3.0 Health System Characteristics

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3.0 Health System Characteristics

Health System

3.1 Coronary Artery Bypass Graft Surgery (Bypass Surgery) Rate

Definition
Age-standardized rate of coronary artery bypass graft (CABG) surgery performed on inpatients in acute care hospitals, per 100,000 population age 20 years and over.

Method of Calculation
(Total number of discharges for CABG for inpatients aged 20 years and over / Total mid-year population age 20 years and over) * 100,000 (Age adjusted)

    CCP*
    48.1^

    CCI*
    1.IJ.76^^

*Code may be recorded in any position. Procedures coded as cancelled, previous, out-of-hospital and "abandoned after onset" are excluded.

Interpretation
As with other types of surgical procedures, variation in CABG surgery rates can be attributed to numerous factors, including differences in population demographics, physician practice patterns, and availability of services. In cases amenable to treatment with less invasive procedures percutaneous coronary intervention (PCI), an alternative intervention to improve blood flow to the heart muscle, may be used. Variations in the extent to which PCI is utilized may result in variations in the rate of bypass surgery.

Standards/Benchmarks
In 2004, the Cardiac Care Network of Ontario recommended a minimum provincial target rate for CABG of 120 interventions per 100,000 adults, to be achieved by 2005-06. This recommendation is based on analyses of the historical trends in Ontario procedure rates, as well as incidence rates of the underlying conditions linked to CABG surgery.

Data Source
Discharge Abstract Database (DAD), CIHI
Fichier des hospitalisations MED-ÉCHO, Ministère de la Santé et des Services sociaux

Reference Period

April 1, 2006 - March 31, 2007

Comprehensiveness
Available for all provinces and territories.

References
Cardiovascular Health and Services in Ontario. ICES, 1999

Cardiac Care Network of Ontario. Consensus Panel on Target Setting. Final Report and Recommendations, 2004. http://www.ccn.on.ca/pdfs/Cons_Panel_Target_Setting_FRR.pdf.

Conigliaro J, Whittle J, Good CB, Hanusa BH, Passman LJ, Lofgren RP, Allman R, Ubel PA, OConnor M, Macpherson DS. Understanding racial variation in the use of coronary revascularization procedures: the role of clinical factors. Archives of Internal Medicine 2000; 160(9): 1329-35

Faris PD, Grant FC, Galbraith PD, Gong Y, Ghali WA; Canadian Cardiovascular Outcomes Research Team. Diagnostic cardiac catheterization and revascularization rates for coronary heart disease. Canadian Journal of Cardiology 2004;20:391-7.

Yap AG, Baladi N, Allman G, Avenmarg J, Yap S, Shaw RE. Coronary artery bypass surgery on small patients. Journal of Invasive Cardiology 2000; 12(5): 242-6.

Comments
Rates are based on the total number of discharges for CABG in a given year. Therefore, a patient who received more than one CABG procedure during the same hospitalization would be counted once. 

3.2 Percutaneous Coronary Intervention Rate

Definition
Age-standardized rate of percutaneous coronary interventions (PCI) performed on patients in acute care hospitals, same day surgery facilities or catheterization laboratories, per 100,000 population age 20 years and over.

Method of Calculation
(Total number of discharges for PCI for patients aged 20 years and over / Total mid-year population age 20 years and over) * 100,000 (Age adjusted)

    CCP*
    48.02^, 48.03^

    CCI*
    1.IJ.50^^, 1.IJ.57.GQ^^, 1.IJ.54.GQ-AZ

* Code may be recorded in any position. Procedures coded as cancelled, previous, out-of-hospital and "abandoned after onset" are excluded.

Interpretation
In many cases, PCI serves as a non-surgical alternative to coronary artery bypass graft (CABG) surgery and is undertaken for the purpose of opening obstructed coronary arteries. While PCI encompasses several techniques, angioplasty is the procedure most frequently provided. The choice of revascularization mode (i.e. PCI or CABG) depends on numerous factors including physician preferences, availability of services, referral patterns, as well as differences in population health and socio-economic status.

Standards/Benchmarks
In 2004, the Cardiac Care Network of Ontario recommended a minimum provincial target rate for PCI of 221 interventions per 100,000 adults, to be achieved by 2005/06, and 260 procedures to be achieved by 2008/09. These recommendations are based on analyses of the historical trends in Ontario procedure rates, as well as incidence rates of the underlying conditions linked to PCI.

Data Sources
Discharge Abstract Database (DAD), CIHI
National Ambulatory Care Reporting System (NACRS), CIHI
Alberta Ambulatory Care Database, Alberta Health and Wellness

Reference Period
April 1, 2006 - March 31, 2007

Comprehensiveness
Rates for Quebec are not available due to differences in data collection.

References
Cardiovascular Health and Services in Ontario. ICES, 1999.

Consensus Panel on Target Setting. Final Report and Recommendations. Cardiac Care Network of Ontario, 2004. http://www.ccn.on.ca/pdfs/Cons_Panel_Target_Setting_FRR.pdf.

Faris PD, Grant FC, Galbraith PD, Gong Y, Ghali WA; Canadian Cardiovascular
Outcomes Research Team.  Diagnostic cardiac catheterization and revascularization rates for coronary heart disease. Can J Cardiol 2004;20:391-7.

Smith SC Jr, Dove JT, Jacobs AK, et al; American College of Cardiology; American Heart Association Task Force on Practice Guidelines. Committee to Revise the 1993 Guidelines for Percutaneous Transluminal Coronary Angioplasty. ACC/AHA guidelines of percutaneous coronary interventions (revision of the 1993 PTCA guidelines)--executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty). J Am Coll Cardiol 2001;37:2215-39.

Comments
Rates are based on the total number of discharges for PCI in a given year. Therefore, a patient who received more than one PCI procedure during the same hospitalization would be counted once.

PCI is generally provided in a day surgery facility or catheterization laboratory after which the patient will be admitted to acute care for an overnight or longer stay. In order to prevent double counting of PCI procedures reported by both day surgery and acute care facilities, PCI procedures coded as being performed out-of-hospital or reported by facilities without on-site PCI services were excluded.

3.3 Cardiac Revascularization Rate

Definition
Age-standardized rate of coronary artery bypass graft (CABG) surgery performed on inpatients in acute care hospitals or percutaneous coronary interventions (PCI) performed on patients in acute care hospitals, same day surgery facilities or catheterization laboratories, per 100,000 population age 20 years and over.

Method of Calculation
(Total number of discharges for CABG or PCI for patients aged 20 years and over / Total mid-year population age 20 years and over) * 100,000 (Age adjusted)

    CCP*
    48.1^, 48.02^, 48.03^

    CCI*
    1.IJ.76^^, 1.IJ.50^^, 1.IJ.57.GQ^^, 1.IJ.54.GQ-AZ

* Code may be recorded in any position. Procedures coded as cancelled, previous, out-of-hospital and "abandoned after onset" are excluded.

Interpretation
The choice of revascularization mode (i.e. PCI or CABG) depends on numerous factors including physician preferences, availability of services, referral patterns, as well as differences in population health and socio-economic status. The combined cardiac revascularization rate represents total activity of cardiac revascularization in a jurisdiction.

Standards/Benchmarks
In 2004, the Cardiac Care Network of Ontario recommended a minimum provincial target rate for CABG of 120 interventions per 100,000 adults and 221 interventions per 100,000 adults for PCI to be achieved by 2005-06, as well as a minimum provincial target rate for PCI of 260 procedures per 100,000 adults to be achieved by 2008/09.  These recommendations are based on analyses of the historical trends in Ontario procedure rates, as well as incidence rates of the underlying conditions linked to CABG and PCI surgery.

Data Sources
Discharge Abstract Database (DAD), CIHI
National Ambulatory Care Reporting System (NACRS), CIHI
Alberta Ambulatory Care Database, Alberta Health and Wellness

Reference Period
April 1, 2006 - March 31, 2007

Comprehensiveness
Rates for Quebec are not available due to differences in data collection.

References
Cardiovascular Health and Services in Ontario. ICES, 1999.

Cardiac Care Network of Ontario. Consensus Panel on Target Setting. Final Report and Recommendations, 2004. http://www.ccn.on.ca/pdfs/Cons_Panel_Target_Setting_FRR.pdf.

Faris PD, Grant FC, Galbraith PD, Gong Y, Ghali WA; Canadian Cardiovascular
Outcomes Research Team.  Diagnostic cardiac catheterization and revascularization rates for coronary heart disease. Can J Cardiol 2004;20:391-7.

Comments
Rates are based on the total number of discharges for a cardiac revascularization procedure in a given year. Therefore, a patient who received more than one procedure (either CABG or PCI) during the same hospitalization would be counted once.

PCI is generally provided in a day surgery facility or catheterization laboratory after which the patient will be admitted to acute care for an overnight or longer stay. In order to prevent double counting of PCI procedures reported by both day surgery and acute care facilities, PCI procedures coded as being performed out-of-hospital or reported by facilities without on-site PCI services were excluded.

3.4 Hip Replacement Rate

Definition
Age-standardized rate of unilateral or bilateral hip replacement surgery performed on inpatients in acute care hospitals per 100,000 population age 20 years and over.

Method of Calculation
(Total number of discharges for hip replacement surgery for inpatients aged 20 years and over / Total mid-year population age 20 years and over) * 100,000 (Age adjusted)

    CCP*
    93.51, 93.52, 93.53, 93.59

    CCI*
    1.VA.53.LA-PN, 1.VA.53.PN-PN

*Code may be recorded in any position. Procedures coded as cancelled, previous, out-of-hospital and "abandoned after onset" are excluded.

Interpretation
Hip replacement surgery has the potential to improve functional status, reduce pain, as well as contribute to other gains in health-related quality of life. Over the past two decades, rates of hip replacement surgery have increased substantially. Wide inter-regional variation in joint replacement rates may be attributable to numerous factors including the availability of services, provider practice patterns, and patient preferences.

Standards/Benchmarks
Benchmarks have not been established for this procedure.

Data Sources
Discharge Abstract Database (DAD), CIHI
Alberta Acute Care Database, Alberta Health and Wellness
Fichier des hospitalisations MED-ÉCHO, Ministère de la Santé et des Services sociaux

Reference Period
April 1, 2006 - March 31, 2007

Comprehensiveness
Available for all provinces and territories.

References
Naylor CD, DeBoer DP.Variations in selected surgical procedures and medical diagnoses by year and region. Total Hip and Knee Replacement. In: Goel V, Williams JI, Anderson GM, Blackstein-Hirsch P, Fooks C, Naylor CD, (eds): Patterns of Health Care in Ontario, 2nd Ed., Canadian Medical Association, Ottawa, 1996:54.

University of Toronto, Ontario Hospital Association. The Hospital Report 98. A System-wide review of Ontarios hospitals. Toronto: Ontario Hospital Association, 1998.

Wright CJ, Robens-Paradise Y. Evaluation of Indications and Outcomes in Elective Surgery. May 2001. Centre for Clinical Epidemiology and Evaluation, Vancouver Hospital and Health Services Centre.

Comments
Rates are based on the total number of discharges for hip replacement surgery in a given year. Therefore, a patient who received both a left and a right hip replacement in the same year but at separate admissions would be counted twice.

Beginning with 2005/06, this indicator is calculated for the population aged 20 years and over and therefore is not comparable with rates reported for previous years. Rates based on the new definition were calculated for the previous years to allow for comparisons over time.

Hospitalization data for 2006/07 for Peace Country health region in Alberta were incomplete; therefore the indicator could not be calculated for this region.

3.5 Knee Replacement Rate

Definition
Age-standardized rate of unilateral or bilateral knee replacement surgery performed on patients in acute care hospitals or same-day surgery facilities, per 100,000 population age 20 years and over.

Method of Calculation
(Total number of discharges for knee replacement surgery for patients aged 20 years and over / Total mid-year population age 20 years and over) * 100,000 (Age adjusted)

    CCP*
    93.40, 93.41

    CCI*
    1.VG.53^^

*Code may be recorded in any position. Procedures coded as cancelled, previous, out-of-hospital and "abandoned after onset" are excluded.

Interpretation
Knee replacement surgery has the potential to improve functional status, reduce pain, as well as contribute to other gains in health-related quality of life. Over the past two decades, rates of knee replacement surgery have increased substantially. Wide inter-regional variation in joint replacement rates may be attributable to numerous factors including the availability of services, provider practice patterns, and patient preferences.

Standards/Benchmarks
Benchmarks have not been established for this procedure.

Data Source
Discharge Abstract Database (DAD), CIHI
National Ambulatory Care Reporting System (NACRS), CIHI
Alberta Acute Care Database, Alberta Health and Wellness
Alberta Ambulatory Care Database, Alberta Health and Wellness
Fichier des hospitalisations MED-ÉCHO, Ministère de la Santé et des Services sociaux

Reference Period
April 1, 2006 - March 31, 2007

Comprehensiveness
Available for all provinces and territories.
References

Naylor CD, DeBoer DP.Variations in selected surgical procedures and medical diagnoses by year and region. Total Hip and Knee Replacement. In: Goel V, Williams JI, Anderson GM, Blackstein-Hirsch P, Fooks C, Naylor CD, (eds): Patterns of Health Care in Ontario, 2nd Ed., Canadian Medical Association, Ottawa, 1996:54.

University of Toronto, Ontario Hospital Association. The Hospital Report 98. A System-wide review of Ontarios hospitals. Toronto: Ontario Hospital Association, 1998.

Wright CJ, Robens-Paradise Y. Evaluation of Indications and Outcomes in Elective Surgery. May 2001. Centre for Clinical Epidemiology and Evaluation, Vancouver Hospital and Health Services Centre.

Comments
Rates are based on the total number of discharges for knee replacement surgery in a given year. Therefore a patient who received both a left and a right knee replacement in the same year but at separate admissions would be counted twice.

Beginning with 2005/06, this indicator is calculated for the population aged 20 years and older and includes same day surgery procedures, and therefore is not comparable with rates reported for previous years. Rates based on the new definition were calculated for the previous years to allow for comparisons over time.

Hospitalization data for 2006/07 for Peace Country health region in Alberta were incomplete; therefore the indicator could not be calculated for this region.

3.6 Hysterectomy Rate

Definition
Age-standardized rate of hysterectomy provided to patients in acute care hospitals or same-day surgery facilities, per 100,000 women age 20 years and over.

Method of Calculation
(Total number of discharges for hysterectomy for women age 20 years and over / Total mid-year female population age 20 years and over) * 100,000 (Age adjusted)

    CCP*
    80.2^-80.6^

    CCI*
    1.RM.89^^, 1.RM.91^^, 1.RM.87.BA-GX**, 1.RM.87.CA-GX**, 1.RM.87.DA-GX**, 1.RM.87.LA-GX**

*Code may be recorded in any position. Procedures coded as cancelled, previous, out-of-hospital, and "abandoned after onset" are excluded.

** Procedures with these CCI codes were included only if they also were coded with the extent attribute 'SU', identifying them as subtotal hysterectomies.

Interpretation
As with other types of surgical procedures, variation in hysterectomy rates can be attributed to numerous factors, including differences in population demographics, physician practice patterns, and availability of services. Utilization rates may reflect the level of uncertainty about the appropriate use of this surgical procedure. The "right" level of utilization is not known.

Standards/Benchmarks
Benchmarks have not been established for this procedure.

Data Sources
Discharge Abstract Database (DAD), CIHI
National Ambulatory Care Reporting System (NACRS), CIHI
Alberta Ambulatory Care Database, Alberta Health and Wellness
Fichier des hospitalisations MED-ÉCHO, Ministère de la Santé et des Services sociaux

Reference Period
April 1, 2006 - March 31, 2007

Comprehensiveness
Available for all provinces and territories.

References
Carlson KJ, Schiff I. Current concepts. Indications for hysterectomy. New England Journal of Medicine 1993; 328:826-860.

Cohen MM, Young W. Hysterectomy. In: Goel V, Williams JI, Anderson GM, Blackstein-Hirsch P, Fooks C, Naylor CD, (eds): Patterns of Health Care in Ontario, 2nd Ed., Canadian Medical Association, Ottawa, 1996:141.

Cumming DC. Hysterectomy Revisited. Journal of Obstetrics and Gynecology Canada 1996; 18:869-79.

Zekam N, Oyelese Y, Goodwin K, Colin C, Sinai I, Queenan JT. Total versus subtotal hysterectomy: a survey of gynecologists. Obstetrics and gynecology 2003; 102:301-5.

Comments
Beginning with 2006-2007 data, hysterectomy rates include both total and sub-total hysterectomies, similar to the reporting prior to 2001-2002 data. Sub-total hysterectomy was not uniquely identified in the Canadian Classification of Health Interventions (CCI) versions 2001 and 2003, therefore hysterectomy rates reported for 2001-2002 to 2005-2006 fiscal years included only total hysterectomies. Identification of sub-total hysterectomies became possible again with version 2006 of CCI. For jurisdictions with higher volumes of sub-total hysterectomies comparability with the previous years might be affected.

Beginning with 2005/06, this indicator includes same day surgery procedures. However, due to small counts of same day surgery procedures, comparability with the previous years is not affected.

Hospitalization data for 2006/07 for Peace Country health region in Alberta were incomplete; therefore the indicator could not be calculated for this region.

3.7 Inflow/Outflow Ratio

Definition
A ratio of the number of separations (discharges and deaths) from acute care/same day surgery facilities within a given region divided by the number of acute care/same day surgery separations generated by residents of that region.

Method of Calculation
Numerator: Number of separations (discharges and deaths) from acute care/same day surgery facilities within a given region (including non-residents).
Denominator: Number of separations generated by residents of a given region, where region is as specified in the numerator.

An Overall Ratio was calculated for discharges associated with any diagnosis or procedure for acute care discharges only, and separately for coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), hip replacement, knee replacement, and hysterectomy procedures*.

CABG (Acute care discharges only):

    CCP
    48.1^

    CCI
    1.IJ.76^^

PCI (Acute care and same day surgery discharges):

    CCP
    48.02, 48.03

    CCI
    1.IJ.50^^, 1.IJ.57.GQ^^, 1.IJ.54.GQ-AZ

Hip Replacement (Acute care discharges only):

    CCP
    93.51, 93.52, 93.53, 93.59

    CCI
    1.VA.53.LA-PN, 1.VA.53.PN-PN

Knee Replacement (Acute care and same day surgery discharges):

    CCP
    93.40, 93.41

    CCI
    1.VG.53^^

Hysterectomy (Acute care and same day surgery discharges):

    CCP
    80.2^-80.6^

    CCI
    1.RM.89^^, 1.RM.91^^ or 1.RM.87.BA-GX, 1.RM.87.CA-GX, 1.RM.87.DA-GX, 1.RM.87.LA-GX with extent attribute coded as "SU"

*Code may be recorded in any position. Procedures coded as cancelled, previous, out-of-hospital, and "abandoned after onset" are excluded.

Interpretation
This indicator reflects the balance between the quantity of hospital stays provided to both residents and non-residents by all relevant facilities (acute care hospitals/same day surgery) in a given region and the extent of utilization by residents of that region, whether they receive care within or out of the region. A ratio of less than one indicates that health care utilization by residents of a region exceeded care provided within that region, suggesting an outflow effect. A ratio greater than one indicates that care provided by a region, exceeded the utilization by its residents, suggesting an inflow effect. A ratio of one indicates that care provided by a region is equivalent to the utilization by its residents, suggesting that inflow and outflow activity, if it exists at all, is balanced. A ratio of zero is an indication that none of the institutions in the region provided the service and residents received care outside of their region.

Standards/Benchmarks
Benchmarks are not available for this measure.

Data Sources
Discharge Abstract Database (DAD), CIHI
National Ambulatory Care Reporting System (NACRS), CIHI
Alberta Acute Care Database, Alberta Health and Wellness
Alberta Ambulatory Care Database, Alberta Health and Wellness
Fichier des hospitalisations MED-ÉCHO, Ministère de la Santé et des Services sociaux

Reference Period
April 1, 2006 - March 31, 2007

Comprehensiveness
Available for all provinces and territories.

Comments
Beginning with 2006-2007 data, hysterectomy cases include both total and sub-total hysterectomies, similar to the reporting prior to 2001-2002 data. Sub-total hysterectomy was not uniquely identified in the Canadian Classification of Health Interventions (CCI) versions 2001 and 2003, therefore hysterectomy rates reported for 2001-2002 to 2005-2006 fiscal years included only total hysterectomies. Identification of sub-total hysterectomies became possible again with version 2006 of CCI. For jurisdictions with higher volumes of sub-total hysterectomies comparability with the previous years might be affected.

Beginning with 2005/06, hysterectomy, hip replacement and knee replacement totals include same day surgery procedures. Due to small counts of same day surgery procedures, comparability with previous years is not affected.

Hospitalization data for 2006/07 for Peace Country health region in Alberta were incomplete; therefore the inflow/outflow ratios for hip and knee replacement, hysterectomy and overall could not be calculated for this region.

3.8 General/Family Physicians (GP/FP) and Specialist Physicians

Definition
General practitioners or family practitioners (family medicine and emergency medicine specialists) on December 31st of the reference year, per 100,000 population;
Specialist physicians (medical, surgical and laboratory specialists) on December 31st of the reference year, per 100,000 population.

The data include physicians in clinical and non-clinical practice and exclude residents and physicians who are not licensed to provide clinical practice and have requested that their information not be published in the Canadian Medical Directory.

Method of Calculation
(Total number of General and Family Practitioners / Total mid-year population) * 100,000
(Total number of Specialists / Total mid-year population) * 100,000

Physicians are geo-coded to a region based on the postal code of correspondence submitted to the Scott's Medical Database. Records with invalid, missing, or partial postal codes are excluded from the regional totals.

Interpretation
Physician to population ratios are used to support health human resource planning. While physician density ratios are useful indicators of changes in physician numbers relative to the population, inference from total numbers or ratios as to the adequacy of provider resources should not be made. Various factors influence whether the supply of physicians is appropriate, such as: distribution and location of physicians within a region or province; physician type (i.e., family medicine physicians vs. specialists); level of service provided (full-time vs. part-time); physician age and gender; population's access to hospitals, health care facilities, technology and other types of health care providers; population needs (demographic characteristics and health problems); and society's perceptions and expectations.

In some regions, health facilities and personnel provide services to a larger community than the residents of the immediate region. In others, residents may seek care from physicians and specialists outside the region where they live. The ratio of physicians to population reflects the number of doctors in a region and has not been adjusted to take these movements into account. The extent to which this affects individual regions is likely to vary.

Standards/Benchmarks
Benchmarks are not available for this measure.

Data Source
Scott's Medical Database, CIHI

Reference Period
December 31, 2006

Comprehensiveness
Available for all provinces and territories.

Comments
While the postal code of correspondence may not necessarily reconcile with a physician's place of practice, approximately 90% of postal codes submitted refer to the physician's office, office-in-home or hospital address.

For all jurisdictions and data years specialist physicians include certificants of the Royal College of Physicians and Surgeons of Canada (RCPSC) and/or the College des médecins du Québec (CMQ). As of 2004, Saskatchewan and Newfoundland and Labrador specialists also include physicians who are licensed as specialists but who are not certified by the RCPSC or the CMQ (i.e., non-certified specialists). For all other jurisdictions, and for Saskatchewan and Newfoundland and Labrador prior to 2004, non-certified specialists are counted as family practitioners. With the exception of the criteria just noted all other physicians are counted as family practitioners, including certificants of the College of Family Physicians of Canada (CCFP and CCFP-Emergency Medicine). For further information on physician count methodologies please see CIHI's reports on the "Supply, Distribution and Migration of Canadian Physicians" and "Certified and Non-Certified Specialists: Understanding the Numbers" (www.cihi.ca).

It is recognized that physician specialty classification as noted above does not necessarily reflect the services provided by individual physicians. The range of services provided by a physician is subject to provincial licensure rules, medical service plan payment arrangements, and individual practice choices. Therefore, CIHI physician-to-population rates may differ from those published by other sources.

Note: Scott's Medical Database (SMDB) information may undercount physicians due to Provincial/Territorial licensing authority data supply interruptions. SMDB data does not reflect licensing authority updates for the following jurisdictions and years: British Columbia 2004; Québec 2003; Ontario 2002; Alberta and the Yukon 2000.