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TRANSCRIPT
Evidence Guiding Health Care
Medical Practice Variations in Ontario,
Canada
Presentation to the OECD, March 2, 2012
Therese Stukel, PhD & Ashley Corallo, MPH
Institute for Clinical Evaluative Sciences
Toronto ON, Canada
Evidence Guiding Health Care
ICES Atlases
• ICES has complete, linkable, population-based health care
utilization data data for residents of Ontario
• Atlases are regularly updated, beginning in 1994
• ICES Atlases have typically been created for specific conditions,
including: Primary care including supply
Cancer
Cardiovascular diseases including stroke
Arthritis/ Musculoskeletal conditions
Asthma
Diabetes care
• ICES work is summarized through maps and tables in a form that
is easily accessible to policy-makers, researchers and clinicians
• All slides are downloadable from the ICES website:
http://www.ices.on.ca/webpage.cfm?site_id=1&org_id=31
Evidence Guiding Health Care
Primary Care
• Prenatal care
• Screening
• Preventive care
Evidence Guiding Health Care
Evidence Guiding Health Care
Proportion of women receiving prenatal care, by physician
specialty, overall and by region, 2003/04
* This includes women whose physician did not
bill the Ontario Health Insurance Plan (OHIP),
those who were seen predominantly by
midwives or nurse practitioners and those who
received little or no prenatal care (<4 visits).
** Some women receive the majority of their
prenatal care (≥75% of their OHIP visits) from
GP/FPs while others receive the majority of
their care (≥75% of their OHIP visits) from OBs.
In other women, prenatal care is “shared” more
evenly between OBs and GP/FPs.
GP/FP = General practitioner/family physician
OB = Obstetrician 0
46
29
32
18
33
17
10
14
14
19
16
14
23
9
3
13
30
24
50
22
46
53
54
41
33
38
42
24
53
2
19
22
33
21
16
27
27
20
35
39
33
27
41
29
1
23
19
11
11
30
9
9
12
10
9
13
17
12
10
0% 20% 40% 60% 80% 100%
All Ontario
13. North East
11. Champlain
9. Central East
7. Toronto Central
5. Central West
3. Waterloo Wellington
1. Erie St. Clair
Lo
ca
l H
ea
lth
In
teg
rati
on
Ne
two
rk
Proportion of women receiving prenatal
care
≥75% of visits to GP/FP
≥75% of visits to OB
Visits shared between GP/FP & OB**
No billings*
0
46
29
32
18
33
17
10
14
14
19
16
14
23
9
3
13
30
24
50
22
46
53
54
41
33
38
42
24
53
2
19
22
33
21
16
27
27
20
35
39
33
27
41
29
1
23
19
11
11
30
9
9
12
10
9
13
17
12
10
0% 20% 40% 60% 80% 100%
All Ontario
14. North West
13. North East
12. North Simcoe Muskoka
11. Champlain
10. South East
9. Central East
8. Central
7. Toronto Central
6. Mississauga Halton
5. Central West
4. Hamilton Niagara Haldimand Brant
3. Waterloo Wellington
2. South West
1. Erie St. Clair
Lo
cal
Healt
h I
nte
gra
tio
n N
etw
ork
Proportion of women (%)
0
46
29
32
18
33
17
10
14
14
19
16
14
23
9
3
13
30
24
50
22
46
53
54
41
33
38
42
24
53
2
19
22
33
21
16
27
27
20
35
39
33
27
41
29
1
23
19
11
11
30
9
9
12
10
9
13
17
12
10
0% 20% 40% 60% 80% 100%
All Ontario
13. North East
11. Champlain
9. Central East
7. Toronto Central
5. Central West
3. Waterloo Wellington
1. Erie St. Clair
Lo
ca
l H
ea
lth
In
teg
rati
on
Ne
two
rk
Proportion of women receiving prenatal
care
≥75% of visits to GP/FP
≥75% of visits to OB
Visits shared between GP/FP & OB**
No billings*
0
46
29
32
18
33
17
10
14
14
19
16
14
23
9
3
13
30
24
50
22
46
53
54
41
33
38
42
24
53
2
19
22
33
21
16
27
27
20
35
39
33
27
41
29
1
23
19
11
11
30
9
9
12
10
9
13
17
12
10
0% 20% 40% 60% 80% 100%
All Ontario
13. North East
11. Champlain
9. Central East
7. Toronto Central
5. Central West
3. Waterloo Wellington
1. Erie St. Clair
Proportion of women receiving prenatal care
Lo
cal H
ealt
h In
teg
rati
on
Netw
ork
≥75% of visits to GP/FP
≥75% of visits to OB
Visits shared between GP/FP & OB**
No billings*
0
46
29
32
18
33
17
10
14
14
19
16
14
23
9
3
13
30
24
50
22
46
53
54
41
33
38
42
24
53
2
19
22
33
21
16
27
27
20
35
39
33
27
41
29
1
23
19
11
11
30
9
9
12
10
9
13
17
12
10
0% 20% 40% 60% 80% 100%
All Ontario
13. North East
11. Champlain
9. Central East
7. Toronto Central
5. Central West
3. Waterloo Wellington
1. Erie St. Clair
Lo
ca
l H
ea
lth
In
teg
rati
on
Ne
two
rk
Proportion of women receiving prenatal
care
≥75% of visits to GP/FP
≥75% of visits to OB
Visits shared between GP/FP & OB**
No billings*
All Ontario
North West 14
South East 10
North Simcoe Muskoka 12
North East 13
South West 2
Central West 5
Champlain 11
Central East 9
Hamilton Niagara Haldimand Brant
Mississauga Halton 6
Toronto Central 7
Wellington Waterloo 3
Central 8
Erie St. Clair 1
Lo
cal H
ealt
h In
teg
rati
on
Netw
ork
0 20 40 60 80 100
Proportion of women (%)
4
Evidence Guiding Health Care
Evidence Guiding Health Care
Evidence Guiding Health Care
Evidence Guiding Health Care
Evidence Guiding Health Care
Cardiovascular care
• CVD risk factors and drug costs
• Ischemic Heart Disease (IHD)
• Congestive Heart Failure (CHF)
• Acute Myocardial Infarction (AMI)
Evidence Guiding Health Care
Evidence Guiding Health Care
Evidence Guiding Health Care
Evidence Guiding Health Care
Evidence Guiding Health Care
Evidence Guiding Health Care
Evidence Guiding Health Care
Stroke/TIA Care
Evidence Guiding Health Care
Percentage of adults seen in an emergency department (ED) or
hospitalized with an ischemic stroke or TIA who underwent carotid
imaging, by sex and region, in Ontario, 2005/06
Evidence Guiding Health Care
Evidence Guiding Health Care
Evidence Guiding Health Care
Evidence Guiding Health Care
Cancer Care
• Hysterectomy
• Mastectomy
• Prostatectomy
Evidence Guiding Health Care
Age-standardized hysterectomy rate for benign conditions per
100,000 women aged 15-84, by region, 2007
Evidence Guiding Health Care
Evidence Guiding Health Care
Evidence Guiding Health Care
Hip, knee and joint replacement
Evidence Guiding Health Care
Evidence Guiding Health Care
Evidence Guiding Health Care
Evidence Guiding Health Care
Evidence Guiding Health Care
Variations in Diagnostic Radiology (CT
and MRI) – A Chart-Based Study
• Used the Diagnostic Imaging Referral Guidelines, set out by Canadian Association of Radiologists (CAR)
• Indicated:
Test will likely contribute to diagnosis and management
• Not routinely indicated:
Specialized test – resource intensive, perform only after discussion with radiologist, or
Indicated in specific circumstances – non-routine examination
• Not indicated:
Rationale for the investigation is untenable
Evidence Guiding Health Care
Top 4 indications for MRI vs. Guidelines
Brain
Extr
Spine
18.2
13.5
13.4
12.6
31.7
28.7
14.6
11.1
26.4
25.8
17.3
12.0
0 10 20 30 40 50
Suspected cancer
Headache
Suspected multiple sclerosis
Cancer follow-up
Suspected meniscal tear
Knee pain / swelling / restricted mobility
Suspected rotator cuff tear
Shoulder pain / restricted mobility
Back pain
Leg pain / radiculopathy
Arm pain / radiculopathy
Neck pain
Percent
CAR Recommendation:
Indicated (B)
Not routinely Indicated (C)
Indicated (A)
Not addressed by guidelines
Not routinely Indicated (B)
Not routinely Indicated (C)
Indicated (B)
Not addressed by guidelines
Back pain + “red flag” – Indicated (B)
Acute back pain – not routinely indicated (B)
Chronic back pain – not routinely indicated (C)
Not addressed by guidelines
Not routinely Indicated (B)
Not routinely Indicated (B)
Evidence Guiding Health Care 33
Variation in indications by hospital - MRI Brain
0
10
20
30
40
50
60
70
80
90
100
1 2* 3 4 5 6 7 8 9 10 11* 12* 13* 14* 15* 16* 17* 18* 19 20
Hospital
Perc
en
t o
f s
ca
ns
wit
h i
nd
icati
on
Suspected cancer (EQ 5.6)
Headache (EQ 8.9)
Suspected MS (EQ 8.6)
* = regional cancer centre
EQ = extremal quotient
(ratio of highest to lowest)
North South – community South - academic
Variation in indications by hospital – MRI brain
Evidence Guiding Health Care
Is Higher Health Care Spending
Related to Better Outcomes?
Hospitalized patients admitted for
incident admission with:
• AMI
• CHF
• Hip Fracture
• Colon Cancer with Resection
Fisher et al. Annals (2003)
Stukel et al. JAMA (2012)
Evidence Guiding Health Care
Regional Variations in U.S. Spending Intensity
L6M
Medicare $
per Capita
9,074 3,922
10,636 4,439
11,559 4,940
12,598 5,444
14,644 6,304
(r = 0.81)
Evidence Guiding Health Care
1.00 1.5 2.0 0.5 2.5
Reperfusion in 12 hours (Heart attack)
Effective Care: benefit clear for all
Ratio of rate in high to low spending regions
Preference Sensitive: values matter
Supply sensitive: often avoidable care
Evaluation and Management (visits)
Imaging
Diagnostic Tests
Inpatient Days in ICU or CCU
Total Inpatient Days
Total Hip Replacement
Total Knee Replacement
Back Surgery
CABG following heart attack
Aspirin at admission (Heart attack)
Mammogram, Women 65-69
Pap Smear, Women 65+ Pneumococcal Immunization
Higher spending
regions get more
services (if right of bar)
U.S. health care system:
Services in highest vs. lowest spending regions
Evidence Guiding Health Care
Decreased risk
1.00 1.05 1.10 0.95
1.00 1.05 1.10 0.95
Colorectal
Cancer
Q1
Q2
Q3
Q4
Q5
Hip Fracture Q1
Q2
Q3
Q4
Q5
Acute
Myocardial
Infarction
Q1
Q2
Q3
Q4
Q5
Increased risk
Rates of mortality in US were no different or higher in high spending regions
Fisher et al. Annals (2003)
Evidence Guiding Health Care
Where is Canada on the
Health Benefit – Spending Curve?
Health
Benefits
Healthcare Spending
U.S. is here
Where is
Canada?
Evidence Guiding Health Care
CHF: Mortality rate within 30 days –
Ontario, Canada
0.04
0.06
0.08
0.10
0.12
0.14
0.16
0.18
0.20
0.22
20,000 25,000 30,000 35,000 40,000 45,000 50,000
End of Life Expenditure Index (EOL-EI)
Pro
po
rtio
n
Evidence Guiding Health Care
Hip fracture: Mortality rate within 30 days -
Ontario, Canada
0.00
0.04
0.08
0.12
0.16
0.20
20,000 25,000 30,000 35,000 40,000 45,000 50,000
End of Life Expenditure Index (EOL-EI)
Pro
po
rtio
n
Evidence Guiding Health Care
0.4 0.6 0.8 1.0 1.2 1.4 1.6
Adjusted Relative Mortality Rate
Colon Cancer
AMI
CHF
Hip Fracture
Colon Cancer
AMI
CHF
Hip Fracture
30 days
1 year
Low EOL-EI
Medium EOL-EI
High EOL-EI
Adjusted Relative 30-day and 1-year Mortality Rates for Medium
and High vs. Low Hospital Expenditure Groups
Ontario, Canada
Evidence Guiding Health Care
0.4 0.6 0.8 1.0 1.2 1.4 1.6
Adjusted Relative Readmission Rate
AMI
AMI
CHF
CHF
Hip Fracture
Hip Fracture
Colon Cancer
Colon Cancer
Low EOL-EI
Medium EOL-EI
High EOL-EI
30 days
1 year
Adjusted Relative 30-day and 1-year Cardiac (AMI, CHF) and All-Cause
Readmission Rates for Medium and High vs. Low Hospital Expenditure Groups
Ontario, Canada
Evidence Guiding Health Care
Conclusions
• Ontario ICES Atlases have documented large regional variations
in: Overall hospital admissions
Physician visits and wait times
Screening
Prescription drug use
Diagnostic testing
Surgical procedures, such as coronary artery bypass grafting (CABG),
hysterectomy, prostatectomy, etc.
• Studies of Causes of Variations Require More Complex Methods
than Simple Descriptive Rates