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ICES Pr imary Care and Populat ion Heal th Research Program Ins t i tu te for C l in ica l Eva luat ive Sc iences ICES Pr imary Care and Populat ion Heal th Research Program
Using linked data to measure performance at the healthcare system and clinical practice
level in Canada: putting primary healthcare in the picture
Challenging Ideas Seminar Nov 9, 2015 NSW Bureau of Health Information
Rick Glazier, MD, MPH, FCFP Senior Scientist, Institute for Clinical Evaluative Sciences
Scientist, Centre for Research on Inner City Health, St. Michael’s Hospital Professor, Family and Community Medicine, University of Toronto
ICES Pr imary Care and Populat ion Heal th Research Program
Faculty/Presenter Disclosure
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•Faculty: Rick Glazier
•Relationships with commercial interests:
– Grants/Research Support: none
– Speakers Bureau/Honoraria: none
– Consulting Fees: none
– Other: none
ICES Pr imary Care and Populat ion Heal th Research Program
Disclosure of Commercial Support
This program has received financial support from N/A in the form of N/A
This program has received in-kind support from N/A in the form of N/A.
Potential for conflict(s) of interest: – Rick Glazier has received N/A from N/A
– N/A a product that will be discussed in this program: N/A
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ICES Pr imary Care and Populat ion Heal th Research Program
Mitigating Potential Bias
• Mitigation N/A
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ICES Pr imary Care and Populat ion Heal th Research Program
Learning Objectives
1. Appreciate the role of primary healthcare in health systems
2. Compare Canadian and Australian contexts
3. Learn about Canadian data linkage initiatives
4. Appreciate varied sources and types of primary healthcare data
5. Consider the benefits of aligned versus linked data
6. Discuss the value of putting primary healthcare in the picture
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ICES Pr imary Care and Populat ion Heal th Research Program
Health System Role of Primary Healthcare
•Health services accessed each day
- extensive contact with the public
•Primary care and health outcomes
- better health outcomes, satisfaction with care, lower costs
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ICES Pr imary Care and Populat ion Heal th Research Program
Health Services Accessed Each Day (ICES Primary Care Atlas)
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ICES Pr imary Care and Populat ion Heal th Research Program
Primary Healthcare and Outcomes
•Primary care associated with
• Lower • mortality, premature mortality, infant mortality
• disparities in overall mortality, infant mortality, low birth weight, stroke mortality, self-reported health, and avoidable hospitalizations
• Higher • satisfaction in relation to overall costs
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Macinko J et al. Health Services Research. 2003;38:831-65
Shi L et al. Health Services Research. 2002;37:529-50
Engstrom S et al. Scand J Prim Health Care 2001; 19:131-4
ICES Pr imary Care and Populat ion Heal th Research Program 9
Population 35.4 m 23.6 m Population density 3.8 per sq km 2.9 per sq km Seniors 16.8% 14.7% Net migration 5.66/1000 5.74/1000 Life expectancy 79.1/84.4 79.6/84.6 GDP per capita US $43,100 US$43,000 Health care spending 10.9% GDP 9.4% GDP Public vs private 69.8% 66.6%
We’re the same!
ICES Pr imary Care and Populat ion Heal th Research Program 10
Physicians 2.5/1000 pop 3.4/1000 pop Primary care physicians 1.0/1000 pop 1.4/1000 pop Physician visits 7.7 per person 7.1 per person Hospital beds 1.7/1000 pop 3.4/1000 pop Same day/next day access 45% 65% Difficulty after hours 65% 59% ER use in past 2 years 44% 33% Data sources: OECD, Commonwealth Fund
But there are differences in health care
ICES Pr imary Care and Populat ion Heal th Research Program
ICES Pr imary Care and Populat ion Heal th Research Program
ICES Pr imary Care and Populat ion Heal th Research Program
Canadian Health Care
• Canada Health Act • doctors and hospitals fully covered, no deductibles or co-payments
• drug coverage only for seniors and social assistance
• all other services vary
• Provinces and territories • responsible for health, organization of care and services vary
• Federal • transfer payments, national standards, drug approvals
• Primary healthcare • mostly independent small businesses, trend from solo to groups
• private provision, public payment
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ICES Pr imary Care and Populat ion Heal th Research Program
Systems are Transforming
•Health systems reforms •rapid change – teams, EMRs, guidelines, payment reform
• Australia – GP Divisions, Medicare Locals, Primary Health Networks
• Canada – different in every province/territory, Patient’s Medical Home
• U.S. – PCMH, ACOs, Affordable Care Act
• U.K. – constant reform of funding, incentives
• New Zealand – independent practitioner associations
• Netherlands – regulated competition
• other countries – multiple reforms
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ICES Pr imary Care and Populat ion Heal th Research Program
Primary Healthcare Transformation - Canada
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Hutchison B, Levesque JF, Strumpf E, Coyle N. Primary health care in Canada: systems in motion. Milbank Q. 2011;89(2):256-88. doi: 10.1111/j.1468-0009.2011.00628.x.
ICES Pr imary Care and Populat ion Heal th Research Program
Canadian Data Linkages Example: Institute for Clinical Evaluative Sciences, Ontario
These data sets are held securely in a linked, de-identified form
Similar settings: Manitoba Centre for Health Policy, Population Health BC
1. Health Services Administrative Data
Physician billings
Prescription drug claims for those 65 and older
Inpatient hospital discharges
Emergency and ambulatory care visits
Home care and rehabilitation claims
Long-term care visits
2. People and Geography
Population estimates
Canada census profiles
Death records
All Ontarians eligible for health care benefits
3. Special Collections
Registries (cancer, stroke, cardiac care)
First Nations/Métis
Developmental disabilities
Federal immigration information
Electronic primary care office records
4. Derived Conditions
Diabetes
Hypertension
Chronic obstructive pulmonary disease (COPD)
Asthma
Acute myocardial infarction
Congestive heart failure
Inflammatory bowel disease
5. Survey Data
Health Surveys
6. Clinical Data
Patient information collected with consent in primary clinical studies
Supplementary clinical data from individual hospitals and other institutions
7. Chart Abstraction Data
Information on processes and quality of care collected directly from
patients’ charts
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ICES Pr imary Care and Populat ion Heal th Research Program
Coded ICES Data
• Most data collected by ICES are record level with direct personal identifiers —
usually health card number and/or last name, first name, date of birth, gender and
postal code. This is necessary for the accurate assignment of a unique, confidential
ICES number — or "code". Each person in Ontario is assigned his/her own ICES
number. This ICES number (IKN) is the key to successful linkage across data sets.
• The first step when ICES collects data is the removal of direct personal
identifiers and assignment of a confidential code, the IKN, to each record. An
IKN exists for every Ontario resident who has been eligible for health care over
time. This identifier is created using a secure ICES algorithm that is based on the
Ontario health card number. Once records in a data set have an IKN assigned, the
directly identifying information is stripped off the file and the data become part of the
ICES data inventory – uniquely coded and linkable across health services data
bases within the inventory. Researchers have access only the ICES data
inventory that contains coded data.
Heal th Sys tem Trans format ion 17
ICES Pr imary Care and Populat ion Heal th Research Program
Sources of Primary Healthcare Data (Ontario)
• Databases • population registry – age, sex, rurality, SES, immigration status
• physician and lab claims (FPs and specialists)
• model of care – FFS, blended FFS, blended capitation, salary, team
• hospitals, ER, homecare, long-term care, medications
• EMR data (sample) - diseases, health behaviours, BP, BMI, lab results
• population surveys of access, patient experience
• payments
• Derived measures through linkage • disease registries – cancer, diabetes, hypertension, CHF, COPD, mental health, etc.
• continuity of care, comprehensiveness
• performance – chronic disease management (eg diabetes), cancer screening
• costs by sector
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ICES Pr imary Care and Populat ion Heal th Research Program
Aligned versus Linked Data
• Aligned data (system or practice level aggregation)
• obtained from different sources, different sectors
• about the same practice, with comparators
• ability to construct composite measures
• useful to practices for identifying priorities for improvement
• descriptive
• Linked data (patient level aggregation)
• same patient within and across different sectors
• unique identifier, track health care trajectories
• relate utilization and outcomes to patient characteristics (eg rurality, low income)
• useful for performance measurement, essential for research
• analytic
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ICES Pr imary Care and Populat ion Heal th Research Program
System-Level Aligned Data: Patient Survey and ER Use
Heal th Sys tem Trans format ion 20
Glazier RH, Kopp A, Schultz SE, Kiran T, Henry DA. Healthc Q. 2012;15(3):17-21
ICES Pr imary Care and Populat ion Heal th Research Program Heal th Sys tem Trans format ion 21
Practice-Level Aligned
Data: Demographics and
Patent Survey
ICES Pr imary Care and Populat ion Heal th Research Program
Linked Data: Income, Morbidity and Capitation Payments
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Sibley LM, Glazier RH. Health Policy. 2012;104(2):186-92.
ICES Pr imary Care and Populat ion Heal th Research Program
Linked Data: Cancer Screening and Payments
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• No change in cervix or breast cancer screening
• Net increase of 1.7% per year in colorectal screening after incentives
• Combined annual costs more than $35 million
Kiran T. et al. Ann Fam Med. 2014 Jul;12(4):317-23
ICES Pr imary Care and Populat ion Heal th Research Program
Linked Data: Performance of Models of Care
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Diabetes processes of care Colorectal cancer screening
Kiran T et al CMAJ 2015
ICES Pr imary Care and Populat ion Heal th Research Program
Linked data: Population Survey and Model of Care
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Health Analytics Branch MOHLTC: Ontario Health Care Experience Survey 2012/13
Capitation Fee for service
ICES Pr imary Care and Populat ion Heal th Research Program Heal th Sys tem Trans format ion 26
Linked Data: Population Survey, ED Visits and Admissions
Glazier RH, Moineddin, R, Agha MM, Zagorski B, Hall R, Manuel DG, Sibley LM, Kopp A. The Impact of Not Having a Primary Care Physician Among People with Chronic Conditions. ICES Investigative Report. Toronto: Institute for Clinical
Evaluative Sciences; 2008. www.ices.on.ca
ICES Pr imary Care and Populat ion Heal th Research Program
Practice Level Linked Data: EMR and Diabetes Care Measures
ICES Pr imary Care and Populat ion Heal th Research Program 28
Standardized Feedback Reports
ICES Pr imary Care and Populat ion Heal th Research Program
Extensively Linked Data
• Primary healthcare • utilization and performance in relation to health system transformation
• payment reform
• inter-professional teams
• impact of technology
• Other topics and sectors • cardiac care, cancer care
• management of chronic conditions – diabetes, hypertension, CHF, COPD, mental health
• drug safety and effectiveness
• Integration • avoidable hospitalizations
• readmissions
• 1% and 5% highest system users
• system costs
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ICES Pr imary Care and Populat ion Heal th Research Program
Putting Primary Healthcare in the Picture
• Underpinning of high functioning health systems
• Measurement has historically lagged other sectors, especially hospitals
• Technology enabling rich data (EMRs)
• Align data at the system or practice level (descriptive)
• Link for research and performance measurement (analytic) • effectiveness, safety
• efficiency
• equity
• integration
• achieving healthy system goals
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ICES Pr imary Care and Populat ion Heal th Research Program
Team-Based Research
Project: 177411
Alex Kopp, Sue Schultz, Brandon Zagorski, ICES
Tara Kiran, St. Michael’s Hospital, ICES
Brian Hutchison, Health Quality Ontario
Jennifer Rayner, Community Health Centres
many others
ICES Pr imary Care and Populat ion Heal th Research Program ICES Pr imary Care and Populat ion Heal th Research Program
Comments, Questions?
Heal th Sys tem Trans format ion 32