3. Health system performance

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Acceptability
Accessibility
Appropriateness
Continuity
Effectiveness
Safety

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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.

3.2 Accessibility

Influenza immunization

Definition:
Population aged 12 and over who reported when they had their last influenza immunization (flu shot). The 2009 data on flu shots may include H1N1 vaccines received in the Fall of 2009. In 2010, the word "seasonal" was added to the questions in order to collect the two types of vaccines separately.

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

Mammography

Note: this indicator was changed in June 2009 to include all reasons for mammography because the questionnaire does not allow a specific reason to be associated with the most recent mammogram. Most reasons provided in the response categories however are associated with screening

Definition:
Women aged 50 to 69 who reported when they had their last mammogram within the last 2 years 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.

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.

Colorectal cancer screening

Definition:
Population aged 50 and over who reported they had a fecal occult blood test (FOBT) in past two years or colonoscopy or sigmoidoscopy in past five years.

Screening using the fecal occult blood test (FOBT) or colonoscopy or sigmoidoscopy is an important early screening strategy for colorectal cancer.

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

Regular medical doctor

Definition:
Population aged 12 and over who reported that they have a regular medical doctor. In 2005 and 2003, the indicator in French only included "médecin de famille". Starting in 2007, this concept was widened to "médecin régulier", which includes "médecin de famille".

For many Canadians, the first point of contact for medical care is their doctor. Being without a regular medical doctor is associated with fewer visits to general practitioners or specialists, who can play a role in the early screening and treatment of medical conditions.

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

Wait time for hip fracture surgery

Definition:
Risk-adjusted proportion of hip fracture patients age 65 and older who underwent hip fracture surgery within 48 hours of admission to hospital.

Operative delay in older patients with hip fracture is associated with a higher risk of post-operative complications and mortality. Wait time for surgery following hip fracture provides a measure of access to care. The wait time may be influenced by comorbid conditions, hospital transfers and practice differences related to certain types of medications, like blood thinners. However, longer waits may indicate lack of resources, physician unavailability and/or other issues related to access to care.

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

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

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 5.CA.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 (CIHI), Discharge Abstract Database (DAD); Fichier des hospitalisations MED-ÉCHO, ministère de la Santé et des Services sociaux du Québec.

Patients with repeat hospitalizations for mental illness

Definition:
Risk-adjusted percentage of individuals that had three or more episodes of care for a selected mental illness over all those who had at least one episode of care for a selected mental illness in general hospitals within a given year. An episode of care refers to all contiguous hospitalizations and same-day surgery visits in general hospitals.

This indicator is considered an indirect measure of appropriateness of care, since the need for frequent admission to hospital depends on the person and the type of illness. Challenges in getting appropriate care/support in the community and/or the appropriate medication often lead to frequent hospitalizations. Variations in this indicator across jurisdictions may reflect differences in the services that help individuals with mental illness remain in the community for a longer period of time without the need for hospitalization.

This indicator may help to identify a population of frequent users, and further investigations could provide a description of the characteristics of this group. Understanding this population can aid in developing/enhancing programs that may prevent the need for frequent rehospitalization.

Note:
The mental illnesses selected for this indicator are substance-related disorders; schizophrenia, delusional and non-organic psychotic disorders; mood/affective disorders; anxiety disorders; and selected disorders of adult personality and behaviour.

Source (s):
Canadian Institute for Health Information (CIHI), Discharge Abstract Database (DAD); Ontario Mental Health Reporting System (OMHRS), Fichier des hospitalisations MED-ÉCHO, ministère de la Santé et des Services sociaux du Québec.

3.4 Continuity

30-Day readmission rate for mental illness

Definition:
Risk-adjusted rate of readmission following discharge for a mental illness. A case is counted as a readmission if it is for a selected mental illness diagnosis and if it occurs within 30 days of the index episode of inpatient care. An episode of care refers to all contiguous hospitalizations and same-day surgery visits in general hospitals.

Readmission to inpatient care may be an indicator of relapse or complications after an inpatient stay. Inpatient care for people living with a mental illness aims to stabilize acute symptoms. Once stabilized, the individual is discharged, and subsequent care and support are ideally provided through outpatient and community programs in order to prevent relapse or complications. High rates of 30-day readmission could be interpreted as a direct outcome of poor coordination of services and/or an indirect outcome of poor continuity of services after discharge.

Note:
The mental illnesses selected for this indicator are substance-related disorders; schizophrenia, delusional and non-organic psychotic disorders; mood/affective disorders; anxiety disorders; and selected disorders of adult personality and behaviour.

Source(s):
Canadian Institute for Health Information (CIHI), Discharge Abstract Database (DAD); Ontario Mental Health Reporting System (OMHRS); National Ambulatory Care Reporting System (NACRS); Fichier des hospitalisations MED-ÉCHO, ministère de la Santé et des Services sociaux du Québec.

3.5 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. With this change, 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 (CIHI), Discharge Abstract Database (DAD); Fichier des hospitalisations MED-ÉCHO, ministère de la Santé et des Services sociaux du Québec.

30–day acute myocardial infarction (AMI) 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 than 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 (CIHI), Discharge Abstract Database (DAD).

30–day stroke 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 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 (CIHI), Discharge Abstract Database (DAD).

Acute myocardial infarction (AMI) 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 than 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 (CIHI), Discharge Abstract Database (DAD), National Ambulatory Care Reporting System (NACRS); Alberta Health and Wellness, Alberta Ambulatory Care Database.

30-Day Obstetric Readmission Rate

Definition:
Risk-adjusted rate of unplanned readmission for obstetric patients. Non-elective return to an acute care hospital for any cause is counted as a readmission if it occurs within 30 days of the index episode of inpatient care. An episode of care refers to all contiguous inpatient hospitalizations and same-day surgery visits.

Source(s):
Discharge Abstract Database and National Ambulatory Care Reporting System, Canadian Institute for Health Information; Fichier des hospitalisations MED-ÉCHO, ministère de la Santé et des Services sociaux du Québec.

30-Day Pediatric Readmission Rate

Definition:
Risk-adjusted rate of unplanned readmission for pediatric patients. Non-elective return to an acute care hospital for any cause is counted as a readmission if it occurs within 30 days of the index episode of inpatient care. An episode of care refers to all contiguous inpatient hospitalizations and same-day surgery visits.

Source(s):
Discharge Abstract Database and National Ambulatory Care Reporting System, Canadian Institute for Health Information; Fichier des hospitalisations MED-ÉCHO, ministère de la Santé et des Services sociaux du Québec.

30-day surgical readmission rate

Definition:
Risk-adjusted rate of unplanned readmission for adult surgical patients. Non-elective return to an acute care hospital for any cause is counted as a readmission if it occurs within 30 days of the index episode of inpatient care. An episode of care refers to all contiguous inpatient hospitalizations and same-day surgery visits.

Source(s):
Discharge Abstract Database and National Ambulatory Care Reporting System, Canadian Institute for Health Information; Fichier des hospitalisations MED-ÉCHO, ministère de la Santé et des Services sociaux du Québec.

30-day medical readmission rate

Definition:
Risk-adjusted rate of unplanned readmission for adult medical patients. Non-elective return to an acute care hospital for any cause is counted as a readmission if it occurs within 30 days of the index episode of inpatient care. An episode of care refers to all contiguous inpatient hospitalizations and same-day surgery visits.

Source(s):
Discharge Abstract Database and National Ambulatory Care Reporting System, Canadian Institute for Health Information; Fichier des hospitalisations MED-ÉCHO, ministère de la Santé et des Services sociaux du Québec.

Self-injury hospitalization rate

Definition:
Age-standardized rate of hospitalization in a general hospital due to self-injury per 100,000 population.

Self-injury is defined as a deliberate bodily injury that may or may not result in death. This type of injury is the result of either suicidal or self-harming behaviours, or both. Self-injury can be prevented, in many cases, by early recognition, intervention and treatment of mental illnesses. While some risk factors for self-injury are beyond the control of the health system, high rates of self-injury hospitalization can be interpreted as the result of a failure of the system to prevent self-injuries that are severe enough to require hospitalizations.

Source(s):
Canadian Institute for Health Information (CIHI), Discharge Abstract Database (DAD); Ontario Mental Health Reporting System (OMHRS); National Ambulatory Care Reporting System (NACRS); Fichier des hospitalisations MED-ÉCHO, ministère de la Santé et des Services sociaux du Québec.

Potentially avoidable mortality rate

Definition:
Premature deaths that could potentially have been avoided through all levels of prevention (primary, secondary, tertiary). Premature deaths are those that occur among individuals younger than age 75. Expressed as the age-standardized mortality rate and age-standardized potential years of life lost (PYLL) per 100,000 population.

Source(s):
Statistics Canada, Vital Statistics, Death Database.

Rate of avoidable mortality from preventable causes

Definition:
Premature deaths that could potentially have been prevented through primary prevention efforts. Mortality from preventable causes is a subset of potentially avoidable mortality. Expressed as the age-standardized mortality rate and age-standardized PYLL per 100,000 population.

Source(s):
Statistics Canada, Vital Statistics, Death Database.

Rate of avoidable mortality from treatable causes

Definition:
Premature deaths that could potentially have been avoided through secondary or tertiary prevention. Mortality from treatable causes is a subset of potentially avoidable mortality. Expressed as the age-standardized mortality rate and age-standardized PYLL per 100,000 population.

Source(s):
Statistics Canada, Vital Statistics, Death Database.

3.6 Safety

Hospitalized hip fracture event rate

Definition:
Age-standardized rate of new hip fractures admitted to an acute care hospital per 100,000 population age 65 years and over. New event is defined as a first-ever hospitalization for hip fracture or a subsequent hip fracture occurring more than 28 days after the admission for the previous event in the reference period. A person may have more than one hip fracture event in the reference period.

ICD–10–CA

S72.0, S72.1, S72.2

ICD-9/ICD-9-CM

820.0-820.3, 820.8, 820.9

Hip fractures represent a significant health burden for seniors and for the health system. As well as causing disability or death, hip fracture may have a major effect on independence and quality of life. Measuring occurrence of hip fractures in the population is important for planning and evaluating preventive strategies, allocating health resources and estimating costs.

Source (s):
Canadian Institute for Health Information (CIHI), Discharge Abstract Database (DAD); Fichier des hospitalisations MED-ÉCHO, ministère de la Santé et des Services sociaux du Québec.

In-hospital hip fracture

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 rates are reported by the jurisdiction where hospitalization has occurred rather than by the jurisdiction of patient residence.  With this change the indicator will better reflects 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 (CIHI), Discharge Abstract Database (DAD).

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