3. Health system performance

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Acceptability
Accessibility
Appropriateness
Effectiveness
Safety

3.1 Acceptability

Patient satisfaction (and quality rating of services received)

Definition:
Population aged 15 and over receiving health services in the past 12 months who rate their level of satisfaction with those services as either "very satisfied" or "somewhat satisfied". Perceived rating of the quality of services received rated as "excellent" or "good" is another component of this indicator. ‘Health services’ are broken down as follows: Overall health care services; hospital care; physician care, community-based care; and telephone health line or tele-health services.

Source (s):
Statistics Canada, Canadian Community Health Survey 2005, 2003, 2000/2001.

3.2 Accessibility

Influenza immunization

Definition:
Population aged 12 and over (aged 65 and over for data from the National Population Health Survey) who reported when they had their last influenza immunization (flu shot).

Source (s):
Statistics Canada, Canadian Community Health Survey; Statistics Canada, National Population Health Survey, 1996/1997, cross sectional sample, Households component, health file.

Screening mammography

Definition:
Women aged 50 to 69 who reported when they had their last mammogram for routine screening or other reasons.

Screening mammography is an important strategy for early detection of breast cancer.

Source (s):
Statistics Canada, Canadian Community Health Survey; Statistics Canada, National Population Health Survey, 1996/1997, cross sectional sample, Households component, health file.

Pap (Papanicolaou) test

Definition:
Women aged 18 to 69 who reported when they had their last Pap smear test.

Pap tests detect pre–malignant lesions before cancer of the cervix develops.

Source (s):
Statistics Canada, Canadian Community Health Survey; Statistics Canada, National Population Health Survey, 1994/1995, 1996/1997 and 1998/1999, cross sectional sample, Households component, health file and north component.

Regular medical doctor

Definition:
Those who did not were asked to report why not. Respondents were considered not to have looked for a regular medical doctor if their responses included "Have not tried to contact one" or "Other reasons". All other respondents without a regular medical doctor were considered to have been unable to find one. Their responses included various combinations of the following: "No medical doctors available in the area", "Medical doctors in the area are not taking new patients" and "Had a medical doctor who left or retired".

Establishing an ongoing relationship with a regular medical doctor is believed to be important in maintaining health and ensuring appropriate access to health services.

Source (s):
Statistics Canada, Canadian Community Health Survey.

Wait time for hip fracture surgery (CIHI)

Definition:
Wait time for hip fracture (surgery (same/next day)
Proportion with surgery same or next day: risk-adjusted proportion of hip fracture patients aged 65 and older who underwent hip fracture surgery on the day of admission or the next day.

Wait time for hip fracture surgery (same/next/ day after)
Proportion with surgery same, next day or day after: risk-adjusted proportion of hip fracture patients aged 65 and older who underwent hip fracture surgery on the day of admission, the next day or the day after that.

Refer to technical notes for details www.cihi.ca/indicators.

Wait time for surgery following hip fracture provides a measure of the access to care. While some hip fracture patients need medical treatment to stabilize their condition before surgery, research suggests patients typically benefit from timely surgery in terms of reduced morbidity, mortality, pain, length of stay in hospital, as well as improved rehabilitation.

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

Source (s):
Canadian Institute for Health Information, Discharge Abstract Database.

3.3 Appropriateness

Caesarean section

Definition:
Proportion of women delivering babies in acute care hospitals by caesarean section.

Method of calculation:
(Number of caesarean sections/Number of deliveries (live births and stillbirths))*100

Delivery:
I. ICD–9
Any one diagnosis code of 641 to 676 and with a fifth digit of "1" or "2"; 650 or V27

II. ICD–10–CA
Any one diagnosis code of O10 to O16, O21 to O29, O30 to O37, O40 to O46, O48, O60 to O69, O70 to O75, O85 to O89, O90 to O92, O95, O98, O99 with a sixth digit of "1" or "2"; or Z37

Deliveries in which an abortive procedure was provided are excluded:
I. CCP*
Any one procedure code of 78.52, 86.3, 86.4, 87.0, 87.1, or 87.2.

II. CCI*

Any one procedure code of 88^^, 5.CA.89^^ or 5.CA.93^^ .

Caesarean section (Caesarean section is a subset of deliveries):

I. CCP*

Any one procedure of 86.0 to 86.2, 86.8, or 86.9.

II. CCI*

5.MD.60^^.

*Code may be recorded in any position with cancelled, previous, out-of-hospital, and "abandoned after onset" cases excluded.

Source (s):
Canadian Institute for Health Information, Discharge Abstract Database.

3.4 Effectiveness

Ambulatory care sensitive conditions

Definition:
Age-standardized acute care hospitalization rate for conditions where appropriate ambulatory care prevents or reduces the need for admission to hospital, per 100,000 population under age 75 years.

This definition is based on the work of Billings et al (see Billings, J., Zeital, L., Lukomnik, J., Carey, TS., Blank, A.E., Newman, L., “Impact of socio–economic status on hospital use in New York City”. Health Affairs. Spring: pages 162 to 173; Billings, J., Anderson, GM., Newman, LS., 1996. “Recent findings on preventable hospitalizations”. Health Affairs; 15(3): pages 239 to 249.)

Inclusion criteria: Any one most responsible diagnosis code of:

• Grand mal status and other epileptic convulsions
• Chronic obstructive pulmonary disease
• Asthma
• Heart failure and pulmonary edema **
• Hypertension**
• Angina**
• Diabetes

** Excluding cases with a specific procedure recorded (refer to technical notes for details www.cihi.ca/indicators).

Ambulatory care sensitive conditions have been considered to be a measure of access to appropriate primary health care. While not all admissions for ambulatory care sensitive conditions are avoidable, it is assumed that appropriate prior ambulatory care could prevent the onset of this type of illness or condition, control an acute episodic illness or condition, or manage a chronic disease or condition. A disproportionately high rate is presumed to reflect problems in obtaining access to primary care.

Effective with 2006–2007 data, the definition of the ambulatory care sensitive conditions (ACSC) indicator was refined. The diabetes component will only include diabetes with short-term complications or diabetes without mention of complication; angina, hypertension and heart failure components will exclude records where cardiac procedures were also coded. Rates for the previous years using the new definition were calculated to enable comparisons over time.

Source (s):
Canadian Institute for Health Information, Discharge Abstract Database.

30 day acute myocardial infarction in hospital mortality rate

Definition:
The risk–adjusted rate of all-cause in-hospital death occurring within 30 days of first admission to an acute care hospital with a diagnosis of acute myocardial infarction (AMI).

Refer to technical notes at www.cihi.ca/indicators for more details.

To enable comparison across regions, a statistical model was used to adjust for differences in age, sex and co-morbidities. Adjusted mortality rates following AMI may reflect, for example, the underlying effectiveness of treatment and quality of care. Inter–regional variation in 30 day in hospital mortality rates may be due to jurisdictional and institutional differences in standards of care, as well as other factors that were not included in the adjustment.

Effective with the 2004 rates, the case selection criteria for acute myocardial infarction (AMI) mortality rates were revised to include the increasing number of AMI patients who are undergoing revascularization procedures at the facility to which they are initially admitted (index admission). In these instances AMI may not have been coded as “most responsible diagnosis” and was previously excluded from the indicator. In addition, exclusion criteria have also been revised. Patients with a length of stay of less then 3 days who were discharged alive are no longer excluded. Therefore, comparison of 2004 rates with those of previous years should be made with caution.

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

Source (s):
Canadian Institute for Health Information, Hospital Morbidity Database, Discharge Abstract Database.

30 day stroke in hospital mortality (CIHI)

Definition:
The risk-adjusted rate of all–cause in–hospital death occurring within 30 days of first admission to an acute care hospital with a diagnosis of stroke.

Refer to technical notes at www.cihi.ca/indicators for more details.

To enable comparison across regions, a statistical model was used to adjust for differences in age, sex and co-morbidities. Adjusted mortality rates following stroke may reflect, for example, the underlying effectiveness of treatment and quality of care. Inter-regional variations in rates may be due to jurisdictional and institutional differences in standards of care, as well as other factors that are not included in the adjustment. Beginning with 2004 rates, case selection criteria for stroke mortality rates were revised to include patients transferred to rehabilitation during their index admission. In this case, stroke may not be coded as “most responsible diagnosis” and was previously excluded from the indicator. In addition, stroke resulting from occlusion of pre-cerebral arteries is now included in the indicator. These cases were previously excluded because their identification was not possible in the ICD–9 coding system. Comparisons of 2004 rates with those of previous years should be made with caution.

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

Source (s):
Canadian Institute for Health Information, Hospital Morbidity Database, Discharge Abstract Database.

Acute myocardial infarction readmission rate

Definition:
The risk–adjusted rate of unplanned readmission following discharge for acute myocardial infarction (AMI). A case is counted as a readmission if it is for a relevant diagnosis and occurs within 28 days after the index AMI episode of care. An episode of care refers to all contiguous in-patient hospitalizations and same-day surgery visits.

To enable comparison across regions, a statistical model was used to adjust for differences in age, sex and co–morbidities. The risk of readmission following an AMI may be related to the type of drugs prescribed at discharge, patient compliance with post–discharge therapy, the quality of follow-up care in the community, or the availability of appropriate diagnostic or therapeutic technologies during the initial hospital stay. Although readmission for medical conditions can involve factors outside the direct control of the hospital, high rates of readmission act as a signal to hospitals to look more carefully at their practices, including the risk of discharging patients too early and the relationship with community physicians and community–based care. 

Effective with the 2004 rates, the case selection criteria for AMI readmission rates were revised to include the increasing number of AMI patients who are undergoing revascularization procedures at the facility to which they are initially admitted (index admission). In these instances AMI may not have been coded as “most responsible diagnosis” and was previously excluded from the indicator. In addition, exclusion criteria have also been revised. Patients with a length of stay of less then 3 days who were discharged alive are no longer excluded. Comparisons of 2004 rates with those of previous years should be made with caution.

Refer to technical notes at www.cihi.ca/indicators for more details.

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

Source(s):
Canadian Institute for Health Information, Discharge Abstract Database, National Ambulatory Care Reporting System; Alberta Health and Wellness, Alberta Ambulatory Care Database.

Asthma readmission rate

Definition:
The risk-adjusted rate of unplanned readmission following discharge for asthma. A case is counted as a readmission if it is for a relevant diagnosis and occurs within 28 days after the index episode of care. An episode of care refers to all contiguous in–patient hospitalizations and same–day surgery visits.

To enable comparison across regions, a statistical model was used to adjust for differences in age, sex and co–morbidities. Although readmission for medical conditions may involve factors outside the direct control of the hospital, high rates of readmission act as a signal to hospitals to look more carefully at their practices, including the risk of discharging patients too early and the relationship with community physicians and community–based care. These rates should be interpreted with caution due to potential differences in the coding of comorbid conditions across provinces and territories.

Refer to technical notes at www.cihi.ca/indicators for more details.

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

Source (s):
Canadian Institute for Health Information, Discharge Abstract Database, National Ambulatory Care Reporting System; Alberta Health and Wellness, Alberta Ambulatory Care Database.

Hysterectomy readmission rate

Definition:
The risk-adjusted rate of unplanned readmission following discharge for hysterectomy. A case is counted as a readmission if it is for a relevant diagnosis and occurs within 7 or 28 days after the index episode of care. An episode of care refers to all contiguous in-patient hospitalizations and same–day surgery visits.

To enable comparison across regions, a statistical model was used to adjust for differences in age and co–morbidities. Although readmission for surgery may involve factors outside the direct control of the hospital, high rates of readmission act as a signal to hospitals to look more carefully at their practices, including the risk of discharging patients too early and the relationship with community physicians and community–based care. These rates should be interpreted with caution due to potential differences in the coding of comorbid conditions across provinces and territories.

Refer to technical notes at www.cihi.ca/indicators for more details.

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

Source (s):
Canadian Institute for Health Information, Discharge Abstract Database, National Ambulatory Care Reporting System; Alberta Health and Wellness, Alberta Ambulatory Care Database.

Prostatectomy readmission rate

Definition:
The risk-adjusted rate of unplanned readmission following discharge for prostatectomy. A case is counted as a readmission if it is for a relevant diagnosis or procedure and occurs within 28 days after the index episode of care. An episode of care refers to all contiguous in–patient hospitalizations and same–day surgery visits.

To enable comparison across regions, a statistical model was used to adjust for differences in age and co–morbidities. Although readmission for surgery may involve factors outside the direct control of the hospital, high rates of readmission act as a signal to hospitals to look more carefully at their practices, including the risk of discharging patients too early and the relationship with community physicians and community–based care. These rates should be interpreted with caution due to potential differences in the coding of comorbid conditions across provinces and territories.

Refer to technical notes at www.cihi.ca/indicators for more details.

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

Source (s):
Canadian Institute for Health Information, Discharge Abstract Database, National Ambulatory Care Reporting System; Alberta Health and Wellness, Alberta Ambulatory Care Database.

3.5 Safety

Hip fracture hospitalization (CIHI)

Definition:
Age-standardized acute care hospitalization rate for fracture of the hip, per 100,000 population age 65 and over.

(Most responsible diagnosis code of: ICD–9 820.0 to 820.3, 820.8, 820.9 or ICD–10–CA S72.0, S72.1, S72.2).

Hip fractures occur for various reasons including environmental hazards, the prescription of potentially inappropriate psychotropic medications to the ambulatory elderly, and safety issues in long–term care facilities. As well as causing disability or death, hip fractures can have a major impact on independence and quality of life. This measure is based on the number of cases admitted to hospital. Some cases may represent readmissions for additional treatments or transfers from one medical setting to another. Thus, the hospitalization rate may over–estimate the incidence of hip fractures.

Source (s):
Canadian Institute for Health Information, Discharge Abstract Database.

In-hospital hip fracture (CIHI)

Definition:
Risk-adjusted rate of in-hospital hip fracture among acute care inpatients age 65 years and over, per 1,000 discharges.

Proposed by the Agency for Healthcare Research and Quality and based on the Complications Screening Program, this indicator represents a potentially preventable complication resulting from an inpatient stay in an acute care facility. Variation in the rates may be attributed to numerous factors, including hospital processes, environmental safety, and availability of nursing care. High rates may prompt investigation of potential quality of care deficiencies.

Effective with the 2005 rates, in-hospital hip fracture rate will be reported by the jurisdiction where hospitalization has occurred rather than by the jurisdiction of patient residence.  With this change the indicator will better reflect the concept of patient safety in the hospitals. In addition, the risk-adjustment model was revised to refit the effect of adjustment factors. These changes may affect the comparability of rates with those appearing in previous Health Indicator reports.

Refer to technical notes at www.cihi.ca for more details.

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

Source (s):
Canadian Institute for Health Information, Discharge Abstract Database.