This article was originally published in Maclean's Magazine on June 7, 1999
I think it is obvious that when you're spending $80 billion a year as Canadians do on health care, there's a need to know more about what we're getting for our money. - Health Minister Allan Rock, Feb. 3, 1999
Two weeks after Rock's statement, Ottawa matched the rhetoric with real money in the so-called health-care budget. While it increased cash transfers to the provinces to fund HEALTH CARE, it also committed $1.4 billion to its own direct investment in health. Of that, $350 million is earmarked over the next three years to a data-gathering project designed to improve health service - and to make its operations more visible to the public. But even as that key program gets under way, huge strides are being made elsewhere in the collection of health-care information that truly matters to Canadians. Until this year, the only publicly available comparisons using national data have been at the province-to-province level. Now, for the first time, the Maclean's Health Report contains comparative data at the community level, producing an unprecedented ranking of health services in 16 major urban centres from Victoria to St. John's, Nfld.
The results clearly demonstrate that excellence respects no boundaries. Topping the list is Edmonton, followed closely by Toronto, Halifax and Quebec City. The ranked cities showed hugely varying results on many of the 13 individual indicators forming the basis of the overall ranking, such as numbers of physicians and specialists, coronary bypass and hip replacement surgeries and hospital patients admitted for conditions that could have been treated elsewhere. But the positives and negatives evened out considerably in the final grading: the marks range from Edmonton's top score of 89 per cent to Sudbury's 16th-place showing of 79 per cent. "It should come as no surprise that health-care service in all of Canada's cities gets a good grade," says Dr. John Millar, vice-president of the Canadian Institute for Health Information, Maclean's partner in preparing the Health Report. "But those communities can now use the results, especially their poorer showings on individual indicators, to look at how they might do some things better."
The absence of any clear failure is a reassuring reminder that, despite its notorious shortcomings, the Canadian health system in most respects ranks among the finest on the planet. Nonetheless, headlines and newscasts scream daily about long, occasionally fatal, waits for critical treatments. Dangerously overcrowded emergency departments. Sadly inadequate home-care facilities. Seriously overworked and underpaid nurses. Alarming disparities in care between urban and rural areas. Frankly appalling health services in many native communities. And the alarms keep sounding, prompting Canadians to wonder what is going right.
Plenty, as it turns out. Even as health ministries across the land closed wards and entire hospitals over the past five to 10 years, taking beds out of the system, the dire consequences foreseen by vocal critics simply did not happen. Serious problems erupted from time to time, rivetting the attention of the communities where they happened. "But for one reason or another," says Millar, "the health of the population has continued to get better."
Still, could $80 billion be spent more effectively? Are all Canadians getting the same high standard of care? Are the practitioners well enough trained? Where is the medical and surgical excellence in Canada? Who does the best coronary bypass surgery, and who does the best job of treating cancer? Why do overcrowding crises persist in hospital emergency departments? Those are all valid questions. Unfortunately, there are no thorough answers to any of them, not even a hint of an answer to some.
The data used to produce this initial ranking, however, cover enough critical facets to give regional health authorities reason to reassess some of their practices. For the top-ranking community, Edmonton, the ranking is a sign that it is "on the right track". In the No. 2 city, Toronto, the numbers are seen as a tool to improve performance. And in fact, the information system that produced those indicators is already one of the best in the world, says Richard Alvarez, president of CIHI, the independent agency responsible for managing and circulating health-system data. "But as more and more treatments are moved out of the traditional hospital setting into clinics, home care, day surgery and other procedures," he adds, "we find we just don't have good data." Consequently, a prime focus at CIHI is on developing means to collect material from those sources. "How efficiently was a procedure done? How effectively? How long did the patient wait?" asks Alvarez. "These are the questions we have to be able to answer."
As those initiatives get under way, CIHI has gained agreement from communities across the country as to which indicators from already available data can be used as valid, comparable measurements of service delivery - the basis of the Maclean's ranking. Millar, who spearheaded CIHI's involvement in the Health Report, sees that kind of progress as a fundamental part of the organization's mandate. "At the heart of our basic philosophy is the regular need to report directly to the public," he says. "We are striving to fill the gaps between credible sources of information, not on behalf of any government, but on behalf of the people."
A year ago, Maclean's joined the widening campaign for more openness and accountability in such a vital, yet surprisingly secretive, facet of Canadians' lives. The inaugural Health Report of June 15, 1998, showed where each province stood on a multitude of health factors, including overall spending, availability of hospital beds and high-tech equipment, and status of its residents' health (generally better in the West compared with the East). This year, the ranking goes a significant step further to look at service delivery at the community level in 16 cities representing a cross-section of Canada's major urban centres.
The people who work daily with the data gap believe the public and political understanding of what makes people healthy is changing for the better. Sophisticated information is available from hospitals not only because they are a handy medium for collecting data, but also because of the traditional view that effectiveness depends on institutional and technical superiority - more equipment, more beds, better surgical expertise. "Now, there is a growing understanding that the system has to capture what happens outside the hospital or doctor's office," says Jennifer Zelmer, CIHI's director of analysis and special studies. Canada, she adds, is making as much progress in that respect as any other country.
Another encouraging development is the vast improvement recently in the computers and transmission facilities required to gather and sort data from so-far untapped sources of critical health-care information. That is especially important as hospitals play a decreasing role in the overall health-care picture. Community-care agencies, drugs and non-hospital mental health treatments, for instance, have become much more important factors in recent years - yet all remain virtually unmeasured. Even one element of the traditional system - the physician's office - has remained beyond the data gatherers' reach until now. In Canada, 25 per cent of the health budget goes to physicians' services. But the paper records they keep in each office simply cannot be captured nationally. Now, physicians, armed with computers and data-management software, have joined numerous pilot projects across the country aimed at making their records available for comparative purposes.
Across the country, Canadians are showing no signs of letting up in their criticism of perceived faults in the health care they receive. But better funding is not the answer. "If we just want to keep pouring more money into the health sector, we can do that," says Alan Nymark, federal associate deputy minister of health. "But the public doesn't want that." More money is being diverted to information management to cope with the underlying problem, the lack of reliable evidence to be used to improve the system. "It is often estimated," notes CIHI's Millar, "that as much as 40 per cent of health-care funding is used in inappropriate or unnecessary ways." In that case, constant monitoring and reporting can only help to improve the system.
CIHI Aims Sky-high
The title is ungainly - the Canadian Institute for Health Information - so people took to calling it by its acronym, pronounced "ky-hy." For years, the agency's managers balked at the informality of the moniker, pleading to have CIHI referred to in speech by its initials, C-I-H-I. They have conceded defeat. Just as a mysterious cultural force deposited "loonie" and "toonie" into the Canadian vocabulary, "ky-hy" has become entrenched in the health community's consciousness. The people have spoken, and five years after its inception, Canada's primary health information agency is gaining national recognition under its cheery nickname. "Frankly, we don't care what they call us," says CIHI president Richard Alvarez, "as long as they appreciate the job we're doing."
Canada's health ministers - federal, provincial and territorial - created CIHI to deal with a crying need for nationally co-ordinated health information. The independent agency, established in 1994, has taken over the management of many information programs from Health Canada, Statistics Canada and other agencies. The agency received an enormous boost in February, when Health Canada put CIHI in charge of a $95-million project to revolutionize the health information system.
One focus will be on what Alvarez calls "the areas of darkness" outside the hospital setting. "Compared to other countries, we have a rich national database using hospital records," says Alvarez. "Now, for the next three years we will be developing ways of collecting better information from other expanding parts of the health system, including home care, emergency services, and clinics." Other aspects of the new project will establish a national registry to record the progress of patients receiving hip and knee replacements; develop ways to track waiting times and patient satisfaction; and study the cost-effectiveness of using drugs as a replacement for other kinds of treatment.
Maclean's association with CIHI began last year with the publication of the inaugural Health Report, which compared services and health status province by province. The joint venture helps CIHI fulfil its mandates of improving health system management and getting more - and more useful - health information to the general public.
Given CIHI's goals, the quality of that information can only improve. "It is not enough to know that a particular operation - a hip replacement, for instance - has been done in a particular hospital," says Alvarez. "We have to be able to measure how long the replacement lasts before it fails, and how well one procedure and one device stacks up against another." That is where "ky-hy" is going - and the direction Maclean's health-care ranking will take in the coming years.
How the Ranking Was Done
The ranking is based on data gathered nationally by the Canadian Institute for Health Information. It features 13 indicators for which data are available that were endorsed at a national consensus conference. Where necessary, CIHI standardized the data to remove discrepancies arising from age or sex differences in the populations of the 16 participating cities. The numbers, the most recent available, are from the fiscal years 1996-1997 or 1997-1998. Rates of physicians and specialists are from Dec. 31, 1997.
Maclean's consultant for the project, University of Toronto statistician David Andrews, teaches in both the statistics and public health sciences departments. Andrews converted raw data into grades on a scale from 60 to 100 per cent. The resulting final mark for each city comes from weighting the individual grades under five categories. The weights attach more importance to indicators of patient health and the availability of practitioners than to management issues such as efficiency.
The assigned weights: health outcomes and services provided, 2; resources, 1.5; and appropriateness and efficiency, 1. As data for two indicators were not available from Montreal or Quebec City, their rankings are an aggregate of the other 11.
The inaugural Maclean's ranking of the services provided in Canada's major health regions is based on performance in 13 varied areas of care. The survey used material gathered by the Canadian Institute for Health Information, Canada's main health data agency; and awarded 16 major communities from Victoria to St. John's, Nfld., a mark under each of those categories. When combined according to a statistical formula, they produce the first overall ranking ever published in Canada. First place goes to Edmonton with a mark of 89 per cent, with Sudbury in 16th place, just 10 percentage points behind at 79 per cent. As health services shift from hospitals into smaller facilities and the home, CIHI's focus is on collecting a broader range of indicators. In the coming years, that will enable Maclean's to produce increasingly relevant ranking reports.
Rank By Region
1. Edmonton: 89%
2. Toronto: 87%
3. Halifax: 87%
4. Quebec City: 87%
5. Hamilton: 87%
6. Saskatoon: 87%
7. Victoria: 86%
8. Vancouver/Richmond: 85%
9. Winnipeg: 85%
10. Ottawa: 85%
11. Regina: 84%
12. Calgary: 84%
13. Montreal: 83%
14. St. John's: 83%
15. Fredericton: 80%
16. Sudbury: 79%
Maclean's June 7, 1999