Research

Winter 2005 Publications

New publications by HPME faculty released in the Winter 2005 include the results of the Canadian Stroke Quality of Care Study, which is destined to influence stroke care management and delivery across Canada (Lindsay et al.); lessons learned from six years of hospital reporting in Ontario (Brown, et al.); and an analysis of the effects of the 2003 First Minister's Accord on Health Renewal on home care (Motiwala et al.). These publications represent the range of primary research, reflection and policy analysis that HPME faculty are continually engaged in around key healthcare issues in Canada today. A synopsis of each study is provided below.

Canadian Stroke Quality of Care Study: Identification of Performance Indicators for Acute Stroke Care

By M. Patrice Lindsay, Moira K. Kapral, Robert Holloway, David J. Gladstone, Jack V. Tu, Andreas Laupacis, Jeremy M. Grimshaw

Results of the Canadian Stroke Quality of Care Study were published in the February 1, 2005 issue of CMAJ (Vol. 172 No. 3: Online-1 to Online-8), identifying a core set of 23 indicators of the quality of acute stroke care. There are currently no published consensus statements or guidelines, or consensus-based indicators to evaluate hospital-based stroke care. The study builds on a set of acute stroke care indicators developed in the US and reflects differences between US and Canadian health care systems. A Canadian expert panel was convened to select key indicators using a modified Delphi process. Panel members evaluated a list of 51 potential indicators based on 6 criteria: validity, feasibility, relevance, opportunity for improvement, expected impact of improvement and overall utility. The highest rated indicators focused on maximizing tissue plasminogen activator (tPA) administration for eligible patients, admission of patients to a specialized stroke unit and in-hospital initiation of secondary stroke prevention therapies. The authors propose that the 23 core indicators be used to improve the quality of care and inform efforts to develop consensus guidelines in Canada for acute stroke management.

In a commentary on the study in the same issue of CMAJ, the authors state, "We hope that these indicators will be adopted by hospitals and embedded in routine clinical care as a means of ensuring a minimum standard of practice and to make transparent to front-line clinicians the criteria by which their performance is being judged (p.363)."

The Development of Performance Measurement System in Healthcare: Lessons Learned from Reporting on Hospitals in Ontario, Canada

By Adalsteinn Brown, George Pink and François Champagne

In the February 2005 issue of Infoletter, ( Vol. 2, No. 1), Adalsteinn Brown (Assistant Professor in HPME), George Pink and François Champagne summed up the lessons learned from developing a system for assessing the performance of hospitals in Ontario . The Ontario Hospital Reports were first produced in 1998 and have since expanded from acute care to include complex continuing care, emergency department care, rehabilitation, and women's health. The top ten lessons learned from over six years of producing Hospital Reports include: pay attention to issues of feasibility, link the performance system to organizational priorities and objectives, develop a conceptual framework, develop performance assessment priorities, put together a consultation and advisory team to oversee development, use expert advisors to develop indicators, develop core and context-specific indicators, ensure a high quality of data, consider different reporting methods, and become familiar with the system before going public.

The Hospital Report Research Collaborative (HRRC) includes faculty and staff from six universities and five institutes. It is sponsored by the Ontario Ministry of Health and Long-Term Care and the Ontario Hospital Association. For more information, see the website: www.hospitalreport.ca.

Infoletter is published three times a year by the CHSRF/CIHR Chair on governance and transformation of healthcare organizations (GETOS) and the CIHR/FRSQ strategic training program on analysis and assessment of healthcare interventions (AnÉIS). For the complete article on lessons learned, see this issue at: www.medsp.umontreal.ca/getos/infol.asp.

First Minister's Accord on Health Renewal and the Future of Home Care in Canada

By Sanober Motiwala, Colleen Flood, Peter Coyte and Audrey Laporte

On February 5, 2003 , the Prime Minister and Premier of seven provinces signed an agreement, the First Minister's Accord on Health Care Renewal, outlining the direction of public healthcare in Canada in the near future. In this feature article on the impact of the First Minister's Accord on Home Care in Canada ( Longwoods Review Vol. 2, No. 4, 2005), the authors find the Accord lacking. They provide a comprehensive review of existing home care services, which straddle medical and social services, the growing need for home care among seniors and the failure of the Accord to address key issues. These include access to long-term care and non-professional home care, legislative protection under the Canada Health Act for home care and the development of a separate funding stream for home care.

Home care currently only accounts for 4.5% of healthcare spending but is the fastest growing sector. The greatest use of home care is in the over 85 population with an expected 80% increase in expenditures expected by 2026 for this group. This included either post-acute (up to 3 months post-discharge) or long-term (minimum of 17 weeks) care. Long-term home care straddles health and social services. Most home care funding is directed to post-acute care which is deemed “medically necessary” and is provided by professionals. Long-term costs for personal support workers, even when “medically necessary” are largely borne by private individuals.

Motiwala, Flood, Coyte and Laporte argue that the setting in which care is delivered should not influence the level of funding received. Yet the failure of the First Minister's Accord to change the Canada Health Act and to establish separate funding for homecare affects its accessibility to Canadians in need. Failure to include home-care under CHA or to provide separate funding enables user-fees to be charged for “medically necessary” services. The 5-year Health Reform Fund established by the Accord can be used by provinces to fund primary care, home care or catastrophic drug coverage. Without separate funding, there is no guarantee that any of the money will be used for home care, particularly for long-term care in the home.

Research and Teaching Profile

Faculty associated with the Department of Health Policy, Management and Evaluation (HPME) are involved in a broad range of research activities with a variety of organizations. Success of the HPME Knowledge Transfer initiative is dependent on presenting our stakeholders with a unified, clear image of the depth and breadth of Departmental expertise. To promote greater internal awareness of the knowledge developed through HPME, faculty research profiles are a regular feature of the newsletter.

This issue of the HPME newsletter features a research profile for Dr. James Wright, paediatric orthopedic surgeon and Surgeon-in-Chief at the Hospital for Sick Children in Toronto.

+ + PROFILE OF THE MONTH + +

James G. Wright, MD, MPH, FRCSC

Dr. James Wright is a Professor in the Department of Surgery, Public Health Sciences, and Health Policy, Management and Evaluation at the University of Toronto . Dr. Wright's major research interests include joint replacement surgery, scoliosis and spina bifida, neuromuscular conditions and foot disorders. He has also written extensively on the measurement of outcomes, including patient satisfaction and quality of life, and evidence-based orthopaedics.

Education and Work Background

Dr. Wright obtained his MD in 1981 and completed his orthopaedic surgical training at the University of Toronto in 1988. He was a Robert Wood Johnson Clinical Scholar and obtained his Master of Public Health from Yale University in 1991. Dr. Wright completed post-graduate medical training at Dalhousie University , the University of Toronto , the Hospital for Sick Children, the Royal Children's Hospital in Melbourne, Australia and Yale. Currently based out of the Hospital for Sick Children, he is the Surgeon-in-Chief, Program Head of the Population Health Sciences, Research Institute, and holder of the Robert B. Salter Chair of Pediatric Surgical Research at the Hospital for Sick Children. In his capacity as Surgeon-in-Chief, he is responsible for overseeing six surgical divisions (Cardiovascular, General, Neurosurgery, Orthopaedic, Plastic and Urology), three Departments (Dentistry, Ophthalmology, Otolaryncology), Anaesthesia, and Critical Care. The Surgical Services staff are engaged in highly complex clinical care, basic and clinical research, undergraduate and postgraduate education and numerous administrative responsibilities. Dr. Wright is also a consultant to the Bloorview MacMillan Rehabilitation Centre.

Research Activities

Dr. Wright's research has focused on the development of measures to evaluate surgical therapy, randomized clinical trials, and evaluating unmet need and disparity in the use of orthopaedic procedures. Through his involvement with HPME, he began collaborating on a program of research on outcomes in joint replacement surgery with Dr. Peter Coyte and Dr. Gillian Hawker in 1989. Since 1995, they have had continuous funding totaling over $8M, including grants from the US Agency for Health Care Policy and Research (1990-1995), the Arthritis Society (1994-2002), Canadian Arthritis Network (2000-2003), Medical Research Council (1995-2002), and CIHR (2005-2007). This research was ahead of its time in studying wait lists and patient needs for joint-replacement surgery. They found that many patients who met the criteria for hip and knee replacement were not receiving treatment and were not on waiting lists. By uncovering unmet patient needs and variations in access to treatment across sub-groups, Dr. Wright and colleagues have put joint replacement surgery on the policy agenda. Hip and knee replacement has been identified as one of the four priority areas identified by the Ontario government for improvement as part of the provincial Wait Times Strategy. (For more about the strategy, see “ICES Report on Wait Times Released” in the In the News section of this newsletter.)

Dr. Wright's work has also received recognition from his peers. In 2002, Dr. Wright, Dr. Coyte and Dr. Hawker, were awarded the Elizabeth Winston Lanier Kappa Delta Award (the "nobel prize" of orthopaedics) for the manuscript, "Area variation and unmet need for orthopaedic surgical procedures." Dr. Wright has recently been awarded the 2005 CIHR, Institute of Musculoskeletal Health and Arthritis (IMHA), Quality of Life Research Award for his on-going work on physician decision-making for joint replacement. For more information on this body of research, see the following publications:

• Coyte PC, Wright JG , Hawker G, Bombardier C, Dittus R, Paul JE, Freund DA, Ho E. Waiting times for knee-replacement surgery in the United States and Ontario . New Engl J Med . 1994; 331(16):1068-1071.
  
  
• Wright JG , Coyte P, Hawker G, Bombardier C, Cooke D, Heck D, Dittus R, Freund D. Variation in orthopaedic surgeons' perceptions of the indications for and outcomes of knee replacement . Can Med Assoc J. 1995; 152(5):687-697.
  
  
• Hawker GA, Wright JG , Coyte PC, Williams JI, Harvey B, Glazier R, Badley EM. Differences between men and women in the use of total joint arthroplasty. N Engl J Med . 04/2000;342(14):1012-1022.

Dr. Wright has more than 120 peer-reviewed publications, including publications in Science, New England Journal of Medicine, JAMA, and the British Medical Journal. In addition to his hospital and administrative activities, he is Associate Editor for Evidence Based Orthopedics for the Journal of Bone and Joint Surgery and past member-at-large of the Board of the Pediatric Orthopedic Society of North America.

Teaching and Supervisory Responsibilities

Dr. Wright first became involved with the Clinical Epidemiology and Health Care Research Program in 1991 while he was a graduate student at Yale. When he moved to Toronto to join the Hospital for Sick Children, he was very active on early committees to develop the HPME “Clin Epi” program and has taught the Measurement in Clinical Research Course (HAD 5302) with Dr. Claire Bombardier for ten years. Dr. Wright continues to lecture in this course and to lead seminars in health services research. Dr. Wright is also active in medical resident education, having won the Robert B. Salter Excellence in Orthopaedic Education Award in May of 1997. Since 1994 he has served, or is currently serving, as primary or secondary supervisor for more than 25 MSc or PhD students.

Future Research Activities

Dr. Wright is currently exploring the reasons for variations in access to joint replacement surgery across sub-groups. He is currently the Principal Investigator of two CIHR funded research grants investigating physician bias as a possible explanation for gender disparity in the utilization of knee arthroplasty surgery. He is also embarking on a new 5-year $3.5M study of the effectiveness of braces for children with scoliosis. This study was recently featured in the April 19, 2005 issue of Macleans Magazine and the Medical Post (Volume 41, Issue 15).

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