This article was originally published in Maclean's Magazine on June 15, 1998
Maclean's 1998 Health Report
Where do Canadians live the longest and healthiest lives? Which provinces have the most hospital beds, doctors and nurses, or spend the most on health care? Those are some of the findings in the inaugural Maclean's Health Report, presenting the best available indicators of the state of health-care delivery, province by province. Altogether, they provide a fascinating inside view of health care in Canada - and the major differences among the provinces. Some highlights:
Westerners are generally in better health and will live longer than Atlantic Canadians. Why? The answer may have as much to do with social conditions and lifestyle choices as with the standard of medical care.
Across Canada, the numbers of hospital beds, nurses and, in some areas, doctors are diminishing. The latest per capita numbers show Saskatchewan left with the most beds, Prince Edward Island with the least; New Brunswick with the most nurses, Ontario with the least; the Yukon with the most general and family practitioners, Prince Edward Island again with the least; and Quebec with the most specialists, the Northwest Territories with the least.
British Columbia leads the provinces in health-care spending per capita; Newfoundland is at the other extreme.
Rates at which medical conditions occur, procedures used to treat them, and the availability of the latest high-tech medical equipment vary - sometimes widely - from province to province.
Hospitals acknowledge that what they call "misadventures" do happen, but analysts say the rates of accidental injury are actually much higher than the incidents reported.
Visits to hospital emergency departments have decreased since the late 1980s, while use of other hospital outpatient facilities has increased.
Newfoundland has the highest incidence of overweight people in its population; Quebec and British Columbia have the lowest.
The Maclean's Health Report appears at a time when Canadians are anguishing over a medicare system they proudly regard as a fundamental characteristic of their country. Their positive attitude is well placed. Canada ranks among the world leaders in the critical measurements of longevity, infant mortality and freedom from preventable disease. Given that accomplishment, criticism may seem to be carping. But the fact is, Canadians do not get enough information about how well their health-care dollars are being spent.
Is it too much, for instance, to expect a system that sucked $76.6 billion out of the country's treasuries last year in the name of health care to show exactly how many people died in its hospitals? Apparently so, because death statistics are complicated by the fact that some hospitals count DOAs (patients dead on arrival), and some don't. "Information-gathering is improving," says Michael Decter, chairman of the Canadian Institute for Health Information, an Ottawa-based independent health data agency, and Maclean's partner in preparing the Health Report. "I think CIHI and Statistics Canada are making ground. But it is astonishing how much more information for the consumer is available in the United States, some of it mandated by state laws."
Gordon Lever's experience is one indicator of the need for more openness in Canada's health system. The Kingston, Ont., resident has helped found a patients' right organization since the death of his 49-year-old wife last year, just a month after being diagnosed with stomach cancer. "From the family doctor to the test centre to the hospital there was a litany of errors," says Lever. When he tried to get his wife's medical record after her death, "the hospital told me I wasn't entitled to it," he says.
Canadians are confused. The same governments that squeezed health-care spending in the name of fiscal prudence and the need to "restructure" are suddenly throwing money into the system. Alberta did it. Ontario did it. And last week, Quebec put $110 million back into this year's health-care budget - as the province's 7,200 GPs, complaining of low pay, threatened to withdraw services for at least four days starting this week. Meanwhile, even as many experts say funding is not the problem, federal Health Minister Allan Rock says he is counting on more money for home care and other programs in the next federal budget.
Is the system suffering because governments made their cuts too hastily? Any attempts to address questions like that on a community level are frustrated by a myriad of problems: confidentiality and privacy legislation, inconsistent measuring formats, differing functions of hospitals. Even the phrase "health-care system" is a misnomer, Decter says, because it is made up of independent sectors operating with little co-ordination. No one agency is monitoring the operations of all Canadian hospitals, or even comparing the care provided by major communities. Only at the provincial and territorial level have strides been made in reporting information in a consistent way, taking account of changes over time.
Maclean's worked closely with CIHI to define the issues and gather the material that appears in this Canada-wide report. Other organizations have published in-depth surveys of some aspects of the system - Statistics Canada, for instance, periodically reviews such issues as the distances people travel in various parts of the country to see a physician. And within some provinces, information-gathering is much more advanced than it is on the national level. The Institute for Clinical Evaluative Sciences in Toronto has produced two exhaustive studies of practices and outcomes at all Ontario hospitals. And other reports are expected this year, including a provincewide comparison from the Ontario Hospital Association and another from the University of Toronto on patient satisfaction at the city's teaching hospitals.
The computer revolution has made information management much more efficient. "It is only now that technology is getting cheap enough that we can measure the indicators of health-care delivery," says Decter. "Until now, we've been saying, 'Sure, there's a wait in emergency, but how bad is it? No one knows.' " But are health authorities across Canada devoting enough of their budgets to providing the answers that patients - and potential patients - want to have? "We don't know," says Decter, "because we don't collect that information."
Going Straight to the Source
The collection of medical data underwent a revolution in 1993 with the creation of the Canadian Institute for Health Information. An independent, nonprofit national agency, it was mandated by Ottawa and the provinces to develop and maintain "a comprehensive and integrated health information system for Canada." Taking over some programs from Statistics Canada, Health Canada and some smaller agencies, CIHI has become the country's principal source of official health information. StatsCan still provides some health-related data, and specialized information comes from other agencies such as the Canadian Co-ordinating Office for Health Technology Assessment.
Much of the information in this package is drawn from CIHI's Discharge Abstract Database, which holds data as recent as 1996-1997. It records the procedures performed on more than 85 per cent of patients discharged from or who died in Canada's hospitals. The biggest missing element is Quebec, where only a handful of small institutions submit data to DAD. Similarly, roughly 60 per cent of hospitalizations in Manitoba, 20 per cent in Prince Edward Island, and one per cent in Saskatchewan are not captured there.
Information for most of the full national comparisons comes from the National Morbidity database maintained jointly by CIHI and Statistics Canada. Its most recent data is from the fiscal year 1995-1996.
Maclean's June 15, 1998