Transcript Back to Basics, 2003 POPULATION HEALTH

Back to Basics, 2010
POPULATION HEALTH (3A):
Health Care Organization and
Vital Stats
N Birkett, MD
Epidemiology & Community Medicine
Based on slides prepared by Dr. R. Spasoff
April 1, 2010
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THE PLAN(2)
• First class
– mainly lectures
• Other classes
– About 2 hours of lectures
– Review MCQs for 60 minutes
• A 10 minute break about half-way through
• You can interrupt for questions, etc. if
things aren’t clear.
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THE PLAN (5)
• Session 3 (April 1)
– Organization of Health Care Delivery in
Canada
– Elements of Health Economics
– Vital Statistics
– Overview of Communicable Disease control,
epidemics, etc.
April 1, 2010
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C2LEO
COMMUNICATIONS!!!
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Organization of Health Care (0)
• Provincial governments are responsible for Health Care.
• 1962: First universal medical care insurance
• 1965: Hall commission recommended federal leadership
on medical insurance
• 1966: Medical Care Act (federal) established medical
insurance with 50% funding from federal government
• 1977: EPFA reducing federal role; led to extra billing
debate
• 1984: Canada Health Act
• 2001: Kirby & Romanow commissions
• 2005: Chaoulli decision (Quebec)
– Controversial interpretation of the CHA in regards to banning of
private clinics.
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Organization of Health Care (0A)
• Canada Health Act established five
principles
–
–
–
–
–
Public administration
Comprehensiveness
Universality
Portability
Accessibility
• Bans ‘extra-billing’
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Organization of Health Care (0B)
• 2003: total health care expenditures were
$3,839/person or about $135billion, 10% of
GDP
• 73% from public sector (45% in the USA)
• 32% spent on hospitals, 16% on drugs,14%
on MD’s and 12% on other HCP’s
• Research shows that private-for-profit care
is more expensive and less effective
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Methods of paying doctors (I&PH link)
• Fee-for-service: unit is services. Incentive to
provide many services, especially procedures.
• Capitation: unit is patient. Fixed payment per
patient. Incentive to keep people healthy, but not
to make yourself accessible.
• Salary: unit is time. Productivity depends on
professionalism and institutional controls
– Practice plans
• Combinations of above, e.g., "blended funding“
– Family networks (Ontario) (I&PH link)
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Methods for paying hospitals
• Line-by-line: separate payments for staff,
supplies, etc. Cumbersome, rigid.
• Global budget: fixed payment to be used as
hospital sees fit. Fails to recognize differences in
case mix.
• Case-Mix weighted: payment for total cost of
episode, greater for more complicated cases. Now
used in Canada.
• New technology: OHTAC reviews requests. If
approved, government pays. If declined, hospitals
can pay for it from core budget.
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How good is the Canadian health
care system?
• The World Health Report 2000 (from
WHO) placed Canada 30th to 35th in the
world, slightly above US but well below
most of western Europe
• Implies that we should be healthier, given
our high levels of income and education
• Methods used by the Report have been
highly criticized
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Organization of Health Care (1)
Student & Resident Issues
• “The role of student and resident
associations in promoting protecting their
members’ interests.”
• Student organizations will be familiar to
you
• PAIRO (Professional Assoc of Interns and
Residents of Ontario) has been extremely
effective in negotiating salaries, working
conditions, educational programs
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Organization of Health Care (2)
CMPA
• “The role of the CMPA as a medical defence
association representing the interests of individual
physicians.”
• Canadian Medical Protective Association is a cooperative, replacing commercial malpractice
insurance. It advises physicians on threatened
litigation (talk to them early), and pays legal fees
and court settlements. Fees vary by region and
specialty ($500-$75,000/year).
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Organization of Health Care (3)
Interprovincial Issues
• “The portability of the medical degree.”
– Degrees are portable across North America
• “The transferability of provincial medical
licences.”
– Traditionally, provincial Colleges of Physicians and
Surgeons set own requirements (with input from
provincial governments)
• As part of attempts to improve intra-provincial trade, recent
legal changes have established a common lisencing standard
– Pass LMCC
– Family med or Royal College fellowship
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Organization of Health Care (3b)
• Certification vs. licensing
– Medical College of Canada
• Certifies MD’s (LMCC)
– Royal College of Physicians and Surgeons of
Canada
• Certifies specialists
– College of Family Physicians of Canada
• Certifies family physicians
– College of Physicians and Surgeons of Ontario
• Issues a licence to practice to MD’s.
April 1, 2010
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Organization of Health Care (4a)
Physician Organizations
• Medical Council of Canada
– Maintains the Canadian Medical Registry
– Does not grant licence to practice medicine
• College of Physicians and Surgeons of Ontario
– Responsible for issuing license to practice medicine
– Handles public complaints, professional discipline, etc.
– Does not engage in lobbying on matters such as
salaries, working conditions.
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Organization of Health Care (4b)
Physician Organizations
• Royal College of Physicians and Surgeons of
Canada.
– Maintains standards for post-graduate training throughout Canada.
– Sets exams and issues fellowships for specialty training
• Ontario Medical Association
– Professional association; lobbies on behalf of
physicians re: fees, working conditions, etc.
• College of Family Physicians of Canada
– Organization certifying/promoting family practice
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Organization of Health Care (5)
Medical Officer of Health
• Reports to municipal government.
• Responsible for:
–
–
–
–
Food/lodging sanitation
Infectious disease control and immunization
Health promotion, etc.
Family health programmes
• E.g. family planning, pre-natal and pre-school care, Tobacco
prevention, nutrition
– Occupational and environmental health surveillance.
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Organization of Health Care (6)
Medical Officer of Health
• Powers include ordering people, due to a
public health hazard, to take any of these
actions:
– Vacate home or close business;
– Regulate or prohibit sale, manufacture, etc. of
any item
– Isolate people with communicable disease
– Require people to be treated by MD
– Require people to give blood samples
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The Coroner
• Notify coroner of deaths in the following cases:
–
–
–
–
–
–
–
–
Due to violence, negligence, misconduct, etc.
During work at a construction or mining site.
During pregnancy
Sudden/unexpected
Due to disease not treated by qualified MD
Any cause other than disease
Under suspicious circumstance or by ‘unfair means’
Deaths in jails, foster homes, nursing homes, etc.
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78.1: MEDICAL ECONOMICS (1)
• Define the socio-economic rationales,
implications and consequences of medical
care
• Medical care costs society financial and
other resources.
• This objective aims to raise awareness of
these types of issues.
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MEDICAL ECONOMICS (2)
• Is there a net financial benefit from medical
care?
• How do we value non-fiscal benefits such
as quality of life, ‘health’, not being dead?
• Should resources be spent on health or other
societal objectives?
• How do we value non-traditional
expenditures, etc which impact on health
(Healthy Public Policy).
April 1, 2010
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Principles of cost-containment
• Eliminate ineffective care
• Reduce costs of effective care
– Substitute cheaper but equally effective care,
• day surgery for hospital admission,
• nurse practitioners for some primary care,
• generic drugs
– Reduce unit costs
• reduce salaries (risk of reduced effectiveness) or
fees (but quantity provided may increase)
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Types of economic analysis
[Costs always expressed in dollars]
• Cost-minimization: assume equal outcomes
• Cost-benefit: outcomes in dollars
• *Cost-effectiveness: outcomes in natural
units (deaths, days of care or disability, etc.)
• *Cost-utility: outcomes in QALYs (qualityadjusted life years)
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78.1: VITAL STATISTICS
INFORMATION
• What are the key causes of illness or death
in Canada? Common things are common –
using epidemiology can help you run a
better clinical practice
• How have disease incidence and mortality
change in Canada in the past 20 years?
– Little good information on disease incidence
except for cancer (cancer registries)
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# deaths in Canada from 1979-2004; men and women.
13/7/2008
April 1, 2010
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Mortality RATES in Canada from 1979-2004; men and women.
13/7/2008
April 1, 2010
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VITAL STATISTICS (2)
• Leading causes of death
– ‘Cardiovascular disease’: 37%
• Heart disease: 20%
• ‘Other circulatory disease’: 10%
• ‘Stroke’ 7%
– ‘Cancer’: 28%
• Lung cancer: 9% (M); 6% (W)
• Breast cancer: 4% (W)
• Prostate cancer: 4% (M)
–
–
–
–
Respiratory Disease: 10%
Injuries: 6%
Diabetes: 3%
Alzheimer’s: 1%
April 1, 2010
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Mortality (2004) - Canada, both sexes
Age standardized: 1991 population
Cancer: Lung (8.1%)
CHD:other (5.4%)
Cancer: Colon (3.3%)
Cancer: Breast (2.2%)
CANCER:
30.3%
IHD (16.1%)
Circ
Disease:
27.6%
Cancer: Other (16.7%)
Stroke (6.1%)
Accidents:MVA (1.5%)
Other (21.8%)
Accidents:Other (2.8%)
Diabetes (3.5%)
Infections (1.2%)
††
† Respiratory (6.7%)
Suicide (1.9%)
April 1, 2010
Alzheimer's (2.2%)
† Pneumonia & influenza grouped with respiratory disease.
Would increase infectious % to about 3.4%.
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Mortality (2004) - Canada, MEN only
Age standardized: 1991 population
Cancer: Lung (8.5%)
CHD:other (4.9%)
Cancer: Colon (3.3%)
Cancer: Prostate (3.3%)
IHD (18.8%)
CANCER:
29.8%
Circ
Disease:
29.0%
Cancer: Other (14.7%)
Stroke (5.3%)
Accidents:MVA (1.8%)
Other (20.8%)
Accidents:Other (3.0%)
Diabetes (3.5%)
†Infections (1.1%)
†
Respiratory (7.2%)
Suicide (2.3%)
April 1, 2010
Alzheimer's (1.5%)
† Pneumonia & influenza grouped with respiratory disease.
Would increase infectious % to about 3.5%.
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Mortality (2004) - Canada, WOMEN only
Age standardized: 1991 population
Cancer: Lung (7.8%)
CHD:other (5.8%)
Cancer: Colon (3.2%)
Cancer: Breast (5.0%)
IHD (14.5%)
CANCER:
31.6%
Circ
Disease:
27.3%
Cancer: Other (15.6%)
Stroke (7.0%)
Accidents:MVA (1.0%)
Accidents:Other (2.4%)
Other (22.7%)
Diabetes (3.4%)
Infections (1.0%)
†
†
Respiratory (6.5%)
Suicide (1.1%) Alzheimer's (2.9%)
April 1, 2010
† Pneumonia & influenza grouped with respiratory disease.
Would increase infectious % to about 3.3%.
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Sex ratio (M/F) in Canada from 1979-2004.
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Age/sex-specific Mortality.
Canada, 2005
14000
Combined
Males
Females
12000
Rate/100,000
10000
8000
6000
4000
2000
0
0
20
40
60
80
Age at death (years)
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Age/sex-specific Mortality.
Canada, 2005
log-scale for mortality
Combined
Males
Females
10000
Rate/100,000
1000
100
10
1
0
20
40
60
80
Age at death (years)
April 1, 2010
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Age-specific mortality: male:female mortality ratio
Canada, 2005
1.0=same mortality in both sexes; > 1.0 -> higher male mortality
2.8
2.6
2.4
Ratio (M:F)
2.2
2.0
1.8
1.6
1.4
1.2
1.0
0
20
40
60
80
Age (years)
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Injury Mortality in Canada, 2004
350
Total
MVA
Falls
Suffocation
Other unintentional
Suicide
Homicide
300
Rate/100,000
250
200
150
100
50
0
0
20
40
60
80
Age at death (years)
April 1, 2010
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Injury Mortality in Canada, 2004
Excluding poeple over age 80
70
Total
MVA
Falls
Suffocation
Other unintentional
Suicide
Homicide
60
Rate/100,000
50
40
30
20
10
0
0
20
40
60
80
Age at death (years)
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Pattern of Injury deaths, Canada, 2004
Age 1 to 10.
MVA
Falls
Suffocation
Other unintentional
Homicide
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Pattern of Injury deaths, Canada, 2004
Age 80 and over.
MVA
Falls
Suffocation
Other unintentional
Suicide
Homicde
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Vital Stats (3)
• In the USA, it is estimated that 86,000
people are sent to ER every year after a fall
caused by a cat or dog!
– Mainly minor injuries but 10% are fractures,
internal bleeding, etc.
– Cats mainly trip people by walking under your
feet.
– Dogs (the main source of injuries!) causes trips,
push people over or pull them over on walks.
• Watch out!!
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Overall trends in mortality from Cancer 1976-2005:
rates and numbers
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Overall trends in mortality 1976-2005: rates and numbers
April 1, 2010
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Cancer and Age
Age-Specific Incidence Rates for All Cancers by Sex, Canada, 2003
April 1, 2010
Surveillance Division, CCDPC, Public Health Agency of Canada
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Cancer and Age
Age-Specific Mortality Rates for All Cancers by Sex, Canada, 2003
April 1, 2010
Surveillance Division, CCDPC, Public Health Agency of Canada
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Time trends in incidence - Males
160
Estimated
140
Prostate
120
Lung
100
80
Colorectal
60
40
Bladder
Stomach
NHL
20
Melanoma
0
1975
Larynx
Liver
Thyroid
1980
1985
1990
1995
2000
2005
Age-Standardized
April 1, 2010 Incidence Rates (ASIR) for Selected Cancer Sites, Males, Canada, 1978-2007
Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada
45
Time trends in mortality - Males
100
Estimated
Lung
80
ASMR (/100,000)
60
40
Colorectal
Prostate
20
Stomach
NHL
Oral
Larynx
Hodgkin's
0
1980
1985
1990
1995
2000
2005
Age-Standardized
April 1, 2010 Incidence Rates (ASIR) for Selected Cancer Sites, Males, Canada, 1978-2007
Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada
46
Time trends in incidence - Females
160
Estimated
140
120
100
Breast
80
60
Colorectal
40
Lung
20
Thyroid
Stomach
NHL
Cervix
Larynx
0
1975
1980
1985
1990
1995
2000
2005
Age-Standardized
April 1, 2010 Incidence Rates (ASIR) for Selected Cancer Sites, Females, Canada, 1978-2007 47
Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada
Time trends in mortality - Females
100
Estimated
80
ASMR (/100,000)
60
40
Lung
Breast
Colorectal
20
Stomach
NHL
Cervix
0
1980
1985
1990
1995
2000
2005
Age-Standardized
April 1, 2010 Incidence Rates (ASIR) for Selected Cancer Sites, females, Canada, 1978-2007 48
Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada
Population Pyramids
•
•
•
•
Canada, 1901-2001
Newfoundland 1951-2001
Ontario 1951-2001
Nunavut, 1991-2001
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