Moving the Health AgendaFrom Evidence to Policy

Moving the Health AgendaFrom Evidence to Policy

Dr. Penny BallemDeputy Minister of HealthBritish Columbia

Optimal health status for all British Columbians

Improved access, reduced waiting times: now and in the future

Improved quality of care; optimal health outcomes for British Columbians

Sustainable and affordable health care now and in future

What are we trying to achieve?

Policy Areas:Continuum of health systemSpecial populationsHealth Human Resources including labourrelations, scope of practice, supply, regulationHealth TechnologyHealth facility planningHealth governanceSafety and quality“health insurance” policies

Government: the dynamics of “evidence to policy”Assumption: solid evidence supports policy

Timing – political cycleOpportunity cost / priorities / political commitmentsIncremental benefit versus incremental costOther impactsValidators (including other jurisdictions)/ opposition / politicsFeasibilityAffordability/ business caseSustainability

Learning to tell the story is key

100.0%

41.6%

53.6%

71.3%

27.0%27.0%

27.0%

-0.6%

16.6%

28.4%

-10%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13 13/14 14/15 15/16 16/17 17/18

Year

Perc

ent

Total

Health

Education

Other

SUSTAINABILITY/ AFFORDABILITY

Revenue Growth – 3%Education Growth – 3%Health Growth – 8%Balanced BudgetOther spending reaches zero by 17/18

BASIC EVIDENCE:HOW ARE WE DOING?

Better Cancer Outcomes5 Year Age-Standardized Mortality Rate, Malignant Neoplasms, 1999-2003

16.93

16.09

16.316.52

16.74

15

16

17

1999 2000 2001 2002 2003

Rat

e pe

r 10,

000

Stan

dard

Pop

ulat

ion

Source: BC Vital Statistics Agency

International Comparisons

Cancer (2001)

0

200

400

600

800

1000

1200

Sweden

B.C.*

Australia

Canada

United States

U.K.‡New

Zealan

d†

France

PYLL

Heart Disease(2001)

050

100150200250300350400450

France

B.C.*

Sweden

Austra

lia

Canada

New Zealan

d†

U.K.‡

United Stat

es

PYLL

Premature years of life lost (PYLL) cancer & heart disease

Joint Canada/United StatesSurvey of Health, 2002-03

Keeping the population healthy

Modelling: The Influenza Pandemic Curve

Wave 1 Wave 2 Wave 3

WHO declares pandemic

week 1 week 4 to 11 week 15

cumulative clinical attack rate 15% to 35%

Potential mitigation if effective vaccine developed

from Wave 1Health Surveillance picks up sporadic cases

Timeframe Unknown1 day to several

weeks

15 weeks

Wave 1

3-6 months

Inter-Wave phase

variable time period

Prop

n to

tal c

ases

, con

sultn

s ,

hosp

italiz

atio

ns, d

eath

s

Obesity Trends - 1990

Source: Katzmarzyk PT. Can Med Assoc J 2002;166:1039-1040.

No Data <10% 10%-14% 15-19% ≥20%

Obesity Trends - 2000

Source: Statistics Canada. Health Indicators, May, 2002.

No Data <10% 10%-14% 15-19% ≥20%

400

500

600

700

800

900

1000

Mill

ions

2000 2010 2020 2030 2040 2050

0% smoking rate

10% smoking rate

20% smoking rate

26% smoking rate

Cost of Tobacco Use

Health Care Burden

Serving sizes in 1955 & 2001

1955Fries 72gCoke 200ml

2001Fries 205gCoke 950ml

Source:

Estimated number of coronary events, females, Canada

Making the Case

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

1971 1976 1981 1986 1991 1996 2001 2006 2011 2016

Year

Cas

es

No intervention

Diet, smoking, exercise

Body mass index

Moderate alcohol

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

1971 1976 1981 1986 1991 1996 2001 2006 2011 2016

Year

Cas

es

No intervention

Diet, smoking, exercise

Body mass index

Moderate alcohol

No interventionNo intervention

Diet, smoking, exerciseDiet, smoking, exercise

Body mass indexBody mass index

Moderate alcoholModerate alcohol

Chart is for illustrative purposes only. Intended to show that various interventions can have a positive effect on health.

Intervention begins

Local evidencePrevalence of Overweight/Obesity Among Girls and Boys

0

5

10

15

20

25

30

35

40

1981 1996 Fall 1999 Spring 2003 1981 1996 Fall 1999 Spring 2003

Prev

alen

ce, %

Obese*

Overweight (not obese)*

Boys Girls

Canadian

Canadian

Richmond

Richmond

1981 and 1996 data (Canadian data Children Aged 7-13 years) – Source: adopted from MS Tremblay and JD Willms, “Secular Trends in the Body Mass Index of Canadian Children”, CMAJ:164(7), 970.Fall 1999 and Spring 2003 data (Richmond data) – Source: Heather McKay

ActNow BC

Understanding the evidencewhich describes our population in the health system

B.C. seniors – fastest growing segment of the population

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

2014

2016

65-74 75-79 80-84 85-89 90+

BC Stats, Ministry of Management Services

Seniors Use Health System More Intensively

BC Ministry of Health Discharge Abstracts Database (DAD)

Acute Care Workload Per Capita by Age British Columbia, 2004/2005*

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

<1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Age group

Wei

ghte

d C

ases

per

Per

son

in A

ge G

roup

Total Workload per Person

Surgical Demand is Rising

Compared to 1990/91, an 80-year-old British Columbian today is:

– Twice as likely to have a knee replacement– Twice as likely to have cataract surgery– Twice as likely to have a coronary bypass– Eight times as likely to have an angioplasty

0

1000000

2000000

3000000

4000000

5000000

6000000

7000000

8000000

9000000

10000000

1990

/1991

1991

/1992

1992

/1993

1993

/1994

1994

/1995

1995

/1996

1996

/1997

1997

/1998

1998

/1999

1999

/2000

2000

/2001

2001

/2002

Most complex

care level

Less complex

care levels

Residential Care Days 1990 - 2002

5%

15%

80%

High UsersVery high risk 30%

High Risk

MultipleIllness

Population Expenditures

UNDERSTANDING WHO WE SERVE

Reid et al., BC Centre for Health Services and Policy Research (2002)

QUALITY IN OUR SYSTEM

Percent of people with diabetes receiving care according to guidelines

0%

20%

40%

60%

80%

100%

1999

/00

2000

/01

2001

/02

2002

/03

2003

/04

2004

/05

Year

Perc

ent

TRACKING EVIDENCE FOR QUALITY IN THE TRENCHES

DiabetesDiabetes Patients as a Percentage of Selected Procedures/Surgeries

British Columbia 2002/03

59%

56%

46%

32%

25%

21%

0% 10% 20% 30% 40% 50% 60% 70%

Retinal surgery

Lower limb amputations

Dialysis

Coronary bypass

Angioplasties

Cataract surgery

Slide 2: CHF Collaborative% CHF Patients on appropriate meds

93%

0%

20%

40%

60%

80%

100%

Jun-0 3Jul-03

Aug -03Sep -03Oct-0

3Nov-03Dec-03Jan-0 4Feb-04Mar-0

4Apr-0

4May-04

% %

Goal

Health human resources

KeremeosPrinceton

FruitvaleCreston

Salmo

RiondelKaslo

Winlaw

EdgewoodLumbyLytton

Logan LakeSeton Portage

LillooetClinton

Gold Bridge

FernieSparwoodElkford

Grand Forks

Sayward

RevelstokeGolden

FieldClearwater

Blue RiverBella Coola

Anahim Lake

Alexis Creek

ValemountWells

McBride

MacKenzie

Bear Lake

New AiyanshHazelton

KitwangaGransisle Tumbler Ridge

ChetwyndHudsons HopeStewart

HoustonFort Fraser

Bella Bella

GreenwoodMidway

Galiano IslandSalt Sprint IslandMayne Island

Pender IslandPort RenfrewGabriola

UclueletQualicum Bay

Denman IslandGold River

TahsisZeballos

Port AlicePort McNeill

Sandspit

Queen Charlotte City

Port ClementsMasset

Fort NelsonDease Lake

Atlin

Communities with Chronic BCAS Shortages/Turnover

Productivity Analysis BC Ambulance Service

VGH EmergencyRegular Shifts and Overtime shifts worked - 24hr. Totals

Period 7 (9/9-10/6) and Period 8 (10/7-11/3)

16

18

20

22

24

26

28

30

32

Period

7

Sun Wed

Sat Sun Wed

Sat Sun Wed

Overtime

Regular

Baseline

Nur

ses

Period

8

BC Nursing Workforce: structural issuesJob Status by Age Cohort

0%

10%

20%

30%

40%

50%

60%

< = 25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 > = 61

Full-Time %Part-Time %Casual %

*Source: HSCIS 2004 Q4

Decline in WCB Injury Rates1994 – 2003

0

50,000

100,000

150,000

200,000

250,000

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

Total Work Injuries Reported STD, LTD and Fatal Claims

WCB reports a steady decline in base rates in health care in the past three years and expect a further decrease by 20% in 2005

Fewer Services Performed Per Physician in BC than Elsewhere

3,606

4,241

5,250

4,260

3,801

4,868

2,500

3,000

3,500

4,000

4,500

5,000

5,500

BritishColumbia

Alberta Saskatchewan Manitoba Ontario Canada

Source: Canadian Institute for Health Information

Understand and Maximize productivity

Health technology

Age Standardized PCI Procedures and CABG/OHS per 100,000 Population, BC

0

50

100

150

200

250

2000/01 2001/02 2002/03 2003/04 2004/05

PCI

OHS

Utilization rates by HAPlace of Residence

2004/05 Rates/100,000 >age 20

0

50

100

150

200

250

Interior Fraser Coastal Island Northern BC

PCIOHS

BC PharmaCare: 10 Years of Growth

0% 50% 100% 150%

Population

Beneficiaries

# of Paid Rx per BeneficiaryExpenditure per Beneficiary

Paid Prescriptions

PharmaCare Expenditure

Source: Public Accounts Plan Expenditures (1995/96 to 2004/05) and Utilization Data from Ministry of Health, HNData (1995 to 2004)

PharmaCare Growth 1995/96 to 2004/05

PMPRB Drug CategoriesPatented drug products reviewed by the Patented Medicines Review Board (PMPRB), 2000-2004

2000 2001 2002 2003 20045 YEAR TOTAL

Breakthrough -1 3 3 1 2 0 9Line Extension 2 36 23 29 26 40 154Me-Too 3 42 21 18 24 28 133Total 81 47 48 52 68 296

1. Category 2: New class of drug or substantial improvement over existing drugs for a specific disease

2. Category 1: Usually a new strength of an existing drug3. Category 3: New version or dosage of an existing medicine

Proton - Pump Inhibitor Expenditure and Utilization Trends

$-

$5.0

$10.0

$15.0

$20.0

$25.0

$30.0

$35.0

$40.0

$45.0

2000/01 2001/02 2002/03 2003/04 2004/05

Tota

l Exp

endi

ture

($M

illio

ns)

-

0.050

0.100

0.150

0.200

0.250

0.300

0.350

0.400

0.450

0.500Prescriptions Paid by Pharm

aCare

(Millions)

Value for Money - PharmaCare Policy

Therapeutic Substitution Policy Introduced

Pharmacare: more room to move –learning from other jurisdictions:New Zealand/BC Comparison of Drug Program Expenditures

$-

$200

$400

$600

$800

$1,000

93 94 95 96 97 98 99 00 01 02 03 04 05 06 07

Drug Cost (millions)

NZ Actual and Projected Expenditure (including rebates)

BC PharmaCare Program Expenditures

34% increase over 14 years

BC's increase: 168% over 14 years

Canada's increase: 231% over 14 years

2006 and 2007 are projected

NZ$ converted to CAN$

NZ year ending June 30, BC year ending March 31

Health infrastructure

Many Health Facilities are Old

0 10 20 30 40 50 60 70 80 90 100

St. Paul's Hospital, Burrard Bldg

Royal Jubilee Hosp, East and South Blk

Lions Gate Hosp., Activation Bldg

Royal Jubilee Hosp, Centre Blk

St. Joseph's General Hospital

Chilliw ack General Hospital, Acute

G.F. Strong Centre, Old Bldg

C&W Shaughnessy C Block - Clinic

Vernon Jubilee Hospital

Penticton Regional Hospital

Queen Charlotte Isl. Gen. Hospital

Bulkley Valley District Hospital

G.R. Baker Memorial Hospital, Main

Campbell River District Hosp

Years

020406080

100120140160180200

1961 1966 1971 1976 1981/82 1986/87 1991/92 1996/97 2001/02 2004/05*

Acute, Rehab, DPU, LTC-in-Acute, and ALC Day Care

BC Hospitalization and Day surgery Rates: 1960 – 2004/05

summaryEvidence is key

Scientific consensusEvidence at the system/population levelEvidence of affordability, sustainabilityEvidence of feasibilityEvidence of “value for investment”Evidence of corollary impactsMoving to policy requires strategy, timing, effective communication and persistence