have the same levels of appropriateness as others. CONCLUSIONS We conclude that alternatives to hospital care must first be established and made known and available before a shift in health care resources can occur.

Using Population-Based Data to Enhance Clinical Practice Guideline Development

OBJECTIVES Working with the College of Physicians and Surgeons of Manitoba, and using tonsillectomies as a basis of inquiry, MCHPE examined surgical rates and patterns of practice. This project had three major aims: to review whether current patterns of delivery provide optimal care; to enhance the development of clinical guidelines; and to inform and influence physician practice. RESEARCH DESIGN Both a population-based method of inquiry (which permits comparisons across population groups) and a provider-based approach (which offers insights into differences in the nature of care offered by different types of hospitals and physicians) were used. MEASURES Synergies between these two approaches offered useful insight into aspects of quality and efficiency of care. RESULTS Consistent with other jurisdictions, there was a high degree of variability across regions. However, there were also a number of surprising findings, including high rates of surgery in females, in older children, and among residents of rural areas. Data analysis raised a number of quality-of-care issues related to small caseload volumes, performance of procedures in very young children, and patterns of postoperative care in rural hospitals. The analyses provided impetus for addressing these issues in the guideline and suggested that the target audience for intervention should be rural physicians rather than urban specialists. CONCLUSIONS This project demonstrated that data analysis can provide a powerful adjunct to the development and implementation of clinical practice guidelines.

Designation, diligence and drift: understanding laboratory expenditure increases in British Columbia, 1996/97 to 2005/06

BackgroundLaboratory testing is one of the fastest growing areas of health services spending in Canada. We examine the extent to which increases in laboratory expenditures might be explained by testing that is consistent with guidelines for the management of chronic conditions, by analyzing fee-for-service physician payment data in British Columbia from 1996/97 and 2005/06.MethodWe used direct standardization to quantify the effect on laboratory expenditures from changes in: fee levels; population growth; population aging; treatment prevalence; expenditure on recommended tests for those conditions; and expenditure on other tests. The chronic conditions selected were those with guidelines containing laboratory recommendations developed by the BC Guidelines and Protocol Advisory Committee: diabetes, hypertension, congestive heart failure, renal failure, liver disease, rheumatoid arthritis, osteoarthritis and dementia.ResultLaboratory service expenditures increased by

Classifying physician practice style: a new approach using administrative data in British Columbia.

98 million in 2005/06 compared to 1996/97, or 3.6% per year after controlling for population growth and aging. Testing consistent with guideline-recommended care for chronic conditions explained one-third (1.2% per year) of this growth. Changes in treatment prevalence were just as important, contributing 1.5% per year. Hypertension was the most common condition, but renal failure and dementia showed the largest changes in prevalence over time. Changes in other laboratory expenditure including for those without chronic conditions accounted for the remaining 0.9% growth per year.ConclusionIncreases in treatment prevalence were the largest driver of laboratory cost increases between 1996/97 and 2005/06. There are several possible contributors to increasing treatment prevalence, all of which can be expected to continue to put pressure on health care expenditures.

Examining regional variation in health care spending in British Columbia, Canada

Background:Primary medical care is changing—more female providers, desire for better work-life balance, and increasing availability of walk-in clinics have altered service delivery. There is no uniform physician practice style, and understanding service availability and delivery requires analysis of family physicians’ practice patterns, rather than just physician counts. Methods:This paper offers a new approach for describing the practice habits of primary care physicians. We use administrative data to identify activities associated with acting as “most responsible” physicians. We used British Columbia’s administrative health care data from 2007/2008 to 2011/2012 to derive information regarding physicians, patients, and service delivery. We developed 5 variables to describe practice style: referrals, oversight, screening, initial prescribing for long-term medications, and repeat visits. Cluster analysis revealed 3 distinct groups of physicians. Results:Only 24% of the primary care physicians were assigned to the high-responsibility group, whereas 36% and 39% were in the low-responsibility and mixed-practice groups, respectively. All cluster variables follow a similar pattern, with the high-responsibility and low-responsibility physicians many multiples apart on the means and the mixed group falling in between. Several forms of sensitivity analysis confirmed the robustness of these results. Conclusions:Physician practice patterns influence the effective supply of primary care. The fact that more than one third of British Columbia physicians are identified as “low responsibility” has implications for the delivery of primary care, both in ensuring that people have access to regular care and in insuring high-quality and comprehensive care.

Admission to hospital for pneumonia and influenza attributable to 2009 pandemic A/H1N1 Influenza in First Nations communities in three provinces of Canada

Examining regional variation in health care spending may reveal opportunities for improved efficiency. Previous research has found that health care spending and service use vary substantially from place to place, and this is often not explained by differences in the health status of populations or by better outcomes in higher-spending regions, but rather by differences in intensity of service provision. Much of this research comes from the United States. Whether similar patterns are observed in other high-income countries is not clear. We use administrative data on health care use, covering the entire population of the Canadian province of British Columbia, to examine how and why health care spending varies among health regions. Pricing and insurance coverage are constant across the population, and we adjust for patient-level age, sex, and recorded diagnoses. Without adjusting for differences in population characteristics, per-capita spending is 50% higher in the highest-spending region than in the lowest. Adjusting for population characteristics as well as the very different environments for health service delivery that exist among metropolitan, non-metropolitan, and remote regions of the province, this falls to 20%. Despite modest variation in total spending, there are marked differences in mortality. In this context, it appears that policy reforms aimed at system-wide quality and efficiency improvement, rather than targeted at high-spending regions, will likely prove most promising.

Effect of incentive payments on chronic disease management and health services use in British Columbia, Canada: Interrupted time series analysis

BackgroundEarly reports of the 2009 A/H1N1 influenza pandemic (pH1N1) indicated that a disproportionate burden of illness fell on First Nations reserve communities. In addition, the impact of the pandemic on different communities may have been influenced by differing provincial policies. We compared hospitalization rates for pneumonia and influenza (P&I) attributable to pH1N1 influenza between residents of First Nations reserve communities and the general population in three Canadian provinces.MethodsHospital admissions were geocoded using administrative claims data from three Canadian provincial data centres to identify residents of First Nations communities. Hospitalizations for P&I during both waves of pH1N1 were compared to the same time periods for the four previous years to establish pH1N1-attributable rates.ResultsResidents of First Nations communities were more likely than other residents to have a pH1N1-attributable P&I hospitalization (rate ratio [RR] 2.8-9.1). Hospitalization rates for P&I were also elevated during the baseline period (RR 1.5-2.1) compared to the general population. There was an average increase of 45% over the baseline in P&I admissions for First Nations in all 3 provinces. In contrast, admissions overall increased by approximately 10% or less in British Columbia and Manitoba and by 33% in Ontario. Subgroup analysis showed no additional risk for remote or isolated First Nations compared to other First Nations communities in Ontario or Manitoba, with similar rates noted in Manitoba and a reduction in P&I admissions during the pandemic period in remote and isolated First Nations communities in Ontario.ConclusionsWe found an increased risk for pH1N1-related hospital admissions for First Nations communities in all 3 provinces. Interprovincial differences may be partly explained by differences in age structure and socioeconomic status. We were unable to confirm the assumption that remote communities were at higher risk for pH1N1-associated hospitalizations. The aggressive approach to influenza control in remote and isolated First Nations communities in Ontario may have played a role in limiting the impact of pH1N1 on residents of those communities.

A population-based analysis of prescription drug use and costs in IBD

We studied the effects of incentive payments to primary care physicians for the care of patients with diabetes, hypertension, and Chronic Obstructive Pulmonary Disease (COPD) in British Columbia, Canada. We used linked administrative health data to examine monthly primary care visits, continuity of care, laboratory testing, pharmaceutical dispensing, hospitalizations, and total h ealth care spending. We examined periods two years before and two years after each incentive was introduced, and used segmented regression to assess whether there were changes in level or trend of outcome measures across all eligible patients following incentive introduction, relative to pre-intervention periods. We observed no increases in primary care visits or continuity of care after incentives were introduced. Rates of ACR testing and antihypertensive dispensing increased among patients with hypertension, but none of the other modest increases in laboratory testing or prescriptions dispensed reached statistical significance. Rates of hospitalizations for stroke and heart failure among patients with hypertension fell relative to pre-intervention patterns, while hospitalizations for COPD increased. Total hospitalizations and hospitalizations via the emergency department did not change. Health care spending increased for patients with hypertension. This large-scale incentive scheme for primary care physicians showed some positive effects for patients with hypertension, but we observe no similar changes in patient management, reductions in hospitalizations, or changes in spending for patients with diabetes and COPD.