Medical Practice Variations in Ontario, Canada - OECD.org · Evidence Guiding Health Care Medical...

Evidence Guiding Health Care

Medical Practice Variations in Ontario,

Canada

Presentation to the OECD, March 2, 2012

Therese Stukel, PhD & Ashley Corallo, MPH

Institute for Clinical Evaluative Sciences

Toronto ON, Canada


ICES Atlases

• ICES has complete, linkable, population-based health care

utilization data data for residents of Ontario

• Atlases are regularly updated, beginning in 1994

• ICES Atlases have typically been created for specific conditions,

including: Primary care including supply

Cancer

Cardiovascular diseases including stroke

Arthritis/ Musculoskeletal conditions

Asthma

Diabetes care

• ICES work is summarized through maps and tables in a form that

is easily accessible to policy-makers, researchers and clinicians

• All slides are downloadable from the ICES website:

http://www.ices.on.ca/webpage.cfm?site_id=1&org_id=31


Primary Care

• Prenatal care

• Screening

• Preventive care


Proportion of women receiving prenatal care, by physician

specialty, overall and by region, 2003/04

* This includes women whose physician did not

bill the Ontario Health Insurance Plan (OHIP),

those who were seen predominantly by

midwives or nurse practitioners and those who

received little or no prenatal care (<4 visits).

** Some women receive the majority of their

prenatal care (≥75% of their OHIP visits) from

GP/FPs while others receive the majority of

their care (≥75% of their OHIP visits) from OBs.

In other women, prenatal care is “shared” more

evenly between OBs and GP/FPs.

GP/FP = General practitioner/family physician

OB = Obstetrician 0

46

29

32

18

33

17

10

14

14

19

16

14

23

9

3

13

30

24

50

22

46

53

54

41

33

38

42

24

53

2

19

22

33

21

16

27

27

20

35

39

33

27

41

29

1

23

19

11

11

30

9

9

12

10

9

13

17

12

10

0% 20% 40% 60% 80% 100%

All Ontario

13. North East

11. Champlain

9. Central East

7. Toronto Central

5. Central West

3. Waterloo Wellington

1. Erie St. Clair

Lo

ca

l H

ea

lth

In

teg

rati

on

Ne

two

rk

Proportion of women receiving prenatal

care

≥75% of visits to GP/FP

≥75% of visits to OB

Visits shared between GP/FP & OB**

No billings*

0

46

29

32

18

33

17

10

14

14

19

16

14

23

9

3

13

30

24

50

22

46

53

54

41

33

38

42

24

53

2

19

22

33

21

16

27

27

20

35

39

33

27

41

29

1

23

19

11

11

30

9

9

12

10

9

13

17

12

10

0% 20% 40% 60% 80% 100%

All Ontario

14. North West

13. North East

12. North Simcoe Muskoka

11. Champlain

10. South East

9. Central East

8. Central

7. Toronto Central

6. Mississauga Halton

5. Central West

4. Hamilton Niagara Haldimand Brant


2. South West

1. Erie St. Clair

Lo

cal

Healt

h I

nte

gra

tio

n N

etw

ork

Proportion of women (%)

0

46

29

32

18

33

17

10

14

14

19

16

14

23

9

3

13

30

24

50

22

46

53

54

41

33

38

42

24

53

2

19

22

33

21

16

27

27

20

35

39

33

27

41

29

1

23

19

11

11

30

9

9

12

10

9

13

17

12

10

0% 20% 40% 60% 80% 100%

All Ontario

13. North East

11. Champlain

9. Central East

7. Toronto Central

5. Central West


1. Erie St. Clair

Lo

ca

l H

ea

lth

In

teg

rati

on

Ne

two

rk


care




No billings*

0

46

29

32

18

33

17

10

14

14

19

16

14

23

9

3

13

30

24

50

22

46

53

54

41

33

38

42

24

53

2

19

22

33

21

16

27

27

20

35

39

33

27

41

29

1

23

19

11

11

30

9

9

12

10

9

13

17

12

10

0% 20% 40% 60% 80% 100%

All Ontario

13. North East

11. Champlain

9. Central East

7. Toronto Central

5. Central West


1. Erie St. Clair

Proportion of women receiving prenatal care

Lo

cal H

ealt

h In

teg

rati

on

Netw

ork




No billings*

0

46

29

32

18

33

17

10

14

14

19

16

14

23

9

3

13

30

24

50

22

46

53

54

41

33

38

42

24

53

2

19

22

33

21

16

27

27

20

35

39

33

27

41

29

1

23

19

11

11

30

9

9

12

10

9

13

17

12

10

0% 20% 40% 60% 80% 100%

All Ontario

13. North East

11. Champlain

9. Central East

7. Toronto Central

5. Central West


1. Erie St. Clair

Lo

ca

l H

ea

lth

In

teg

rati

on

Ne

two

rk


care




No billings*

All Ontario

North West 14

South East 10

North Simcoe Muskoka 12

North East 13

South West 2

Central West 5

Champlain 11

Central East 9

Hamilton Niagara Haldimand Brant

Mississauga Halton 6

Toronto Central 7

Wellington Waterloo 3

Central 8

Erie St. Clair 1

Lo

cal H

ealt

h In

teg

rati

on

Netw

ork

0 20 40 60 80 100

Proportion of women (%)

4


Cardiovascular care

• CVD risk factors and drug costs

• Ischemic Heart Disease (IHD)

• Congestive Heart Failure (CHF)

• Acute Myocardial Infarction (AMI)


Stroke/TIA Care


Percentage of adults seen in an emergency department (ED) or

hospitalized with an ischemic stroke or TIA who underwent carotid

imaging, by sex and region, in Ontario, 2005/06


Cancer Care

• Hysterectomy

• Mastectomy

• Prostatectomy


Age-standardized hysterectomy rate for benign conditions per

100,000 women aged 15-84, by region, 2007


Hip, knee and joint replacement


Variations in Diagnostic Radiology (CT

and MRI) – A Chart-Based Study

• Used the Diagnostic Imaging Referral Guidelines, set out by Canadian Association of Radiologists (CAR)

• Indicated:

Test will likely contribute to diagnosis and management

• Not routinely indicated:

Specialized test – resource intensive, perform only after discussion with radiologist, or

Indicated in specific circumstances – non-routine examination

• Not indicated:

Rationale for the investigation is untenable


Top 4 indications for MRI vs. Guidelines

Brain

Extr

Spine

18.2

13.5

13.4

12.6

31.7

28.7

14.6

11.1

26.4

25.8

17.3

12.0

0 10 20 30 40 50

Suspected cancer

Headache

Suspected multiple sclerosis

Cancer follow-up

Suspected meniscal tear

Knee pain / swelling / restricted mobility

Suspected rotator cuff tear

Shoulder pain / restricted mobility

Back pain

Leg pain / radiculopathy

Arm pain / radiculopathy

Neck pain

Percent

CAR Recommendation:

Indicated (B)

Not routinely Indicated (C)

Indicated (A)

Not addressed by guidelines

Not routinely Indicated (B)

Not routinely Indicated (C)

Indicated (B)


Back pain + “red flag” – Indicated (B)

Acute back pain – not routinely indicated (B)

Chronic back pain – not routinely indicated (C)




Evidence Guiding Health Care 33

Variation in indications by hospital - MRI Brain

0

10

20

30

40

50

60

70

80

90

100

1 2* 3 4 5 6 7 8 9 10 11* 12* 13* 14* 15* 16* 17* 18* 19 20

Hospital

Perc

en

t o

f s

ca

ns

wit

h i

nd

icati

on

Suspected cancer (EQ 5.6)

Headache (EQ 8.9)

Suspected MS (EQ 8.6)

* = regional cancer centre

EQ = extremal quotient

(ratio of highest to lowest)

North South – community South - academic

Variation in indications by hospital – MRI brain


Is Higher Health Care Spending

Related to Better Outcomes?

Hospitalized patients admitted for

incident admission with:

• AMI

• CHF

• Hip Fracture

• Colon Cancer with Resection

Fisher et al. Annals (2003)

Stukel et al. JAMA (2012)


Regional Variations in U.S. Spending Intensity

L6M

Medicare $

per Capita

9,074 3,922

10,636 4,439

11,559 4,940

12,598 5,444

14,644 6,304

(r = 0.81)


1.00 1.5 2.0 0.5 2.5

Reperfusion in 12 hours (Heart attack)

Effective Care: benefit clear for all

Ratio of rate in high to low spending regions

Preference Sensitive: values matter

Supply sensitive: often avoidable care

Evaluation and Management (visits)

Imaging

Diagnostic Tests

Inpatient Days in ICU or CCU

Total Inpatient Days

Total Hip Replacement

Total Knee Replacement

Back Surgery

CABG following heart attack

Aspirin at admission (Heart attack)

Mammogram, Women 65-69

Pap Smear, Women 65+ Pneumococcal Immunization

Higher spending

regions get more

services (if right of bar)

U.S. health care system:

Services in highest vs. lowest spending regions


Decreased risk

1.00 1.05 1.10 0.95

1.00 1.05 1.10 0.95

Colorectal

Cancer

Q1

Q2

Q3

Q4

Q5

Hip Fracture Q1

Q2

Q3

Q4

Q5

Acute

Myocardial

Infarction

Q1

Q2

Q3

Q4

Q5

Increased risk

Rates of mortality in US were no different or higher in high spending regions

Fisher et al. Annals (2003)


Where is Canada on the

Health Benefit – Spending Curve?

Health

Benefits

Healthcare Spending

U.S. is here

Where is

Canada?


CHF: Mortality rate within 30 days –

Ontario, Canada

0.04

0.06

0.08

0.10

0.12

0.14

0.16

0.18

0.20

0.22

20,000 25,000 30,000 35,000 40,000 45,000 50,000

End of Life Expenditure Index (EOL-EI)

Pro

po

rtio

n


Hip fracture: Mortality rate within 30 days -

Ontario, Canada

0.00

0.04

0.08

0.12

0.16

0.20

20,000 25,000 30,000 35,000 40,000 45,000 50,000

End of Life Expenditure Index (EOL-EI)

Pro

po

rtio

n


0.4 0.6 0.8 1.0 1.2 1.4 1.6

Adjusted Relative Mortality Rate

Colon Cancer

AMI

CHF

Hip Fracture

Colon Cancer

AMI

CHF

Hip Fracture

30 days

1 year

Low EOL-EI

Medium EOL-EI

High EOL-EI

Adjusted Relative 30-day and 1-year Mortality Rates for Medium

and High vs. Low Hospital Expenditure Groups

Ontario, Canada


0.4 0.6 0.8 1.0 1.2 1.4 1.6

Adjusted Relative Readmission Rate

AMI

AMI

CHF

CHF

Hip Fracture

Hip Fracture

Colon Cancer

Colon Cancer

Low EOL-EI

Medium EOL-EI

High EOL-EI

30 days

1 year

Adjusted Relative 30-day and 1-year Cardiac (AMI, CHF) and All-Cause

Readmission Rates for Medium and High vs. Low Hospital Expenditure Groups

Ontario, Canada


Conclusions

• Ontario ICES Atlases have documented large regional variations

in: Overall hospital admissions

Physician visits and wait times

Screening

Prescription drug use

Diagnostic testing

Surgical procedures, such as coronary artery bypass grafting (CABG),

hysterectomy, prostatectomy, etc.

• Studies of Causes of Variations Require More Complex Methods

than Simple Descriptive Rates

Medical Practice Variations in Ontario, Canada - OECD.org · Evidence Guiding Health Care Medical...

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