What a difference a year makes. Last June, Macleans broke new ground with the first-ever ranking of health services available to Canadians in major centers across the land. That became possible when the Canadian Institute for Health Information, the magazines main partner in its periodic health reports, made a leap of its own. In a pilot project, the national health information agency broke out data on 16 urban centers from its national sources. That allowed those regions, home to almost 40 per cent of Canadians, to compare their performance in 13 specific areas with other regions’ for the first time. For Maclean's, it was the raw data required to launch the ranking project. Bragging rights went to Edmonton, with an overall score of 89 per cent. The other 15 regions followed remarkably close behind, all within 10 percentage points, down to the vast, difficult-to-service Sudbury region of Northern Ontario, trailing at 79 per cent.
Fast-forward to the present. Because that pilot project produced useful, comparable numbers, CIHI has extracted data for all 113 provincial and territorial health regions—fodder for a much more inclusive ranking. Starting on page 22, Maclean's ranks the health services available to residents of 50 of those regions with populations over 100,000, representing fully 85 per cent of Canadians. With so many regions involved, this second ranking separates them into three sections: 1. communities with medical schools; 2. other major communities; 3. largely rural communities.
The results: Edmonton rules again—in section 1, where results are generally higher than in section 2, which in turn scores better overall than the rural section 3. But in an outstanding exception to that trend, regions from section 2 finished first, second and third overall, with marks even higher than Edmonton’s. The top spots go to two suburban additions to the ranking: the North Shore region embracing North and West Vancouver, followed closely by the similarly affluent Mississauga/Brampton/Burlington district neighboring Toronto. Victoria, ranked seventh last year, jumps to a strong third among the 50.
In the largely rural section 3, Moncton, N.B., and Lethbridge, Alta., tie for first place. Their scores, in fact, would place them proudly in the top third of section 2; they even outscore four communities in the medical schools section. On the other hand, seven of the rural sections 16 regions produce the lowest marks among the 50. Overall, the rankings provide graphic documentation that, despite legislated guarantees of equal access to health care, the rural, northern regions are simply not equipped to offer health services on a par with those in the cities and big suburbs. For those rural Canadians, there is some reassuring news. Once again, the overall spread is tight, with just 15.6 percentage points separating first place from 50th, the region around Prince George, B.C.
The more comprehensive ranking stems from the success of CIHIs pilot project last year. The 16 participating centers found their regional data so useful for comparison purposes that they asked for more. As word of the regional project spread, managers from the 97 other health regions showed their interest. Says Jennifer Zelmer, CIHI director of health reports and analysis: “People outside the 16 regions called up and asked, ‘Can we have our data, too, please?’ ” As a result, CIHI produced the entire set this year.
The rankings, unfortunately, cannot include the least populous regions, including all three spread across the territories. Their small numbers tend to vary widely and misleadingly from year to year. As well, extremely small numbers for some procedures create a significant risk that individual patients could be identified. Consequently, CIHI only publishes the numbers for regions with populations over 100,000. “We’re very strong on protecting the privacy and confidentiality of both individuals and service providers,” says Zelmer.
Quantity is not the only factor to improve over the past year. With CIHI and Statistics Canada expanding their knowledge, the store of relevant information is constantly growing. This year, the rankings include two important new indicators of effective services: life expectancy and the rate of babies born with low birth weights in each region (page 21). As well, four of the original indicators now reward high scores only up to a level where higher numbers do not necessarily represent better service. Those indicators are hip and knee replacements (high marks could indicate a failure of preventive measures) and numbers of physicians and specialists (inflated in the largest centers by the need to serve many patients from outlying regions).
For the rural regions clustered at the bottom of the ranking, the numbers confirm the frustrations of their daily struggle. There are complex factors at play, says Joe de Mora, president of the Sudbury Regional Hospital, whose region ranked last of 16 last year and 49th out of 50 this year. Northern, rural regions face a double disadvantage, he notes. Not only are their facilities and staff levels not up to national standards, but their patients tend to be sicker. A generally lower socioeconomic status—based on education, employment and affluence—contributes to lower levels of health. “And because of the distances involved,” adds de Mora, “those people are less likely to go for care until its too late.”
De Mora, like other rural region administrators, sees no sign of significant funding to improve prevention and health promotion activities or to upgrade services. “Its not in the interest of the public that is well served—the urban population—to provide what they think is a subsidization for areas that are less well served,” he observes. “But for people in rural, northern areas, ifs a matter of equity. Accessibility to service is a basic tenet of the Canada Health Act. There shouldn’t be these kinds of discrepancies in distribution.”
The main challenge in producing the ranking is to make the best use of available data. If a hilly developed information system could provide 100 per cent of needed data, “we’re in the 50-per-cent range,” says CIHI’s Toronto-based chairman, Michael Decter, a noted health consultant. “We know about as much as we don’t know.” Decter shares the frustration of the public at large—that much of the most clearly illuminating information is still unavailable on a nationally comparable basis: waits in emergency; the time it takes to see a specialist; the survival rate after cancer or heart attacks strike. “I think the questions at the top of the public’s mind,” says Decter, “have to do with speed, quality and appropriateness of service delivered.”
Results from the efforts under way to fill in those blanks will be incorporated into future rankings. Meanwhile, the project rests on a solid set of numbers covering a wide range of indicators. David Andrews, a University of Toronto statistician with a keen interest in public-health policy, believes the measurements are comprehensive enough that any new factors are unlikely to make a significant difference. “I wouldn’t expect huge changes in communities moving from very disadvantaged to very advantaged,” says Andrews, Maclean's consultant in converting the raw data into a representative ranking. “New indicators will simply make the ranking more credible and more meaningful.”
Meanwhile, as Ottawa and the provinces feud over conditions for adding federal dollars to the health system, the strains are apparent. In Alberta, 10,000 auxiliary nurses staged an illegal strike for 36 hours last week, returning to work when the province made some concessions on their wage demands. For that day and a half, hospitals cancelled some surgery as registered nurses, managers and family members scrambled to feed and bathe patients. Across the country, Canadians bridle at perceived threats to their widely cherished medicare: Alberta’s legislation to expand the duties of private clinics; magnetic resonance imaging (MRI) and other services available for a fee. They ponder the approaching grey wave and wonder if there will be a place for them in the health system. www.macleans.ca for links
On a positive note, federal Health Minister Allan Rock credits the provinces with leading the way in much-needed reforms—investments in home care and the introduction of information-sharing technology. “If we can reach a long-term plan to make health care sustainable and affordable,” he told Maclean's, “Ottawa is prepared to talk about long-term financial commitments.” But the federal and provincial ministers continue to meet, and adjourn, without agreement. In turbulent times, the Maclean's ranking helps show where the system is working, and where it needs help.
How the second ranking was done
Maclean's produces its annual ranking of the health care available in communities across Canada from information gathered nationally by the Canadian Institute for Health Information and Statistics Canada. Where necessary, those agencies standardize the data to remove discrepancies arising from age differences in the population of the country’s 113 provincial and territorial health regions.
Using the 13 best, nationally recognized indicators, Maclean’s has ranked 50 communities with populations over 100,000, representing 85 per cent of the national population.The rankings do not include lesser-populated regions because their small numbers are subject to large variations from year to year. This year’s numbers, the latest available, are from the fiscal years 1997-1998 or 1998-1999. Life expectancy figures are from 1996.
Maclean's project consultant, University of Toronto statistician David Andrews, converted raw data into percentage grades for each indicator in each region. Grouping those grades into five categories with assigned weights produced the final scores. The category weights: outcomes, 2; prenatal care, 2; community health, 2; mainly elderly services, 2; efficiencies, 1; resources, 1.
The charts on the following pages rank the 50 regions in three groups with basic similarities-communities with medical schools, other major communities and largely rural communities. But because the same methodology applies to all three groups, the charts also provide each region’s overall ranking within the group of 50, As data for two of the three efficiency indicators were not available from Quebec regions, their efficiency score is based on just one indicator. Life expectancy results for most Ontario regions and two in British Columbia were calculated from data gathered in health units approximating those regions.
Judgments based on a growing store of health data
The annual Maclean's ranking of health care available in Canadian communities uses the best available data collected on a comparable basis in all health regions by the Canadian Institute for Health Information and Statistics Canada. The 13 indicators this year:
The age to which a person would be expected to live, based on mortality rates in 1996. Higher scores go to greater life expectancies.
The proportions of babies weighing less than 2,500 g (five pounds, eight ounces) at birth, a measure of prenatal care as well as community education and health-awareness programs. The higher the rate, the lower the score.
The percentage of women who deliver babies by c-section. Health authorities attribute above-standard rates in most regions to some c-sections being done unnecessarily. The best standings go to the lowest rates.
Hospitalization of people over 64 for hip fractures, pneumonia or influenza, as a measure of community preventive-care and health-awareness programs. Higher rates mean lower scores.
Total hip-replacement surgeries. The higher the rate, the higher the mark—short of the highest levels. Because very high numbers may suggest a failure of preventive efforts, ranking scores do not increase for any result above 80 per cent of the average rate.
Total knee-replacement surgeries per 100,000 population, as a measure of available services. The higher the rate, the higher the mark, but scores do not increase for rates above the national average.
Patients in hospitals who likely could have received the medical service they required elsewhere. Lower numbers mean higher marks.
The amount of time patients spend in hospital relative to a national standard for particular conditions. Shorter stays— generally indicating efficient treatment and the availability of follow-up care in the community— mean higher scores.
Hospital admissions per 100,000 people for conditions (such as diabetes or asthma) that could be avoided by appropriate care in doctors’ offices or clinics. Higher rates produce lower marks.
Active GPs and family practitioners or medical specialists per 100,000 people. Scores increase with higher ratios, peaking at 80 per cent of the average for communities over 100,000 population.