How many surgeons does a province need, and how do we determine appropriate numbers?

The study compared each province's supply of surgeons in three specialities (ophthalmologists--orthopedic--surgeons, and cardiac and thoracic surgeons) with the rates of key procedures (cataract removal, hip and knee replacement, and coronary artery bypass) that residents received. We found little or no relationship between the supply of surgeons and a population's surgery rate. We conclude that the supply of surgical specialists is the wrong focus for health care resource planning.

Monitoring health reform: a report card approach.

UNLABELLED: During the past several years, budget cuts have forced hospitals in several countries to change the way they deliver care. Gilson (Gilson, L. (1998). DISCUSSION: In defence and pursuit of equity. Social Science & Medicine, 47(12), 1891-1896) has argued that, while health reforms are designed to improve efficiency, they have considerable potential to harm equity in the delivery of health care services. It is essential to monitor the impact of health reforms, not only to ensure the balance between equity and efficiency, but also to determine the effect of reforms on such things as access to care and the quality of care delivered. This paper proposes a framework for monitoring these and other indicators that may be affected by health care reform. Application of this framework is illustrated with data from Winnipeg, Manitoba, Canada. Despite the closure of almost 24% of the hospital beds in Winnipeg between 1992 and 1996, access to care and quality of care remained generally unchanged. Improvements in efficiency occurred without harming the equitable delivery of health care services. Given our increasing understanding of the weak links between health care and health, improving efficiency within the health care system may actually be a prerequisite for addressing equity issues in health.

Characteristics of patients with a regular source of care.

This study was designed to describe patient characteristics associated with having a regular source of care among all patients who received care from large urban clinics in Manitoba over a three-year period (N = 298,222). Using administrative data, patients were classified as having a regular source of care if they made 75% or more of their total ambulatory visits to the same clinic. Overall, 44.2% of patients had a regular source of care. A logistic regression showed that children and adults aged 45 and older were more likely to have a regular source of care than patients aged 18-44. Moreover, patients with a regular source of care tended to live in more affluent neighbourhoods and were healthier than individuals with no regular source of care. Systemic changes might be needed to enhance continuity of care (e.g., mechanisms to enhance access) among vulnerable segments of the population like the poor.

What is right about the Canadian health care system?

Canadians tend to dwell on problems in their health care system, looking to the United States for magical fixes. Evidence on comparative system performance, which rarely surfaces in public debate, indicates that Canadians are healthier, not only because the social environment is more benign, but also because health care is allocated by need rather than ability to pay. Expenditures are much lower, but Canadians receive equivalent care because their system is more efficient. Although Canadian "waiting lists" are highly publicized, the United States avoids the issue by excluding those who cannot pay. Why, then, do American notions keep pushing north? All expenditures are someone's income. There is a great deal of money to be made by wrecking Canadian Medicare.

Standard cost lists for healthcare in Canada. Issues in validity and inter-provincial consolidation.

A standard cost list is a listing of recommended costs for a selected group of services. Standard costs are used in economic evaluation studies to eliminate that proportion of cost differences between interventions that are due to cost differences between providers. In this article we provide a summary of cost lists for pharmaceutical economic evaluation purposes which have been developed in 2 provinces in Canada-Alberta and Manitoba. We then assess these 2 lists from 2 different viewpoints. First, we developed criteria for the internal and external validity of costs and, in light of these validity criteria, we assessed how the 2 standard cost lists compared with the 'ideal' measure of long run marginal costs. Second, we identified the criteria for the inter-provincial consolidation of standard cost measures (in order to develop a single, consolidated cost list); in light of these criteria, we assessed whether the degree to which the 2 separate lists could be consolidated. The lists achieved a considerable degree of external validity, but fared less well in terms of internal validity. However, these results depend on the 'ideal' measure of cost which is used. The lists, in the forms which were developed, are not easily consolidated into a single list. Further refined cost data would be needed in order to achieve consolidation.

A comparative study of the costliness of Manitoba hospitals.

OBJECTIVES: In light of ongoing discussions about health care policy, this study offered a method of calculating costs at Manitoba hospitals that compared relative costliness of inpatient care provided in each hospital. RESEARCH DESIGN: This methodology also allowed comparisons across types of hospitals-teaching, community, major rural, intermediate and small rural, as well as northern isolated facilities. MEASURES: Data used in this project include basic hospital information, both financial and statistical, for each of the Manitoba hospitals, hospital charge information by case from the State of Maryland, and hospital discharge abstract information for Manitoba. The data from Maryland were used to create relative cost weights (RCWs) for refined diagnostic related groups (RDRGs) and were subsequently adjusted for Manitoba length of stay. These case weights were then applied to cases in Manitoba hospitals, and several other adjustments were made for nontypical cases. This case mix system allows cost comparisons across hospitals. RESULTS: In general, hospital case mix costing demonstrated variability in hospital costliness, not only across types of hospitals but also within hospitals of the same type and size. CONCLUSIONS: Costs at the teaching hospitals were found to be considerably higher than the average, even after accounting for acuity and case mix.

The unintended and unexpected impact of downsizing: costly hospitals become more costly.

OBJECTIVES: In this project we assessed the impact of 1992 budget cuts ($50 million, or approximately 7% of urban hospitals' budgets) on the relative costliness of Manitoba's hospitals. The cuts targeted the teaching hospitals, those institutions we had found to be particularly costly in a previous Manitoba Centre for Health Policy and Evaluation study. RESULTS: Unexpectedly, we found that because budget cuts were smaller proportionately than the number of beds closed, the care at the teaching hospitals (as well as at several other hospitals) became relatively more, not less, costly. Also quite contrary to public perceptions, once other expenditures such as new hospital programs and expansions were accounted for, the actual change in urban hospital expenditures over the years compared was less than 1%. CONCLUSIONS: The study highlighted the importance of monitoring program outcomes.

Monitoring the impact of hospital downsizing on access to care and quality of care.

The most recent data used for monitoring the potential effects of bed closures in Winnipeg hospitals since 1992/93 found that despite downsizing, access to care was by no means compromised. Just as many patients were cared for in 1995/96 as in 1991/92. Changes in patterns of care included more outpatient and fewer inpatient surgeries, and a decrease in the number of hospital days. The number of high-profile surgical procedures, such as angioplasty, bypass, and cataract surgery, performed increased dramatically during downsizing. Quality of care delivered to patients, measured by mortality and readmission rates, was unaffected by bed closures. Of particular concern was the impact of downsizing on the two most vulnerable health groups--the elderly and Manitobans in the lowest income group. Access and quality of care for these groups also remained unchanged. However, those in the lowest income group spent almost 43% more days in hospital than those in the middle income group, and research demonstrates that these variations in hospital use across socioeconomic groups reflect real and important health differences and are not driven by social reasons for admissions. Finally, a large decrease in waiting time for nursing home placement underlines the relationship between downsizing and availability of alternatives to hospitalization.

Establishing a population data-based policy unit.

The Manitoba Centre for Health Policy and Evaluation (MCHPE) developed POPULIS, a population-based health information system, as a vehicle for changing the way we think about the role of health care as a determinant of health. Serving as a bridge between analysts who produce research and politicians and policymakers who use it, MCHPE has developed a research infrastructure that can transform routinely collected administrative data into policy-relevant information. This paper provides a description of Manitoba and its health care system, as well as how MCHPE was started and how it functions. It describes how we at the Centre work with various databases, from the acquisition process through developing concepts and capabilities to the final validity and sensitivity testing of results. We detail the role of a population-based conceptual framework in challenging those who suggest more spending on medical care is self-evidently desirable.

Issues in planning for specialist physicians.

OBJECTIVES: The Manitoba Centre for Health Policy and Evaluation worked in support of a provincial Physician Resource Committee to address questions pertinent to assessing Manitoba's supply of specialist physicians. RESEARCH DESIGN: Because there was no direct method of determining whether the province's supply of specialists was adequate, three types of evidence were reviewed: the supply of specialists relative to recommended population/physician ratios; the supply of specialists relative to other Canadian provinces; and the level of care delivered by specialists in Manitoba relative to other provinces. Four additional questions were addressed: is a problem developing from the aging of Manitoba's specialist physicians? and will the supply of specialists be sufficient to keep up with the aging of the population? How well do specialists serve as a provincial resource? and how well do specialists serve high-need populations?

Needs-based planning for generalist physicians.

OBJECTIVES: The Manitoba Centre for Health Policy and Evaluation (MCHPE) collaborated with a provincially-appointed Physician Resource Committee in an assessment of provincial physician resources. RESEARCH DESIGN: Beginning with map-based analyses of physician supply and contacts across the province, compared with the health and socioeconomic characteristics of local populations, the study moved to a needs-based, regression-based approach to physician resource planning. RESULTS: The results challenged the popular belief that Manitoba suffers from an increasing shortage of physicians. A handful of high-need, low-supply and low-use areas are identified, as is the expensive surplus of generalist physicians in Winnipeg. (Generalist physicians include general and family practitioners as well as general internists and pediatricians.) No relationship between physician supply and health characteristics of populations, or between high physician supply and low hospital use patterns were found. Given the Committee's interest in what drives high physician contact rates, analyses of visit patterns of hypertensive patients were undertaken. We found that patients who had more complex medical conditions made more contacts, but that after controlling for this and other key patient characteristics, the patient's primary care physician's patient recall rate was a strong influence on how frequently visits were made.

Managing health services: how the Population Health Information System (POPULIS) works for policymakers.

OBJECTIVES: University-based researchers in Manitoba, Canada, have used administrative data routinely collected as part of the national health insurance plan to design an integrated database and population-based health information system. This information system is proving useful to policymakers for answering such questions as: Which populations need more physician services? Which need fewer? Are high-risk populations poorly served? or do they have poor health outcomes despite being well served? Does high utilization represent overuse? or is it related to high need? More specifically, this system provides decision makers with the capability to make critical comparisons across regions and subregions of residents' health status, socioeconomic risk characteristics and use of hospitals, nursing homes, and physicians. The system permits analyses of demographic changes, expenditure patterns, and hospital performance in relation to the population served. The integrated database has also facilitated outcomes research across hospitals and countries, utilization review within a single hospital, and longitudinal research on health reform. The discussion highlights the strengths of integrated population-based information in analyzing the health care system and raising important questions about the relationship between health care and health.

From research to policy: what have we learned?

The Manitoba Centre for Health Policy and Evaluation has now had eight years of experience as an academic research unit interfacing with policymakers. Most of our research has focused on the determinants of health and on the delivery of health care from a population perspective. Each project that we have undertaken has made its own contribution and reinforced or built on the contribution of others. By communicating closely with policymakers at all levels, while maintaining an arm's-length relationship and the right of publication, MCHPE acts as a knowledgeable non-stakeholder with a commitment to inform the broader public.

Factors influencing the frequency of visits by hypertensive patients to primary care physicians in Winnipeg.

BACKGROUND: As part of a recent project focused on needs-based planning for generalist physicians, the authors documented the variety of practice styles of primary care physicians for managing patients with hypertension. They investigated the validity of various explanations for these different styles and the relative contributions of physician and patient characteristics to the rates at which hypertensive patients contact physicians. METHODS: Retrospective descriptive study using regression analyses to simultaneously adjust for the influence of key patient and physician characteristics. Hypertensive patients in Winnipeg were identified using Manitoba physician claims data for fiscal years 1993/94 and 1994/95. Patients were included if they were 25 years of age or more and had at least one physician contact in both 1993/94 and 1994/95 during which hypertension was diagnosed. In addition, the primary care physician had to be the physician that the patient contacted most frequently in 1993/94 and 1994/95 and with whom she or he had at least 2 visits during this period. Only patients of family practitioners whose practice included at least 50 hypertensive patients were included. RESULTS: To control for the effects of large samples and to validate the results, the authors conducted all analyses for half (6282) the sample of hypertensive patients who met the study criteria (12,563). A total of 132 primary care physicians who met the study criteria were identified. The patients made on average 9.3 ambulatory visits to physicians (both general practitioners and specialists) in 1994/95. Those who had more complex medical conditions (i.e., were formally referred to a specialist), those who had 3 or more serious medical problems and those who had been admitted to hospital made more visits to their primary care physician than those without these characteristics. After these and other key patient characteristics were controlled for, a primary care physician's patient recall rate in 1993/94 was strongly related to the number of visits his or her hypertensive patients made to all doctors for any reason in 1994/95. Physicians with high patient recall rates (i.e., who saw their hypertensive patients on average 8 or more times) in 1993/94 also had high recall rates in 1994/95. INTERPRETATION: Because patient characteristics most strongly associated with high visit rates were those reflecting patient illness, policy measures aimed at patients (e.g., user fees and deinsurance) do not appear to be the appropriate policy tool for dealing with high visit rates. Given the influence of a physician's patient recall rate on patient visit patterns, physician profiling and feedback may prove more appropriate.

How many physicians does Canada need to care for our aging population?

BACKGROUND: There is concern that the aging of Canada's population will strain our health care system. The authors address this concern by examining changes in the physician supply between 1986 and 1994 and by assessing the availability of physicians in 1994 relative to population growth and aging, and relative to supply levels in the benchmark province of Alberta. METHODS: Physician numbers were obtained from the Canadian Institute for Health Information. The amount of services provided by each specialty to each patient age group was analysed using Manitoba physician claims data. Population growth statistics were obtained from Statistics Canada. Age- and specialty-specific utilization data and age-specific population growth patterns were used to estimate the number and type of physicians that would have been required in each province to keep up with population growth between 1986 and 1994, in comparison with actual changes in the physician numbers. Physician supply in Alberta was used as a benchmark against which other provinces were measured. RESULTS: Overall, Canada's physician supply between 1986 and 1994 kept pace with population growth and aging. Some specialties grew much faster than population changes warranted, whereas others grew more slowly. By province, the supply of general practitioners (GPs) grew much faster than the population served in New Brunswick (16.6%), Alberta (6.5%) and Quebec (5.3%); the GP supply lagged behind in Prince Edward Island (-5.4%). Specialist supply outpaced population growth substantially in Nova Scotia (10.4%), Newfoundland (8.5%), New Brunswick (7.3%) and Saskatchewan (6.8%); it lagged behind in British Columbia (-9.2%). Using Alberta as the benchmark resulted in a different assessment: Newfoundland (15.5%) and BC (11.7%) had large surpluses of GPs by 1994, whereas PEI (-21.1%), New Brunswick (-14.8%) and Manitoba (-11.1%) had substantial deficits; Quebec (37.3%), Ontario (24.0%), Nova Scotia (11.6%), Manitoba (8.2%) and BC (7.6%) had large surpluses of specialists by 1994, whereas PEI (-28.6%), New Brunswick (-25.9%) and Newfoundland (-23.8%) had large deficits. INTERPRETATION: The aging of Canada's population poses no threat of shortage to the Canadian physician supply in general, nor to most specialist groups. The marked deviations in provincial physician supply from that of the benchmark province challenge us to understand the costs and benefits of variations in physician resources across Canada and to achieve a more equitable needs-based availability of physicians within provinces and across the country.

Managing health services: how administrative data and population-based analyses can focus the agenda.

University-based researchers in Manitoba, Canada, have used administrative data routinely collected as part of the national health insurance plan to design an integrated database and population-based health information system. This information system is proving useful to policymakers for providing answers to such questions as: which populations need more physician services? Which need fewer? Are high-risk populations poorly served or do they have poor health outcomes despite being well served? Does high utilization represent overuse or utilization related to high need? More specifically, this system provides decision-makers with the capability to make critical comparisons across regions and subregions of residents' health status, socioeconomic risk characteristics, and use of hospitals, nursing homes, and physicians. The system permits analyses of demographic changes, expenditure patterns, and hospital performance in relation to the population served. The integrated database has also facilitated outcomes research across hospitals and counties, utilization review within a single hospital, and longitudinal research on health reform. A particularly interesting application to planning physician supply and distribution is discussed. The discussion highlights the strengths of integrated population-based information in analyzing the health care system and raising important questions about the relationship between health care and health.