Mythbusters Using evidence to debunk popular myths in Canadian healthcare Jenn Thornhill, M.Sc., BJH Senior Advisor, Knowledge Summaries 17 October 2008

Overview About CHSRF About Canada’s healthcare “systems” – key features About Mythbusters – key examples & lessons learned http://www.dolighan.com/ July 30, 2004

About us Publicly-funded, not-for-profit organization Registered charity under the Canadian Corporations Act (1997) $100M endowment $15-16M annual operating budget Board of Trustees (14) – regional reps; researchers and decision makers New President and CEO, Maureen O’Neil 45 staff with “best place to work” awards

Our Vision & Mission Our vision is a strong Canadian healthcare system that is guided by solid, research-informed management and policy decisions. Our mission is to support evidence-informed decision-making in the organization, management and delivery of health services through funding research, building capacity and transferring knowledge.

CHSRF 2007-2011 A focus on enabling organizations that are predisposed to using evidence, and disseminating innovation Products that are more responsive to the needs of decision makers Increasing differentiation from the granting councils A shift along the spectrum of conceptual versus instrumental use

What do we really do?

Canada – an Overview ~ 10M km2 land area 31.6M people (2006) 10 provinces and 3 territories Discrepancies between: urban and rural/remote areas east/west north/south major economic centres: Toronto, Montreal and Vancouver

Sept 13, 2004

Canadian Healthcare Systems 1947 (Saskatchewan): national and provincial components of current Medicare system introduced – public financing, private delivery Hospitals are private, NFP; physicians mainly self-employed and FFS; but increasingly salaried employees Current system covers medically necessary hospital and physician services for all Canadians in 10 provinces and 3 territories Federal role: oversight of Canada Health Act; transfer payments to P/Ts; healthcare services for federal prisons, armed forces, and aboriginal people Provincial role: manage services through provincial health insurance plans with federal transfer payments; majority of healthcare funds raised through taxation 70% of healthcare expenditures are publicly funded; 30% private

Healthcare in Canada (cont’d) Five principles underlying the Canada Health Act (1984): universality, public administration, portability, accessibility, and comprehensiveness Private insurance/physicians cannot offer services for which there is public health insurance coverage Supplementary private insurance offered by most employers 9.8% of GDP (2005) spent on healthcare (average within G7) Approx. 36% of P/T budgets spent on health Regionalization within P/Ts – local responsiveness Strong public support for healthcare system, but concerns exist

Mythbusters (2000+) “. . . healthcare ‘zombies’ – ideas, or positions, that often appear, on first blush to be ‘common sense’ (or are widely held beliefs) but under which there turns out to be embarrassingly little research evidence.” Barer, M. 2005. Evidence, Interests and Knowledge Translation: Reflections of an Unrepentant Zombie Chaser. Healthcare Quarterly; 8(1): 46-53.

To every complex problem there is a simple answer: Neat, plausible, and wrong. - H.L. Mencken We can talk a little about how to identify myths, if you like. Mainly these seem to originate from the same folks – those who are critics of Medicare, Canada’s publicly funded healthcare system. Another way is that if the solution seems to good to be true, it probably is. 12

Ex I – Private-sector Care Public healthcare covers “medically necessary” hospital and physician services Public sector accounts for 70% of total healthcare spending; Private accounts for 30% Most insurance schemes forbid doctors from offering services that are offered under the public insurance plan May 9, 2005

Framing of privatization – the myths Canada (like communist Cuba and N. Korea) disallows private payment for healthcare Parallel private systems reduce wait times For-profit ownership of facilities improves efficiency Healthcare costs are spiraling out of control* User fees stop consumer waste NEW: Activity-based funding will ensure that money follows the patient – better quality; rewards and penalties for hospital performance

Privatization – the players (for) Recent growth in investor-owned medical clinics and DI facilities June 2005, historic Supreme Court of Canada case (“Chaoulli decision”) CMA – “Medicare Plus” Right-wing think tanks (i.e., Fraser Institute) Federal gov`t largely criticized for its absenteeism in enforcing CHA June 11, 2005

Privatization – the players (against) Canadian Doctors for Medicare & Médecins Québécois pour le Régime Public Canadian Union of Public Employees – launched a campaign to “Tell Tony Clement to keep health care public” Council of Canadians Coalition Solidarité Santé

Ex II – Financial Sustainability Discussing this topic is “the national pastime” Framing of the issue: Medicare is a monopsony, with no competition, therefore, costs remain perpetually high. Public funding and administration cannot meet the needs of an aging population

Financial Sustainability Total health spending as a share of GDP is comparable to elsewhere Increases are moderate Real cost drivers fall outside of Medicare Declining tax base; but Canadians are willing to pay higher taxes

Ex III – Physician Brain Drain Physician Migration, 1970–2006 Canadian Institute for Health Information. Scott's Medical Database (SMDB). 2000-2007. Supply, Distribution and Migration of Canadian Physicians, 1999-2006. 19

“More Doctors More Care” CMA’s ad campaign 2008 Canadian Medical Association. 2008. www.moredoctors.ca 20

The News Headlines Maclean’s. 2008, January 3 - The doctor crisis | Five million Canadians are currently without a family doctor - and things are only getting worse Maclean’s. 2008. March 17 – Fixing a doctor crisis CBC DocZone. 2008, January 19 - Desperately Seeking Doctors 21

The problem: Supply? No, but there are problems “Why does it feel like we have a physician shortage? If it is true that an increasingly sever shortage has been developing since the mid-1990s, it must be a shortage of physicians’ services, not of physicians per se, perhaps reflecting declining average clinical workload per physician.” Chan B. 2002. From perceived surplus to perceived shortage: What happened to Canada’s Physician Workforce in the 1990s? Ottawa: Canadian Institute for Health Information. 22

Ex IV – Aging population (2002) Fact: the proportion of Canadians over 65 is increasing. Fact: the elderly need more medical services than younger people. The real issue is with changes in the number and nature of medical services for elderly patients; Also, it’s actually healthy seniors who have driven the most significant increases in healthcare use Is intensified care for healthy elderly people appropriate and necessary?

In healthcare, less maybe more Inspired by Ivan Illich’s (Austrian philosopher, social critic, historian) Medical Nemesis (1976); Hypothesized: The greatest threat to mankind is healthcare Roemer’s Law: “A built hospital bed is a filled hospital bed” Dartmouth Atlas Project: examines geographical variations in care

Key Messages Most myths originate from the same place – the critics of Medicare As such, myths are created and debunked through ongoing political posturing and positioning of the issues. The CHSRF is well-positioned to confront these myths given our bias for the best-available evidence.

Lessons Learned for writing Mythbusters

Mythbusters Teaching Resource Spotting the Myth Searching for Evidence Writing the Summary Adding Visual Appeal Undergoing Review Sharing Evidence-Informed Messages

Mythbusters as a teaching tool Summaries are used: as course readings; as samples of KT strategies; to inform class discussions/seminars; to inform the development of a curriculum module. CHSRF. Summer 2007. Links; 10(2): 8. 28

Knowing your audience It’s useful to think of all audiences as ‘decision-makers’ since ‘decisions’ are what might be improved with research evidence.” - Reardon et al., 2006

Knowing your audience ggg

Storytelling

Why are stories important? A single narrative is as powerful as any health care intervention; it is the one language that all of us - health care worker and lay person - share... a single narrative can change the way we live our lives, practice our art, and even reform our policies. When we don't tell our stories, our experiences... can disappear forever. So can the possibility of a more relevant and meaningful kind of health care. Chen, P.W. 2008. Narrative Matters: “Stories beyond the box.” Health Affairs; 27 (4): 1148-53. 32

Getting to the point “What the story is about involves the context (the background, facts, and people involved); the point of the story is the main theme, the thread that connects each part of the story, or the ‘so what’ factor.” Roberts M. 2006. Finding a story’s focus. www.concernedjournalists.org/node/474 33

Relying on Opinion Leaders Opinion leaders disseminating and implementing “best evidence” is one innovative method that holds promise as a strategy to bridge know-do gaps. When it comes to encouraging change, opinion leaders’ views have greater sway than other people’s constructive criticism. Identifying opinion leaders can take a lot of work and be hard to validate, but when they are found they can boost the amount of research being used in everyday practice. G. Doumit, M. Gattellari, J. Grimshaw, and M.A. O’Brien. 2007. “Local opinion leaders: Effects on professional practice and health care outcomes.” Cochrane database of systematic reviews.

Should the Drug Industry Use Key Opinion Leaders? British Medical Journal 336(7658) June 2008 Drug marketing: Key opinion leaders: independent experts or drug representatives in disguise? (Ray Moynihan)

Measuring impact Thornhill J., Neeson J. & Clements D. 2008. Myths, “Zombies” and “Damned Lies” Plague Canadian Healthcare Systems. What’s a Researcher to Do? Healthcare Quarterly; 11(3): 14-15.

Implementation How do we move from distribution (passive) to dissemination (active) to implementation (most active)?

Thank You jennifer.thornhill@chsrf.ca www.chsrf.ca Aug 18, 2005