Health Report

THE FOURTH ANNUAL RANKING Measuring health care

DANYLO HAWALESHKA June 17 2002
Health Report

THE FOURTH ANNUAL RANKING Measuring health care

DANYLO HAWALESHKA June 17 2002

THE FOURTH ANNUAL RANKING Measuring health care

North and West Vancouver, Edmonton, Victoria, Kelowna, B.C.—Western centres top the list

Health Report

DANYLO HAWALESHKA

Imagine for a moment that you’re a smoker who’s been meaning to quit a pack-a-day habit for a while now. Or, if you can’t picture yourself as a nicotine addict, maybe your doctor has been after you to trim that Molson muscle around your expanding midriff. Perhaps your cholesterol is bad, or your blood pressure is high, you have diabetes, or you just can’t seem to pry yourself off the couch. And let’s face it, none of us is getting any younger, right? Now that you’ve identified a health risk or two, consider what could happen. Would you know you were possibly about to die if suddenly you felt dizzy and your vision blurred? How about if you experienced an abrupt weakness, numbness or tingling in the face, arm or leg, had trouble speaking, or got a severe headache out of the blue? In a few cases you might shrug it off, lie down and hope the discomfort passes.

Not a good idea. You’d be ignoring the warnings signs associated with a stroke, says Maureen McKeen, director of health protection and promotion at the CountyCity Health Unit in Peterborough, Ont. “You don’t just kind of wait around and self-diagnose, or say maybe it’s nothing,” cautions McKeen. “Often, we go into denial, but we should let somebody who knows make the diagnosis.”

Making the right call isn’t easy if you don’t know the vital signs. The same can be said about the challenges besetting the 54 centres across Canada included in this year’s fourth annual Macleans ranking of healthcare services. If we don’t know how the system is functioning, how can anyone ever hope to fix it? Hard numbers help, including this year, for the first time, data from the Canadian Institute for Health Information (CIHI) on where Canadians are most likely to survive a stroke. The ranking casts a wide net, from the densely populated urban centres blessed with superb teaching hospitals to vast rural regions with few specialized services. The charts on the following pages rank the regions according to their performance in 22 indicators of proficient healthcare delivery.

These findings, comparing the services available to more than 87 per cent of Cana-

dians, give medical professionals, patients and their families an opportunity to take stock and compare how their regions measure up to the rest of the country. Given the health-care systems enormous complexities, and its differences from province to province, community to community, it isn’t always immediately obvious why one region is performing better than another. The trick, though, is to identify problem areas, then dissect them.

This year’s ranking, as in previous years, divides the health regions into three categories. Group 1 includes the 15 centres that benefit from the advantages associated with being home to a medical school. Several —Vancouver/Richmond, Toronto and Montreal among them—are comprised entirely of the cities giving them their names. But most of them include significant surrounding rural territory, which presents a greater challenge in terms of service delivery. Edmonton is just such a place, and for the fourth straight year the Alberta capital and its environs lead Group 1. Overall, the region ties for second place among the 54, up from fourth last year.

Prospects for improving further still are good, says Sheila Weatherill, chief executive of Edmonton’s Capital Health Authority. The region’s excellent showing came despite its dismal, 52nd-place finish in the category counting newborns with low birth weights. Edmonton has significant pockets of low-income households and a large

GROUP 1: COMMUNITIES WITH MEDICAL SCHOOLS

OUTCOMES PRENATAL CARE COMMUNITY HEALTH ELDERLY SERVICES Overall Heart Vaginal Rank in Overall Overall rank Life attack Stroke Low birth Caesarean births after Hip Pneumonia Pap Hip Knee rank score last year expectancy survival survival weight section c-section fractures and flu Mammograms smears replacement replacemen 1 Edmonton 2* 86.1 4 15 2 2 52 20 17* 29 29_14* 18* 11 1* 2 Hamilton 84.4 10 29 14 15 34* 22 8* 28 15_14* 32* 14 1* 3 Saskatoon 8 83.7 12* 23 16* 13* 36 30_20* 8* 1* 1* 4 Ottawa 83.4 14* 11 28 16 40* 17 27* 14 13_20* 18* 36 1* M 5 Toronto 10 83.3 7* 11 53 33 34* 17 8 27* 45 38 33 6 London, Ont. 11 83.2 25* 18 22 31* 48 14_30* 18* 16 1* 7* Quebec City 13* 82.7 11 31* 16* 12 8* 23 3_11* 46 54 53 V Ip! 7* Calgary 13* 82.7 54 30 39 32 42* 32* 29 36 — rA 9 Winnipeg 16 82.6 16* 31* 17 40* 14 22* 15 17_26 32* 12 1* 10* Sherbrooke, Que. 17* 82.4 22 34* 49’ 38 10 4* 48* 46 54 10* Halifax/Dartmouth 17* 82.4 26* 34* 28 28* 37 4 31 37* 1 1* 1* 12* Montreal 25* 80.5 20* 31* - 48 24 17* 20 2 14* 48* 50 51 12* Vancouver/Richmond 25* 80.5 16*_9 - -_16* 51 34* 32 23 46* 51 42 46 14 Kingston, Ont. 30* 79.4 30_40 11 20 24* 34 39* 43 37 32* 18* 1* 1* 15 St. John's, Nfld. 43 76 45 27* - 23 34* 42 54 26 6 53 8* 49 52 Numbers are overall ranks by indicator ‘indicates a tie - indicates data unavailable

aboriginal population, says Weatherill, two factors that contribute to higher rates of underweight babies. But a retargeting of health services at those groups has reduced the percentage from 6.4 per cent of births to 5.9 per cent, she says. Which is not to suggest everything else is fine. “Once you’re in the system here, the care is good,” Weatherill says, “but people do wait too long in many cases.”

Edmonton stands out for another reason, one which may have caught the attention of the Commission on the Future of Health Care in Canada. In May, Weatherill made her case to commissioner Roy Romanow, arguing Edmonton’s success in organizing all health-care services under one regional board, as opposed to organizing by specific services. One board then makes all the calls. “You focus resources better,” says Weatherill, “and you reduce duplication and competition.”

The group of communities with medical schools—featuring the best and brightest, latest and greatest—remains a powerhouse this year, with 13 out of 15 placing in the top half of all regions. Within Group 1, Halifax/Dartmouth made major gains, climbing nine places to rank 17th overall. Vancouver/Richmond and Calgary, however, slipped significantly, in part because of their low standings under two indicators new this year: the numbers of women receiving mammograms and Pap smears.

The results for Group 2 show that affluent suburbs and satellite communities remain among the best places to get sick.

HEALTH CARE’S VITAL SIGNS

The Maclean’s ranking of health care in Canadian communities is based on scores computed from data collected on a comparable basis from health regions across the country by the Canadian Institute for Health Information and Statistics Canada. The indicators (* new this year):

LIFE EXPECTANCY

The age to which a person would be expected to live, based on average mortality rates between 1995 and 1997. 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.)

Many have impressive health-care centres of their own, bolstered by the services available in large urban facilities just a short ambulance ride away. For the third year running, North/West Vancouver, the affluent neighbour to the north of Vancouver, leads not only the 19 major urban centres in Group 2 but finishes first overall. Among its strengths: the life expectancy of its resi-

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.)

LOW BIRTH WEIGHT

Babies weighing less than 2,500 g (five pounds, eight ounces) at birth—a measure of prenatal care as well as community education and healthawareness programs. The higher the rate, the lower the ranking.

CAESAREAN SECTION

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.

HIP FRACTURES; PNEUMONIA AND FLU

Hospitalization of people over 64 for those causes-an indication of community preventivecare and health-awareness programs. Higher rates mean lower marks.

MAMMOGRAMS*

Women aged 50 to 69 who reported having

dents, few low-weight births and success in preventing unnecessary hospital admissions by having patients treated in doctors’ offices or clinics.

Victoria and the Mississauga/Brampton/Burlington region bordering Toronto finish second and third in Group 2, reversing their standing of a year ago. (Their overall scores have been so close both years

a mammogram for routine screening in the past two years. Higher rates mean higher marks.

PAP SMEARS*

Women aged 18 to 69 who reported having a Pap-smear test for cervical cancer in the past three years. Higher rates mean higher marks.

HIP REPLACEMENTS

The higher the rate of hip-replacement surgeries, the higher the mark, up to a cut-off. Marks are considered a tie for the first nine positions 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 31 regions with rates above the national average.

POSSIBLE OUTPATIENTS Hospital patients who likely could have received necessary medical services without hospitalization. Lower rates give higher marks. (Not available from Quebec.)

EARLY DISCHARGE

The length of time patients spend in hospital relative to a national norm for particular condi-

that they—like many regions separated by a ranking point or two—are virtually tied.) Three other Ontario regions— Windsor/Sarnia, Brantford and Peterborough—advance at least seven places this year. Although most of Group 2 finishes in the middle of the overall ranking, four Quebec regions rank lower—between 38th and 51st place.

tions. Shorter stays-generally indicating efficient treatment and the availability of follow-up care in the community-mean higher scores. (Not available from Quebec.)

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 AND PROSTATECTOMY READMISSIONS*

Unplanned readmissions to hospital following discharge for specific treatments. Lower rates mean higher marks. (Not available from Manitoba, Quebec or, for heart attacks, Newfoundland.) 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 inflows from other regions.

PHYSICIANS; SPECIALISTS Active GPs and family practitioners or medical specialists per 100,000 people. Marks increase with higher ratios, to a cut-off: the top nine are shown tied for first place.

EFFICIENCIES RESOURCES Possible Early Preventable Heart attack Asthma Hysterectomy Prostatectomy Local Physicians Specialists outpatients discharge admissions readmission readmission readmission readmission services per capita per capita 1 16_5_1_5_1_12_6 12 12 2 _2_2_12_1_19_3_10 32_1* 29 33 13_15 38_4_33_4 11 11 9 19_6_16 22_20_24_16 13 10 6 12_4_U_19_14_22_11_1* 1* 19 7 20_13 15_6_29_9 37 1* - _7 _-_-_-_8_1* 1* 24 32_12_4_13*_29_2_13 24 15 11 40 18 - - 7 15 1* - _ 24_-_-_-_-_20_1* 13 22 35 22_2_33_28_31_3_1* 1* - - 21_-_-_-_-__5_1* 1* 12 28 23_6 39 12_14_1_1* 1* 3 17 19_31_6_22_30_33 20 16 41 41 32 - 3 25 19 2 1* 1*

But as in earlier years, it is the largely rural regions, relatively far from the modern equipment and highly trained specialists in the major centres, that dominate the bottom end of the overall ranking. Among the 20 in Group 3, only two B.C. regions—Kelowna (a remarkable fifth overall) and Nanaimo (23rd)—make their way into the top half of the rankings. Holding down the bottom three spots are Sudbury, Ont., North Bay/Huntsville, Ont., and—dead last in 54th spot— Prince George, B.C.

The trick now is for each region, regardless of ranking, to find ways to address its weaknesses, says CIHI chairman Michael Decter. It’s up to the medical community to examine the data and determine what needs doing. “The goal here isn’t to award a prize to the best region,” says Decter. “It is to shift the whole performance curve in a positive direction.”

Health care eats through sacks of dough— more now than ever. In 2001, CIHI notes in its annual “Health Care in Canada” re% port, Canadians passed the $ 100-billion ! barrier, spending $ 102.5 billion on private 1 and public medical treatment and services. I Up 4.3 per cent from the previous year, ! that’s about $3,300 for every living—and i dying—Canadian. Hospitals accounted

for 32 per cent of the spending, drugs 15 per cent and doctors 14 per cent. In 2000, health-care expenses accounted for 32 per cent of spending by the provinces and territories, up from 27 per cent in 1975.

Medication costs are worrisome. Last year, Canadians spent about $15.5 billion on retail drugs, up 8.6 per cent from 2000, or just over $500 per person. Among the industrialized nations, only the United States, France, Japan and Belgium spend more. The burden is greatest for the lowest income households in Canada. They spend more on health care, as a percentage of family income, than do the richest households: 3.9 per cent versus 2.6 per cent. But for all that spending, one in eight Canadians said their health-care needs were not met in fiscal year 2000-2001, a substantial increase from one in 17 in 1998-1999. A common complaint: long waits for care.

In some cases, there just aren’t enough doctors to go around. By numbers alone, there would seem to be about as many physicians as ever, says Dr. Ben Chan, a se-

nior scientist at the Institute for Clinical Evaluative Sciences in Toronto. But in a study of physician numbers throughout the 1990s, prepared for CIHI and released last week, Chan notes that an aging population is placing higher demands on doctors. At the same time, he reports, more physicians are women, who typically work about one-fifth fewer hours than their male counterparts. Taking these two factors into account, Chan noted the ratio of doctors to the general population peaked in 1993, and has since fallen five per cent. The main reason for the decline, Chan says, is that doctors are spending more time training, so they’re not on the front lines as quickly as they used to be. The proportion of graduates who become general or family practitioners also dropped sharply in the past decade, from a high of 80 per cent in 1992 to just 45 per cent in 2000.

Chan challenges the common belief that cuts to medical-school enrolments in the early ’90s are the main cause of current shortages. Those cuts played a role, he says, but other factors—namely the longer training times, fewer foreign doctors entering Canada and more physicians retiring

—had bigger impacts. Canadas practice of mounting major health-care planning initiatives only every eight to 10 years should be re-examined, Chan says. He believes trends need to be monitored more frequently, and changes made more quickly to adjust doctor numbers. “It’s very difficult to predict the future—you’re always going to be a little too high or too low,” says Chan. “But we should be trying to do a better job of smoothing out the bumps.”

Getting the provinces to supply health-care data is a little like herding cats—each one wants to head offin its own direction. That leads to gaps in information. British Columbia and Quebec, for instance, gather research on heart attacks and strokes differently than other provinces, so their numbers cannot be included in CIHI’s national data. CIHI also has no numbers for heart attacks in Newfoundland and Labrador. And while several provinces track how long patients wait in emergency rooms for a hospital bed, only Ontario, Nova Scotia and New Brunswick supplied CIHI with their findings. That hardly

GROUP 2: OTHER MAJOR COMMUNITIES

OUTCOMES PRENATAL CARE COMMUNITY HEALTH ELDERLY SERVICES Overall Heart Vaginal Rank in Overall Overall rank Life attack Stroke Low birth Caesarean births after Hip Pneumonia Pap Hip Knee rank score last year expectancy survival survival weight section c-section fractures and flu Mammograms smears replacement replacement 1 North/West Vancouver_1 87.7 1_1_ 2* 46 41* 12 5 44* 30* 1* 39 2 Victoria_2* 86.1 6_4 4 52 39* 2 4 9* 2* 19 35 3 Mississauga/Brampton/ Burlington, Ont. 4 86 3_3 10 7 34* 27 13* 21 9_9* 25* 23 1* 4 Kitchener/Waterloo, Ont. 7 84.2 12* 12* 9 6 12* 25 22* 37 34 11* 8* 20 1* 5 Markham/ Richmond Hill, Ont. 12 82.9 18_5 17 8 28* 31 44* 46 28_4* 18* 32* 1* 6 Regina 13* 82.7 23_22* 25 12 14* 7 3_18 35_3 5* 21 38 7 Windsor/Sarnia, Ont 19 82 32* 37* 24 13 16* 21 7 31 19 1 39* 13 1* 8* Longueuil/Brossard/ Granby, Que. 20* 81.8 25 22* 31* 10 13*_8 24_2 41 48 45 8* Surrey, B.C. 20* 81.8 19 6 24* 48 27* 10 18 32* 43* 37 34 8* Burnaby/Coquitlam/ New Westminster, B.C. 20* 81.8 24 10 16* 36 31* 41 26_24* 43* 40 37 11 Laval, Que. 23* 80.9 12* 16* 34* 9 17* 16 1 32* 52 45 48 12 St. Catharines/ Niagara, Ont. 27 80.2 28_ 18* 26 21 5* 28 41* 27 12_32* 30* 22 1* 13* Brantford, Ont. 28* 80.1 37_37* 19 26 31* 15 22* 34 22_14* 5* 24 1* 13* Peterborough, Ont. 28* 80.1 35*_18* 21 9 24* 49 44* 50 38_4* 4 1* 1* 15 Chilliwack, B.C. 34 79.3 29 16* 5* 40 31* 33 39 44* 32* 30* 1* 16 St-Jérôme/ Ste-Thérèse, Que. 38 77.9 35*_44p 44* 3 6_19 27_52 18* 41 49 17 Gatineau, Que. 39 77.3 39 47 49* 23 8* 25 36_18* 8* 51 40 18 Joliette, Que. 40 77.1 40* 43 44* 5 8* 3 40 20* 42 53 50 19 Chicoutimi, Que. 51 73.4 44 49 40* 11 27* 22 25 49* 48* 52 42 Numbers are overall ranks by indicator ‘indicates a tie - indicates data unavailable

makes for a national picture, but for what its worth: 80 per cent of people admitted in those three provinces waited less than six hours for a bed. Three per cent waited longer than 24 hours—becoming part of those periodic back-ups of patients on gurneys in Emerg that create headlines.

CIHI is working on collecting better wait-time data, says Jennifer Zelmer, the institute’s director of health reports and analysis. It often comes down to getting all the provinces to count things the same way. Waits for bypass surgery, for instance. “When do you start the clock?” asks Zelmer. “When the first symptoms appear? When you first see your GP? Or when you first meet with a specialist?”

The provinces are beginning to get the message. Alberta promises to change in at least one regard. “We will be trying to work on a common definition of when wait times start and stop so we can compare them across Canada,” says Gary Mar, the province’s minister of health and wellness. The ball is already rolling. At a first ministers’ conference in Ottawa in September, 2000, the premiers agreed to harmonize how provinces track 14 medically impor-

tant factors, including life expectancy, infant mortality and waiting times for key diagnostic and treatment services. The first standardized reports on these indicators are due in September. It’s an encouraging first step toward a truly national snapshot, says CIHI’s Decter. “Over time, we hope to get there,” he says. “It depends on the goodwill of each province.”

A Close look at an individual regions results illustrates how the rankings can shift from year to year. Peterborough’s, for example. The city and its largely rural surroundings, home to 130,000 Ontarians, gained an impressive seven places from last year, landing in the middle of the pack at 28th place overall. In part, that’s due to the inclusion this year of data that CIHI and Statistics Canada have gathered for the first time on several new health-care indicators. Peterborough, it turns out, does exceptionally well coping with stroke, as measured by the numbers who die within 30 days of being hospitalized. McKeen at the County-City Health Unit thinks Peterborough’s fourth-place score may have to do with the region’s comprehensive cam-

EFFICIENCIES RESOURCES Possible Early Preventable Heart attack Asthma Hysterectomy Prostatectomy Local Physicians Specialists outpatients discharge admissions readmission readmission readmission readmission services per capita per capita 31 28 34 29 30 11 23 18 17 10 10 20 15 20 37 49 41 10 27 17 17 46 50 39 18 23 21 46 42 30 30 50 16 22 23 11 42 29 36 54 36 26* 47 27 33 10 15 11 20 37 26 49 48 45 13 24 21 15 19 42 24 53 34 26 17 43 21 31 21 40 32 36 34 34 50 54 15 17 30 28 10 48 51 48 21 13 38 17 32 27 41 41 49 28 44 30 50 26* 43 29 37 33 54 52 46 24 23

TAKING CARE OF STROKES The best survival rates four weeks after

hospital admission for a new stroke:

1 RE.I.

2 Edmonton

3 Saskatoon

4 Owen Sound, Ont.

5 Calgary

6 Kitchener/Waterloo, Ont.

7 Mississauga/Brampton/Burlington, Ont.

8 Markham/Richmond Hill, Ont.

9 Peterborough, Ont.

10 Thunder Bay, Ont.

(Includes health regions over 125,000 pop. Data not available for B.C. and Quebec)

WATCHING FOR BREAST CANCER

Who’s giving the most mammograms?

1 Windsor/Sarnia, Ont.

2 Longeull/Brossard/Granby, Que.

3 Regina

4* Nanaimo, B.C.

Markham/Richmond Hill, Ont. Peterborough, Ont.

Sherbrooke, Que.

Yarmouth/Digby, N.S.

ON GUARD AGAINST CERVICAL CANCER

Who’s giving the most Pap smears?

1 Halifax/Dartmouth 2* Victoria Fredericton

4 Peterborough, Ont.

5* Kelowna, B.C.

Regina

Brantford, Ont.

(* indicates a tie. Includes health regions over 125,000 pop.)

paign to raise awareness of heart and stroke issues. “Its reassuring,” says McKeen, “to think that the road we’ve been on—working with other community partners—is the right way to go.”

The Eastern Region of Newfoundland, on the other hand, shows what happens when resources are stretched to the limit. The sprawling rural jurisdiction, just west of the St. John’s region, has too few residents to be included in the Macleans ranking. CIHI’s data, however, show it to be noteworthy for one staggering finding. Of its people hospitalized for stroke, more than one third die within 30 days—the highest mortality rate among the 36 regions that ClffI cited in that category. “The figures are not surprising,” says Dr. Catherine Donovan, the area’s medical officer of health, “but they’re disturbing.” Hardly a day goes by when she isn’t trying to convince others of the need to spend on public education. Money is scarce and the benefits of raising awareness would likely be seen only 20 years from now, says Donovan, but it is essential. “Somebody,” she says, “has to have the courage to put that investment in there now.”

The reasons for specific results in specific

regions are myriad. Why, for instance, would Vancouver/Richmond do poorly in providing Pap smears? According to a recent study by the B.C. Cancer Agency, women in the region’s large Chinese community are less likely to have themselves tested than women in the general population. Dr. John Blatherwick, chief medical health officer for the Vancouver Coastal Health Authority, says the behaviour seems to be culturally rooted, with Chinese women more reluctant to be examined by a male physician. “We may have become complacent,” says Blatherwick, “in not doing more public education.” That seems to be changing. “We’re trying to develop culturally appropriate materials that will be sensitive,” says Dr. Greg Hislop at the B.C. Cancer Agency, “to facilitate going for Pap testing within different communities.” Even when things go right they can go wrong. Nova Scotia has one of the best ground and air ambulance services in North America. Yet the Yarmouth/Digby region in the southwest of the province is one of those disadvantaged rural areas, ranking 45th overall. In terms of stroke survival, it places 31st—better than in many other categories, but still a sign of negative factors at play. Smoking, education levels and obesity tend to be a problem in

the area, says Morris Green, a spokesman in Nova Scotia’s health department. So no matter how fast an ambulance arrives, it won’t help if it’s been called too late, or the person is so sick there isn’t much that can be done to help. “The good news,” says Green, “is we are aware of it.” Now the provincial health department will work with the Heart and Stroke Foundation of Nova Scotia to develop an integrated stroke strategy, including province-wide standards for care, treatment and better public education. “Certainly,” says Green, “the anecdotal evidence suggests that in some parts of the province, a lot of people don’t know the warning signs.”

So once again, it’s back to training people to do more to help themselves. Heart disease and stroke are bad news, accounting for one in five men and a little more than one in 10 women admitted to hospital. What to do about it? The same old advice: eat better, exercise more, quit smoking. Some Canadians are taking heed, judging by a StatsCan survey in seven provinces and the Yukon. About half of adults and teens said they’d acted in the past year to improve their health—more physical activity, losing weight, changing diet, cutting back or quitting cigarettes. Several provincial efforts to reduce the numbers of people with flu

GROUP 3: LARGELY RURAL COMMUNITIES

OUTCOMES PRENATAL CARE COMMUNITY HEALTH ELDERLY SERVICES Overall Heart Vaginal Rank in Overall Overall rank Life attack Stroke Low birth Caesarean births after Hip Pneumonia Pap Hip Knee rank score last year expectancy survival survival weight section c-section fractures and flu Mammograms smears replacement replacement 1 Kelowna, B.C. 5 85.3 2_2 - - 16* 39 22* 44 20* 18* 5* 10 1* 2 Nanaimo, B.C. 23* 80.9 32* 18* - - 1 43 41* 52 20* 4* 8* 27 1* 3* Lethbridge, Alta. 30* 79.4 34_37* 3 19 12* 13 13*_7 51_11* 32* 1* 1* 3* Lévis, Que. 30* 79.4 14* 22* - - 16* 32 36* 24 16 24* 54 39 43 3* Moncton, N.B. 30* 79.4 20* 14 13 27 9* 26 52* 1 41 49* 15 32* 1* 6 Trois-Rivières/ Drummondville, Que. 35 79.2 31 44* 24* 6 17* 13 7 37* 47 47 47 7 Owen Sound, Ont 36 79.1 38_25* 20 4_5* 18 27* 51 47_32* 25* 15_ 8 Rimouski, Que. 37 78.8 26* 27* - - 40* 16 31* 6 11 37* 53 43 44 9 Thunder Bay, Ont. 41 76.6 48 54 8 10 2* 29 36* 35 45 27* 16* 1* 1* 10 Kamloops, B.C. 42 76.2 46* 46 16* 50 46 40 33 27* 25* 1* 1* 11 Saint John, N.B. 44 75.9 40* 42 12 18 44* 44 48* 9 46 51 25* 18 1* 12 Yarmouth/Digby, N.S. 45 75.6 43 41 27 31 34* 19 47 11 43 4* 16* 34 1* 13 Fredericton 46 75.4 46* 36 15 30 9* 53 52* 5 52 46* 2* 26 1* 14 Témiscaming, Que. 47 75.2 49 52 - - 34* 2 2 54 42 30* 25* 44 41 15 Red Deer, Alta. 48 74.8 42 18* 4 14 49* 38 26 53 53 42* 8* 1* 1* 16 Prince Edward Island 49 74.7 53 30 16 1 9* 41 36* 47 48 37* 8* 28 1* 17 Cape Breton, N.S. 50 73.6 51 53 22 25 14* 35 21 42 44 54 32* 17 1* 18 Sudbury, Ont. 52 72.9 50 51 29 24 44* 47 50* 45 49_46* 32* 30* 1* 19 North Bay/Huntsville, Ont 53 71.9 54_50 30 29 28* 54 50* 49 50_20* 18* 25 1* 20 Prince George, B.C. 54 71.8 52_48 - -_5* 45 48* 30 54_37* 39* 35 1* Numbers are overall ranks by indicator ‘indicates a tie - indicates data unavailable

HOW THE RANKING WAS DONE

Our fourth annual ranking of health-care services available in communities across Canada incorporates all 54 health regions with populations over 125,000, representing more than 87 per cent of the national population. It is based on more in-

clogging emergency rooms seem to be working. In 2000-2001, 27 per cent of Canadians over the age of 11 got a flu shot, almost doubled from 1996-1997.

One way of improving health care is to take a relative few physicians or facilities that are good at something and have them do more of it. Take knee surgery. Seven in 10 knee replacements in 1999-2000 were performed in hospitals doing more than 100 a year, but almost seven per cent—

dicators than ever: 22 compared with 15 last year. Three charts rank regions that share some basic characteristics: communities with medical schools, other major communities and largely rural regions. They also show each region’s overall ranking within the full group of 54. The rankings do not include lesser-populated regions because their small numbers can be subject to misleadingly large fluctuations from year to year.

Maclean’s calculates its rankings 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 among regions. The rankings are based on the best nationally recognized indicators. The latest numbers available, they generally come from

more than 1,400 cases—were in hospitals doing fewer than 50 a year. For many types of care, CIFil reports, research shows patients treated in hospitals that perform the procedure frequently are less likely to experience complications or to die after surgery. Obviously, medical practice makes, if not perfect, certainly better.

Alberta’s Mar promotes the idea of concentrating certain services to improve outcomes and save money. “Some of the best pediatric cardiac surgery in Canada is done

the fiscal years 1998-1999 or 1999-2000. Lifeexpectancy and low-birth-weight figures are threeyear averages from earlier years.

To transform those numbers into a ranking, University of Toronto statistician David Andrews, a specialist in the analysis of medical data, converts the results for each indicator into scores for each region. Grouping those scores into six categories with assigned weights produces the overall rankings. (The category weights: outcomes 2; prenatal care 2; community health 2; elderly services 1; efficiencies 2; resources 1.)

Data were not available for some indicators from British Columbia, Manitoba, Quebec or Newfoundland and Labrador. In those cases, scores are based on the available indicators within the same categories.

in Edmonton,” says Mar, citing the city as a centre for the Prairies region. “Does it make sense for Saskatoon or Regina to have a similar type of pediatric cardiac surgery? No, I don’t think it does.”

But which surgeries do you target? It can become a delicate balancing act, risking hurt to institutional, community and even provincial pride. There are trade-offs, says Decter. While it isn’t necessarily desirable to have a pregnant woman travel great distances, that may be best in the event of complications. “The idea isn’t to have one giant hospital in downtown Toronto doing all surgeries,” says Decter. “There are a lot of surgeries that should be done close to home because there’s enough volume. It comes down to: can we manage the system more on the data and the evidence, rather than on history and tradition?”

Critics could argue that because of gaps in the data, the Macleans ranking doesn’t truly reflect what is going on across the country. True, the picture is incomplete. But it’s the best one we’ve got, and it’s getting clearer every year. Five years ago a ranking simply couldn’t have been done. “There was no comparable data, in which case everyone thinks they’re doing a terrific job unless you’ve got blatantly visible quality problems,” says Decter. Now, CIFil distributes a growing body of data, allowing health authorities to compare their performances. “People can ask themselves if they should be concerned Ithat they’re maybe one or two per cent § worse than some other hospital,” says I Decter. “What we’re doing is providing I the basis for a lot of questions to get f asked—and eventually answered.” It’s a I giant step in the right direction. [¡3

EFFICIENCIES RESOURCES Possible Early Preventable Heart attack Asthma Hysterectomy Prostatectomy Local Physicians Specialists outpatients discharge admissions readmission readmission readmission readmission services per capita per capita 14 5 40 14 35 16 - 21 19 20 16 23 31 39 24 3 11 45 14 31 20 25 53 18 - 35 - 31 26 38 3 - - 51 18 40 35 36 39 19 26 2 34 14 22 21 15 - - 38 40 25 27 8 44 22 23 30 23 39 44 53 25 - - 35 10 19 28 22 52 24 27 31 25 30 33 43 37 14 34 36 10 7 26 18 35 27 32 38 29 7 9 33 32 15 36 18 26 34 37 28 29 - - 52 31 46 39 27 51 32 13* 18 27 25 39 30 35 - - - - 27 21 29 38 26 47 26 36 36 - 29 38 51 40 39 54 35 25 24 35 22 47 35 36 37 41 33 4 - 10 34 28 34 25 20 48 25 18 11 8 23 45 28 33 18 49 38 8 - 13 42 23 44 31 21 45 37 30 34 28 26 25 47