“Mind the gap” Which Manitoba health outcomes show increased or decreased inequity over time, and what programs are associated with these?

Speaker: Patricia J. Martens PhDDirector: Manitoba Centre for Health Policy;CIHR/PHAC Applied Public Health Chair;Associate Professor, Department of Community Health Sciences, Faculty of Medicine, University of Manitoba

ABSTRACT AUTHORS: Martens PJ, Fransoo R, The Need To Know Team, Burland E, Prior H, Burchill C, Romphf L.

What Works? A first look at evaluating Manitoba’s regional health programs and policies at the population level.

Authors of report: Patricia Martens, Randy Fransoo, The Need To Know Team, Elaine Burland, Heather Prior, Charles Burchill, Linda Romphf, Dan Chateau, Angela Bailly, Carole Ouelette. Plus a massive Working Group!!

Chapters 7, 10 and 11

CIHR’s The Need To Know Team •CIHR-funded, through the Community Alliances for Health Research (CAHR) program 2001-2007; CIHR KT Award (2007/08); CIHR/PHAC Applied Public Health Chair (2008-2013)

•MCHP, RHAs, Manitoba Health

Burntwood

Nor-Man

Interlake

Parkland

Assiniboine

North Eastman

Central

South Eastman

BrandonWinnipeg

Churchill

Burntwood

Nor-Man

Interlake

Parkland

Burntwood

Nor-Man

Interlake

Parkland

Assiniboine

North Eastman

Central

South Eastman

BrandonWinnipeg

Churchill

Do upstream systems approaches really work to reduce inequity?

Methods• The Population Health Research Data Repository,

housed at MCHP, contains anonymized administrative data for all Manitobans.

• Three health outcomes measured:– Breastfeeding initiation: % newborns breastfeeding on

hospital discharge (1988/89-2003/04)– Mammography tests: % women aged 50-69 receiving 1+

mammography within 2 years (1994/96-2002/04)– Cervical cancer screening: % women aged 18-69 receiving

1+ Pap test within 3 years (1986/89-2001/04)

• Regional age- and sex-adjusted rates and time trends: regression modelling (negative binomial, poisson or logistic regression)

Measure of ‘inequity’

Geographical “inequity” at earliest and latest time period: – subtracting highest and lowest aggregate

area rates = rate difference (RD) – aggregate areas:

• non-Winnipeg areas (Brandon, Rural South, Mid, North);

• three Winnipeg areas (most healthy, average, least healthy).

Burntwood

Nor-Man

Interlake

Parkland

Assiniboine

North Eastman

Central

South Eastman

BrandonWinnipeg

Churchill

Burntwood

Nor-Man

Interlake

Parkland

Burntwood

Nor-Man

Interlake

Parkland

Assiniboine

North Eastman

Central

South Eastman

BrandonWinnipeg

Churchill

“North” = Nor-Man, Burntwood, Churchill

“South” = Assiniboine, Central, South Eastman

“Mid” = Parkland, Interlake, North Eastman

Figure 7.5: Trends in Non-Winnipeg Breastfeeding Initiation Rates

Maternal age-adjusted percent of newborns breastfeeding at hospital discharge

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1988/891989/901990/911991/921992/931993/941994/951995/961996/971997/981998/991999/002000/012001/022002/032003/04

Time period

SouthMidNorthBrandonManitoba

Source: Manitoba Centre for Health Policy, 2007

RD 13.9%

RD 19.8%

Figure 7.6: Trends in Winnipeg Breastfeeding Initiation Rates

Maternal age-adjusted percent of newborns breastfeeding at hospital discharge

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1988/891989/901990/911991/921992/931993/941994/951995/961996/971997/981998/991999/002000/012001/022002/032003/04

Time Period

Wpg Most HealthyWpg Average HealthWpg Least HealthyWinnipegManitoba

source: Manitoba Centre for Health Policy, 2007

Canada Prenatal Nutrition Programs, Healthy Baby and Family First

RD 16.0%

RD 11.7%

Significant “jump” at program onset, p<.003

Figure 10.5: Trends in Non-Winnipeg Mammography Rates

Age-adjusted percentage of women age 50-69 receiving at least one mammogram in two years

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1984/86 1986/88 1988/90 1990/92 1992/94 1994/96 1996/981998/20002000/02 2002/04Time period

SouthMidNorthBrandonManitoba

Source: Manitoba Centre for Health Policy, 2008

RD 47.0%

RD 9.1%

Mid-1990s: Beginning of notification and rural Mobile Screening Program

Figure 10.6: Trends in Winnipeg Mammography RatesAge-adjusted percentage of women age 50-69 receiving at least one mammogram in two years

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1984/86 1986/88 1988/90 1990/92 1992/94 1994/96 1996/981998/20002000/02 2002/04Time Period

Wpg Most HealthyWpg Average HealthWpg Least HealthyWinnipegManitoba

Source: Manitoba Centre for Health Policy, 2008

RD 21.1%

RD 24.3%

Figure 11.5: Trends in Non-Winnipeg Cervical Cancer Screening Rates

Age-adjusted percent of women age 18-69 with one or more Pap smears in a three-year period, excluding those who have had a hysterectomy

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1986/89 1989/92 1992/95 1995/98 1998/2001 2001/04Time period

SouthMidNorthBrandonManitoba

Source: Manitoba Centre for Health Policy, 2008

RD 18.2% RD 31.8%

Figure 11.6: Trends in Winnipeg Cervical Cancer Screening Rates

Age-adjusted percent of women age 18-69 with one or more Pap smears in a three-year period, excluding those who have had a hysterectomy

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1986/89 1989/92 1992/95 1995/98 1998/2001 2001/04Time Period

Wpg Most HealthyWpg Average HealthWpg Least HealthyWinnipegManitoba

source: Manitoba Centre for Health Policy, 2008

RD 8.2%

RD 12.9%

Key Results

BREASTFEEDING RATES: Winnipeg’s breastfeeding rates showed decreased inequity, associated with national (CPNP) and provincial perinatal core-area initiatives.

MAMMOGRAPHY RATES: mammography gap increased slightly in Winnipeg, but decreased dramatically outside Winnipeg. Provincial notification and rural mobile screening began in mid-1990s.

PAP TEST RATES: Pap tests showed increased inequity over time, both within Winnipeg, and more so outside Winnipeg. There was no cervical cancer provincial screening program.

Inte

rnal

val

idit

y

Low

High

Cross-sectionalPre-experimentalAnecdote/case study

Time series with comparisonObservational (prospective, historical prospective)Case-controlTime series with qualitative layer

Randomized Controlled Trials RCTQuasi-experimental comparison group studies

Associated, not causal!

"Le mieux est l'ennemi du bien.", from Voltaire's Dictionnaire Philosophique

(1764)

"The best is the enemy of good.“

More commonly cited as: "The perfect is the enemy of the good."

John B. McKinlay, 1998

Time series! (plus “systems” approach)

Key Message

“Upstream systems approaches”– Greater health inequity reductions were

associated with federal or provincial programs to increase access.

“Making the right choice the easy choice”

ManitobaCentre forHealth Policy

MCHP

www.umanitoba.ca/medicine/units/mchp/

Important to read the whole report!