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Measures and Trends – Insight and Questions!
Measures and Trends – Insight and Questions! by Peter Glynn
here is a paradox in the Canadian healthcare system. A high level of technological sophistication has been achieved in providing care to individuals. However, we do not really understand how to utilize the immense investment in acute care services to improve population health status. We need to ensure effectiveness, efficiency, and accessibility for the entire population both in the short and long term. It is essential that research be undertaken to better understand the needs of populations and our collective effectiveness at meeting those needs. Only in this way, can we ensure that the investment in hospital and medical care contributes appropriately to the health of our population, and thus the vitality and productivity of the country.
T
Peter Glynn
The nine papers that have been prepared by Manitoba Centre for Health Policy (MCHP) researchers for this special supplement to Healthcare Management FORUM focus on three broad topics of relevance to health system managers and researchers: Performance measurement, appropriateness of use, and access. I describe what I see as the major issues that emerge from each set of papers, and some of the questions that remain.
Performance Measurement Three papers address measures of health system performance. One message from this research is that there are a number of criteria for developing meaningful indicators of performance, including relevance, availability of data, and quality of information. A second is that the monitoring of such indicators will rarely give unequivocal answers, but will often provide a valuable sense of direction. In “Assessing the Performance of Rural Hospitals”, performance is evaluated by comparing actual and expected utilization. Not unexpectedly, there is wide variation in this ratio across facilities. This study demonstrates the difficulty of seeking a simple answer to the question “Are the rural hospitals of Manitoba being used appropriately?” The two papers that deal most directly with financial performance provide valuable insight into the “how” and “what” of healthcare financing. If we are ever to have confidence in the validity and comparability of performance indicators, then the information systems from which they are developed must contain standardized information. In “Comparing Apples to Apples: The Relative Financial Performance of Manitoba’s Acute Care Hospitals” the authors demonstrate that this is just as important when monitoring financial performance as when comparing clinical performance. The paper “Relative Cost of Inpatient Care in Manitoba’s Largest Hospitals” uses a well-defined methodology to show that teaching hospitals are more costly than community hospitals after adjusting for differences in cases. Why this discrepancy exists and whether it can be justified are questions that remain. The work of the MCHP has been helpful in attempting to examine this issue. 65
Appropriateness of Use
northern part of the province. Studies of geographic variations in health status draw attention to the complexity of health issues in regional populations and point to the need to understand the determinants of health in a broader way than merely hospitals and doctors.
The four papers that examine the resource implications of hospital use demonstrate that reducing inappropriate use is a complex task. The paper “Patients Hospitalized for Medical Conditions in Winnipeg, Canada: Appropriateness and Level of Care” describes a dilemma facing hospitals across Canada. Most patients will require acute care on the day of admission but an alternate level of care on almost one-half of the following days. There are systematic impediments to placement, including waits for home care or long-term care. However, in “Long-Stay Patients in Winnipeg Acute Care Hospitals” the authors identify the fact that system problems go well beyond access to long-term care services. While these papers provide useful retrospective insights we do not yet understand how to implement a systematic approach to providing needed services for vulnerable persons that prevent, as much as possible, the use of unnecessary acute care services.
“Health Service Use in the Winnipeg RHA” comes to the discouraging conclusion that “visits to specialized physicians, a variety of high profile procedures and screening and preventative services appear not to be provided in accordance with need”. Healthcare organizations must rethink the provision of services to populations that have the potential to be marginalized because of health or socioeconomic status.
Concluding Comments This special supplement to Healthcare Management FORUM contains only a small sample of the excellent health services research being carried out across Canada on performance measurement, appropriateness of use, and access to hospitals. While raising more questions than answers, these papers, and other similar work, are necessary to help guide the planning and evaluation of services to ensure that they actually do what is intended, that is, improve the health of the individual and the population as a whole. To fully achieve this goal we must all embrace the need for such research and ensure that the knowledge gained is appropriately applied. Without it we are steering a multi-billion dollar enterprise without either a map or a compass.
“Tonsillectomy Rates for Manitoba Children: Temporal and Spatial Variations” focuses on appropriateness of a procedure that is known to be performed frequently in some areas, and much less frequently in others. Are some physicians inappropriately removing tonsils in some rural areas of the province, or conversely are some children in Winnipeg being left with their tonsils intact when they should have had them removed? The shortlived impact of the implementation of clinical guidelines is also disturbing. While benchmarks are beginning to be established for surgical procedures, wide variations in rates identify areas where it makes sense to examine how care is delivered. ”Seasonal Patterns of Hospital Use in Winnipeg: Implications for Managing Winter Bed Crises” is an excellent example of research that assists in the management of operational challenges. Seasonal variations are recurrent phenomena and are generally related to peaks in respiratory illness. These data can be used to plan preventative responses as well as to facilitate the operational planning of hospital services.
Access Peter Glynn, PhD, is a national and international healthcare consultant based in Kingston, Ontario. He was most recently the President and CEO of the Kingston General Hospital, from which he retired in 2000. He has been an Assistant Deputy Minister with Health Canada and the Associate Deputy Minister of Health in Saskatchewan. He is the Board Chair of the Institute for Clinical Evaluative Sciences (ICES) and Chair of the Governing Council of the Centre for Studies in Primary Care at Queen’s University.
The third group of papers present some unsettling findings regarding health system access in a population where universal access is intended to remove impediments. ”Trends in Health and Healthcare Use in Manitoba” shows that while health status improved for the province as a whole between 1985 and 1999 the gap between northern and southern regions increased. Indeed, there was no improvement in health status over time in the 66
Additional hard copies of this journal can be obtained from the Manitoba Centre for Health Policy at the address below. There is no fee for residents of Manitoba. If you live outside of Manitoba, the price (in Canadian funds) is $10.00 in Canada and $12.00 outside of Canada. We cannot accept personal cheques drawn on non-Canadian banks, nor can we accept a purchase order. Please send your cheque or international money order, payable to the University of Manitoba, to: Manitoba Centre for Health Policy University of Manitoba 727 McDermot Avenue, 4th Floor Winnipeg, Manitoba Canada R3E 3P5 Phone: 204-789-3805
Copies can also be downloaded from MCHP’s Web site: www.umanitoba.ca/centres/mchp. Also on the Web site are complete copies of the deliverable reports on which the papers in this journal are based. For standardized descriptions of the concepts defined in these papers, click on the Concepts/Research icon on our home page.
here is a paradox in the Canadian healthcare system. A high level of technological sophistication has been achieved in providing care to individuals. However, we do not really understand how to utilize the immense investment in acute care services to improve population health status. We need to ensure effectiveness, efficiency, and accessibility for the entire population both in the short and long term. It is essential that research be undertaken to better understand the needs of populations and our collective effectiveness at meeting those needs. Only in this way, can we ensure that the investment in hospital and medical care contributes appropriately to the health of our population, and thus the vitality and productivity of the country.
T
Peter Glynn
The nine papers that have been prepared by Manitoba Centre for Health Policy (MCHP) researchers for this special supplement to Healthcare Management FORUM focus on three broad topics of relevance to health system managers and researchers: Performance measurement, appropriateness of use, and access. I describe what I see as the major issues that emerge from each set of papers, and some of the questions that remain.
Performance Measurement Three papers address measures of health system performance. One message from this research is that there are a number of criteria for developing meaningful indicators of performance, including relevance, availability of data, and quality of information. A second is that the monitoring of such indicators will rarely give unequivocal answers, but will often provide a valuable sense of direction. In “Assessing the Performance of Rural Hospitals”, performance is evaluated by comparing actual and expected utilization. Not unexpectedly, there is wide variation in this ratio across facilities. This study demonstrates the difficulty of seeking a simple answer to the question “Are the rural hospitals of Manitoba being used appropriately?” The two papers that deal most directly with financial performance provide valuable insight into the “how” and “what” of healthcare financing. If we are ever to have confidence in the validity and comparability of performance indicators, then the information systems from which they are developed must contain standardized information. In “Comparing Apples to Apples: The Relative Financial Performance of Manitoba’s Acute Care Hospitals” the authors demonstrate that this is just as important when monitoring financial performance as when comparing clinical performance. The paper “Relative Cost of Inpatient Care in Manitoba’s Largest Hospitals” uses a well-defined methodology to show that teaching hospitals are more costly than community hospitals after adjusting for differences in cases. Why this discrepancy exists and whether it can be justified are questions that remain. The work of the MCHP has been helpful in attempting to examine this issue. 65
Appropriateness of Use
northern part of the province. Studies of geographic variations in health status draw attention to the complexity of health issues in regional populations and point to the need to understand the determinants of health in a broader way than merely hospitals and doctors.
The four papers that examine the resource implications of hospital use demonstrate that reducing inappropriate use is a complex task. The paper “Patients Hospitalized for Medical Conditions in Winnipeg, Canada: Appropriateness and Level of Care” describes a dilemma facing hospitals across Canada. Most patients will require acute care on the day of admission but an alternate level of care on almost one-half of the following days. There are systematic impediments to placement, including waits for home care or long-term care. However, in “Long-Stay Patients in Winnipeg Acute Care Hospitals” the authors identify the fact that system problems go well beyond access to long-term care services. While these papers provide useful retrospective insights we do not yet understand how to implement a systematic approach to providing needed services for vulnerable persons that prevent, as much as possible, the use of unnecessary acute care services.
“Health Service Use in the Winnipeg RHA” comes to the discouraging conclusion that “visits to specialized physicians, a variety of high profile procedures and screening and preventative services appear not to be provided in accordance with need”. Healthcare organizations must rethink the provision of services to populations that have the potential to be marginalized because of health or socioeconomic status.
Concluding Comments This special supplement to Healthcare Management FORUM contains only a small sample of the excellent health services research being carried out across Canada on performance measurement, appropriateness of use, and access to hospitals. While raising more questions than answers, these papers, and other similar work, are necessary to help guide the planning and evaluation of services to ensure that they actually do what is intended, that is, improve the health of the individual and the population as a whole. To fully achieve this goal we must all embrace the need for such research and ensure that the knowledge gained is appropriately applied. Without it we are steering a multi-billion dollar enterprise without either a map or a compass.
“Tonsillectomy Rates for Manitoba Children: Temporal and Spatial Variations” focuses on appropriateness of a procedure that is known to be performed frequently in some areas, and much less frequently in others. Are some physicians inappropriately removing tonsils in some rural areas of the province, or conversely are some children in Winnipeg being left with their tonsils intact when they should have had them removed? The shortlived impact of the implementation of clinical guidelines is also disturbing. While benchmarks are beginning to be established for surgical procedures, wide variations in rates identify areas where it makes sense to examine how care is delivered. ”Seasonal Patterns of Hospital Use in Winnipeg: Implications for Managing Winter Bed Crises” is an excellent example of research that assists in the management of operational challenges. Seasonal variations are recurrent phenomena and are generally related to peaks in respiratory illness. These data can be used to plan preventative responses as well as to facilitate the operational planning of hospital services.
Access Peter Glynn, PhD, is a national and international healthcare consultant based in Kingston, Ontario. He was most recently the President and CEO of the Kingston General Hospital, from which he retired in 2000. He has been an Assistant Deputy Minister with Health Canada and the Associate Deputy Minister of Health in Saskatchewan. He is the Board Chair of the Institute for Clinical Evaluative Sciences (ICES) and Chair of the Governing Council of the Centre for Studies in Primary Care at Queen’s University.
The third group of papers present some unsettling findings regarding health system access in a population where universal access is intended to remove impediments. ”Trends in Health and Healthcare Use in Manitoba” shows that while health status improved for the province as a whole between 1985 and 1999 the gap between northern and southern regions increased. Indeed, there was no improvement in health status over time in the 66
Additional hard copies of this journal can be obtained from the Manitoba Centre for Health Policy at the address below. There is no fee for residents of Manitoba. If you live outside of Manitoba, the price (in Canadian funds) is $10.00 in Canada and $12.00 outside of Canada. We cannot accept personal cheques drawn on non-Canadian banks, nor can we accept a purchase order. Please send your cheque or international money order, payable to the University of Manitoba, to: Manitoba Centre for Health Policy University of Manitoba 727 McDermot Avenue, 4th Floor Winnipeg, Manitoba Canada R3E 3P5 Phone: 204-789-3805
Copies can also be downloaded from MCHP’s Web site: www.umanitoba.ca/centres/mchp. Also on the Web site are complete copies of the deliverable reports on which the papers in this journal are based. For standardized descriptions of the concepts defined in these papers, click on the Concepts/Research icon on our home page.