Health Report

CENTRES OF EXCELLENCE

More than ever, major cities dominate the top spots in the fifth annual Maclean's ranking of health-care delivery

ROBERT MARSHALL June 16 2003
Health Report

CENTRES OF EXCELLENCE

More than ever, major cities dominate the top spots in the fifth annual Maclean's ranking of health-care delivery

ROBERT MARSHALL June 16 2003

CENTRES OF EXCELLENCE

More than ever, major cities dominate the top spots in the fifth annual Maclean's ranking of health-care delivery

Health Report

ROBERT MARSHALL

WHERE DO CANADIANS get the best health services? The fifth annual Maclean’s ranking of the delivery of care across the country points ominously to a big challenge: bringing standards in less populous and rural health regions closer to the levels available in our major cities. Perhaps not surprisingly, 13 of the top 20 communities in this year’s ranking are university cities with medical schools—precisely where you’d expect to find superior services. But in fact, that’s two more than in the top 20 in the previous two years, and three more than in the 2000 ranking. So if there’s a trend there, it’s towards centralization, not distribution of resources.

“There’s always going to be a difference in services between the bigger centres and the more remote regions,” says Jennifer Zelmer, vice-president, research and analysis, for the Canadian Institute for Health Information. “It doesn’t make sense to put some of the highly specialized services in communities without the population base to support them.” That said, great efforts are in place across the country to help people, even in remoter regions, get better treatment closer to home. “Tele-triage” hotlines are one example, says Zelmer. Now operating in six provinces with more on the way, they put vital health information just a telephone call away. Another growing trend, especially in rural and hardpressed inner-city settings: bringing nurse practitioners and other health professionals

into partnerships with physicians (page 26).

Sheila Weatherill, CEO of Edmonton’s Capital Health Region, ranked No. 1 this year, sees a bright future for that kind of teamwork. “But when I think of collaborative care now,” she says, “I think about how we’ve put in place a nurse-manned, 24/7 telephone support line.” Operating in Edmonton since the fall of 2000, it’s going province-wide this month. “In the past, a mom who’s got a child screaming with an earache at 1 a.m. would have had to get in her car and drive, then wait in emergency,” she says. “Now she can get immediate advice from a registered nurse.” And, with luck, avoid joining the lineups in emergency.

What accounts for Edmonton’s success? Weatherill gives a lot of credit to the centralized regional structures put in place in Alberta, and all other provinces but Ontario, in the 1990s. “You can pull your senior operational people together, make one request, and everyone hears it and implements it at the same time—every hospital, every public health centre,” she says. That’s particularly important in the face of threats like SARS, the respiratory disease at the centre of Toronto’s continuing health crisis. “You can tell the senior people these are our standards, this is how we will undertake surveillance in our hospitals and with our family physicians,” Weatherill

notes. “It’s a structure that allows flexibility, a nimble approach.”

This year’s ranking incorporates all 57 health regions with populations over 125,000, representing just over 90 per cent of the national population. That’s three more regions than in previous years, due to a redefinition of their boundaries in some provinces. They vary in their makeup from strictly urban (e.g., Vancouver, Toronto and Montreal), to an urban/rural mix (Regina, Fredericton, Halifax) and sprawling, sparsely populated areas (Prince George, B.C., Grande Prairie, Alta., Thunder Bay, Ont.). Regional boundaries have changed so significantly in several provinces, particularly B.C. and Alberta, that comparisons of this year’s results with previous rankings are impractical.

The rankings are based on 18 nationally recognized indicators gathered by CIHI and Statistics Canada (page 25). The latest numbers available, they generally come from the fiscal year 2000-2001. Maclean’s excludes lesser-populated regions because their small numbers can be subject to misleadingly large fluctuations from year to year.

To transform that raw data into a ranking, statistician David Andrews, professor emeritus at the University of Toronto and a specialist in the analysis of medical data, converts the results under each indicator into scores for each region. Grouping those scores into six broader categories with assigned weights representing their relative importance produces the overall ranking. (The

weights: outcomes 2; resources 2; community health 2; elderly services 1; prenatal care 1; efficiencies 2.) In rare instances where data is not available from some regions for some indicators, scores are based on available indicators within the same categories.

The charts below show the 57 regions in their ranked order, along with the rankings in each of the indicator categories for the top 20 overall. Clearly, even the best regions face major challenges in some categories. A lower ranking may suggest that residents of a particular health region simply aren’t making good use of available services. But to Andrews, that’s still a measure of the region’s performance. “If you think about vaccinations and small children,” he says, “where the rate is low, the health establishment works to increase the vaccination rates.” Whatever the reason for lower scores, they suggest a region has work to do.

Two regions illustrate how the boundary changes have produced different results. Take Kelowna, B.C. For the past two years it has finished in the top five—an outstanding performance for an essentially rural region. This year it ranks 14th, still respectable but a significant drop. The reason, says regional CEO Murray Ramsden: its boundaries expanded into “a broader catchment area” of rural B.C., where residents were receiv-

ing services that weren’t up to the same standards. Edmonton, finishing in first to fourth place in previous rankings, also gained a chunk of territory—again largely rural—to its west. But it has maintained its winner status. That, says Weatherill, is because many of the people in the new territory were already driving into Edmonton for services, so the data now simply includes more peo-

ple getting the same high level of care.

Headline-grabbing threats such as SARS, the mosquito-borne West Nile disease and Lyme disease, spread by ticks, make Canadians acutely aware of their need for a system that responds to new challenges. Weatherill understands that as well as anyone. “It’s nice to know we’re hanging in there and we’re able to keep the organization moving forward,” she says. “But as we’re basking in the glory of this great ranking, it doesn’t mean everything is fine.” lifl

THE TOP 20 HEALTH REGIONS, AND HOW THEY RANKED IN EACH CATEGORY

OUTCOMES RESOURCES COMMUNITY HEALTH ELDERLY SERVICES Rank Overall Life Heart attack Stroke Local Physicians Specialists Hip Pneumonia Hip Knee score expectancy survival survival services per capita per capita fractures and flu replacements replacement: 1 Edmonton 86.3 10 1 12 21 13 21 26 18 24 2 Victoria 86.2 17 14 19 41 3 Winnipeg 85 30 22 14 11 12 30 11 4 Saskatoon 85 12 10 12 11 31 29 18 5 Toronto 84.9 13 10 10 21 41 39 6 Ottawa 84.1 11 20 12 15 11 10 19 19 35 32 7 Calgary 83.9 16 31 16 42 24 31 34 8 Mississauga/Burlington, Ont. 83.7 11 37 53 41 18 27 26 9 Quebec City 83.6 32 16 10 55 55 10 Hamilton 83.4 26 17 10 32 28 28 32 19 11 London, Ont. 83.3 21 17 21 38 48 34 30 12 Montreal 83.2 31 19 55 57 13 Sherbrooke, Que. 83.1 23 19 12 28 34 44 51 14 Kelowna, B.C. 82.9 19 15 21 39 18 14 15 Halifax/Dartmouth 82.5 34 32 22 13 16 16 Regina 82.4 28 25 11 12 19 25 40 31 17 North Vancouver/Whistler 82.3 44 22 34 14 23 37 18 Vancouver 82.1 17 37 45 54 19 Richmond, B.C. 82 31 26 27 33 13 47 42 20 Saint John, N.B. 81.9 39 16 13 35 17 43 37

HEALTH CARE’S VITAL SIGNS

The annual Maclean’s ranking of how well health care is delivered in health regions across Canada is compiled from a range of data gathered by the Canadian Institute for Health Information and Statistics Canada. The overall ranking of the 57 regions with populations over 125,000 comes from scores calculated from the following indicators, collected in a uniform manner from across the country:

LIFE EXPECTANCY The age to which a person would be expected to live, based on average mortality rates between 1996 and 1998. Greater ages mean higher marks.

HEART ATTACK SURVIVAL Deaths in hospital within 30 days of admission after a new heart attack. Higher marks go to regions with the lowest mortality rates. (Not available for British Columbia, Quebec or Newfoundland and Labrador.)

STROKE SURVIVAL Deaths in hospital within 30 days of admission after a new stroke. Higher marks go to regions with the lowest mortality rates. (Not available for British Columbia or Quebec.)

LOCAL SERVICES Concentrations of medical services in some centres attract an inflow of patients, as people from other regions travel to obtain specialized care. Higher scores reflect high net inflows from other regions.

PHYSICIANS; SPECIALISTS Active GPs and family practitioners or medical specialists per 100,000 people. Marks increase with higher ratios. The top nine marks for GPs and 15 for specialists are considered ties because the highest concentrations may not improve service for that particular region.

HIP FRACTURES; PNEUMONIA AND FLU Hospitalization of people over 64 for those causesan indication of community preventive-care and health-awareness programs. Higher rates mean lower marks.

HIP REPLACEMENTS The higher the rate of

hip-replacement surgeries, the higher the mark, up to a cut-off. The first nine places are treated as ties for scoring because very high numbers may indicate a failure of preventive efforts. KNEE REPLACEMENTS Knee-replacement surgeries per 100,000 population-a measure of available services. The higher the rate, the higher the mark, but scores are considered a tie for the 39 regions with rates above the national average.

CAESAREAN SECTIONS Women who deliver babies by C-section. Above-standard rates often mean some C-sections are being done unnecessarily. High marks reflect low rates. VAGINAL BIRTHS AFTER C-SECTION Vaginal births by women who previously gave birth by C-section. The higher the rate, the better the ranking.

PREVENTABLE ADMISSIONS Hospital admissions-for conditions such as diabetes or asthma-that can often be avoided by appropriate care in doctors’ offices or clinics. Higher rates produce lower marks.

HEART ATTACK, ASTHMA, HYSTERECTOMY, PROSTATECTOMY AND PNEUMONIA READMISSIONS Unplanned readmissions to hospital following discharge for specific conditions or treatments. Lower rates mean higher marks. (Not available from Manitoba and Quebec and, for heart attacks and prostatectomy, Newfoundland and Labrador.)

.AND THE OTHER 37 PRENATAL CARE EFFICIENCIES jesarean Vaginal births Preventable Heart attack Asthma Hysterectomy Prostatectomy Pneumonia 21 St. John’s, Nfld. 39 Joliette, Que._ actions after C-sections admissions readmissions readmissions readmissions readmissions readmissions 22 Laval, Que. 40 Gatineau, Que. 24 20 25 1 29 23 Moncton, N.B. 41 Oshawa, Peterborough/ Ont. 50 34 36 10 27 24 Lévis, Que._ 42 Nanaimo, B.C. 25 Markham/Richmond 12 17 21 Hill, Ont._ 43 Brantford, Ont. 13 25 15 36 10 27 35 26 Kitchener/Waterloo, 44 Owen Sound, Ont. 35 39 13 25 14 31 Ont._ 45 Fredericton 21 22 14 18 27 19 17 27 Lethbridge, Alta. 46 Yarmouth/Digby, N.S. 33 15 19 19 24 33 28 Surrey, B.C._ 47 Témiscaming, Que. 31 36 17 14 24 29 Rimouski, Que. 48 Thunder Bay, Ont. 8 16 30 Burnaby/Coquitlam, 49 Kamloops, B.C. 25 10 12 14 39 B.C._ 50 Cape Breton, N.S. 31 Longueuil/Brossard/ 5 17 16 12 31 Granby, Que._ 51 Jasper/Cold Lake, Alta. 19 24 20 32 Trois-Rivières/ 52 Sudbury/Sault Ste. 1 33 Drummondville, Que. Marie, Ont. 39 42 35 11 43 11 33 Chicoutimi, Que. 53 Prince Edward Island 40 12 17 31 33 33 31 34 Windsor/Sarnia, Ont. 54 Red Deer, Alta. 6 48 15 31 19 14 35 St. Catharines/ 55 North Bay/Huntsville, Niagara, Ont. 51 47 22 17 10 21 19 37 Ont._ 36 Kingston, Ont. 56 Prince George, B.C. 49 33 29 38 11 53 37 Chilliwack, B.C. 57 Grande Prairie, Alta. 55 50 11 39 24 38 St-Jérôme/ 48 16 26 22 Ste-Thérèse, Que.