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Dr. Joshua Tepper

Measuring the System’s Fault Lines

A quality health care system seamlessly delivers care across a broad spectrum of care settings and patient populations. Unfortunately, even a good health care system can have fault lines into which patients can fall and where quality care is deficient.

Measuring Up, Health Quality Ontario’s newly released 11th annual report on the performance of the province’s health system and on the health of Ontarians, documents those fault lines as well as other areas where the provincial system can improve. It takes the pulse of the system through measurement and through narratives from people like Gordon, Lilac and Elgin who share their experiences as patients and that of Shawn Dookie, a nurse practitioner.

Starting with initial entry into the system, Measuring Up this year identifies areas of concern. Compared to 10 other developed countries, Ontario scores as one of the worst when it comes to having access to a primary care provider the same or next day when someone is sick. More than half of Ontarians surveyed reported having this problem.

Then, when patients have to go to the emergency department they are spending on average of an hour-and-a-half longer in the emergency department before being admitted to a hospital bed than they were the previous year. This can, at least partially, be attributed to the fact that an average of 3,961 beds daily were occupied by patients waiting for care elsewhere in 2015/16 (known as Alternate Level of Care). For those of you who want to see a good Rick Mercer-type rant about Alternate Level of Care and its impact on the system, this video was filmed by the chair of Health Quality Ontario’s Quality Standards Committee, Dr. Chris Simpson, two years ago when he was president of the Canadian Medical Association.

Little progress was documented in reducing the number of people with a mental health or substance use issue who went to the emergency department without seeing a psychiatrist or other physician first (33.1% in 2015).

Some wait times also continue to be an issue in Ontario. Hip and knee replacements are increasingly common yet fewer patients are receiving surgery within the target time. For example, 5% fewer of those awaiting Priority 4 knee surgery in 2016/17 had their procedure within the target time, compared to in 2014/15.

Furthermore, only 56.7% of home care patients felt strongly involved in the development of their own care plan. And caregiver distress among those caring informally for patients needing home care has increased from 21.2% in 2012/13 to 24.3% in the first part of 2016/17.

Health Quality Ontario always brings an equity lens to the delivery of care and here again Measuring Up identifies areas of concern.

  • About 1 in 12 people in Ontario reported having trouble paying their medical bills
  • Variations exist by region and by rural vs. urban in reported having ongoing consistent care over time with the same physician. For example, the proportion of people who had high continuity of care ranged from 66.5% in the South-East Local Health Integrated Health Network (LHIN) LHIN region to 49.8% in the Central West LHIN region.
  • The premature mortality rate shows striking variations across the province with the rate of potential years of life lost being 2.5 times higher in the North West LIHN region) at 7,647 potential years of life lost per 100,000 people compared with 3,026 potential years of life lost per 100,000 people in the Central LHIN region over the same time period.
  • Colorectal cancer screening has inequities by income. Urban residents in the lowest income neighbourhoods had the highest rate of being overdue for screening in 2015 at 46.5% compared to 32.7% of these in the highest income neighbourhoods.

The measures of involvement in home care and continuity of care referenced above are two of four new indicators added to Measuring Up this year. The other two indicators are:

  • The wait time from when a patient is assessed or registered in the emergency department to the time they are first seen by a physician. The average time patients waited to see a physician increased slightly this year from last year to 1.5 hours from 1.4 hours.
  • The wait time between when a cancer patients is referred by a primary care physician to a surgeon to the time of their first appointment with the surgeon. About 6 out of 7 Ontario patients who had cancer surgery had their first surgical appointment within target wait times in 2016/17.

In addition, findings are now available on the delivery of primary care in the LHIN sub-regions, smaller geographic planning areas within Local Health Integration Networks.

In Quality Matters: Realizing Excellent Care For All, our report on how to improve quality in the system, it is noted that measurement gaps exist in documenting transitions in care and that “safer and more efficient transitions for patients require appropriate accountabilities and hard data rather than anecdotes.” Measuring Up this year is an example of where we are bridging those gaps in knowledge, by producing numbers that shine a light on where we can do better.

The report also documents where Ontario is doing well and these findings are not insignificant as they show that overall Ontarians are living longer and losing fewer years of their lives to premature death. Measuring Up also shows long-term care residents are receiving better care on a number of parameters and more people are receiving colorectal cancer screening in a timely manner.

These statistics are also useful as they show improvement is possible and guidance on how that improvement might occur.

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