Health Cover

Indicators of Excellence

Factors in the ranking include numbers of doctors, specific surgeries and reasons for hospitalizations

June 7 1999
Health Cover

Indicators of Excellence

Factors in the ranking include numbers of doctors, specific surgeries and reasons for hospitalizations

June 7 1999

Indicators of Excellence

Factors in the ranking include numbers of doctors, specific surgeries and reasons for hospitalizations

Maclean's used Canadian Institute for Health Information data on 13 indicators in order to generate the first-ever ranking of health care in urban Canada, presented on the previous pages. It is the most comprehensive list of factors published on a national, comparable basis for measuring the service delivered by hospitals and other key components of a community’s health-care system. CIF1I continues efforts to reach a consensus among provinces on how to collect many other kinds of health data, including those affecting rural Canadians. They will be included, as available, in future editions of the Health Report ranking. (Two indicators, hip replacements and knee replacements, were combined in one definition.)


These indicators, although derived from hospital data, capture broader aspects of community health. Hip fractures, for instance, indirectly measure nutrition, and the range of services in a community.

Hip fractures

This ranking comes from the rate of hospitalization for hip fractures among people over 64, after statistically accounting for age and sex differences across regions. It is an important indicator of the health of communities because the falls that cause most of the fractures can be prevented and because success in lowering this number benefits the community. “Hip fractures are a tremendous strain on the healthcare system,” says Dr. Gerald Rear-

don, slated to become chief of orthopedics at the QEII Health Sciences Centre in Halifax in September. “There is a great cost involved, apart from the fact that the hospital stays are long and difficult for patients and family.” High numbers could signal a community’s failure to reduce risks for falls among the elderly, such as the overprescribing of drugs, vision and mobility problems, lack of nutritional counselling, inadequate safety programs and even poor snow removal.

Pneumonia and flu

These results are based on the rates (per 100,000 seniors, over 64) of hospitalization for influenza or pneumonia. If the rate is high, “it might tell us that a community is not doing enough to prevent these infections,” says Dr. Andrew Simor, head of microbiology and an infectious disease consultant at Sunnybrook and Women’s College Health Sciences Centre in Toronto. Vaccines to prevent flu and pneumonia are readily available and quite effective, says Simor, but “may not be used as often as they should be.” Other effective measures are smoking cessation programs and making sure seniors with respiratory illnesses are cared for properly before their symptoms get worse.


Coronary bypass

These are indicators of medical services available in the community. While some heart bypass operations may be unnecessary, this category simply measures the varying rates of services provided. Provision of unnecessary services is assessed under efficiency.

This list ranks the rate of coronary artery bypass graft surgery (per 100,000 adults in the community) in acute-care hospitals. During an open-heart operation, the surgeon grafts lengths of healthy blood vessels from other parts of the body into place to bypass blockages in the arteries in the heart, restoring blood flow to that organ. “It is an important procedure which improves quality of life and can be life-extending,” says Dr. David Navlor. professor of medicine at the University of Toronto and an expert in charting regional health trends. A high rate, says Naylor, can suggest that more of those procedures are being done than necessary, or it can indicate more disease

and a failure to provide proper preventive services, such as smoking cessation programs, blood pressure control, cholesterol-lowering medication or diabetes control. But as a measurement of service delivery, as in this survey, the higher the ratio, the higher the mark.

Hip and knee replacements

These marks are based on the number of total hipor knee-replacement surgeries performed on inpatients in acutecare hospitals per 100,000 population.

It is a complex category. “Genetics are involved in the rates,” says Halifax orthopedic surgeon Dr. Gerald Reardon.

A high number in any one community “may simply mean that in that area there is more osteoarthritis.” But it could also mean a community is being more generous about which cases need surgery.

As a measurement of service^ mvuUrl in this survey, the higher the ratio, the higher the mark!


This category considers the current number of physicians and specialists working in each community. Rates may appear high in some major communities because they do not account for significant numbers of people from outlying areas being referred there for care.

Physicians per capita

This ranking is derived from the number of active civilian (non-military) GPs and family practitioners per 100,000 people. However, there is no simple definition of an optimum number. The difficulty, notes Dave Kelly, British Columbia’s deputy minister of health, is that the optimum number has to take affordability into account, along with access. But as a measurement of available resources, the higher the ratio, the higher the grade.

Specialists per capita

A shortage of medical specialists (measured per 100,000 people) in a community suggests that the people there do not have access to required specialized care, whether for heart problems, vision disturbances, respiratory failure, childbirth or numerous other health needs. Shortages can be corrected over time with incentive programs and medical training. One complicating factor is that specialists, like all doctors, are independent business people, not government employees, and make their own choices as to where they want to live and practise. “It is difficult,” says Kelly, “to achieve a balance to address what doctors expect, what the community expects and what it is possible to provide.”


Current research suggests that a high rate for some established procedures may not be effective or in the patients' best interests. Some clearly beneficial procedures, on the other hand, may be underused.



This standing is drawn from the proportion of women who deliver babies by caesarean section (rather than vaginally) in acute-care hospitals. According to Dr. John Millar, vice-president of the Canadian Institute for Health Information, international guidelines suggest caesarean sections

are necessary and beneficial in only about 10 to 15 per cent of births. As that is below Canadian rates ranging from 15 per cent to 26 per cent in the measured communities (page 34), the highest standings go to the lowest rates.

Births after c-sections

These results reflect the percentage of women who, after having previously had a baby delivered by caesarean section, then give birth vaginally in a hospital. In obstetrical circles, that is called VBAC, or vaginal birth after caesarean. “A higher VBAC rate does not necessarily equal higher quality,” says Dr. André Lalonde, vice-president of the Society of

Obstetricians and Gynecologists of Canada in Ottawa, “but it shows regions are offering women more choice for how they deliver.” Low VBAC numbers may signify that high-tech methods are used more than is necessary for the good health of mother and baby. “We think 60 to 80 per cent of women who have had a caesarean section can deliver safely vaginally,” says Lalonde.


This rating is derived from the rate of hysterectomies done on inpatients over age 19 in acutecare hospitals, per 100,000 women. “Twenty or 30 years ago, women in their 40s would say to each other, ‘Have you had your hysterectomy yet?’ ” says Dr. Knox Ritchie, chief of obstetrics and gynecology at Toronto’s Mount Sinai Hospital. Hysterectomies were not unusual for women who had finished having children and were having trouble with their periods. “Now,” he says, “women are more inclined to look for alternatives,” such as medication or endometrial ablation, which destroys unwanted tissue and can be done on a daysurgery basis. High rates of hysterectomy—resulting in a lower mark here—are not only a social issue, but a political/fmancial one as well. “We know that endometrial ablation stops bleeding in 60 to 80 per cent of cases and reduces it in another 20 per cent,” says Dr. André Lalonde of Ottawa, vicepresident of the Society of Obstetricians and Gynecologists of Canada, “but we have a very, very hard time getting hospitals to buy the equipment.”


These indicators were selected to gauge whether a community's hospitals and ambulatorycare (non-hospital) services are being applied appropriately.

Possible outpatients

This indicator looks at patients who may have been admitted unnecessarily to hospitals. They needed medical service, but not necessarily in a hospital bed. The most common reason for high numbers—and lower marks—says Steven Lewis, CEO of the Saskatchewan Health Services Utilization and Research Commission in Saskatoon, is doctors admitting patients they would like to observe, such as a young child with a sore throat. Better guidelines and the development of special observation units are two possible ways to improve performance in this category. “If you were perfectly efficient and had perfect judgment, you would have no unnecessary admissions,” says Lewis.

“But sometimes you want to err on the side of caution.”

Preventable admissions

This mark is based on hospitalizations for conditions such as diabetes or asthma that can usually be looked after in doctors’ offices or clinics. “These conditions should be manageable without admission to hospital,” explains Carolyn DeCoster, researcher at the Manitoba Centre for Health Policy and Evaluation in Winnipeg. A higher rate— producing a lower mark—could indicate poor access to primary care, more typical of conditions in remote communities than in major cities. Or it could hint at poor quality of care by physicians.

Early discharge

The amount of time patients spend in hospital relative to the standard for particular conditions determined this standing.

One cause of a longer stay—leading to a lower mark—would be admitting a patient days before surgery for tests that could have been done on an outpatient basis. A shorter stay is generally the goal, as long as patients stay relatively healthy after leaving hospital. “If a place has systematically shorter lengths of stay on this measure and if there aren’t high readmission rates and higher mortality rates,” says Saskatoon health services researcher Steven Lewis, “then bravo for them. They may just be more efficient.”