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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

    2

    •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

    3

  • ICES Pr imary Care and Populat ion Heal th Research Program

    Mitigating Potential Bias

    • Mitigation N/A

    4

  • 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

    5

  • 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

    6

  • ICES Pr imary Care and Populat ion Heal th Research Program

    Health Services Accessed Each Day (ICES Primary Care Atlas)

    7

  • 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

    8

    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

    13

  • 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

    14

  • ICES Pr imary Care and Populat ion Heal th Research Program

    Primary Healthcare Transformation - Canada

    15

    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

    16

  • 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,