Mortality rates for acute myocardial infarction (AMI) in the province of Manitoba were studied by a retrospective, randomized survey of urban and rural hospital records. Urban hospitals had formal coronary care unit (CCU). Selected rural hospitals lacked CCUs but usually possessed portable monitoring and defibrillation equipment. Twenty-seven percent of 852 cases in the study population died. The mortality rate for unequivocal AMI was 14% to 15% to both urban and rural hospitals. Patients with possible AMI had high mortality rates in both facilities (41% to 45%). Subgroup analysis of the definite AMI population failed to reveal statistically significant differences in urban vs rural mortality, although a consistent trend toward superior performance in urban centers was found. The magnitude of the potential of a rural hospital intervention program to reduce the AMI mortality nevertheless appeared to be small.
An overview of the Manitoba study of common surgical procedures is presented. The research is oriented toward describing and explaining the outcomes of nine relatively common procedures, using longitudinal data from the Manitoba Health Services Commission's population registry, medical claims, and physician claims. The research approach recognizes differences among surgical procedures, tailoring the analyses to specific characteristics of a given procedure. At the same time, this article describes the efforts made to achieve economies of scale in organizing the data base and writing the computer programs. The strategy used for assessing surgical risks and benefits is described at some length. Health services utilization before and after surgery is compared across small areas with widely differing surgical rates. Comparisons between surgical and other groups are suggested. The wealth of data permits a number of different types of studies. One study deals with patterns of surgical practice, types of operations performed, and risk characteristics of patients brought to surgery in areas with differing surgical rates. High-risk patients residing in high-rate areas are more likely to be operated upon than their counterparts in low-rate areas. A second study found that hysterectomy is apparently being used in situations where women have high rates of contact with the health care system before surgery; their rates of contact after surgery are almost as high. Ongoing activities in the research project are outlined.
In this study, population-based data were used to examine the appropriateness of Papanicolaou (Pap) testing from the perspective of the women being tested and their physicians. The approach used is unique in its assessment of overtesting and undertesting in the primary care setting. From the data base of the province of Manitoba's universal health insurance plan, 4-year health histories (1981 to 1984) were constructed for each woman from a random sample of the population of women who, in 1982, were between the ages of 25 to 64 years (n = 22,287). At the last visit to a general practitioner, gynecologist, or general surgeon in 1984 (termed the current visit), the authors determined whether a Pap test was given for each woman. Using decision rules from a Canadian task force report on cervical screening and previous health history, the authors evaluated the appropriateness of screening by determining whether a Pap test was given and was needed, or whether a women who had not received a Pap test required one. Overall, 55.7% of women were tested appropriately. Of the 5352 women who received a Pap test at the current visit, 62.8% were overtested. Of the 16,935 women not tested at the current visit, 38.5% required screening (i.e. were undertested). Characteristics of a physician's practice that were significantly related to compliance with the guidelines included having a high proportion of patients visiting for obstetric or gynecologic reasons. Variables that were associated with negative compliance were 1) being a gynecologist; and 2) having a high proportion of patients who lived in inner city or rural areas. Because physicians are paid a fee for every Pap smear taken and the guidelines were well disseminated, these results should be reasonably representative of fee-for-service practice in North America, where preventive care is not subject to user charges. This study supports previous findings that a passive approach to dissemination of guidelines is insufficient to effect practice.
Claims data from the Manitoba Health Services Commission on all health care contacts during the 2 years preceding and the 2 years following gallbladder surgery were used to describe the histories of patients prior to cholecystectomy, and to assess surgical outcomes. The study is unique in focusing on essentially all patients in the population undergoing surgery (whether at large academic centres or small rural hospitals) and in tracking post discharge events (deaths and complications). Many patients presenting for surgery with acute/urgent conditions were previously asymptomatic or at least their gallbladder disease was undiagnosed (27%). Although overall mortality rates were low (0.7%), 26% of the deaths occurred following discharge from the hospital where surgery was performed. In addition, 3.4% of the patients were readmitted to hospital with complications of the gallbladder surgery, 13.5% continued to visit the physician with abdominal symptoms after surgery and 17% presented with psychological problems. Multiple logistic regression is used to estimate the risk of poor surgical outcomes according to a patient's presurgical characteristics. The analysis suggests that most published data are biased towards underestimating the risks associated with cholecystectomy (as well as the risks associated with other common surgical procedures).
This paper explores outcomes associated with the tonsillectomy operation using multiple control groups and a large claims-based data bank from the Canadian province of Manitoba. Given the difficulty of conducting large-scale clinical trials of common surgical procedures, the use of multiple methods for evaluating such interventions is both advocated and implemented in this study. When the data are restricted to respiratory diagnoses, the findings suggest that, on the average, tonsil surgery saves between one half and one and a half episodes of illness per patient over the two years after surgery. Such savings are much more pronounced among individuals having several tonsillitis episodes in the preoperative year. However, when all medical claims are considered, the estimated savings from the tonsillectomy operation are somewhat reduced. Individual variation in predisposition to "see the doctor" appears to account for such results; visits about conditions other than respiratory take up much of the "savings" produced by tonsil surgery. The findings are discussed in terms of the costs and benefits of the tonsillectomy operation, and future research needs are outlined.
Research on adverse outcomes following common surgical procedures has suggested the importance of hospital and surgeon variables. Policy directions depend on which factors are important in influencing patient outcomes and what sorts of policies are feasible. Focusing on where a given procedure is performed highlights a concern for centralization; emphasizing who should perform a particular operation implies physician certification. Finally, monitoring involves identifying particular hospitals that appear to have relatively poor (or relatively good) results. This paper analyzes patient, surgeon, and hospital characteristics associated with serious postdischarge complications of hysterectomy, cholecystectomy, and prostatectomy in patients age 25 and over in Manitoba, Canada, following surgery during 1974 through 1976. The three procedures differ markedly in the ease of prediction of the probability of complications and in the predictive importance of patient, hospital, and physician variables. The predictors worked fairly well for cholecystectomy, somewhat less well for hysterectomy, and not well at all for prostatectomy. Hospital variables were not generally important in the multiple logistic regressions. After controlling for case mix and type of surgery, physician surgical experience was found to account for relatively large differences (almost two to one) in the probability of patient complications following cholecystectomy. Cholecystectomy might be a candidate for certification because of the epidemiology of the operation. As of the mid-1970s, a substantial proportion of the cholecystectomies were being performed by physicians with comparatively little ongoing experience with this type of procedure. Moreover, a monitoring perspective identified one hospital with a significantly higher postcholecystectomy complication rate, even after physician experience was taken into account. Both identifying which procedures should be attended to and focusing on problems following surgery are important beyond Manitoba and highly relevant to such American requirements as Peer Review Organizations. Methods of increasing the efficiency of using claims data for quality assurance studies are outlined.
The impact of centralized facilities on access to care was tested by studying total hip arthroplasty in the Province of Manitoba, Canada. Data from the Manitoba Health Services Commission, which insures costs of all medical services in the Province, show that the availability of this surgical procedure has increased steadily over the 1973-78 period at a rate similar to that elsewhere in North America. Although Manitoba's population is geographically dispersed, specialized orthopedic services are concentrated in two urban centers. No important difference in access to care for this condition was found between urban center residents and residents distant from the surgical facilities.
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This study was designed to describe patient characteristics associated with having a regular source of care among all patients who received care from large urban clinics in Manitoba over a three-year period (N = 298,222). Using administrative data, patients were classified as having a regular source of care if they made 75% or more of their total ambulatory visits to the same clinic. Overall, 44.2% of patients had a regular source of care. A logistic regression showed that children and adults aged 45 and older were more likely to have a regular source of care than patients aged 18-44. Moreover, patients with a regular source of care tended to live in more affluent neighbourhoods and were healthier than individuals with no regular source of care. Systemic changes might be needed to enhance continuity of care (e.g., mechanisms to enhance access) among vulnerable segments of the population like the poor.
In light of ongoing discussions about health care policy, this study offered a method of calculating costs at Manitoba hospitals that compared relative costliness of inpatient care provided in each hospital.
This methodology also allowed comparisons across types of hospitals-teaching, community, major rural, intermediate and small rural, as well as northern isolated facilities.
Data used in this project include basic hospital information, both financial and statistical, for each of the Manitoba hospitals, hospital charge information by case from the State of Maryland, and hospital discharge abstract information for Manitoba. The data from Maryland were used to create relative cost weights (RCWs) for refined diagnostic related groups (RDRGs) and were subsequently adjusted for Manitoba length of stay. These case weights were then applied to cases in Manitoba hospitals, and several other adjustments were made for nontypical cases. This case mix system allows cost comparisons across hospitals.
In general, hospital case mix costing demonstrated variability in hospital costliness, not only across types of hospitals but also within hospitals of the same type and size.
Costs at the teaching hospitals were found to be considerably higher than the average, even after accounting for acuity and case mix.