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Research to improve public
confidence and views on quality
in the Canadian health care
system

Diane Watson PhD MBA
International Visiting Health Services Research Fellow
The Sax Institute

29 April 2009
Outline
• Health care and reform in Canada
• The “confidence conundrum”
• Research evidence to inform efforts to:
   – Build public confidence
   – Improve overall views on quality
   – Publicly report on progress
• Who needs to know what …
Outline
• Health care and reform in Canada
• The “confidence conundrum”
• Research evidence to inform efforts to:
   – Build public confidence
   – Improve overall views on quality
   – Publicly report on progress
• Who needs to know what …
Canada
Health Care Expenditure per Capita
                          by Source of Funding in 2004

$7,000               Adjusted for Differences in Cost of Living (US$ PPP)


$6,000                                                                                       Private Spending

                                                                                             Out-of-Pocket Spending
$5,000
         $2,572
                                                                                             Public Spending

$4,000

          $803
$3,000                 $483        $444               $342
                                                                     $354                        $148
                       $472        $239      $906     $313
                                                                                      $370                 $28
                                                                     $582                                              $113
                                                                                                 $396
$2,000                                       $238                                                          $389
                                                                                                                       $359
         $2727
                                   $2,475             $2,350
$1,000                 $2,210                                                        $2,176
                                            $1,894                   $1,940                      $1,917   $1,832      $1,611


   $0
                                                                a               ab                                a
         United       Canada       France Netherlands Germany       Australia        United      OECD     Japan        New
         States                                                                      Kingdom    Median                Zealand

         a2003
         b2002   (Out-of-Pocket)


                                               Source: The Commonwealth Fund, calculated from OECD Health Data 2006.
International Comparison of Spending on Health,
            1980–2006
                                                            Average spending on health
                                                               per capita ($US PPP)

$7,000
                     United States
$6,000               Germany
                     Canada
                     Netherlands
$5,000               France
                     Australia
                     United Kingdom
$4,000

$3,000

$2,000

$1,000

   $0
                                         90




                                                       94
                                                92




                                                              96

                                                                     98

                                                                            00

                                                                                   02




                                                                                                  06
                                                                                          04
      80




                    84
             82




                           86

                                  88

                                       19

                                              19




                                                            19
                                                     19




                                                                   19

                                                                          20

                                                                                 20

                                                                                        20

                                                                                                20
    19

           19




                         19
                  19




                                19




                                                                   Data: OECD Health Data 2008 (June 2008).
Apr 2001: Prime
Minister
establishes Royal
Commission
Senate
establishes a
Committee




Feb 2003: First
Ministers’ Health
Accord
Sept 2004: First
Ministers’ 10-
Year Plan to
Renew Health
Care in Canada
Outline
• Health care and reform in Canada
• The “confidence conundrum”
• Research evidence to inform efforts to:
   – Build public confidence
   – Improve overall views on quality
   – Publicly report on progress
• Who needs to know what …
Overall Confidence in the Health Care System Among Adults in Seven
   Countries, 2007
                  100

                                                           “Very confident” in “getting high
                                                           quality and safe care” when “needed”

                  80




                                                           59
                  60
% of all adults




                  40
                          34                                                                             35
                                                                         30
                                     28                                                 28
                                               24

                  20




                   0
                        Australia   Canada   Germany   Netherlands   New Zealand   United Kingdom   United States


                                                                            Source: 2007 Commonwealth Fund
                                                                           International Health Policy Surveys.
Population Perspectives on Health Care System Reform Among Adults
in Seven Countries, 1988-2007
                   100

                                                         "Overall the system works well,
                                                         only minor changes are needed"

                   80




                                                                                                     Australia
                   60                                                                                Canada
 % of all adults




                                                                                                     Germany
                                                                                                     Netherlands
                                                                                                     New Zealand
                   40                                                                                United Kingdom
                                                                                                     United States




                   20




                    0
                         1988/1990   1994         1998         2001        2004        2007


                                            Sources: 1998, 2001, 2004 and 2007 Commonwealth Fund International
                                                         Health Policy Surveys; Harvard, Harris and Baxter, 1988.
Outline
• Health care and reform in Canada
• The “confidence conundrum”
• Research evidence to inform efforts to:
   – Build public confidence
   – Improve overall views on quality
   – Publicly report on progress
• Who needs to know what …
Public Confidence in Health Care: A
nationwide exploratory analyses in Canada
• Research questions:
   – What underlies confidence among the general public
     that they will get high quality, safe care when they
     need it?
   – What underlies views that everything is fine the way
     it is/ only minor reforms are needed?
• Telephone survey of the general population, 2007
   – Confidence/ views on reform
   – Use and experiences with primary health care,
     specialists, hospitals and emergency departments
   – Views on overall quality of care received in the past
     year
Public Confidence in Health Care: A
nationwide exploratory analyses in Canada
• Age, gender, income and health status matter; but are not
  strong predictors of public confidence.
• Utilization of family doctors, emergency departments and
  hospitals was not significantly related to confidence or
  positive views on reform.
• Use of specialists was negatively associated with both
  outcomes with high users less likely to be confident and less
  likely to think everything is fine/ minor reform is needed.
• The key drivers of public confidence?
    – first-hand experiences with care
    – people overall views on the overall quality of care that
      they received in the past 12 months.
Very confident/            Everything is fine the
      Adjusted odds ratios                          confident get                way it is/ some
                                                  quality/ safe care             minor-tune-ups
No regular medical doctor or place                       0.37*

Experience at least one unmet need
   (past year)                                           0.51*

Wait in ED
  4+ hours                                                                             0.38**
Use of specialists
   1-3 times                                                                           0.65*
   4+ times                                                                            0.56*
Difficulty getting specialist care
    (past year)                                          0.51*                         0.55*

Overall quality of care
  Very good                                             0.46**
  Good                                                  0.35**                         0.47**
  Fair/poor                                             0.20**                         0.37**
                          Source: Watson et al. What drives public confident in the health care system? An
                          exploratory look at the contribution of health care use and experiences with care.
If our intention is to build/ maintain public
confidence …
 • Health care policy makers, managers and providers
   need to know about/ improve:
    – Regular source of care, unmet need, excessive
      times in emergency departments and access to
      specialists
    – Patients ratings of overall quality of care and the
      issues that drive it
 • Researchers need to investigate why high use of
   specialists is associated with lower levels of public
   confidence
Outline
• Health care and reform in Canada
• The “confidence conundrum”
• Research evidence to inform efforts to:
   – Build public confidence
   – Improve overall views on quality
   – Publicly report on progress
• Who needs to know what …
Systematic reviews/ primary research: What
underlies patient overall ratings of quality of care?

•   Staff courtesy/ respect
•   Provider/ patient communication
•   Teamwork among providers
•   Comprehensiveness/ unmet needs
•   Access/ timeliness

         Larson et al. The relationship between meeting patients’ information needs and their satisfaction
                with hospital care and general health status outcomes. Int J Qual Health Care 8: 447-56.
        Taylor C. Benger JR. 2004. Patient satisfaction in emergency departments. Emergency Medicine
                                                                                   Journal 21: 528-32.
      Wong S et al. 2008. What do people think is important about primary health care. Healthcare Policy
                                                                                              3: 89-104.
      Grol R. et al. 1999. Patients’ priorities with respect to general practice: An international comparison.
                                                                                      Family Practice 16: 4-11.
Patient Ratings of Overall Quality of Care, NSW
Overnight inpatients, 2008 and 2007




Top 5 key drivers:
• Doctors and nurses working well together
• Treating patients with respect and dignity
• The availability of nurses
• Confidence and trust in nurses
• Courtesy of nurses

                                         Source: NSW Health, Patient Survey 2008.
Patient Ratings of Overall Quality of Care, NSW
Admitted patients, 2007
• Overall, 90% of those who were admitted to hospital rated
  their care as excellent, very good or good.
• The remainder rate care as fair (6%) or poor (4%).
• The main reasons for rating care as fair/ poor were:
   –   excessive wait time for care (18%)
   –   inadequate medication/ management (15%),
   –   poor quality accommodation (14%)
   –   poor attitude of staff (13%)
   –   not enough staff (13%)
   –   poor technical skill of staff (13%)
   –   communication problems (12%)

                               Source: NSW Health, Population Health Survey 2007.
Patient Ratings of Overall Quality of Care, NSW
Non-admitted emergency patients, 2008 and 2007




•   Top 5 key drivers:
     – Giving patients complete information
     – Giving patients an explanation of what was done to them
     – The availability of doctors
     – Courtesy of emergency department staff
     – Doctors and nurses working well together

                                         Source: NSW Health, Patient Survey 2008.
Patient Ratings of Overall Quality of Care, NSW
emergency department patients, 2007
• Overall, 79% of those who presented to an emergency
  department rated their care as excellent, very good or
  good.
• The remainder rate care as fair (11%) or poor (9%).
• The main reasons for rating care as fair/ poor were:
   –   waiting time (61%)
   –   poor or adequate service (17%),
   –   not enough staff (12%)
   –   poor attitude of clinical staff (8%)
   –   communication problems (7%)


                                    Source: NSW Health, Population Health Survey 2007.
Outline
• Health care and reform in Canada
• The “confidence conundrum”
• Research evidence to inform efforts to:
   – Build public confidence
   – Improve overall views on quality
   – Publicly report on progress
• Who needs to know what …
Public priorities for HOSPITAL performance reporting in
Canada

Rating 9 to 10   Skill of medical staff
out of 10        Patient satisfaction with care
                 Serious medical errors
                 Use of latest technology and equipment
Rating 8 to 9    Extent to which nurses are sensitive and caring
out of 10        Level of coordination: hospital-outside services
                 Patients provided with useful information at discharge
                 Job satisfaction of hospital staff
Rating 7 to 8    Wait time for ED for urgent, non-life threatening
out of 10        Wait time for non-emergency surgery


                    Source: Sandoval GA. 2007. Sustained public preferences on hospital
                      performance across Canadian provinces. Health Policy 83: 246-256.
dwatson@chspr.ubc.ca

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Diane Watson | Research to improve public confidence and views on quality in the Canadian health care system

  • 1. Research to improve public confidence and views on quality in the Canadian health care system Diane Watson PhD MBA International Visiting Health Services Research Fellow The Sax Institute 29 April 2009
  • 2. Outline • Health care and reform in Canada • The “confidence conundrum” • Research evidence to inform efforts to: – Build public confidence – Improve overall views on quality – Publicly report on progress • Who needs to know what …
  • 3. Outline • Health care and reform in Canada • The “confidence conundrum” • Research evidence to inform efforts to: – Build public confidence – Improve overall views on quality – Publicly report on progress • Who needs to know what …
  • 5. Health Care Expenditure per Capita by Source of Funding in 2004 $7,000 Adjusted for Differences in Cost of Living (US$ PPP) $6,000 Private Spending Out-of-Pocket Spending $5,000 $2,572 Public Spending $4,000 $803 $3,000 $483 $444 $342 $354 $148 $472 $239 $906 $313 $370 $28 $582 $113 $396 $2,000 $238 $389 $359 $2727 $2,475 $2,350 $1,000 $2,210 $2,176 $1,894 $1,940 $1,917 $1,832 $1,611 $0 a ab a United Canada France Netherlands Germany Australia United OECD Japan New States Kingdom Median Zealand a2003 b2002 (Out-of-Pocket) Source: The Commonwealth Fund, calculated from OECD Health Data 2006.
  • 6. International Comparison of Spending on Health, 1980–2006 Average spending on health per capita ($US PPP) $7,000 United States $6,000 Germany Canada Netherlands $5,000 France Australia United Kingdom $4,000 $3,000 $2,000 $1,000 $0 90 94 92 96 98 00 02 06 04 80 84 82 86 88 19 19 19 19 19 20 20 20 20 19 19 19 19 19 Data: OECD Health Data 2008 (June 2008).
  • 7. Apr 2001: Prime Minister establishes Royal Commission Senate establishes a Committee Feb 2003: First Ministers’ Health Accord Sept 2004: First Ministers’ 10- Year Plan to Renew Health Care in Canada
  • 8.
  • 9. Outline • Health care and reform in Canada • The “confidence conundrum” • Research evidence to inform efforts to: – Build public confidence – Improve overall views on quality – Publicly report on progress • Who needs to know what …
  • 10. Overall Confidence in the Health Care System Among Adults in Seven Countries, 2007 100 “Very confident” in “getting high quality and safe care” when “needed” 80 59 60 % of all adults 40 34 35 30 28 28 24 20 0 Australia Canada Germany Netherlands New Zealand United Kingdom United States Source: 2007 Commonwealth Fund International Health Policy Surveys.
  • 11. Population Perspectives on Health Care System Reform Among Adults in Seven Countries, 1988-2007 100 "Overall the system works well, only minor changes are needed" 80 Australia 60 Canada % of all adults Germany Netherlands New Zealand 40 United Kingdom United States 20 0 1988/1990 1994 1998 2001 2004 2007 Sources: 1998, 2001, 2004 and 2007 Commonwealth Fund International Health Policy Surveys; Harvard, Harris and Baxter, 1988.
  • 12.
  • 13. Outline • Health care and reform in Canada • The “confidence conundrum” • Research evidence to inform efforts to: – Build public confidence – Improve overall views on quality – Publicly report on progress • Who needs to know what …
  • 14. Public Confidence in Health Care: A nationwide exploratory analyses in Canada • Research questions: – What underlies confidence among the general public that they will get high quality, safe care when they need it? – What underlies views that everything is fine the way it is/ only minor reforms are needed? • Telephone survey of the general population, 2007 – Confidence/ views on reform – Use and experiences with primary health care, specialists, hospitals and emergency departments – Views on overall quality of care received in the past year
  • 15. Public Confidence in Health Care: A nationwide exploratory analyses in Canada • Age, gender, income and health status matter; but are not strong predictors of public confidence. • Utilization of family doctors, emergency departments and hospitals was not significantly related to confidence or positive views on reform. • Use of specialists was negatively associated with both outcomes with high users less likely to be confident and less likely to think everything is fine/ minor reform is needed. • The key drivers of public confidence? – first-hand experiences with care – people overall views on the overall quality of care that they received in the past 12 months.
  • 16. Very confident/ Everything is fine the Adjusted odds ratios confident get way it is/ some quality/ safe care minor-tune-ups No regular medical doctor or place 0.37* Experience at least one unmet need (past year) 0.51* Wait in ED 4+ hours 0.38** Use of specialists 1-3 times 0.65* 4+ times 0.56* Difficulty getting specialist care (past year) 0.51* 0.55* Overall quality of care Very good 0.46** Good 0.35** 0.47** Fair/poor 0.20** 0.37** Source: Watson et al. What drives public confident in the health care system? An exploratory look at the contribution of health care use and experiences with care.
  • 17. If our intention is to build/ maintain public confidence … • Health care policy makers, managers and providers need to know about/ improve: – Regular source of care, unmet need, excessive times in emergency departments and access to specialists – Patients ratings of overall quality of care and the issues that drive it • Researchers need to investigate why high use of specialists is associated with lower levels of public confidence
  • 18. Outline • Health care and reform in Canada • The “confidence conundrum” • Research evidence to inform efforts to: – Build public confidence – Improve overall views on quality – Publicly report on progress • Who needs to know what …
  • 19. Systematic reviews/ primary research: What underlies patient overall ratings of quality of care? • Staff courtesy/ respect • Provider/ patient communication • Teamwork among providers • Comprehensiveness/ unmet needs • Access/ timeliness Larson et al. The relationship between meeting patients’ information needs and their satisfaction with hospital care and general health status outcomes. Int J Qual Health Care 8: 447-56. Taylor C. Benger JR. 2004. Patient satisfaction in emergency departments. Emergency Medicine Journal 21: 528-32. Wong S et al. 2008. What do people think is important about primary health care. Healthcare Policy 3: 89-104. Grol R. et al. 1999. Patients’ priorities with respect to general practice: An international comparison. Family Practice 16: 4-11.
  • 20.
  • 21. Patient Ratings of Overall Quality of Care, NSW Overnight inpatients, 2008 and 2007 Top 5 key drivers: • Doctors and nurses working well together • Treating patients with respect and dignity • The availability of nurses • Confidence and trust in nurses • Courtesy of nurses Source: NSW Health, Patient Survey 2008.
  • 22. Patient Ratings of Overall Quality of Care, NSW Admitted patients, 2007 • Overall, 90% of those who were admitted to hospital rated their care as excellent, very good or good. • The remainder rate care as fair (6%) or poor (4%). • The main reasons for rating care as fair/ poor were: – excessive wait time for care (18%) – inadequate medication/ management (15%), – poor quality accommodation (14%) – poor attitude of staff (13%) – not enough staff (13%) – poor technical skill of staff (13%) – communication problems (12%) Source: NSW Health, Population Health Survey 2007.
  • 23. Patient Ratings of Overall Quality of Care, NSW Non-admitted emergency patients, 2008 and 2007 • Top 5 key drivers: – Giving patients complete information – Giving patients an explanation of what was done to them – The availability of doctors – Courtesy of emergency department staff – Doctors and nurses working well together Source: NSW Health, Patient Survey 2008.
  • 24. Patient Ratings of Overall Quality of Care, NSW emergency department patients, 2007 • Overall, 79% of those who presented to an emergency department rated their care as excellent, very good or good. • The remainder rate care as fair (11%) or poor (9%). • The main reasons for rating care as fair/ poor were: – waiting time (61%) – poor or adequate service (17%), – not enough staff (12%) – poor attitude of clinical staff (8%) – communication problems (7%) Source: NSW Health, Population Health Survey 2007.
  • 25.
  • 26.
  • 27.
  • 28. Outline • Health care and reform in Canada • The “confidence conundrum” • Research evidence to inform efforts to: – Build public confidence – Improve overall views on quality – Publicly report on progress • Who needs to know what …
  • 29.
  • 30. Public priorities for HOSPITAL performance reporting in Canada Rating 9 to 10 Skill of medical staff out of 10 Patient satisfaction with care Serious medical errors Use of latest technology and equipment Rating 8 to 9 Extent to which nurses are sensitive and caring out of 10 Level of coordination: hospital-outside services Patients provided with useful information at discharge Job satisfaction of hospital staff Rating 7 to 8 Wait time for ED for urgent, non-life threatening out of 10 Wait time for non-emergency surgery Source: Sandoval GA. 2007. Sustained public preferences on hospital performance across Canadian provinces. Health Policy 83: 246-256.