Quality of Healthcare in Canada : A Chartbook

Executive Summary

If we could first know where we are, and whither we are tending, we could then better judge what to do, and how to do it. —Abraham Lincoln, 1858


The availability of robust, coherent, defensible and credible data on healthcare system performance is an essential component of any effort to improve quality. Decision makers need a shared understanding of the magnitude and nature of problems facing healthcare systems, along with a basis for communication and co-operation among the many stakeholders responsible for the delivery of health services and enhancing health outcomes. In recent years, the amount of available data and information relevant to the quality of healthcare in Canada has grown – produced by national, provincial, territorial, academic, professional and patient organizations. This chartbook seeks to draw these disparate pieces of data together to build a broad and coherent picture of the quality of healthcare in Canada. The approach adopted for this Canadian chartbook builds upon that developed by the authors for similar chartbooks in Australia, the United States, and the United Kingdom.

The chartbook takes a multifaceted approach to assessing quality and examines international, national and provincial/territorial data. It has been designed using four guiding principles – accessibility, validity, diversity of perspectives, and balance in presentation of data.

The data are presented in six key domains: the effectiveness of the healthcare sector in improving health outcomes; access to healthcare services; the capacity of systems to deliver appropriate services; the safety of care delivered; the degree to which healthcare in Canada is patient-centred; and equity in healthcare outcomes and delivery.

Key Findings

Effectiveness »

Effectiveness in healthcare refers to the extent to which an intervention, whether a service, visit, procedure or diagnostic test, produces the intended result. It also refers to the appropriateness of care – whether interventions are provided to those who would benefit from them and/or withheld from those who would not. Effectiveness measures focus on both outcomes and processes. As in many other countries, Canada has seen a significant decline in mortality rates from major killers such as cancer and heart disease in recent years.

Immunization rates, both childhood immunizations and influenza vaccination in people aged 65 and over, are relatively low in Canada compared to other developed countries.

There is considerable variation across provinces for a wide range of effectiveness indicators. While the provinces typically outperform the territories, there is no clear pattern across provinces, with no one either excellent in all areas or performing uniformly poorly.

Lack of standardized information about healthcare delivery and adherence to evidence-based processes of care across the country hampers the ability to draw more conclusions about the effectiveness of healthcare in Canada.

Access »

Access to healthcare is a prominent concern of patients and the public around the world. In Canada, a 2007 public survey found that wait times were the most commonly cited concern among a range of healthcare issues.

The majority of Canadians (more than 80%) have access to a regular doctor. However, lack of access is a problem in the territories: in the 10 largest communities of Nunavut in 2007, only 13.4% of respondents to the Canadian Community Health Survey indicated that they had a regular doctor; 40.8% of respondents in the Northwest Territories did so. The situation was better in Yukon, where 77.9% reported such access, closer to the Canadian average.

Canada does not fare well in a number of international comparisons. Patients in Canada wait longer for primary care appointments than those in many other developed countries, and a significant proportion of emergency department visits in Canada are attributed to limited availability of primary care. This greater use of the emergency department for primary care may be a factor in the longer wait times found in Canadian emergency departments compared to those in other countries, although there is evidence that simply having a general practitioner does not necessarily reduce emergency department use.1

Within Canada, there is considerable variation across provinces in wait times for key procedures ranked by priority in the 10-Year Plan to Strengthen Health Care (joint replacements, cataract surgery, radiotherapy, coronary artery bypass graft, MRI). The longest waits were for joint replacements.

Capacity »

The provision of reliable, high-quality healthcare depends upon having sufficient capacity to meet individual and population needs. Capacity encompasses the necessary financial resources
(spending), personnel, equipment, information technology, and pharmaceuticals.

Across developed economies generally, spending per person on healthcare has grown steadily in the past decade or so. Canada is in the top 20% of OECD countries in per-person spending on healthcare. However, as a proportion of GDP, healthcare spending in Canada in 2006 was almost the same as it was in 1992. This differs from the situation in many other developed countries, which have seen (sometimes dramatic) increases in the proportion of national wealth dedicated to health. Across provinces, spending varies from a low of $4,653 per capita in Quebec to a high of $5,730 per capita in Alberta. Spending is much higher in the territories than in the provinces, reflecting stark differences in geography, population density, healthcare needs, and delivery models.

In terms of healthcare personnel, Canada has a relatively low level of practising physicians per person, at 1.0 per 1,000 population. However, when these data are further stratified into general practitioners and specialists, Canada fares better in terms of general practitioners. There is marked variation within the country, with practising physicians at a low in Nunavut, with 0.4 per 1,000 population, and at a high in Nova Scotia, with 2.6 per 1,000 population in 2006. Offsetting the shortage of physicians, to some extent, is a higher number of practising nurses in the territories; there were 14.2 practising nurses per 1,000 population in the Northwest Territories/Nunavut in 2006, compared to 6.7 per 1,000 population in British Columbia.

Capacity also encompasses the use of health information technology, which can enable dramatic transformations in the delivery of healthcare, particularly in a country like Canada, with its large size and dispersed population. The use of information technology in Canada appears less well developed than in many comparable countries. This may change if a national plan to introduce electronic health records is implemented.

Safety »

Safety – the elimination of unnecessary risk of harm to patients – is a fundamental attribute of quality in healthcare. In recent years, safety has come to the fore as a pressing concern for policy makers, patients, managers, and healthcare professionals. As is the case with many developed countries, it is difficult to find detailed data on adverse incidents across Canada. It is also difficult to interpret the data that do exist. There is a perennial question of whether a measured increase in adverse events reflects a negative situation of worsening safety or care, or a positive situation of better reporting of safety problems, making it possible to analyze and improve them.

Juxtaposing staff-reported adverse events with patient reports can help unravel what is actually happening in healthcare settings. According to patient surveys, up to one-fifth of patients in Canada report experiencing a medication error or medical mistake (although the veracity of the patients’ perspective has not been corroborated).

Hospital-acquired infections are a serious safety issue for Canada. Within Canada, western provinces report the highest rates of MRSA, a common hospital-acquired infection.

Process measures that gauge the extent to which healthcare providers comply with evidence-based guidelines for improving safety (e.g. hand hygiene regimens, alert systems in place for potentially
dangerous prescribing) can provide valuable information on safety of care. While country-wide data on the level of investment in, and operationalization of, safety strategies are not available, Ontario does release such data for hospitals and reports a steady improvement in compliance with safety advice over the past few years.

Patient-centredness »

A concern for and responsiveness to patient preferences, attitudes and experiences are also key components of quality. Responsiveness can entail improving access to treatment and information, ensuring participation in healthcare decision-making, and supporting involvement in policy-making.

Canada, unlike many countries with quality performance frameworks, does not include an explicit focus on patient-centredness or responsiveness in the conceptualization underpinning quality measurement and reporting.

International surveys, however, reveal that Canadians are relatively satisfied with the healthcare they receive. One such study found that 61% of Canadian respondents rated the care they had received in the preceding year as excellent or very good, compared to 62% of respondents in the United Kingdom and 55% of respondents in the United States. Another international survey, this time of adults with health problems, found that 56% of Canadian respondents indicated that their doctor always involved them in decisions about treatment, a similar percentage to that in many other countries and higher than in France, the United Kingdom and the United States.

Equity »

Equity is an underlying value and much-cherished tenet of healthcare across Canada, such that all people in Canada receive care based on clinical need, and that healthcare contributes to reduced differences in health status and outcomes across groups. It is a value that is difficult to track, due to the paucity of timely data on equity and disparities. An exemplary model of comprehensive data analysis exploring the impact of socioeconomic status, sex and age on processes and outcomes of care has been undertaken by the Manitoba Centre for Health Policy.

Despite a lack of a comprehensive national data set on equity, it is possible to draw some conclusions from the data that are available. Notably, there are serious concerns about deficiencies in the health status of aboriginal people and their ability to access high-quality healthcare.

Furthermore, as is the case in many developed countries, there is a clear correlation between low income/socioeconomic status and poor health status in Canada. This does not appear to be related to healthcare cost concerns. However, an international survey did find that 16% of Canadian respondents indicated that they did not fill a prescription or skipped doses, and that 29% did not seek needed dental
care – both areas that are not publicly funded in Canada – because of cost concerns.

Concluding Comments »

The data presented in this chartbook identify areas where Canada performs well in terms of the quality of the healthcare provided to Canadians and areas that require improvement. The findings should be useful in informing the development of policies and initiatives to address specific quality problems in Canada’s healthcare, and lead to better outcomes for patients. They provide a baseline against which the impact of future quality improvements can be measured. Perhaps most significantly, they underscore the need for improved national data standards, collection and analysis, so that further aspects of quality can be assessed and monitored over time. Patients, practitioners, policy makers and health administrators would all benefit from such an initiative.