ICES Researchers Conduct Preliminary Study of MRI Usage in Ontario
Andreas Laupacis, HPME
Professor and CEO of the Institute for Clinical Evaluative Sciences
(ICES), along with Karey Iron and Raymond Przybysz, recently published
Access to MRI in Ontario: Addressing the Information Gap, a technical
report on access to magnetic resonance imaging (MRI) scanners, and
relevant utilization data. The report is available in full text
on the ICES website.
The researchers conducted a literature review, administrative data
analysis, and qualitative survey of MRI centres in Ontario. Their
literature review revealed that Ontario (and Canada) has low rates
of MRI scanners per population compared with other countries in
the developed world, yet the potential indications for MRI, and
waiting times for MRI appear to be increasing.
The analysis of administrative data for outpatient scans-only demonstrated
that the frequency of MRI scans has increased more than 5-fold in
the last decade and by more than 50% from 1999 to 2001; there are
age- and gender-adjusted regional variations in MRI rates across
the province; and approximately 14% of patients have repeat MRI
scans within two years.
While administrative data can provide helpful information many
important pieces of information are missing. The qualitative survey
of Ontario MRI centres revealed that some, but not all of this missing
data is routinely gathered and could be obtained through chart review.
Along with associated implications, the report offered the following
strategic options:
Create a committee or group with the responsibility for reporting
on quality issues regarding MRI.
Annually monitor MRI utilization.
Establish a standard form for recording the indication and
waiting time for MRI in Ontario. This should be collected electronically
in a format that would allow linkage to administrative data, and
include inpatient and outpatient cases, and public and private providers.
Therese Stukel: No difference in quality of health
care between higher- and lower-spending regions
Dr. Therese Stukel, HPME
Professor and research director of the Institute
for Clinical Evaluative Sciences, participated in a major U.S.
cohort study involving nearly one million Medicare recipients to
determine whether regions with higher Medicare spending actually
provide better care (1,2). The study, published in the February
2003 issue of the Annals of Internal Medicine, found that residents
of higher-spending regions received 60% more care but did not have
better quality or outcomes of care.
Patients hospitalized between 1993 and 1995 for hip fracture, colorectal
cancer or acute myocardial infarction (AMI), plus a sample of patients
drawn from a previous study of Medicare Beneficiaries conducted
between 1992 and 1995 were categorized into different levels of
end-of-life spending in his or her referral region, an indicator
of Medicare spending not linked to regional differences in illness.
Quality of care (for example, use of aspirin after AMI, influenza immunization)
in higher spending regions was no better on most measures and was
worse for several preventive care measures. Access to care (for
example, having a usual source of care) in higher spending regions
was no better compared with lower spending regions.
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL,
Pinder EL. The implications of regional variations in Medicare spending.
Part 1: The content, quality, and accessibility of care. Ann Intern
Med 2003; 138(4): 273-87.
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL,
Pinder EL. The implications of regional variations in Medicare spending.
Part 2: Health outcomes and satisfaction with care. Ann Intern Med
2003;138(4):288-98.
Update on Primary Care Performance Assessment
Phase 1 - Indicator Selection
Phase II - Data Quality/Feasibility
Dr. Jan Barnsley , HPME Associate Professor and Departmental Director of the MSc/PhD program, is leading a research study that involves field-testing previously developed primary care performance measures to assess the feasibility of collecting indicator data. The Primary Care Performance Assessment Project involves Judith MacPhail, the project coordinator, other HPME faculty including Rhonda Cockerill, Whitney Berta and Eugene Vayda, as well as primary care physicians from Mount Sinai Hospital / Department of Family and Community Medicine, University of Toronto (Dr. Jeff Bloom, Dr. Yves Talbot) and from the Institute for Clinical Evaluative Sciences / Sunnybrook and Women's College Health Sciences Centre / Department of Family and Community Medicine, University of Toronto (Dr. Liisa Jaakkimainen).
The purpose of the study is to work collaboratively with Ontario family physicians to develop and test a performance measurement system. This study directly involves primary care physicians in the development of evidence-based practice assessment tools and processes. The study's data collection tools include indicators in the areas of preventive care, screening and health promotion, management of acute and chronic conditions, and practice organization and management. The indicators were selected through consensus by a 12-member primary care panel of active clinicians including physicians and a nurse practitioner from various types of practice and with different reimbursement schemes, in both urban and rural settings. This work took place in 2001.
During 2002 indicator data were abstracted from medical records at ten practice sites. The purpose of this phase of the project was to examine the quality of data, and the usefulness and applicability of the indicators in practice. Indicators will be modified based on input from participating family physicians. Data collected from medical records will be considered in the context of additional information about the organizational structure and office systems gathered through a key informant interview and by direct observation.
Subsequent to each practice visit the investigators provided the family physicians and associated office staff with an onsite, interactive workshop on performance measurement, practice management, and quality indicators. Specific information on the quality of their data and data management practices is also provided. The purpose of the workshop is to explain the relationship of performance measurement to quality of care; familiarize the participants with the evidence for, and the applicability of 48 indicators of quality relevant to family medicine; encourage self-review and assessment of data management practices; and facilitate the identification of gaps in data collection and quality assurance practices.
The research team will continue their work on primary care peformance measurement through ongoing communication with family practitioners and relevant professional associations, and by designing studies to develop, implement and evaluate primary care practice management strategies based upon indicators of quality care.
Research and Teaching Profiles
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 will be included
as a regular feature of this newsletter.
This issue of the HPME newsletter features a research profile
for:
Whitney Berta, an Assistant
Professor in HPME and the Department representative for the Collaborative
Program in Aging and the Life Course. Her research focuses on
organizational performance, organizational learning and knowledge
transfer predominantly in the long term care sector.
+ + PROFILE OF THE MONTH + +
Whitney Berta, PhD
Dr. Berta is an Assistant Professor of Health Services Organization and Management in HPME. Her research interests are in organizational performance, organizational learning and knowledge transfer. Her research involves both longitudinal and multilevel analysis and focuses predominantly on long term care. She also functions as the Department representative for the Collaborative Program in Aging and the Life Course.
Education and Work Background
Dr. Berta completed an MBA in Marketing and Strategy at McGill University. She gained work experience as a marketing director for a small industrial manufacturing firm in Montreal, then as a supervisor of energy management program development for Ontario Hydro in Toronto. She has worked on consulting projects for energy industry organizations including energy management and monitoring programs, and the development of strategic alliance initiatives. In 2000 she acquired a PhD in Organization Theory at the J.L. Rotman School of Management, University of Toronto.
Additional professional activities include membership in the Academy
of Management and service on several committees including: member
of the Leadership and Innovation Network for Long-Term Care in Ontario
of the Institute on Health of the Elderly in Ottawa; member of the
Certified Health Executive Program Sub-Task Force of the Canadian
College of Health Service Executives; chair of the Faculty Development
Survey Sub-Committee of the Gender Issues Committee, Faculty of
Medicine, University of Toronto; member of the Research Committee
for M-THAC (Medicare
to Home and Community)
; member of the Peer Review Committee of The Canadian Initiative
on Social Statistics (CISS) - a Strategic Joint Initiative of SSHRC
and Statistics Canada
; and member of the Executive Committee for the Collaborative Program in Aging and the Life Course. She has served as an academic reviewer for the Administrative Sciences Association of Canada Conferences, the Academy of Management Meetings, and as an external reviewer for the Canadian Institutes of Health Research.
Research Activities
Most recently Dr. Berta has worked with colleagues on studies of
knowledge transfer in nursing home chain organizations operating
in the U.S. A book chapter published last year (Mitchell, Baum,
Banaszak-Holl, Berta, and Bowman 2002) describes a study of chain-to-component
transfer learning and focuses on how the level and similarity of
capabilities of chains and their components affects transfer learning
across component units. The findings show that chains and nursing
home acquisitions and divestitures often lead to substantial component
level changes that align the acquired unit with the capabilities
of its new owner – a good thing when the acquiring chain is
a high performer, but an undesirable situation when the acquiring
chain is a poorer performer than the nursing home it acquires. Another
recently published study (Banaszak-Holl, Berta, Bowman, Baum, and
Mitchell 2001) focuses on the antecedents of nursing home acquisition
and examines how acquisitions affect the operating strategies of
the acquired facilities and the health outcomes of residents. These
results are highly relevant in the nursing home sector, in which
almost half of U.S. nursing homes are now part of chain organizations
and hundreds of acquisitions occur each year.
A subsequent study, being prepared for publication (Banaszak-Holl
et al 2002) further evaluates the impact of chain ownership of U.S.
nursing homes by examining whether facilities demonstrate variation
in services, staffing and health outcomes across three structural
dimensions - chain ownership, chain and facility size and proprietary
status. Another study, funded by the Michigan Blue Cross Blue Shield,
focuses on how chains operating in Michigan use corporate policies
and provide skills and routines to staff in their nursing home units,
and what the impacts of these practices are on the quality of nursing
home services (Kamimura, Banaszak-Holl, and Berta 2003).
Dr. Berta was recently awarded funding as a Co-Principal Investigator -- with Dr. Gary Teare, a Scientist with the Toronto Rehabilitation Institute and Assistant Professor with HPME -- through the CIHR's Knowledge Translation Strategies for Health Research Program for a 3-year project entitled "Learning Capacity in Ontario's Long-Term Care Facilities: A Study of Factors that Affect the Adoption, Transfer and Retention of Clinical Practice Guidelines". Co-Investigators include Dr. Lemieux-Charles, Dr. Ginsburg, Dr. Davis and Dr. Rappolt. Ms. Gilbart, a doctoral student with HPME, is supported through this grant. The research will focus on factors that influence knowledge transfer across and within long-term care (LTC) facilities in Ontario, including guideline-content, individuals within LTC facilities, characteristics of the facilities, and environment-level factors. The findings of this study will help policy makers and administrators of LTC institutions decide where, and how to invest in order to stimulate more uptake and retention of new knowledge and innovations that are intended to improve performance.
Dr. Berta is a co-investigator on a research project led by Dr. Jan Barnsley, HPME Associate Professor, funded by the Ontario Ministry of Health and Long-Term Care, which focuses on testing a set of evidence-based primary care performance indicators identified in a prior study by the project team in consultation with an Expert Panel of 12 clinicians practicing in Ontario. SEE Update on Primary Care Performance Assessment.
Teaching and Supervisory Responsibilities
Dr. Berta has taught several courses for HPME, most recently the
Health Services Organization and Management Comprehensive Examination
Course (co-taught with faculty in the HSO&M research stream),
Health Services Research Methods (co-taught with Dr. Barnsley),
and Theory and Practice of Strategic Planning and Management in
Health Services Organizations. She is currently serving on the thesis
committees of two PhD students and is a practicum supervisor for
the HPME MHSc program.
Future Research
Dr. Berta and Dr. Laporte, also an Assistant Professor with HPME,
were just awarded funding for three years by the Social Sciences
and Humanities Research Council (SSHRC) to undertake a study of
the determinants of operational efficiency estimates of long-term
care facilities in Canada.
