1. Inputs, Outputs and Outcomes: What Measures, What Matters Glenda Yeates, President & CEO Canadian Institute for Health Information October 30, 2007

2. Overview CIHI: Taking Health Information Further Health Inputs Health Outputs Health Outcomes Moving to a Future Vision

3. Taking Health Information Further CIHI works to improve the health of Canadians and the health care system by providing quality health information.

4. Who we are A national, independent, non-profit agency Mandate : –national coordination mechanism for health information in Canada –provide accurate and timely information for: sound health policy effective management of the health system public awareness of health determinants

5. What we do Data Holdings Collect, process and maintain data for a growing number of national and provincial health databases and registries: – Health Services – Health Professionals – Health Expenditures

6. What we do Data Standards Coordinate/promote development and maintenance of health information standards, including: – Financial and Managerial Standards – Minimum Data Sets – Grouping Methodologies – Disease/intervention Classifications ICD-10-CA/CCI International Classification of Functioning, Disability and Health

7. What we do Analytic Products Produce a variety of reports, special studies and analytic products to address questions of interest to stakeholders –Health Care in Canada –Health Indicators –Medical Imaging –Health Expenditures (NHEX) –Many others …

8. Inputs/Outputs/Outcomes “Not everything that can be counted counts, and not everything that counts can be counted.” – Albert Einstein

9. CIHI/STC Health Outcomes Framework

10. Health Inputs-Outputs-Outcomes INPUTS Health Expenditures Human Capital Capital Equipment Health Policy Decisions OUTPUTS Efficiency Productivity Value for Money  OUTCOMES Status of Population Health Results of Interventions (Changes in Morbidity and Mortality) =

11. Health Inputs “Inputs are productive resources: human time, energy, and skills, the services of capital equipment such as buildings and machinery, raw materials, intermediate products which are themselves the outputs of prior production processes, and “knowhow” to combine all these.” - Evans, 1984

12. Distribution of Health Spending in Canada Source : National Health Expenditure Database (forecast 2006), CIHI.

13. Distribution of Health Human Resources in Canada: Physicians and Registered Nurses Sources: Registered Nurses Database, CIHI; Scott’s Medical Database, CIHI; 2005 population estimates, Statistics Canada.

14. What are the Gaps ? There are a number of gaps, for example: –We have a better understanding of health inputs for acute care than we are in other areas of care –We know more about physicians and nurses than we do about other health professionals

15. Health Outputs “The quantity of health care received by patients, in terms of complete treatments, adjusted to allow for the qualities of the services provided.” - Smith & Street, 2006

16. Health System Utilization We know a lot about the types of health care services being accessed by Canadians, for example: –Health Services Utilization Over 14 million ED visits annually 3.1 million hospitalizations in 2005-2006 Median length of stay 4 days 33,590 hip replacements and 25,124 hip replacements in 2004-2005 –Diagnostic Imaging 816,512 MRI scans and 2.8 million CT scans in 2004-2005

17. Trends in age-standardized surgery rates Sources : Discharge Abstract Database, CIHI; National Ambulatory Care Reporting System, CIHI; special tabulations provided by Alberta Health and Wellness and Manitoba Health.

18. What are the Gaps ? There are a number of gaps, for example: –Not all provinces and territories submit data to all databases –Community-based care Primary health care Home care Community mental health –Private sector, Alternative payments for physicians

19. Health Outcomes “A health outcome refers to the effect or result of care or interventions on the health status of patients or populations.” - Donabedian, 1988 “Changes in health status (mortality and morbidity) which result from the provision of health (or other) services.” - OECD, 1992 ”Health outcomes are changes in health as a result of the level of care received.” - ACHORD, 2003

20. Surgical Volumes and Outcomes Based on our results, for every 10 additional procedures a hospital performed, there was a lower risk-adjusted 30-day in- hospital mortality rate for three procedures (angioplasty, esophagectomy, and Whipple). Source: Discharge Abstract Database, CIHI.

21. Regional Variations in Mortality Following an AMI Sources: Hospital Morbidity Database, CIHI; Discharge Abstract Database, CIHI.

22. 30 day Stroke & AMI in-hospital Mortality Rates Over Time Sources: Hospital Mortality Database, CIHI; Discharge Abstract Database, CIHI.

23. Readmissions for Specific Medical Conditions by LHIN Sources: Discharge Abstract Database, CIHI; National Ambulatory Care Reporting System, CIHI.

24. Source: Canadian Organ Replacement Register, CIHI. Unadjusted Short- and Long-Term Survival in Patients on Dialysis With and Without Diabetes

25. Hospital Standardized Mortality Ratio (HSMR) Source: Health Indicators, CIHI.

26. Health Outcomes and Elective Surgery: Cataracts (Charles Wright) Results: 70% of patients indicated post-surgery improvements, but 27% reported worse or no change in outcomes

27. What are the Gaps? There are a number of gaps, for example: –Consensus No agreement on the important questions to ask No agreement on the important outcomes to measure How do we measure “success”? –Data Collection Patient pre- and post-operative function Patient satisfaction –Functional Status of Patients Long-term tracking of patients after interventions

28. Moving to a Future Vision “It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.” — Charles Darwin

29. CIHI’s Vision for Better Measures of Health Output and Outcomes … We will have robust dialogue and consensus around which outcomes are the most important to measure We will have more and better quality data –Pan Canadian –Moving beyond acute care EHR and other sources: constructed and standardized in a way to be able to address the questions that physicians and others are asking As a country we would have better data to enable discussion of outcomes for system-level planning

30. The Road Ahead...

31. To learn more, visit the CIHI website: www.cihi.ca