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Health Care in Canada 2010: Evidence of progress, but care not always appropriate

Regional variations highlight potentially unnecessary surgical procedures

16 December 2010 - A new report released today by the Canadian Institute for Health Information (CIHI) shows that in 2008–2009, more than 3,600 therapeutic knee arthroscopies, used for diagnosing and caring for a variety of knee problems, were performed in Canadian hospitals despite mounting evidence that the procedure fails to improve patient outcomes or reduce discomfort when used to treat osteoarthritis.

CIHI’s report Health Care in Canada 2010 also found that about 1,050 vertebroplasty procedures were performed across Canada in 2008–2009, up from about 600 in 2006–2007. A significant number of these procedures were for patients suffering from vertebral fractures associated with osteoporosis. Recent evidence, however, suggests these patients are no better off than those who undergo placebo procedures.

“Evidence and appropriateness of care are a significant issue in Canada’s health care debate,” said John Wright, CIHI’s President and CEO. “The Organisation for Economic Co-operation and Development [OECD] estimates that improving the efficiency of a public health system could save up to 2% of GDP. One way to improve system efficiency is to ensure the care provided is appropriate, based on the best available evidence.”

Regional variations in Caesarean section and hysterectomy rates point to underlying differences in how care is provided

Caesarean sections and hysterectomies are the most common surgical procedures performed on Canadian women. While there are currently no agreed-upon benchmarks for the appropriate use of these procedures, significant variations in surgical rates among Canadian jurisdictions suggest that some of these procedures may not be appropriate or necessary. CIHI’s report shows that, in 2008–2009, the variation in primary (or first-time) C-section rates was almost twofold across the provinces. Rates ranged from a high of 23% of deliveries in Newfoundland and Labrador to a low of 14% in Manitoba. In the same year, rates of hysterectomies varied by more than 60% between the provinces (after adjusting for population age differences). Rates ranged from a high of 512 per 100,000 women (age 20 or older) in Prince Edward Island to a low of 311 per 100,000 in British Columbia.

“Many of these procedures are medically necessary. However, the wide variation in surgical rates from region to region cannot simply be explained by differences in women’s health,” says Jeremy Veillard, Vice President of Research and Analysis at CIHI. “When we see these kinds of variations, it is a cue to start asking questions about whether the care being provided is appropriate. Reducing unnecessary surgical procedures is beneficial to the patient, but there are cost implications for the system as well.”

Compared with vaginal births, C-section deliveries can cost hospitals twice as much in obstetric care for both mothers and babies. CIHI’s report found that if rates across Canada were lowered to match Manitoba’s primary C-section rate of 14% of all deliveries, there would be 16,200 fewer C-sections performed annually in Canada—generating potential savings of an estimated $36 million yearly in acute care services. Similar analyses also showed potential for savings if hysterectomy rates were lowered across Canada.

The right care in the right setting at the right time

CIHI data also shows that patients are not always receiving care in the most appropriate place. On any given day in Canada, alternate level of care (ALC) patients occupy the equivalent of approximately 7,550 beds in acute care hospitals. ALC refers to patients in acute care who are waiting for a transfer to a more appropriate setting, such as long-term care or a rehabilitation facility. In 2008–2009, there were more than 92,000 hospitalizations and more than 2.4 million hospital days involving ALC stays in Canada.

“When patients stay in acute care hospitals solely because they are waiting to be transferred to a more appropriate care setting, there is often a domino effect on the health care system,” explains Murray T. Martin, President and CEO, Hamilton Health Sciences. “An acute care bed being used by someone who needs home care or long-term care is not available for a patient needing to be admitted from the emergency department, which may result in longer wait times for in-hospital admissions.”

Focused care and attention on the issues can result in care that is more appropriate

Today, compared with only a few years ago, more is known about the care and treatment of patients with heart attacks in Canada. This has led to decreases in heart attack mortality, hospitalizations and readmissions. CIHI’s report shows that between 2004–2005 and 2008–2009, the age-adjusted rate of hospitalization for new heart attacks dropped from 239 per 100,000 people to 217 per 100,000, despite rising rates of risk factors in Canada, such as obesity and high blood pressure.

Progress is also being made across Canada in reducing hospital mortality rates overall. Today, CIHI is releasing its annual hospital standardized mortality ratio (HSMR) results for large acute care facilities and health regions outside Quebec. The HSMR is a measure of quality of care that compares a hospital’s actual (observed) deaths with the number of expected deaths based on the types of patients a hospital sees. CIHI’s report shows that over the past five years, 81% of reportable hospitals saw some decrease in their HSMRs, with 40% experiencing significant decreases.

“What we’ve seen across Canada is that the HSMR has been a great motivator for change,” says Patti Cochrane, Vice President, Patient Services and Quality and Chief Nursing Officer, Trillium Health Centre. “Trillium has been able to use HSMR results to understand what is driving mortality rates and where improvements can be made. As a result, we’ve made tangible changes to the care we provide, making a real difference to patient outcomes and potentially saving lives.”

Quick facts from Health Care in Canada 2010

• More than 3,600 therapeutic knee arthroscopies were carried out in hospitals across Canada in 2008–2009, despite research suggesting that this procedure is a temporary fix that fails to improve outcomes or reduce discomfort when used to treat osteoarthritis.
• In 2008–2009, 1,050 vertebroplasties—a spinal surgery that recent evidence has suggested is ineffective in some cases—were performed. The volume increased over the last three years, with approximately 600 performed in 2006–2007.
• In 2008–2009, the variation in primary C-section rates was almost double across the provinces. Rates ranged from a high of 23% of deliveries in Newfoundland and Labrador to a low of 14% in Manitoba.
• In 2008–2009, rates of hysterectomy varied by more than 60% between the provinces (after adjusting for population age differences). Rates ranged from a high of 512 per 100,000 women (age 20 or older) in P.E.I. to a low of 311 per 100,000 in British Columbia.
• Age-standardized hysterectomy rates were significantly higher (46%) for women living in rural areas (464 per 100,000) than for women living in urban areas (318 per 100,000).
• In 2008–2009, more than 92,000 hospital stays, or more than 2.4 million hospital days, were considered ALC in Canada.
• Between 2004–2005 and 2008–2009, the age-adjusted rate of hospitalization for new heart attacks dropped from 239 per 100,000 people to 217 per 100,000 people.
• Overall, 40% of publicly reportable facilities significantly decreased their HSMRs when 2009–2010 results are compared with those from 2004–2005.

About CIHI

The Canadian Institute for Health Information (CIHI) collects and analyzes information on health and health care in Canada and makes it publicly available. Canada's federal, provincial and territorial governments created CIHI as a not-for-profit, independent organization dedicated to forging a common approach to Canadian health information. CIHI's goal: to provide timely, accurate and comparable information. CIHI's data and reports inform health policies, support the effective delivery of health services and raise awareness among Canadians of the factors that contribute to good health. www.cihi.ca