Primary Care Indicators · 2016-03-30 · Primary care indicators Accountability Target Target source Percentage of diabetics with eye care visits with an optometrist or ophthalmologist

Common Quality Agenda DRAFT - DO NOT CIRCULATE 1

Primary Care Indicators


There are 16 Common Quality Agenda indicators that are relevant to the primary care sector.

Accountability for three of these is specific to primary care; 13 have shared accountability with

another sector. Ten of the primary care indicators selected for the Common Quality Agenda

align with the measurement priorities identified through the Primary Care Performance

Measurement Framework project, a provincial initiative to identify measurement priorities and

indicators for primary care. In addition, the Common Quality Agenda indicators draw from the

QIP indicators and indicators associated with best practice in population health and chronic

disease management. Indicators and targets for this sector were also selected with the support

and guidance of the Cardiac Care Network, Public Health Ontario and BORN.

Primary care indicators Accountability Target Target source

Percentage of diabetics with eye care visits with an optometrist or ophthalmologist within 1 year (CD) (R)

Primary care 80% Expert consultation

Percentage of elderly diabetic patients (>65 years) who regularly filled prescriptions for statins (CD) (E)

Primary care 80%; relative improvement 25% year over year

Expert consultation

Age and population appropriate screening rates for •Colorectal cancer (FOBT) •Breast cancer (mammography) •Cervical cancer (Pap smear) (PH) (E)

Primary care FOBT, 2011 CCC Target = 40% National mammography target = 70% Ontario Cancer plan Pap screening target >85%

Provincial and CCO National target Provincial and CCO

Admission rates for conditions that are sensitive to outpatient (ambulatory) care delivery (CHF, COPD, diabetes, asthma) (R) (CD)

Hospital/Primary Care/Long-Term Care/Home Care

20% relative reduction year over year

Expert panel consultation

Percentage of ALC days in acute care hospitals (E) (CD)


9.46% - 10% year over year relative reduction

Provincial government

Lost-time and non-lost time injury rates per 100 full-time equivalent health care workers (E) (CD)


Context Context indicator

Psychiatric rehospitalisation rate within 30 days (R) (MH)


8% (10-15% year over year relative reduction)


30-day unplanned all-cause readmission rate after hospital discharge to community (index: CHF, COPD, DM, AMI, Asthma, stroke)

Hospital/Primary Care/Home Care

10% year over year for CHF and COPD; stroke goal is to keep below 10% (current

Expert consultation (Note SEQC 2012 report indicates stroke


(R) (CD) performance = 8.6%); Confirming asthma DM AMI targets

readmit benchmark is 8%)

Percentage of patients seeing a primary care provider or a specialist within 7 days of discharge after an inpatient stay for a mental health and addictions condition (R) (MH)

Hospital/Primary Care/Long-Term Care

75% (10-15% relative improvement year over year)


Percent of patients with COPD who have had their diagnosis confirmed with pulmonary function testing (N) (CD)

Hospital/Primary Care

80%; 20% year over year relative improvement


Office visit 7 days following in-patient discharge for

heart failure patients (any provider, primary care provider, cardiologist)

COPD patients (any provider, primary care provider, respirologist)

(N) (CD)


50% relative improvement year over year for HF patients Confirm for COPD patients


Early elective repeat c-section among low-risk women before 39 weeks gestation (N) (PH)


BORN set target of <11.0%; with warning rate set at 11.0-15.0%

BORN Ontario

Induction prior to 41 weeks gestation with an indication of post-dates (N) (PH)


BORN set target of <5.0%; with warning rate set at between 5.0-10.0%

BORN Ontario

Percentage of adults >65 years who have received influenza vaccine(N) (PH)

Long-Term Care / Primary Care/ Public Health

80% PHAC target PHAC (federal government)

School aged children who have received 2 valid doses of measles containing vaccine, on or before 7th birthday(N) (PH)

Primary Care / Ministry/ Public Health

National target =99%

LCDC – federal government

Immunization coverage for 1 dose meningococcal vaccine for 13 year old students (N) (PH)

Primary Care / Ministry/ Public Health

90% by 2012 (Canadian coverage target)

PHAC – federal government


Diabetes eye exam Indicator description

The rate (per 100) of eye exams in a one year interval among Ontarians with diabetes. The higher the indicator result, the better.

Relevance/ Rationale

Currently over one million Ontarians are living with diabetes.1

Diabetic retinopathy (DR), is a non-inflammatory eye disorder caused by changes in the retinal blood vessels. Diabetic retinopathy is a common complication of diabetes, with a prevalence of about 70% in persons with type 1diabetes and 40% in persons with type 2diabetes. 2 Diabetic

retinopathy is the leading cause of new cases of blindness in adults aged 20 to 74. Cataract and glaucoma are also common in people with diabetes. It is estimated that eventually around 20% of people with diabetes experience vision loss.3 Screening is important for early

detection of this treatable disease. Routine screening, referral and treatment for diabetic retinopathy can significantly reduce the onset of blindness and is a cost-effective way to prevent or delay vision loss. The clinical practice guidelines recommend screening for retinopathy in patients with type 2 diabetes every 1-2 years.4 In individuals with type 2

diabetes, screening and evaluation for diabetic retinopathy by an expert professional should be performed at the time of diagnosis of diabetes and annually thereafter. The interval for follow-up assessments should be tailored to the severity of the retinopathy. In those with no or minimal retinopathy, the recommended interval is 1–2 years. 4

Reporting tool/product

This indicator has been reported in Quality Monitor reports using different methodologies and different data sources:

2006 first yearly report “Newly diagnosed diabetes patients, age 30 +, with eye exam within one year” (Data source: DAD; OHIP)

2007 Quality Monitor report “Newly diagnosed diabetes patients, age 30 +, with eye exam within one year” (Data source: DAD; OHIP)

2008 Quality Monitor (from COMP-PC study)

2009 Quality Monitor “Percentage of sicker adults with diabetes who had their feet and eyes checked by a health professional in the last year in Ontario, Canada and other countries”, CMWF

2010 Quality Monitor report (Data source CCHS). The rate (per 100) of Ontarians with diabetes who had an eye test within 1 year.

2011 Quality Monitor report (Data source: ODD; OHIP). The rate (per 100) of Ontarians with diabetes who had an eye test within 1 year. The rate (per 100) of Ontarians with diabetes who had an eye test within 1 year.

2012 Quality Monitor report (Data source: ODD; OHIP). The rate (per 100) of Ontarians with diabetes who had an eye test within 1 year.

1 Booth GL, Polsky JY, Gozdyra G, Cauch-Dudek K, Kiran T, Shah BR, Lipscombe LL, Glazier RH. Regional Measures of Diabetes

Burden in Ontario. April 2012.

2 Buhrmann R, Assaad D, Hux J, Tang M, Sykora K. Diabetes in Ontario. Practice Atlas. Chapter 10. Diabetes and the eye. 3 Diabetes Task Force. Report to MOHLTC. September 2004. 4 Clinical Practice Guidelines 2013. http://guidelines.diabetes.ca/Browse/Chapter30


Attribute Effective

Type Core and process indicator.

External Alignment

Quality Monitor; Potential PCPM alignment; Ontario diabetes strategy, Quality Based Procedures,

Accountability Primary care

Calculation Numerator: Prevalent diabetics (for that specific FY) with any claim for an eye exam within 1 year Inclusion: OHIP feecodes = A115 (major eye exam), A233 to A240 (ophthalmology), C233 to C236 (ophthalmology emergency and out-patient department), V401, V402, V404 to V409, V450, V451 Note: use spec=all when extracting OHIP

OHIP feecodes = K065, K066 where spec=23 (Ophthalmology)

Denominator: All diabetes prevalent cases in ODD database for years from 2002/03-2009/10 (the details for creation of the ODD can be taken from ICES data holdings)

Exclude:

1. People who were not resident in Ontario in each year

2. Age on index date in each corresponding year exams: <20yrs

3. Died before end of follow-up period.

Data source / data elements

OHIP and ODD

The data are received from ICES annually, based on data request for Quality Monitor

Timing and frequency of data release

OHIP is updated by ICES bi-monthly ODD is updates by ICES annually

Levels of comparability

Across time, regional, by age, gender, income, immigration status, place of residence

Targets and/or Benchmarks

80% (for annual screening rate)

Target Source Expert consultation

Limitations ODD doesn’t distinguish type1 and type 2 diabetes The entire ODD is re-created yearly using updated OHIP,

CIHI/SDS, and RPDB data. The reason for re-creating the database is that RPDB may change and also the 2-year diagnosis algorithm will alter the numbers of patients in more recent years as we receive more data.

It is not possible to specifically identify the detail/type of the screening using the admin database, instead it was attempted to select all possible opportunities for retinal screening.

OHIP has data only for MDs with fee for service practice. Some have alternate funding and their services would be missing from analysis

Since the OHIP database is updated bi-monthly there may be delays in capturing the completed eye exams.

Adjustment (risk, age/sex standardization)

Direct standardization Standard population: denominator population in most recent year Standardised by age and sex Age groups are:

20–29, 30–39, 40–49, 50–59, 60–69, 70+


Guidelines, SOPs, Evidence for best practice

2013 Clinical practice Guidelines

Current performance

Figure1. The rates (per 100) of Ontarians with diabetes who had an eye test within 1 year

for years 2003/04 to 2011/12

Figure 2. The rates (per 100) of Ontarians with diabetes who had eye test within 1 year in

fiscal year 2011/12 by LHINs

Table 1. The rates (per 100) of Ontarians with diabetes who had an eye test within 1 year

for years 2011/12 by patient characteristics

2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

Adjusted rate per 100 51.8 51.9 48.5 49.8 49.5 50.5 51.1 51.8 52.7

0

50

100

Rate

54.9 56.5 55.6 54.948.8 50.5 48.3 49.9

52.555.6 53.7 52.9

56.7 55.1

0

50

100

ESC SW WW HNHS CW MH TC C CE SE CH NSM NE NW

Rate

Performance Target= 80%

Performance target = 80%


Variable Stratification

Adjusted rate per 100

95% LCL

95% UCL

Sex Female 53.64 53.45 53.83

Male 52.04 51.86 52.22

Age group

20-64 42.41 42.25 42.56

>65 65.77 65.55 65.99

Income quintile

Q1 51.56 51.28 51.84

Q2 52.69 52.41 52.97

Q3 52.89 52.60 53.19

Q4 53.25 52.96 53.55

Q5 53.19 52.88 53.51

Rural/urban

rural 56.20 55.82 56.59

urban/non-rural 52.25 52.11 52.39

Immigrant/ non-immigrant

Non-immigrant 53.09 52.95 53.23

Immigrant 49.94 49.58 50.32

Statement of results

Despite its proven benefits, about half of Ontarians did not receive regular screening for

this preventable complication within a year, as recommended by clinical practice

guidelines and the one-year screening rates stayed relatively stable over the last eight

years.

The rates varied across the province ranging from 48% in the Toronto Central LHIN to

57% in the North East LHIN.

While almost 66% of diabetic patients aged 65 and older had an eye examination, only

42% of patients aged 20-64 had it. The rates did not vary by gender, neighbourhood

income quintile, immigration status or rural/urban location.


Proportion of diabetics (aged 66+ years) regularly filling at least 3 scripts or 300 days of statins in Ontario Indicator description

This indicator serves to measure the proportion of diabetics aged 66+ that are regularly taking statins. A higher proportion is better. The indicator is reported on an annual basis and at both the provincial and LHIN level.


Diabetes is associated with a high risk of vascular disease (i.e. 2- to 4-fold greater risk than that of individuals without diabetes). In fact, cardiovascular disease (CVD) is the primary cause of death among people with type 1 and type 2 diabetes. Aggressive management of all CVD risk factors, including dyslipidemia, is, therefore, generally necessary in individuals with diabetes. Therefore, for patients with indications for lipid-lowering therapy, treatment should be initiated with a statin. The primary treatment goal for people with diabetes is LDL-C >2.0 mmol/L,


Quality Monitor (2009, 2010, 2011,2012)

Attribute Effective

Type Core and Process indicator

External Alignment

Quality Monitor; Potential PCPM alignment; Action Plan for Health Care; Quality Based Procedures.

Accountability Primary Care

Calculation Numerator: At least three prescription or 300 days doses filled within previous year. Statins – all DINs in subclass group: ANTILIPEMIC: STATINS

Denominator: All prevalent diabetes patients (identified in ODD) as of the day prior to the beginning of the fiscal year of interest from fiscal years 2003/04 to 2011/12.

Exclude: 1. Standard exclusions 2. Age at the beginning of fiscal year of interest < 66 3. Age at the beginning of fiscal year of interest > 105

In ODD <1 year prior to start of fiscal year of interest (i.e., incident cases)


Register Persons Database, Ontario Drug Benefits Database, Ontario Diabetes Database

Data is received on an annual basis from ICES for the Quality Monitor.


RPDB and ODB are updated by ICES monthly DAD and ODD is updated by ICES annually


Data is compared across time, and across LHINs for the particular reporting year. Stratifications are not available


Performance target = 80% Relative year-over-year increase = 25%


Limitations Data is not available for diabetics below the age of 65 as the ODB doesn’t include them. This program provides universal coverage of approved medications for all Ontario residents aged


65 and older, only people in this age group were examined. This group represents about one-half of all people with DM in the province.5

This indicator tracks prescriptions filled, those who get prescriptions filled might not be actually taking the medication, also prescriptions purchased outside the ODB Program were not included in the data, and therefore actual use may differ.


Crude rates are reported.


2013 Clinical practice Guidelines

Current performance

Figure1. Rate of people with diabetes age 66+ who had at least 3 prescriptions or 300

daily doses of a Statin in previous year. FY 2003/04-2011-12

5 Hux J, Booth G, Slaughter P, Laupacis A. Diabetes in Ontario. June 2003

2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

Crude rate per 100 37.8 43.4 48.9 51.4 55.1 58.0 60.0 62.0 63.2

0

50

100

Rate

pe

r 1

00

Performance target = 80%Relative year-over-year increase = 25%


Figure2. Rate of people with diabetes age 66+ who had at least 3 prescriptions or 300

daily doses of Statin in previous year


The proportion of diabetics age 66 and older who filled at least 3 prescriptions for statins

within a year has seen a steady rise from 2003/04 to 2011/12, from 37.8 per 100

population to 63.2 per 100 population

The LHIN variation was small but statistically significant. The Waterloo Wellington LHIN,

had the lowest rate at 61.1 per 100 population while the Central East LHIN had the

highest rate at 65.9 per 100 population.

While the rise in rate is encouraging, there is room for them to move higher as experts

suggest that most elderly diabetics should be on statin therapy.6

6 Clinical Practice Guidelines 2013. http://guidelines.diabetes.ca/

61.8 62.2 61.164.3 62.2 63.1 62.3 62.5

65.9 64.3 63.3 63.9 62.0 61.8

0

50

100

Rate

per

100

Performance target = 80%Relative year-over-year increase = 25%


Colorectal Cancer Screening (FOBT) – Participation Rate Indicator description

Percentage of Ontarians, 50–74 years of age, who underwent at least one FOBT in a two-year period


A fecal occult blood test (FOBT) is recommended by the Canadian Task Force on Preventive Health Care for screening individuals at average risk of colorectal cancer. This is not a diagnostic test. An abnormal FOBT does not necessarily mean that someone has cancer, but it indicates that follow-up with a colonoscopy is needed. Ontario’s colorectal cancer screening program, ColonCancerCheck (CCC), recommends that average-risk people aged 50–74 be screened every 2 years using FOBT. There are other tests, such as colonoscopy, flexible sigmoidoscopy used for colon cancer screening as well.7


Quality Monitor; CCO, Canadian Partnership Against Cancer (CPAC)

Attribute Focused on population health

Type Core, Process

External Alignment

Primary Care Performance Measurement (PCPM), Primary Care QIP, Ontario Action Plan for Health Care, M-SSA, Cancer Screening Quality Index, Cancer Prevention Agency of Canada, Quality Monitor.


Calculation Numerator Total number of Ontario screen-eligible individuals, aged 50–74 who have completed and returned at least one FOBT kit in a given two-year period

Denominator Total number of Ontario screen-eligible individuals, 50–74 years old, in a given two-year period Inclusions

Index date was defined as the midpoint in a two-year period CCC Program FOBT were identified in LRT

Non-program FOBT were identified using fee codes in OHIP(G004; L179 L181)

Each individual was counted once regardless of the number of FOBTs performed in a two-year period

Exclusions Individuals with a missing or invalid HCN, date of birth, sex

or postal code Individuals with an invasive colorectal cancer before Jan 1st

of the two-year period; prior diagnosis of colorectal cancer was defined as: ICD-O-3 codes C18.0, C18.2-C18.9, C19.9, C20.9 except those with histologic codes 9590-9989 (lymphomas), 8240-8246 or 8248-8249 (carcinoid)

7 Cancer Care Ontario. Colorectal Cancer Screening. Accessed 24.July.2013 at http://www.csqi.on.ca/cms/one.aspx?portalId=258922&pageId=273238#


Individuals with a total colectomy before Jan 1st of the two-year period; total colectomy was defined in OHIP by fee codes S169, S170, and S172

Individuals who had colonoscopy in the past five years or flexible sigmoidoscopy in the past five years; colonoscopy was identified in OHIP using fee codes Z555A, Z496A, Z497A, Z498A, and Z499A, and flexible sigmoidoscopy was identified in OHIP using fee code Z580

Individuals with the Q142A exclusion code for colorectal cancer in the given two-year period


LRT (Laboratory Reporting Tool) – CCC FOBTs OHIP CHDB (Claims History Database) – Non-CCC FOBT

claims, colonoscopy, flexible sigmoidoscopy and colectomy claims

OCR (Ontario Cancer Registry) - Resolved invasive colorectal cancers

PIMS (Pathology Information Management System) - Invasive colorectal cancers

RPDB (Registered Persons Database) – Demographics

PCCF+, version 5k - Residence and socio-demographic information


The data are calculated and provided by CCO annually.


Across time, regional, across gender, age and income.


CCO program Target 2011: 40%

Target Source CCO program

Limitations


The 2006 Canadian population was used as the standard population for calculating age-standardized rates


Canadian Task Force on Preventive Health Care. Screening strategies for colorectal cancer: a systematic review of the evidence.8

8 McLeod R, Canadian Task Force on Preventive Health Care. Screening strategies for colorectal cancer: a systematic review of the evidence. Canadian Journal of Gastroenterology. 2001 Oct;15(10):647–60.


Current performance

Figure1. Age-adjusted percentage of individuals aged 50-74 years old who had at least

one FOBT within a two year period, 2004-05 to 2010-2011.

Figure 2. Age-adjusted percentage of individuals aged 50-74 years old who had at least

one FOBT within a two year period, by LHIN, 2010-2011.


Series1 27.842 33.268 35.942 31.299 26.252 27.467 23.151 29.255 29.373 33.155 35.06 25.906 26.601 26.465

0

50

100

CCO program target 2011 = 40%

2004-2005 2006-2007 2008-2009 2010-2011

Ontario 15.8% 23.0% 30.4% 29.8%

0%

50%

100%

Pe

rce

nt

CCO program target 2011 = 40%


Table 1: Age-adjusted percentage of individuals aged 50-74 years old who had at least

one FOBT within a two year period, by patient characteristics, 2010-2011.

Variable

Stratification Rate

Sex (Age-adjusted)

Male 27.6%

Female 32.0%

Age (Crude)

50-54 24.7%

55-59 27.8%

60-64 32.0%

65-69 35.7%

70-74 34.9%

Income (Age-adjusted)

First quintile (Lowest) 26.8%

Second quintile 29.7%

Third quintile 30.4%

Fourth quintile 31.3%

Fifth quintile (Highest) 30.9%


Almost one in three people aged 50 to 74 received screening for colorectal cancer with an FOBT test in the 2010-2011 period. Over the last four 2-year periods, the screening rates have doubled, from 15.8% in 2004-2005 to 29.8% in 2010-2011.

In the most recent 2-year period, women were more likely than men to complete an FOBT (32.0% vs. 27.4%, respectively) and screening rates increased with age from 25% among adults aged 50-54 years to 35% among adults aged 65-74.

There was also small income variation for FOBT screening rates, ranging from 26.8% among adults living in low-income neighbourhoods compared to 31% in adults living in high-income neighbourhoods.

FOBT participation rates ranged from 23.2% in the Toronto Central LHIN to 35.9% in the Waterloo Wellington LHIN.

Although FOBT is the screening test promoted by ColonCancerCheck, it is important to note that other procedures such as colonoscopy and flexible sigmoidoscopy may also be used; individuals who have undergone these tests in the past five years are excluded from the denominator.


Breast cancer screening (Mammogram) participation rate Indicator description

Percentage of Ontario women, 50-74 years of age, who had at least one mammogram within a two-year interval

Relevance/Rationale

Regular cancer screening, combined with greater self-awareness and improvements in treatment, has been shown to save lives. Regular breast cancer screening can find cancer early which can result in a better chance of detecting when it is less likely to spread, providing more treatment options and successful treatment. Between 1990 and 2008, breast cancer death rates in Ontario women aged 50–74 decreased by 37% due to improved cancer treatments, increased participation in breast cancer screening, and a recent decline in breast cancer incidence. The Ontario Breast Screening Program (OBSP) currently recommends screening women aged 50-74 years every two years. 9 New guidelines

published by the Canadian Task Force on Preventive Health Care in 2011 recommend screening for women aged 70–74. As a result, current indicators for breast cancer screening have been expanded to include women aged 70–74. However, results for women aged 50–69 have also been presented to allow for pan-Canadian comparisons.


Quality Monitor, Cancer Care Ontario


Type Process and core

External Alignment

Primary Care Performance Measurement (PCPM), Primary Care QIP, Ontario Action Plan for Health Care, M-SAA, Cancer Screening Quality Index, Cancer Prevention Agency of Canada, Quality Monitor.


Calculation Numerator Total number of Ontario screen-eligible women, 50-74 years old, who have completed at least one mammogram in a given two-year period. Inclusions:

Ontario women (average risk and high risk) aged 50-74 at the index date

Index date was defined as the first screen date per person by screen date in ICMS (Integrated Client Management System) or by service date in OHIP in a two-year period

o X178 (screening bilateral mammogram) o X185 (diagnostic bilateral mammogram)

Each woman was counted once regardless of the number of mammograms performed in a two-year period; if a woman had both a program and non-program mammogram within a two-year period, the program status was selected

Denominator Total number of Ontario screen-eligible women, 50-74 years old in a given two-year period.

9 Cancer care Ontario. Breast cancer Screening. Accessed at https://www.cancercare.on.ca/pcs/screening/breastscreening/


Exclusions:

Women with a missing or invalid HCN, date of birth or postal code

Women with an invasive or in-situ breast cancer before the index date. Prior diagnosis of breast cancer was defined as ICD1O code C50 or ICD-9 code of 174 with a valid morphology code (characters starting with '8050', '8052', '8201', '8210', '8230', '8401', '8500', '8501', '8503', '8504', '8507', '8522' or ‘85203’)

Women with a preventive bonus exclusionary Q-code (Q141 A) prior to the index date (Q141A Exclusions apply for women who have had a mastectomy, or who are being treated for clinical breast disease.)


OHIP (Ontario Health Insurance Program) – Non-OBSP mammogram and mastectomy claims

ICMS (Integrated Client Management System) - OBSP mammograms

OCR (Ontario Cancer Registry) - Resolved invasive breast cancers

PIMS (Pathology Information Management System) - Invasive and in-situ breast cancers

CAPE (Client Agency Program Enrolment database) and

CPDB (Corporate Providers Database) –

PEM status and demographics

RPDB (Registered Persons Database) – Demographics

PCCF+, version 5k - Residence and socio-demographic


CCO updates and provides the data annually


Across time, regional, across age groups (50-54; 55-59; 60-64; 65-69; 70-74) and neighbourhood income quintile



Target Source National mammography target

Limitations Historical RPDB address information is incomplete; therefore, the most recent primary address was selected for reporting, even for historical study periods

CHDB code X178 for screening bilateral mammography was introduced in October 2010

CHDB code X185 was used for both screening and diagnostic mammography prior to October 2010; since October 2010, X185 has been used for diagnostic mammography only; however, some screening mammograms after October 2010 may still use X185 for claims10


The 2006 Canadian population was used as the standard population for calculating age-standardized rates

10 CCO Technical information http://www.csqi.on.ca/cms/One.aspx?portalId=258922&pageId=273162


Income quintile data for each individual’s neighbourhood was obtained through PCCF+, version 5k; this indicator was based on income quintiles developed by Statistics Canada, which were based on the 2006 Census; income quintiles range from 1 to 5 (low to high)

LHIN assignment was obtained through PCCF+, version 5k; residential postal code was used to identify LHIN, and individuals with unknown/missing LHINs were excluded from the analysis


Breast cancer screening Program in Ontario https://www.cancercare.on.ca/pcs/screening/breastscreening/

Current performance

Figure1. Age-adjusted percentage of women aged 50-74 years of age who had at least

one screening mammogram within a two year period, from 2004-2005 to 20010-2011

2004-2005 2006-2007 2008-2009 2010-2011

Ontario 56.9% 59.1% 61.1% 60.8%

0%

50%

100%

Perc

en

t



Figure2. Age-adjusted percentage of Ontario women, 50-74 years of age, who had at least

one mammogram within a two-year interval, 2010-2011

Table 1: Age-adjusted percentage of women aged 50-74 years of age who had at least

one screening mammogram within a two year period by patient characteristics, 2010-

2011

Variable

Stratification Rate

Age (crude)

50-54 57.6%

55-59 62.5%

60-64 65.3%

65-69 64.6%

70-74 53.2%

Income (age-adjusted)

First quintile 53.1%




Fifth quintile 65.9%

ESC SW WW HNS CW MH TC C CE SE CH NSM NE NW

LHIN 63.0 62.1 60.9 60.1 55.4 60.6 55.9 62.0 62.0 60.4 62.7 62.3 60.1 61.1

0

50

100

Performancel target = 70%

Pe

rce

nt



Ontario’s breast cancer screening rate has increased from 56.9% in 2004-2005 to 60.8% in 2010-2011.

The 2010-11 screening participation rates varied by age, ranging from 53.2% in women aged 70-74 to 65.3% in women aged 60-64. Screening rates in the most recent years’ data also varied by neighbourhood income quintile; 53.1% of screen-eligible women living in the lowest-income neighbourhoods underwent mammography compared to 65.9% of screen-eligible women residing in the highest income neighbourhoods.

Breast cancer screening rates also varied across LHINs and ranged from 55.4%

in the Central West LHIN to 63.0% in the Erie St. Clair LHIN.


Cervical Cancer Screening (Pap Test) – Participation Rate Indicator description

Percentage of Ontario women, 20-69 years of age, who had at least one Pap test in a three-year period


Cervical cancer is preventable. Yet, year after year, about 550 women are diagnosed with cancer of the cervix, and about 160 women die from this disease in Ontario. 11

Regular screening is an essential defense against cervical cancer. Cervical cancer screening can detect early cell changes on the cervix caused by persistent human papillomavirus (HPV) infection. These changes seldom cause any symptoms, but can progress to cancer if not found and managed.11

Cancer Care Ontario (CCO) updated its cervical cancer screening guidelines in 2012. Cervical cancer screening is recommended for women aged 21–69 every 3 years if they are or have ever been sexually active. Screening can stop at 70 years of age in women who have had 3 or more normal tests in the prior 10 years.12


Quality Monitor, Cancer Care Ontario, Primary Care QIPs


Type Process and core

External Alignment

Primary Care Performance Measurement (PCPM), Primary Care QIP, Ontario Action Plan for Health Care, M-SAA, Cancer Screening Quality Index, Cancer Prevention Agency of Canada, Quality Monitor.


Calculation Numerator Total number of Ontario screen-eligible women aged 20-69 years, who have had at least one Pap test in a given three-year period Inclusions:

Index date was defined as the first screen date per person by date of specimen collection in CytoBase or by service date in OHIP in a three-year period

Pap tests in Cytobase – note all Pap tests in CytoBase were counted, including those with inadequate specimens

Identifying Pap tests using fee codes in OHIP (E 430: G365: G394: L713; L733; L812)

Each woman was counted once regardless of the number of Pap tests performed in a three-year period

Denominator Total number of Ontario screen-eligible women aged 20-69 years , in a given three-year period Index date was defined as the midpoint in a three-year period, e.g. July 1st 2010 for 2009-2011 Exclusions:

11 Cancer Care Ontario. Cervical screening. Accessed at https://www.cancercare.on.ca/pcs/screening/cervscreening/ 12 Ontario cervical cancer Cytology Guideline Summary. Accessed at: https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=13104

https://www.cancercare.on.ca/pcs/screening/cervscreening/


Ontario women aged 20-69 at the index date

Women with a missing or invalid HCN, date of birth, LHIN or postal code

Women with an invasive cervical cancer before the index date

Women with a hysterectomy before the index date. For more detailed information see Technical notes http://www.csqi.on.ca/cms/One.aspx?portalId=258922&pageId=273195


OHIP (Ontario Health Insurance Program) Hysterectomy claims Cytobase-Pap test OCR (Ontario Cancer Registry) - Resolved invasive cervical cancers PIMS (Pathology Information Management System) - Invasive cervical cancer CAPE (Client Agency Program Enrolment database) and CPDB (Corporate Providers Database) – PEM status and demographics RPDB (Registered Persons Database) – Demographics PCCF+, version 5k - Residence and socio-demographic


Calculated and provided by CCO annually


Across time, regional, across age group (20-29; 30-39; 40-49; 50-59; 60-69), neighbourhood income quintile.


Performance target >85%

Target Source Ontario Cancer Plan target

Limitations


SOGC Clinical Practice Guidelines No 196. August 2007 Canadian Consensus Guidelines on Human Papillomavirus. http://sogc.org/wp-content/uploads/2013/01/gui196CPG0708revised_000.pdf Cancer Care Ontario. Screening Guidelines. https://www.cancercare.on.ca/pcs/screening/cervscreening/screening_guidelines/ Ontario cervical cancer Cytology Guideline Summary


International Agency for Research on Cancer (IARC): Participation rate: Proportion of those screened among those invited according to the scheduled policy (organized screening); in a program not based on invitations, participation has the same meaning as coverage (Cervix Cancer Screening, IARC Handbook of Cancer Prevention, Volume 10, 2005)

Public Health Agency of Canada (PHAC): Participation rate: Percentage of eligible women in the target population (20-69 years of age) with at least one Pap test in a three-year period (Performance monitoring for cervical cancer screening programs in Canada, January 2009)

http://www.csqi.on.ca/cms/One.aspx?portalId=258922&pageId=273195

http://www.csqi.on.ca/cms/One.aspx?portalId=258922&pageId=273195

http://sogc.org/wp-content/uploads/2013/01/gui196CPG0708revised_000.pdf

http://sogc.org/wp-content/uploads/2013/01/gui196CPG0708revised_000.pdf

https://www.cancercare.on.ca/pcs/screening/cervscreening/screening_guidelines/

https://www.cancercare.on.ca/pcs/screening/cervscreening/screening_guidelines/


Canadian Partnership Against Cancer (CPAC): Participation rate: Percentage of women aged 20–69 who had at least one Pap smear (The 2012 Cancer System Performance Report, December 2012)

European Union (EU): Participation Rate: Number of women screened at least once in a defined interval (3-5 years) divided by the number of resident women in the target population; they calculate separately by invitation status (personally invited, not, unknown) and programme status (within or without or unknown), stratify by 5-year age groups, and with eligible women as denominator calculated separately (Arbyn M, Antilla A, Jordan J et al. European Guidelines for Quality Assurance in Cervical Cancer Screening. 2nd ed. Summary document. Ann Oncol. 2010;21(3):448-58)

New Zealand National Cervical Screening Programme: Participation rates are currently reported in Ireland, Nova Scotia and PEI; in New Zealand, Ontario and B.C., the rates are hysterectomy-adjusted (Comparison of the performance indicators used in the New Zealand national cervical screening programme and other programmes internationally: A report to the Independent Monitoring Group of the National Cervical Screening Programme. Technical Report No 11. March 2006) divided by the number of resident women in the target population; they calculate separately by invitation status (personally invited, not, unknown) and programme status (within or without or unknown), stratify by 5-year age groups, and with eligible women as denominator calculated separately (Arbyn M, Antilla A, Jordan J et al. European Guidelines for Quality Assurance in Cervical Cancer Screening. 2nd ed. Summary document. Ann Oncol. 2010;21(3):448-58)

New Zealand National Cervical Screening Programme: Participation rates are currently reported in Ireland, Nova Scotia and PEI; in New Zealand, Ontario and B.C., the rates are hysterectomy-adjusted (Comparison of the performance indicators used in the New Zealand national cervical screening programme and other programmes internationally: A report to the Independent Monitoring Group of the National Cervical Screening Programme. Technical Report No 11. March 2006)


Current performance

Figure1. Age-adjusted percentage of Ontario women, 20-69 years old, who completed at

least one Pap test in a three-year period, 2000-2011.

Figure 2. Age-adjusted percentage of Ontario women, 20-69 years old, who completed at

least one Pap test in a three-year period, 2009-2011 by LHIN.

2000-2002 2003-2005 2006-2008 2009-2011

Ontario 61.6% 63.0% 64.2% 64.9%

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ESC SW WW HNHB CW MH TC C CE SE CH NSM NE NW

LHIN 62.5% 66.3% 67.4% 66.6% 61.5% 64.5% 60.8% 64.8% 65.2% 69.3% 68.6% 66.3% 61.2% 61.8%

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Table 1: Percentage of Ontario women, 20-69 years old, who completed at least one Pap

test in a three-year period, 2009-2011, by age and income

Variable

Stratification Rate

Age

20-29 64.1%

30-39 69.1%

40-49 68.7%

50-59 64.4%

60-69 53.4%

Income

First quintile 57.6%




Fifth quintile 70.0%


During the 3-year period 2009-2011, 65% of eligible women underwent cervical cancer

screening. Participation in cervical cancer screening among eligible women has improved

from 61.6% in 2000-2002 to 64.9% in 2009-2011 (see Figure 1).

The Pap screening rate in the most recent 3-year period varied by age and

neighbourhood income quintile. Screening rates ranged from 57.6% among women living

in the lowest income neighbourhoods to 70% among women living in the highest income

neighbourhoods. Screening rates were highest for women aged 30-49 (69%) and were

lowest for women aged 60-69 (53%) (see Table 1).

Screening rates also varied across LHINs, ranging from 60.8% in the Toronto Central

LHIN to 69.3% in the South East LHIN (see Figure 2).


Admission rate for conditions that are sensitive to outpatient (ambulatory) care delivery: CHF

Indicator description

This indicator measures the hospitalization rate for CHF in Ontario


ACSCs are conditions where appropriate ambulatory care may prevent or reduce the need for hospitalization. It is an important indicator because monitoring potentially avoidable admissions for ACSCs can help tracking the performance of the primary care system.


Quality Monitor

Attribute Efficient / Integrated

Type Outcome and core indicator

External Alignment

HQO Primary Care Performance Measurement (PCPM); M-SAA indicator; May also align with Health Links; Ministry Quarterly Report: Ontario Action Plan for Health Care

Accountability Hospital, Primary care, Long-term care, Home care

Calculation Numerator Number of inpatient records from acute care hospitals during each fiscal year from 2002/03-2011/12 with a CHF as the most responsible diagnosis. Exclude:

1. Death before discharge 2. Patients sign themselves out 3. Transfers from another acute care facility

Denominator Ontario LHIN population files:

2002-2010 population counts

2011projected population counts


DAD

Stats Can LHIN Population Files


Data updated by ICES at each fiscal year


Across time at provincial level (FY2002/03+) ;

By LHIN for the most recent FY, i.e. FY2011/12; The following stratifications for the most recent FY, i.e. FY2011/12:

By age group (<20, 20-44,45-64,65-79,80+);

By sex;

By income quintile;

By rural/urban status.


Twenty percent relative year over year reduction


Limitations n/a


Age-sex standardized rate.



n/a

Comment n/a

Current performance

Figure1. Age and Sex Standardized Hospitalization Rate for CHF, Ontario, FY2002/03-

2011/12

2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

Standardized rate 188.9 179.7 171.0 162.2 151.1 145.8 143.5 139.0 139.0 137.2

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Year over year relative reduction = 20%


Figure2. Age and Sex Standardized Hospitalization Rate for CHF, Ontario, by LHIN,

FY2011/12

Note: The standardized rates in Figure 1 and 2 are adjusted by age and sex.

Table1. Standardized hospitalization rate for CHF, by age, by sex, by rural/urban status

and by income quintiles, FY2011/12.

Variable Stratification Standardized Rate (per 100,000 population) 95%LCL 95%UCL

Age

<20 1.6 1.2 2.1

20-44 5.9 5.2 6.7

45-64 64.7 62.2 67.3

65-79 469.6 458.0 481.3

80+ 1774.2 1737.2 1811.8

Sex

Female 116.5 114.1 118.9

Male 162.6 159.2 165.9

Income quintile

Q1 (Lowest) 170.7 165.6 175.8

Q2 146.2 141.7 150.8

Q3 136.7 132.3 141.3

Q4 127.0 122.7 131.3

Q5 (Highest) 107.6 103.7 111.5

Rural/ Urban

Urban 137.9 135.8 140.1

Rural 132.0 126.7 137.5


Standardized Rate 149.2 129.8 132.1 149.9 147.6 128.7 141.7 128.6 115.8 117.0 137.6 129.1 170.7 221.9

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Over the past ten years, the CHF hospitalization rates have decreased by 27.4%, from

188.9 per 100,000 population in 2002/03 to 137.2 per 100,000 population in 2011/12.

CHF hospitalization rates varied across the LHINs, ranging from 115.8 per 100,000

population in the Central East LHIN to 221.9 per 100,000 population in the North West

LHIN in 2011/12.

The rates of hospitalizations varied significantly by sex, age group and neighbourhood

income quintile but not by rural/urban status. Men and older adults had higher CHF

hospitalization rates than their counterparts. CHF hospitalization rates decreased

consistently with increasing neighbourhood income quintile.


Admission rate for conditions that are sensitive to outpatient (ambulatory) care delivery: COPD


This indicator measures the hospitalization rate for COPD in Ontario


ACSCs are conditions where appropriate ambulatory care may prevent or reduce the need for hospitalization. It is an important indicator because monitoring potentially avoidable admissions for ACSCs can help tracking the performance of primary care system.


Quality Monitor



External Alignment



Calculation Numerator Number of inpatient records from acute care hospitals during each fiscal year from 2002/03-2011/12 with COPD as the most responsible diagnosis. Exclude:




2011 projected population counts


DAD







By age group (<20, 20-44,45-64,65-79,80+);

By sex;

By income quintile;





Limitations n/a





n/a

Comments n/a

Current performance

Figure1. Age and Sex Standardized Hospitalization Rate for COPD, Ontario, FY2002/03-

2011/12

2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12


0.0

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Figure2. Age and Sex Standardized Hospitalization Rate for COPD, Ontario, by LHIN,

FY2011/12


Table1. Standardized Hospitalization Rate for COPD, by age, by sex, by rural/urban status

and by income quintiles, FY2011/12


Standardized Rate(per 100,000 population) 95%LCL 95%UCL

Age

<20 1.0 0.7 1.4

20-44 4.8 4.2 5.5

45-64 123.7 120.1 127.3

65-79 691.6 677.6 705.7

80+ 1459.1 1424.9 1493.9

Sex

Female 145.8 143.0 148.6

Male 185.3 181.8 188.9

Income quintile

Q1 (Lowest) 249.8 243.6 256.1

Q2 173.9 169.0 179.0

Q3 151.4 146.7 156.2

Q4 136.3 131.9 140.8

Q5 (Highest) 103.8 100.0 107.6

Rural/Urban

Urban 153.9 151.6 156.2

Rural 208.4 201.8 215.2



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Over the past ten years, the COPD hospitalization rate has decreased from 166.7 per

100,000 population in 2002/03 to 161.3 per 100,000 population in 2011/12.

COPD hospitalization rates varied across the LHINs, ranging from 85.3 per 100,000

population in the Central LHIN to 314.3 per 100,000 population in the North West LHIN.

The rate of COPD hospitalizations increased with age and was higher among men than

among women. Rates also varied by neighbourhood income quintile and rural/urban

status. The COPD hospitalization rates decreased with increasing neighbourhood

income quintile and populations from rural areas had higher COPD hospitalization rates

than their counterparts. Those living in the lowest income neighbourhoods an almost 2.5

times higher hospitalization rate than those living in the highest income neighbourhoods

(249.8 vs 103.8 per 100,000 population).


Admission rate for conditions that are sensitive to outpatient (ambulatory) care delivery: Diabetes


This indicator measures the hospitalization rate for diabetes in Ontario




Quality Monitor



External Alignment



Calculation Numerator Number of inpatient records from acute care hospitals during each fiscal year from 2002/03-2011/12 with diabetes as the most responsible diagnosis. Exclude: 7. Death before discharge 8. Patients sign themselves out 9. Transfers from another acute care facility





DAD







By age group (<20, 20-44,45-64,65-79,80+);

By sex;

By income quintile;





Limitations n/a





n/a

Comments n/a

Current performance

Figure1. Age and Sex Standardized Hospitalization Rate for Diabetes, Ontario, FY2002/03-

2011/12

Figure2. Age and Sex Standardized Hospitalization Rate for Diabetes, Ontario, by LHIN,

FY2011/12

Note: The standardized rates in Figure 1 and 2 are adjusted by age and sex

2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12


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Table1. Standardized Hospitalization Rate for Diabetes, by age, by sex, by rural/urban

status and by income quintiles, FY2011/12


Standardized Rate ( per 100,000 population) 95%LCL 95%UCL

Age

<20 31.3 29.4 33.4

20-44 33.1 31.5 34.8

45-64 31.8 30.0 33.6

65-79 54.0 50.1 58.1

80+ 112.2 103.0 122.0

Sex

Female 34.7 33.4 36.2

Male 40.5 39.0 42.1

Income quintile

Q1 (Lowest) 54.4 51.6 57.3

Q2 41.5 39.1 44.1

Q3 34.8 32.6 37.2

Q4 30.8 28.7 32.9

Q5 (Highest) 25.9 24.0 27.9

Rural/Urban

Urban 36.7 35.6 37.8

Rural 43.4 40.1 46.9


Over the past ten years, the diabetes hospitalization rate has decreased by 31%, from

54.3 per 100,000 population in 2002/03 to 37.4 per 100,000 population in 2011/12.

Diabetes hospitalization rates varied across the LHINs, ranging from 26.1 per 100,000

population in the Central LHIN to 62.6 per 100,000 population in the North East LHIN in

2011/12.

The rate of hospitalizations for diabetes varied by patient age group, sex, neighbourhood

income quintile and urban/rural status. Men, older adults, those from rural areas of the

province and those living in lower-income neighbourhoods had higher rates of

hospitalizations for diabetes than their counterparts. Diabetes hospitalization rates

decreased as neighbourhood income quintile increased; those living in the lowest

income neighbourhoods had more than twice the hospitalization rate as those living in

the highest income neighbourhoods (54.4 vs 25.9 per 100,000 population).


Admission rate for conditions that are sensitive to outpatient (ambulatory) care delivery: Asthma


This indicator measures the hospitalization rate for asthma in Ontario




Quality Monitor



External Alignment


Accountability Hospital, Primary Care, Long-term care, Home care

Calculation Numerator Number of inpatient records from acute care hospitals during each fiscal year from 2002/03-2011/12 with asthma as the most responsible diagnosis. Exclude:






DAD







By age group (<20, 20-44,45-64,65-79,80+);

By sex;

By income quintile;





Limitations n/a


Age-sex standardized rate



n/a

Comments n/a

Current performance

Figure1. Age and Sex Standardized Hospitalization Rate for Asthma, Ontario, FY2002/03-

2011/12

Figure2. Age and Sex Standardized Hospitalization Rate for Asthma, Ontario, by LHIN,

FY2011/12


2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12


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Table1. Standardized Hospitalization Rate for Asthma, by age, by sex, by rural/urban

status and by income quintiles, FY2011/12

Variable Stratification Standardized Rate ( per 100,000 population) 95%LCL 95%UCL

Age

<20 89.2 85.9 92.6

20-44 15.0 13.9 16.1

45-64 18.7 17.4 20.1

65-79 25.1 22.5 27.9

80+ 37.6 32.7 42.9

Sex

Female 35.4 34.0 36.9

Male 34.6 33.3 36.1

Income quintile

Q1 (Lowest) 46.6 44.1 49.3

Q2 40.1 37.7 42.6

Q3 35.2 33.0 37.5

Q4 30.1 28.1 32.2

Q5 (Highest) 24.9 23.0 26.9

Rural/ Urban

Urban 36.1 35.0 37.2

Rural 31.3 28.4 34.3


Over the past ten years, the asthma hospitalization rates have decreased by 45%, down

from 63.5 per 100,000 population in 2002/03 to 35.4 per 100,000 population in 2011/12.

Asthma hospitalization rates varied across the LHINs, ranging from 24.9 per 100,000

population in the North Simcoe Muskoka LHIN to 61.0 per 100,000 population in the

Central West LHIN in 2011/12.

The rate of hospitalizations for asthma varied by patient age, neighbourhood income

quintile and rural/urban status, but not by sex. The youngest (i.e. <20 years old group)

were more likely to be admitted to hospitals due to asthma than older patients and

asthma admission rates were higher in rural areas than in urban areas. Asthma

hospitalization rates also decreased consistently with increasing neighbourhood income

quintile.


Percent of alternate level of care (ALC) days (as a proportion of total inpatient days) in acute care hospitals Indicator description This indicator measures the number of bed days that are

designated as being ALC in acute hospitals in Ontario.

Relevance/Rationale

The indicator measures the unnecessary use of high cost hospital services. There is a clear and pressing need to improve efficiencies and implement sustainable solutions that maximize our ability to provide the right service, in the right place, at the right time. ALC refers to those cases where a physician (or designated other) has indicated that a patient occupying an acute care hospital bed has finished the acute care phase of his/her treatment. Better quality of care is associated with a lower score of the indicator.


QMonitor

Attribute Efficient

Type Process and core indicator

External Alignment Ontario's Action Plan for Health Care; Sinha Report; QIP- Acute care sector; HSAA indicator; May also align with Health Links; Ministry Quarterly Report; Walker Report


Calculation Numerator Total number of inpatient days designated as ALC in a given time period (i.e. monthly, quarterly, and yearly)

Denominator Total number of inpatient days in a given time period Inclusion: Data are retrieved for acute care hospitals (hospital type = AP, AT) Exclusion: Newborns, stillborns, and records with missing or invalid “Discharge Date” are not included in this indicator.


Discharge Abstract Database (DAD), MOHLTC

FY2011-12 (final data sets), extracted October 2012

Monthly, fiscal quarterly, fiscal yearly


Yearly data reported in QMonitor.


By hospital site, by LHIN, over time trending


Performance target: 9.46% (Note: the indicator reported here is different from what is used for the target – We report % of inpatient days that are designated as ALC days; target set for % of patients who are ALC) 10% relative year over year reduction

Target Source Provincially established + expert consultation

Limitations Only includes acute care hospital beds

Not reported in a timely manner

Only includes closed cases (those patients designated ALC who have been discharged)- and so may miss cases that carry over to the next fiscal year.


This indicator is based on discharge. Successes resulting in a higher rate of discharges in ALC clients will result in an initial spike in the results. Discharges of long-stay ALC clients will attribute all days to the time period of discharge, also potentially skewing the results. Point-in-time results must be analyzed with caution, and trending of this indicator is preferred.

Adjustment (risk, age/sex standardization):

Crude rate


n/a

Comments All numbers used for calculations are as reported by the hospitals. The information is from each acute site of the hospital and the assignment to a LHIN is based on the postal code of the hospital site. All data are suppressed where ALC separations are <5.

Current Performance

Figure1. Percent of inpatient days designated as alternate level of care (ALC) days in

acute care hospitals, FY2006/07-2011/12

Note: *the indicator reported here is different from what is used for the target – We report % of inpatient days that are

designated as ALC days; target set for % of patients who are ALC.

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

Ontario 12.1 14.0 16.1 16.0 16.7 14.6

0.0

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50.0

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Performance target=9.46%Year over year relative reduction= 10%


Figure2. Percent of inpatient days designated as alternate level of care (ALC) days in

acute care hospital, by LHIN, FY2011/12


designated as ALC days; target set for % of patients who are ALC


LHIN 12.1 12.4 16.1 14.9 10.2 10.0 10.4 16.1 16.0 12.1 15.1 19.3 26.7 18.4

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Figure3. Percent of inpatient days designated as ALC days in acute care hospitals, by

hospital, FY2011/12


designated as ALC days; target set for % of patients who are ALC

Table1. Hospital-level distribution of percent of ALC days in acute care hospitals,

FY2011/12

Min 5th

Percentile

10th

Percentile

25th

Percentile Median

75th

Percentile

90th

Percentile

95th

Percentile Max

0.0 0.38 5.0 10.6 16.4 25.4 34.0 44.2 60.4


After several years of increases in the percentage of ALC days, the provinical score has

now decreased from 16.7% in 2010/11 to 14.6% in 2011/12, however even in this most

recent year, approximately one in seven acute care hospital bed days was categorized

as ALC (see figure 1).

There is wide LHIN-level variation in the percentage of ALC days, from 10.0 % to 26.7%

in 2011/12 (see Figure 2).

Across 164 acute care hospitals in Ontario, ALC rates ranged from 0% to 60.4% in

2011/12; 60% of hospitals had rates that were higher than the provinical mean rate (see

Figure 3).

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Injury rate in health care providers Indicator description

Lost-time and non-lost time injury rates per 100 full-time equivalent workers in:

Health Care Sectors (combined)

LTC homes

Hospitals

Nursing services

Treatment clinics

Professional offices and labs


There are 775,800 registered workers in Ontario’s health care sector that work at more than 6,000 hospitals, long-term care homes, retirement homes, community care and other workplaces across Ontario. The health care sector faces some challenges which may have significant impact on worker health and on lost-time injury (LTI) rates. These include increased care requirements resulting from the aging of Ontario’s population, increased patient and resident needs, increased obesity rates and increased demand on health and community care services. In addition, employers face recruitment and retention challenges, an aging workforce, a shortage of skilled professional staff, and an increase in casual and part-time workforce.13 Implementing healthy work environments and building a culture of safety for health care workers are key to ensuring quality patient care. Enhancing morale and reducing absenteeism can reduce adverse events, improve patient safety and support improved patient outcomes.14


Quality Monitor

Attribute Appropriately resourced

Type Context

External Alignment

Quality Monitor


Calculation Numerator Total number of LTIs and NLTIs that occurred in the injury year in each health care setting. Notes: Lost-Time Injuries (LTIs) - allowed injury/illness claims by workers who have lost wages as a result of temporary or permanent impairment. Excludes fatalities. No lost-time injuries (NLTIs) - allowed injury/illness claims by workers who have not lost wages, but who have incurred health care expenses

Denominator Total Full Time Equivalent (FTE) Workers

13 Ontario Ministry of labour. Health care Sector Plan 2013-14. Accessed August2, 2013 at http://www.labour.gov.on.ca/english/hs/sawo/sectorplans/2013/health/index.php 14 HealthForceOntario. Healthy Work Environment. Accessed on August 2, 2013 at http://www.healthforceontario.ca/en/Home/Employers/Healthy_Work_Environments


Note: FTE Workers is an estimate based on the average hourly wage for the rate group and the insurable earnings for the calendar year, assuming a person works an average of 2,000 hours per year.


WSIB Enterprise Information Warehouse as of March 31st, of the following year for each injury year.


Provided by WSIB annually


Across time and health care settings such as:

Long-term care homes,

Residential care homes,

Hospitals,

Nursing services,

Supported group living residences and other facilities,

Treatment clinics and specialized services,

Professional offices and agencies For the detailed descriptions of these settings visit http://www.labour.gov.on.ca/english/hs/sawo/sectorplans/2013/health/healthcare_1.php


NA

Target Source NA

Limitations


None


Comments


Current performance

Figure 1. Lost-time and Non-lost-time injury rates by different health care sectors, 2002-

2011

Source: WSIB

0

5

10

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Rate

pe

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FT

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Homes for nursing Care Homes for Residential Care

Hospitals Nursing Services

Group Homes Treatment clinics &Specialized Services

Professional Offices &Agencies Health Care Sector


Table1. Rate per 100 FTE Injury Years

Statement of results The lost-time and non-lost-time injury rates in all health care sectors have dropped

significantly from 2008 to 2011. From 2010 to 2011, there where around 940 less injuries reported in hospitals, the largest sector in health care, which constitutes to a 12% decrease in injury rates.

RATE GROUP & DESCRIPTION 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Homes for nursing Care 9.0 8.5 9.3 9.1 8.6 8.9 8.9 8.3 8.1 7.6

Homes for Residential Care 5.9 6.8 7.5 5.6 6.3 6.6 6.9 5.2 4.9 4.4

Hospitals 5.2 5.2 4.9 5.0 4.8 4.8 4.9 4.7 4.6 4.1

Nursing Services 5.4 5.9 5.5 5.7 5.6 5.2 5.5 4.9 4.8 4.9

Group Homes 9.0 9.3 8.8 9.6 8.1 8.4 7.3 8.0 8.1 8.0

Treatment clinics &Specialized Services 3.4 3.4 3.4 3.6 3.4 3.3 3.3 2.9 2.6 2.5

Professional Offices &Agencies 2.3 2.2 2.1 2.3 2.2 2.2 2.3 1.9 1.7 1.6

Health Care Sector 5.4 5.4 5.4 5.5 5.2 5.2 5.3 4.9 4.7 4.4


Thirty-Day All Causes Readmission after Congestive Heart Failure (CHF) Discharge Indicator description This indicator measures the rate of non-elective readmissions within

30 days of discharge to community after a CHF admission

Relevance/Rationale

This is an important indicator because monitoring unplanned/potentially avoidable readmissions within one month of discharge can help tracking the impacts of quality improvement initiatives at hospital, LHIN and provincial levels as well as integration across health care sectors.


New indicator that will be presented in QM2013.

Attribute Effective

Type: Outcome and core indicator

External Alignment HQO Quality Based Procedures; HQO Primary Care Performance Measurement QIP – Acute care sector and primary care sector; H-SAA; May also align with Health Links; Ministry Quarterly Report

Accountability Hospital, Primary care, Home care

Unit of analysis The measuring unit of this indicator is per discharge (could include patients more than once within a year). The indicator is expressed as a rate of urgent readmission after a CHF admission

Calculation Numerator Cases within the denominator with a non-elective readmission within 30 days of discharge for a CHF episode.

Denominator CHF episodes discharged between April 1 and March 1 of the fiscal year in an inpatient setting

Discharged alive

Age range: 15 years and over


DAD, RPDB, and PSTLYEAR





By LHIN and by Facility for the most recent FY, i.e. FY2011/12;

The following stratifications for the most recent FY, i.e. FY2011/12:

By age group (15-19; 20-44;45-64; 65-79; 80+);

By sex;

By income quintile;



Ten percent relative year over year reduction

Target source Expert consultation

Limitations n/a


Risk Adjusted using logistic regression:

Factors

o Age


o Sex

o Chronic Pulmonary Disease: Diagnosis Type is 1, W, X or Y


n/a

Comments MOH reports 30-day all causes crude readmission by selected CMG+ group

Current performance

Figure1. 30-day all causes risk-adjusted readmission rate after CHF, Ontario, FY2002/03 -

FY2011/12

2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

Risk adjusted rate 21.1 21.7 21.6 21.3 21.4 21.3 20.7 21.2 22.1 21.8

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Relative year over year reduction = 10%


Figure2. 30-day all causes risk-adjusted readmission rate after CHF, by LHIN, FY2011/12

Note: The risk adjusted rates in Figure 1 and 2 are adjusted by age, sex, and a diagnosis of chronic pulmonary

disease.

Table1. 30-day all causes risk-adjusted readmission rate after CHF, by age group, sex,

income quintile and rural/urban, FY2011/12

Variable Stratification Risk adjusted rate 95%LCL 95%UCL

Age

15-19* 16.9 0.0 50.1

20-44 24.3 19.1 29.6

45-64 19.8 18.1 21.6

65-79 21.5 20.4 22.6

80+ 22.5 21.6 23.4

Sex

Female 20.9 20.0 21.8

Male 22.7 21.8 23.6

Income quintile

Q1 (Lowest) 22.3 20.9 23.6

Q2 22.8 21.5 24.2

Q3 21.9 20.4 23.3

Q4 21.2 19.7 22.7

Q5 (Highest) 20.1 18.5 21.7

Rural/Urban

Urban 21.9 21.2 22.6

Rural 21.4 19.6 23.2 Note: * the rate is unstable due to small numerator and denominator.


Risk adjusted rate 17.2 22.0 20.0 22.3 21.9 18.9 23.4 22.4 22.4 21.1 20.0 23.6 24.4 26.8

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tRelative year over year reduction = 10%



The 30-day, all-cause readmission rate for CHF was 21.8% in 2011/2. It has remained

stable over the past 10 fiscal years.

There was variation in the CHF readmission rates across LHINs, ranging from 17.2 % in

the Erie St. Clair LHIN to 26.8% in the North West LHIN.

Patients aged 45-64 years and those living in the highest income neighbourhoods had

significantly lower readmission rates compared to the provincial average, but the

variation by neighbourhood income quintile or by age group was not significant.

Readmission rates for CHF patients did not vary by sex or urban/rural status.


Thirty-Day All Causes Readmission after Chronic Obstructive Pulmonary Disease (COPD) Indicator description

This indicator measures the rate of non-elective readmissions within 30 days of discharge to community after a COPD admission





Attribute Effective


External Alignment

HQO Quality Based Procedures; HQO Primary Care Performance Measurement QIP – Acute care sector and primary care sector; H-SAA; May also align with Health Links; Ministry Quarterly Report


Unit of analysis The measuring unit of this indicator is per discharge (could include patients more than once within a year). The indicator is expressed as a rate of urgent readmission after a COPD admission

Calculation Numerator Cases within the denominator with a non-elective readmission within 30 days of discharge for a COPD episode.

Denominator COPD episodes discharged between April 1 and March 1 of the fiscal year in an inpatient setting

Discharged alive








By LHIN and by Facility for the most recent FY, i.e. FY2011/12; The following stratifications for the most recent FY, i.e. FY2011/12:

By age group (15-19; 20-44; 45-64; 65-79; and 80+);

By sex;

By income quintile;





Limitations n/a



Factors

o Age

o Sex



n/a


Current performance

Figure1. 30-day all causes risk-adjusted readmission rate after COPD, Ontario,

FY2002/03- FY2011/12

2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12


0.0

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Figure2. 30-day all causes risk-adjusted readmission rate after COPD, by LHIN,

FY2011/12

Note: The risk adjusted rates in Figure 1 and 2 are adjusted by age and sex.

Table1. 30-day all causes risk-adjusted readmission rate after COPD, by age, sex, income

quintile, rural/urban status, FY2011/12


Age

15-19 9.7 3.9 15.5

20-44 7.6 5.6 9.6

45-64 15.3 14.4 16.2

65-79 17.8 17.1 18.5

80+ 16.3 15.6 17.0

Sex

Female 15.5 14.9 16.1

Male 17.0 16.4 17.6

Income quintile

Q1 (Lowest) 18.4 17.6 19.2

Q2 15.6 14.7 16.5

Q3 15.3 14.4 16.3

Q4 16.7 15.7 17.6

Q5 (Highest) 14.2 13.1 15.2

Rural/Urban

Urban 16.5 16.1 17.0

Rural 14.8 13.7 15.8



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The 30-day, all-cause readmission rate for COPD has remained stable over the past 10

years and it was 16.2% in FY2011/12.

The LHIN specific, 30-day, all-cause COPD readmission rate ranged from 14.9% in the

Erie St. Clair LHIN to 18.6=^ in the Toronto Central LHIN (18.6%); the value for the

Toronto Central LHIN was significantly higher than the provincial average.

Patients aged 65-79 years old had the highest readmission rate compared to other age

groups. Men were more likely to be readmitted after a COPD admission compared to

women (17.0% vs. 15.5%).

The readmission rate for patients living in the lowest income neighbourhoods was

significantly higher than the rate for patients living in the highest income neighbourhoods

(18.4% vs. 14.2%).

The readmission rate for patients living in rural areas was lower than the rate for patients

living in urban areas (14.8% vs.16.6%).


Thirty-Day All Causes Readmission after Diabetes


This indicator measures the rate of non-elective readmissions within 30 days of discharge to community after a diabetes admission





Attribute Effective


External Alignment

HQO Primary Care Performance Measurement; QIP – Acute care sector and primary care sector; H-SAA; May also align with Health Links; Ministry Quarterly Report


Unit of analysis The measuring unit of this indicator is per discharge (could include patients more than once within a year). The indicator is expressed as a rate of urgent readmission after a diabetes admission

Calculation Numerator Within the denominator with a non-elective readmission within 30 days of discharge for a diabetes episode.

Denominator Diabetes episodes discharged between April 1 and March 1 of the fiscal year in an inpatient setting

Age range: 15years and over

Discharged alive








By age group (15-19; 20-44; 45-64; 65-79; and 80+);

By sex;

By income quintile;




Target source

Limitations MOH reports 30-day all causes crude readmission by selected CMG+ gp



Factors

o Age

o Sex


n/a

Comments


Current performance

Figure1. 30-day all causes risk-adjusted readmission rate after Diabetes, Ontario,

FY2002/03- FY 2011/12

Figure2. 30-day all causes risk-adjusted readmission rate after diabetes, by LHIN,

FY2011/12

Note: The risk adjusted rates in Figure 1 and 2 are adjusted by age and sex.

2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12


0.0

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nt


ESC SW WWHNH

BCW MH TC C CE SE CH NSM NE NW


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nt



Table1. 30-day all causes risk-adjusted readmission rate after Diabetes, by age, sex,

income quintile, and rural/urban status, FY2011/12


Age

15-19 8.6 5.1 12.1

20-44 15.6 13.8 17.4

45-64 11.3 9.2 13.4

65-79 14.9 12.2 17.6

80+ 16.8 13.8 19.8

Sex

Female 14.3 12.8 15.9

Male 13.4 11.9 14.9

Income quintile

Q1 (Lowest) 16.2 14.2 18.2

Q2 15.6 13.3 17.9

Q3 12.9 10.4 15.5

Q4 12.9 10.3 15.5

Q5 (Highest) 8.8 5.8 11.7

Rural/Urban

Urban 14.2 13.1 15.4

Rural 11.4 8.4 14.4


The 30-day, all-cause readmission rate for diabetes was 13.9% in FY2011/12. The rate

has fluctuated between 12% -15% over the past 10 years.

The 30-day, all-cause diabetes readmission rates varied significantly by LHIN in

2011/12. The Erie St. Clair LHIN’s readmission rate (6.5%) was almost one-third of the

observed rate for the Waterloo Wellington LHIN (18.4%).

There was no significant difference by sex or by urban/rural status. Patients aged 15-19

years and those between 45 and 64 years were less likely being readmitted after

diabetes discharges compared to the provincial average.

The readmission rates decreased as neighbourhood income quintile increased. The

readmission rate was almost twice as high for the lowest income quintile (the least

affluent group) as it was for the highest income quintile (the most affluent group) (16.2%

vs. 8.8%).


Thirty-day all cause readmission rate for patients admitted for acute myocardial infarction (AMI) Indicator description

This indicator measures the rate of non-elective readmissions within 30 days of discharge to community after an acute myocardial infarction (AMI) admission





Attribute Effective


External Alignment



Unit of analysis The measuring unit of this indicator is per discharge (could include patients more than once within a year). The indicator is expressed as a rate of urgent readmission after an AMI admission

Calculation Numerator Cases within the denominator with a non-elective readmission within 30 days of discharge for an AMI episode.

Denominator AMI episodes discharged between April 1 and March 1 of the fiscal year in an inpatient setting

Discharged alive









By age group (15-19; 20-44; 45-64; 65-79; and 80+);

By sex;

By income quintile;





Limitations n/a



Factors

Age

Sex

Shock: diagnosis type is 1, W, X, or Y


Diabetes with complications: diagnosis type is 1, W, X, or Y

Congestive heart failure: diagnosis type is 1, W, X, or Y

Cerebrovascular disease: diagnosis type is 1, W, X, or Y

Pulmonary edema: diagnosis type is 1, W, X, or Y

Renal failure: diagnosis type is 1, W, X, or Y

Cardiac dysrhythmias: diagnosis type is 1, W, X, or Y


n/a


Current performance

Figure1. 30-day all causes risk-adjusted readmission rate after an admission for AMI,

Ontario, FY2002/03-2011/12

2002/03

2003/04

2004/05

2005/06

2006/07

2007/08

2008/09

2009/10

2010/11

2011/12


0.0

25.0

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Ris

k -

ad

jus

ted

Ra

te



Figure2. 30-day all causes risk-adjusted readmission rate after AMI, by LHIN, FY2011/12

Note: The risk adjusted rates in Figure 1 and 2 are adjusted by age, sex, diagnoses of shock, diabetes with

complications, congestive heart failure, cerebrovascular disease, pulmonary edema, renal failure, and cardiac

dysrhythmias.

Table1. 30-day all causes risk-adjusted readmission rate after AMI, by age, sex, income

quintile and rural/urban, FY2011/12


Age

15-19*

20-44 7.6 5.1 10.2

45-64 9.8 9.0 10.7

65-79 12.4 11.6 13.3

80+ 15.8 14.9 16.7

Sex

Female 13.0 12.2 13.8

Male 11.8 11.2 12.5

Income quintile

Q1 (Lowest) 13.8 12.8 14.9

Q2 12.9 11.8 14.0

Q3 11.9 10.8 13.0

Q4 11.2 10.0 12.3

Q5 (Highest) 11.1 9.9 12.3

Rural/Urban Urban 12.3 11.7 12.8

Rural 12.3 11.0 13.6 Note: The rate for this age group is unstable due to small numerator and denominator.

ESC

SW WWHNHB

CW MH TC C CE SE CHNSM

NE NW


0.0

25.0

50.0R

isk-a

dju

ste

d R

ate




The AMI readmission rate has decreased from 15.7% in 2002/03 to 12.6% in 2011/12.

The 30-day, all-cause AMI readmission rate varied significantly by LHIN. In 2011/12, the

rate ranged from 8.8% in the Waterloo Wellington LHIN to 16.8% in the North East LHIN.

The AMI readmission rate did not vary significantly by sex or by urban/rural status. The

rate increased with patient age and varied significantly by neighbourhood income quintile

from approximately 11% among those living in the two highest income neighbourhoods

to approximately 14% among those living in the lowest income neighbourhoods.


Thirty-day all cause readmission rate for patients admitted for stroke Indicator description

This indicator measures the rate of non-elective readmissions within 30 days of discharge after a stroke admission


It is an important indicator because monitoring unplanned/potentially avoidable readmissions within one month of discharge can help tracking the impacts of quality improvement initiatives at hospital, LHIN and provincial levels as well as integration across health care sectors.



Attribute Effective


External Alignment

HQO Quality Based Procedures; HQO Primary Care Performance Measurement QIP – Acute care sector and primary care sector; H-SAA; May also align with Health Links; Ministry Quarterly Report


Unit of analysis The measuring unit of this indicator is per discharge (that is, patients could be included more than once within one year). The indicator is expressed as the rate of non-elective readmissions per 100 stroke admissions.

Calculation Numerator Cases within the denominator with an urgent (non-elective) readmission within 30 days of discharge after a stroke admission.

Denominator Stroke discharges between April 1 and March 1 of the reporting fiscal year in an inpatient setting Includes:

Discharged alive









By age group (15-19; 20-44; 45-64; 65-79; and 80+);

By sex;

By income quintile;

By rural/urban




Limitations n/a


Risk Adjusted using logistic regression: Factors

o Age o Sex o Hypertension (complicated): Diagnosis type is 1, W, X or Y


o Diabetes: Diagnosis type is 1, W, X or Y


n/a


Current performance

Figure1. 30-day all causes risk-adjusted readmission rate after stroke, Ontario,

FY2002/03-2011/12

2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12


0.0

25.0

50.0

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nt

Relative year over year reduction = 10 percent


Figure2. 30-day all causes risk-adjusted readmission rate after stroke, by LHIN,

FY2011/12

Note: The risk adjusted rates in Figure 1 and 2 are adjusted by age, sex, diagnoses of hypertension (complicated),

and diabetes.

Table1. 30-day all causes risk-adjusted readmission rate after stroke, by age, sex, income

quintile, and rural/urban status, FY2011/12


Age

15-19* 10.7 0.0 23.2

20-44 6.4 3.6 9.2

45-64 7.0 5.9 8.1

65-79 8.0 7.1 8.9

80+ 9.7 8.8 10.6

Sex

Female 8.4 7.6 9.2

Male 8.2 7.4 9.0

Income quintile

Q1 (Lowest) 8.6 7.4 9.8

Q2 8.2 7.0 9.4

Q3 8.1 6.8 9.4

Q4 8.4 7.1 9.6

Q5 (Highest) 8.2 6.9 9.5

Rural/Urban

Urban 8.4 7.8 9.0

Rural 7.7 6.1 9.3 Note: * The rate is unstable due to small numerator and denominator.

ESC SW WWHNH



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tRelative year over year reduction = 10 percent



The risk adjusted readmission rate for stroke has been relatively stable and has

fluctuated between 7.9% and 8.8% since 2002/03; the provincial rate in 2011/12 was

8.4%.

The 30-day readmission rate after a stroke admission did not vary significantly by patient

sex, neighbourhood income quintile, rural/urban status or LHIN. Patients aged 45-64

years old had a lower readmission rate (7.0%) than the provincial average, while the

oldest patients had a higher rate (9.7%).


Thirty-day all cause readmission rate for patients admitted for asthma Indicator description

This indicator measures the rate of non-elective readmissions within 30 days of discharge to community after an asthma admission





Attribute Effective


External Alignment



Unit of analysis The measuring unit of this indicator is per discharge (could include patients more than once within a year). The indicator is expressed as a rate of non-elective readmissions per 100 asthma admissions.

Calculation Numerator Cases within the denominator with a non-elective readmission within 30 days of discharge after an asthma admission.

Denominator Asthma discharges between April 1 and March 1 of the reporting fiscal year in an inpatient setting Includes:

- Discharged alive - Age range: all ages








By age group (0-9;10-19;20-44;45-64; 65-79; 80+);

By sex;

By income quintile;

By rural/urban




Limitations n/a


Risk adjusted using logistic regression:

Factors

o Age

o Sex

o Two or more previous asthma admissions (diagnosis type is M, 1,W,X or Y) within a fiscal year



n/a


Current performance

Figure1. 30-day all causes risk-adjusted readmission rate after an admission for asthma,

Ontario, FY2002/03-2011/12

2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12


0.0

25.0

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rc

en

t



Figure2. 30-day all causes risk-adjusted readmission rate after asthma, by LHIN,

FY2011/12

Note: The risk adjusted rates in Figure 1 and 2 are adjusted by age, sex, and having two or more previous asthma

admissions within a fiscal year.

Table1. 30-day all causes risk-adjusted readmission rate after asthma, by age, sex,

income quintiles and rural/urban status, FY2011/12


Age 0-9 3.55 2.46 4.65

10-19 4.09 1.59 6.59

20-44 9.04 7.34 10.73

45-64 9.46 7.72 11.21

65-79 10.14 7.43 12.84

80-84 13.68 10.31 17.05

Sex Female 6.62 5.71 7.54

Male 6.37 5.21 7.54

Income quintile Q1 (Lowest) 5.79 4.38 7.21

Q2 7.32 5.86 8.78

Q3 7.57 5.91 9.22

Q4 5.42 3.71 7.14

Q5 (Highest) 6.27 4.26 8.28

Rural/Urban Urban 6.46 5.7 7.21

Rural 7.24 4.87 9.61



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The risk-adjusted readmission rate for asthma has fluctuated between 5.2% and 6.2%

over a 10-year period and was 6.2% in FY2011/12. Over the past nine years, the

absolute numbers of admissions and readmissions (volumes) have continuously

declined, but the risk-adjusted rate has not changed significantly during this period.

Due to the small sample size at the LHIN level, all LHIN level risk-adjusted readmission

rates had wide confidence intervals. Statistical analysis indicated that only the South

East LHIN had a significantly higher rate than the overall provincial readmission rate

after an asthma admission.

The 30-day readmission rate after an asthma admission did not vary significantly by

patients’ sex, neighbourhood income quintile or rural/urban status but did vary by patient

age (see table 1). In 2011/12, patients aged 9 years and younger had a lower

readmission rate than provincial overall rate, while patient groups aged 20-44, 45-64, 65-

79 and 80+ had higher rates.


Pulmonary function testing (PFT) for patients with COPD Indicator description

Percentage of patients with COPD who have had their diagnosis confirmed with pulmonary function testing within one year (before or after) their diagnosis.


COPD should be diagnosed by PFT; however the use of spirometry in the community is low. Clinical evaluation without spirometry has been found to be specific for COPD, but not highly sensitive and is therefore likely to miss milder cases.


Qmonitor

Attribute Effective

Type Core and Process indicator

External Alignment

Primary Care Performance Measurement, Quality Based Procedures, Ontario Action Plan for Health Care.

Accountability Hospital and Primary care

Calculation Numerator Individuals with COPD who had any pulmonary function testing any time from 1 year before the COPD diagnosis date to 1 year following the diagnosis date. Includes: patients who had PFT based on the following OHIP fee codes

J301 (simple spirometry)

J324 / J327 (spirometry after bronchodilator)

J304 (flow volume loop)

J307 (body plesthysmography)

J310 (carbon monoxide diffusing capacity)

J333 (Non-specific bronchial provocative test (histamine, methacholine, thermal, challenge)

Excludes: Negated OHIP claims, duplicate claims and lab claims

Denominator Individuals who had an incident diagnosis of COPD between fiscal year 2002/03 and 2011/12 based on more sensitive definition used for ICES derived cohort (see Gershon et al, 2009, J of COPD vol 6(5):388-394) Includes:

Patients with ≥ 1 outpatient claim or ≥ 1 hospitalization for COPD

Excludes:

Individuals who were ineligible for OHIP for at least 2 consecutive quarters during the observation period (from 2 years prior to the diagnosis date to 1 year following the diagnosis date, to allow full ascertainment of PFT testing within a period that ends 1 year after diagnosis date), using OHIP yearly contact files.

Individuals who died within 1 year of their incident diagnosis date

Individuals who had Lung Volume reduction surgery or lung transplant prior to diagnosis date

Individuals > 99 years of age at time of COPD diagnosis



ICES derived and validated COPD cohort (Gershon et al, 2009, J of COPD vol 6(5):388-394) OHIP data Data are available for multiple years


Data can be run annually – based on cohort definition


Comparable over time, by LHIN and patient characteristics


Performance Target = 80% Relative year over year increase = 20%


Limitations The use of an ICES derived COPD cohort may miss milder cases of COPD, however it will identify clinically significant COPD. The more sensitive (less specific) definition for the cohort was used to try to capture some milder cases.


Direct standardization was used for the age- and sex-adjusted rates and used the 2002/03 (COPD cohort) data as the reference


Current performance

Figure1. COPD patients who underwent pulmonary function testing within one year

(before or after) diagnosis (rate per 100), in Ontario, 2002/03 - 2011/12

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Adjusted rate per 100 34.1 34.9 34.9 37.2 37.6 37.4 36.5 37.9 38.6 34.9

0

10

20

30

40

50

Rate

pe

r 1

00

Fiscal year

Performance Target = 80%Relative year over year increase = 20%


Table 1. COPD patients who underwent pulmonary function testing within one year (before or after) diagnosis (rate per 100) by patient characteristics, in Ontario, 2011/12

Variable Stratification Adjusted rate per 100 95% LCL 95% UCL

Sex Female 34.92 34.20 35.65

Male 35.00 34.31 35.71

Age

35-39 18.51 17.20 19.89

40-49 25.91 24.97 26.88

50-59 33.24 32.30 34.20

60-69 41.97 40.84 43.13

70-79 44.28 42.91 45.70

80-89 34.81 33.21 36.47

90-99 15.62 12.94 18.69

Income quintile

1 32.11 31.08 33.15

2 34.77 33.70 35.85

3 35.55 34.41 36.71

4 35.91 34.75 37.10

5 36.81 35.58 38.07

Rural/urban Urban 35.37 34.82 35.92

Rural 32.49 31.26 33.76

Figure 2. COPD patients who underwent pulmonary function testing within one year (before or after) diagnosis (rate per 100) by LHIN, in Ontario, 2011/12

EST SW WW HNHS CW MH TC C CE SE CH NSM NE NW

Adjusted rate per 100 36.2 30.5 38.8 36.0 36.5 36.8 35.3 35.7 34.7 34.5 36.8 31.6 29.2 36.3

0

10

20

30

40

50


Rate

pe

r 1

00


Figure 3. COPD patients who underwent pulmonary function testing within one year (before or after) diagnosis (rate per 100) by neighbourhood income quintile, in Ontario, 2011/12

Statement of Results

In 2011/12, only about one-third (34%) of patients who were identified as having COPD based

on an administrative data algorithm underwent PFT within one year (before or after) their

diagnosis date. The age and sex adjusted rate of PFT among COPD patients was similar to the

crude rate (34.9%); as such age and sex adjusted rates are reported for other values. Over

time, since 2002/03 the rate has fluctuated between 34% and 39% and was highest in 2010/11

before dropping down to current fiscal year levels.

The PFT rate for 2011/12 varied significantly by the age of the patient, their neighbourhood

income quintile and rural/urban status but did not vary by patient sex (see Table 1).

The variation across LHINs was also statistically significant and ranged from a low of 29% in the

North East LHIN to a high of 39% in the Waterloo Wellington LHIN.

32.134.8 35.5 35.9 36.8

0

10

20

30

40

50

Q1 Q2 Q3 Q4 Q5

Ra

te p

er

10

0

Neighbourhood income quintile



Physician visit within 7 days of hospital discharge for CHF Indicator description

Percent of patients that say a physician within 7-days after discharge from an acute care hospital for CHF


It is important that patients who are hospitalized for CHF receive timely follow up once discharged from hospital to ensure that the patients are stable, understand their post-discharge instructions and medications and to transition them to community based care


Qmonitor, primary care QIPs

Attribute Access

Type Core and Process indicator.

External Alignment

CHF Quality Based Procedure; Ontario Action Plan for Health Care; Potential PCPM alignment; Canadian Thoracic Society; Potential Health Links alignment; Quality Improvement Plans (Primary Care).


Calculation Numerator Number of patients discharged from acute care hospitals that had a physician visit within 7 days after discharge Includes:

Ontario physician visits taking place in office, home, or long-term care (based on ICES location macro)

Physician visits occurring between days 0 to 7 post-discharge (i.e., includes date of discharge)

Excludes:

Negated OHIP claims, duplicate claims and lab claims Records with missing or invalid data on discharge/admission date, health number, age and gender

Denominator Describe denominator including inclusion/exclusion criteria Includes:

Discharges from acute care hospitals with discharge date in the reporting period

Admission for either o CHF (ICD10 codes I500, I501, I509) o COPD (ICD10 codes J41, J42, J43, J44)

Excludes:

Deaths, acute transfers, patient sign-outs against medical advice;

Records with missing or invalid data on discharge/admission date, health number, age and gender.

Cases with no Resource Intensity Weight (RIW) assigned.


Transfers to other hospital care and to other (palliative care/hospice, addiction treatment centre….) as defined by discharge disposition ‘01’, ‘03’.

Sign-outs, short-stay cases, cadavers and stillbirths


CIHI DAD (for admissions) and OHIP data for follow up visit Administrative data Data are available for multiple years


CIHI DAD closes annually; but can be run quarterly with interim data; OHIP data available monthly


Comparable over time, by LHIN and possibly by HealthLinks or physnet communities (future analyses)


Performance target = 50% year-over-year relative increase.

Target Source Expert consultation.

Limitations Assumes that follow up visit is to transition for hospitalization; but not confirmed; Follow up by NPs (in FHTs) or providers that do not provide billing or shadow billing will not be captured.


Age and sex standardized


Current performance

Figure1: Percent of patients that had a follow-up visit within 7-days after discharge from

hospital for CHF, by physician type, from 2002/03 to 2011/12

2002/03

2003/04

2004/05

2005/06

2006/07

2007/08

2008/09

2009/10

2010/11

2011/12

Any Follow-up 51.2 50.4 53.3 53.5 47.7 45.5 51.8 49.6 45.4 48.2

Primary care provider 32.3 30.0 31.8 30.2 30.0 25.9 29.8 28.3 25.9 25.0

Cardiologist 12.2 7.9 9.5 13.6 9.9 13.6 15.2 12.1 11.1 15.0

0

50

100

Pe

rce

nt

Performance Target = 50% year-over-year relative increase.


Figure 2: Percent of patients that had a physician visit within 7-days after discharge from

hospital for CHF by physician type and LHIN, 2011/12

Table 2. Percent of patients that had a physician visit within 7-days after discharge from

hospital for CHF by patient characteristics and provider type, 2011/12

Variable

Stratification Adjusted rate for any visit

Adjusted rate for PCP visit

Adjusted rate for cardiologist

visit

Sex Female 51.8 26.7 16.0

Male 44.6 23.3 14.1

Age

<20 61.5 11.5 29.6

20-44 42.6 24.6 14.6

45-64 45.9 31.9 8.5

65-79 46.8 34.8 6.6

80+ 42.3 34.3 4.0

Income quintile

Q1 45.0 27.4 11.1

Q2 54.3 24.2 19.3

Q3 46.1 27.4 13.7

Q4 51.3 26.5 13.9

Q5 44.6 23.2 15.2

Rural/urban urban/non-rural 37.2 18.5 15.3

rural 49.3 26.1 12.2


Any follow-up 36 41 29 45 60 53 41 54 48 39 56 26 23 22

PCP 24 24 20 18 37 31 24 32 25 20 20 20 13 12

Cardiologist 5 7 6 24 19 17 14 13 18 11 25 1 1 8

0

50

100P

erc

en

t

Performance target= 50% year-on-year relative increase



In 2011/12 across Ontario close to half of congestive heart failure (CHF) patients did not

have a follow-up visit with a physician (any) after hospital discharge. In 2011/12, 48.2% of

CHF patients who were hospitalized saw a physician within 7 days, 25% had a follow-up

visit with a primary care physician and 15% saw a cardiologist during the same time frame.

While the overall follow-up rates remained stable in the past 10 years the rate of

cardiologist follow-up has increased from 7.9% in 2003/04 to 15% in 2011/12, and the rate

of follow up by a primary care provider during the same period has shown a commensurate

decline (32.3% to 25.0%).

Women had slightly higher rates of follow-up care than men by all physician types. The

rates did not vary significantly by age, income or by urban/rural status.

The overall rates of post-discharge 7-day follow-up with any physician varied significantly by

LHINs. In 2011/12 the rates ranged from 22% in the North West LHIN to 60% in the Central

West LHIN.


Physician visit within 7 days of hospital discharge for COPD Indicator description

Percent of patients that saw a physician within 7-days after discharge from an acute care hospital for COPD


It is important that patients who are hospitalized for COPD receive timely follow up once discharged from hospital to ensure that the patients are stable, understand their post-discharge instructions and medications and to transition them to community based care.


Qmonitor, Primary care QIPs

Attribute Access


External Alignment COPD Quality Based Procedure, Ontario Action Plan for Health Care; Potential PCPM alignment; Potential Health Links alignment; Quality Improvement Plans (Primary Care).


Calculation Numerator Number of patients discharged from acute care hospitals that had a physician visit within 7 days after discharge Includes:

Ontario physician visits taking place in office, home, or long-term care (based on ICES location macro)

Physician visits occurring between days 0 to 7 post-discharge (i.e., includes date of discharge)

Excludes:

Negated OHIP claims, duplicate claims and lab claims Records with missing or invalid data on discharge/admission date, health number, age and gender

Denominator Describe denominator including inclusion/exclusion criteria Includes:

Discharges from acute care hospitals with discharge date in the reporting period

Admission for either o CHF (ICD10 codes I500, I501, I509) o COPD (ICD10 codes J41, J42, J43, J44)

Excludes:

Deaths, acute transfers, patient sign-outs against medical advice;

Records with missing or invalid data on discharge/admission date, health number, age and gender.

Cases with no Resource Intensity Weight (RIW) assigned.

Transfers to other hospital care and to other (palliative care/hospice, addiction treatment centre….) as defined by discharge disposition ‘01’, ‘03’.

Sign-outs, short-stay cases, cadavers and stillbirths


CIHI DAD (for admissions) and OHIP data for follow up visit Administrative data Data are available for multiple years



CIHI DAD closes annually; but can be run quarterly with interim data; OHIP data available monthly


Comparable over time, by LHIN and possibly by HealthLinks or physnet communities (future analyses)


50% year-over-year relative improvement

Target Source Expert Consultation

Limitations Assumes that follow up visit is to transition for hospitalization; but not confirmed; Follow up by NPs (in FHTs) or providers that do not provide billing or shadow billing will not be captured.


Age and sex standardized


Current performance

Figure1. Percent of patients that had a follow-up visit within 7-days after discharge from

hospital for COPD, by physician type, from 2002/03 to 2011/12

2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

Any Follow-up 41.0 41.1 37.6 40.0 36.8 37.8 38.5 39.9 31.9 35.1

Primary care provider 28.2 29.8 28.5 29.6 25.2 25.3 29.6 28.5 24.7 26.7

Respirologist 2.8 2.7 2.1 2.1 2.5 2.9 2.4 1.8 1.7 3.2

0

50

100

Pe

rce

nt


Figure 2. Percent of patients that had a physician visit within 7-days after discharge from

hospital for COPD by physician type and LHIN, 2011/12

Table 1. Percent of patients that had a physician visit to any provider within 7-days after

discharge from hospital for COPD by patient characteristics, 2011/12


Sex

Female 34.7 20.9 54.15

Male 35.5 28.4 43.84

Age

<20 33.3 7.7 92.33

20-44 36.4 28.4 45.91

45-64 35.2 33.4 36.92

65-79 34.3 33.1 35.49

80+ 35.3 33.9 36.7

Income quintile

Q1 25.6 20.6 31.41

Q2 25.0 20.0 31.02

Q3 30.1 22.4 39.67

Q4 28.5 21.6 36.88

Q5 56.3 32.2 91.44

Rural/Urban

Urban/non-rural 38.7 29.9 49.36

Rural 21.3 16.3 27.24

EST SW WWHNH


Any Follow-up 29 27 31 38 32 54 33 37 32 20 30 37 20 23

Primary care provider 26 22 25 25 25 45 19 34 20 17 19 19 14 17

Respirologist 1 7 1 6 1 3 5 2 8 0 1 0 2 0

0

50

100

Pe

rce

nt


Table 2: Percent of patients that had a physician visit within 7-days after discharge from hospital for COPD by patient characteristics and provider type, 2011/12

Variable

Stratification Adjusted rate for

any visit Adjusted rate for PCP visit

Adjusted rate for Respirologist visit

Sex Female 34.7 28.7 2.5

Male 35.5 24.9 3.8

Age group

<20 33.3 25.1 2.7

20-44 36.4 27.1 4.1

45-64 35.2 27.3 2.9

65-79 34.3 26.9 2.2

80+ 35.3 30.0 1.2

Income quintile

Q1 25.6 19.5 2.1

Q2 25.0 19.4 1.1

Q3 30.1 22.2 2.0

Q4 28.5 21.1 4.0

Q5 56.3 48.6 6.4

Rural/urban urban/non-rural 38.7 28.8 3.9

rural 21.3 16.7 0.7

Statement of Results

In the last 10 years, the percent of chronic obstructive pulmonary disease (COPD) patients

who had a follow up visit within 7 days of hospital discharge has declined slightly from

41.0% in 2002/03 to 35.1% in 2011/12.

In Ontario in 2011/12, 35% of COPD patients had a 7-day follow-up visit with a physician

after hospital discharge. One in four COPD patients had their visit with a primary care

provider and 3% saw a respirologist.

Patients residing in the highest-income neighborhoods had significantly higher follow up

rates with any provider (56.3%), compared to those living in the lowest income areas

(25.6%).

There was no significant variation in follow up rates by age and gender. The rate of follow-

up in urban settings was almost double (38.7%) the rate of follow-up in rural settings

(21.3%).

In 2011/12, the rate of 7-day follow-up visit with any provider varied by LHIN and ranged

from 20% in the North East and South East LHINs to 54% in the Mississauga Halton LHIN.


Early-term Elective Repeat C-section (ERCS) Indicator description

The number of low-risk* women with a caesarean section performed between 37 and 39 weeks' gestation (37 weeks + 0 days to 38 weeks + 6 days gestation), expressed as a percent of the total number of low-risk women who had a repeat caesarean section at term (≥37 weeks).


Early-term elective repeat caesarean section (ERCS) (37-38 weeks) is associated with increased risks to the neonate, respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN) and higher rates of admission to neonatal intensive care units (NICU). Many obstetric organizations around the world now advocate that uncomplicated ERCS not be performed before 39 weeks gestation. The 2008 Canadian Perinatal Health Report indicates that the proportion of elective repeat c-section has increased by 18.2% between 1995-1996 and 2004-2005. The rate of ERCS /Other deliveries in Canada accounted for 6.7/100 of hospital births. BORN Ontario reports ERCS as one of its key performance indicators on its hospital dashboard


BORN Ontario dashboard Early Repeat C Section rates were reported in Canadian Perinatal Health Report.

Attribute Appropriate


External Alignment BORN Ontario; Provincial Council for Maternal and Child Health

Accountability Hospital and Primary Care

Calculation Numerator Number of low-risk women with a repeat caesarean section performed from ≥37 to <39 weeks' gestation Women with indications for caesarean section are excluded, other than women with the following indications: fetal malposition/malpresentation, previous caesarean section, accommodates care provider/organization, or maternal request

Denominator Total number of low-risk women with a repeat caesarean section performed at term (≥37 weeks' gestation) Inclusion criteria:

No labour (caesarean section)

Live births

Singleton (One fetus)

with a history of one or more previous caesarean sections

≥37 weeks + 0 days gestational week No indications of c section, except

Fetal | Malposition/Malpresentation

Maternal | Previous C/Section

Accommodates Care Provider/Organization

Maternal Request

Unknown


Exclusions

Multiple fetuses

<=36 weeks+6days

Spontaneous vaginal births

Assisted vaginal births

Induced or spontaneous Labour C-section

Indications for caesarean section

Complications of pregnancy

Labour and birth complications

Preexisting maternal health conditions

Diabetes and pregnancy

Hypertension disorder in pregnancy Repeat caesarean section in low-risk women is defined as a caesarean section performed prior to the onset of labour, among women with a singleton live birth, with a history of one or more previous caesarean sections and with no fetal or maternal health conditions or obstetrical complications.


BORN Information System (BIS) data elements. For this indicator, values for type of birth are derived from the Birth Mother encounter, unless a different value was entered in the Birth Child encounter, in which case the value from the Birth Child encounter is used. The BORN Information System (BIS) collects data on every birth and young child in the province from Data is collected from a number of sources including:

Prenatal Screening laboratories

Hospitals (labour, birth, and early newborn care information including NICU admissions)

Midwifery Groups (labour, birth, and early newborn care information)

Specialized antenatal clinics (information about congenital anomalies)

Newborn screening laboratory

Prenatal screening and newborn screening follow-up clinics

Fertility clinics

Data are collected and reported through a variety of mechanisms including HL7, batch upload, manual data entry along with standard and analytical reports.


Reported quarterly by BORN Reporting hospital data are shown only if data have been acknowledged for submission.


Across time (based on quarterly data Provincial Facility PCMCH Level of care


Summary of maternal levels of care hospital designation definitions15 (for more details see http://www.pcmch.on.ca/publications-resources/clinical-practice-guidelines) Level 1: GREATER THAN OR EQUAL TO 36 WEEKS AND 0 DAYS (Includes 1a and 1b levels of care) –Delivery for women with low maternal and neonatal risk including no significant medical diseases or risk factors. Women between 36 + 6 days and 36 + 0 days only if spontaneous preterm labour and with the absence of any other fetal maternal complications. For all other cases less than 37 weeks consultation or transfer is recommended. Operative vaginal deliveries are undertaken only when low risk and a backup plan is in place. The level 1b may care for uncomplicated dichorionic twin pregnancies greater than or equal to 36 weeks and 0 days. Level 2: GREATER THAN OR EQUAL TO 34 WEEKS AND 0 DAYS (Includes 2a, 2b and 2c levels of care): In addition to the care above hospitals with this designation can provide care to women carrying a fetus with minor anomalies. Low-to-moderate maternal risk experiencing low risk medical/obstetrical complications where SGA (small for gestational age) is not suspected. May care for uncomplicated dichorionic twin pregnancies. If less than 36 weeks and 0 days consider consultation and transfer. Level 3: ANY GESTATIONAL AGE OR WEIGHT Care as above plus high risk maternal and/or neonatal care; high maternal risk and/or complex medical, surgical and/or obstetrical complications requiring complex multidisciplinary and subspecialty critical care at any gestational age. High fetal risk complications such as diagnosis of congenital malformations Neonatal intensive care services as per Neonatal Scopes of Services document. On-site adult intensive care unit services available.


Less than 11 per 100 live births

Target Source BORN Ontario

Limitations Data can only be reported for hospitals who submit and acknowledge their own data; though rates are high Information on patient characteristics are not available


N/A

15Provincial Council of Maternal and Child health. Standardized Maternal and Newborn levels of care

definitions. July 2011. Accessed at: http://www.pcmch.on.ca/publications-resources/clinical-practice-guidelines

http://www.pcmch.on.ca/publications-resources/clinical-practice-guidelines






BORN evidence summary No Canadian guidelines

*Low-risk for this indicator is defined as women how had almost no indication for C- section

except the ones mentioned above

Current performance*

Provincial rate Oct 1 - Dec 31,

2012 (Q3) Jan 1 - Mar 31, 2013

(Q4)

Proportion of women with a caesarean section performed from ≥37 to <39 weeks' gestation among low-risk women having a repeat caesarean section at term 53.5% 46.8%

Note: MND (maternal Newborn Dashboard launched November 19, 2012)

*Of 106 eligible hospitals data for 14 hospitals were not available (had not been acknowledged) for Q4

Figure 1. Proportion of women with a caesarean section performed from ≥37 to <39 weeks' gestation among low-risk women having a repeat caesarean section at term in Ontario, by maternal level of care la and Ib hospitals, Jan 1 - March 31, 2013 (Q4)

0.0

50.0

100.0

1 3 5 7 9 11 13 15 17 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32

la Ib

Pe

rce

nt

Hospital



Figure 2. Proportion of women with a caesarean section performed from ≥37 to <39 weeks' gestation among low-risk women having a repeat caesarean section at term in Ontario, by maternal level of care ll(IIa; IIb; IIc) hospital, Jan 1 - March 31, 2013 (Q4)

Figure 3. Proportion of women with a caesarean section performed from ≥37 to <39 weeks' gestation among low-risk women having a repeat caesarean section at term in Ontario, by maternal level of care III hospital, Jan 1 - March 31, 2013 (Q4)

0.0

50.0

100.0

1 2 3 4 5 6 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1 2 3 4 5 6 7 8 9 10 11

IIa llb IIc

Pe

rce

nt

Hospital

0.0

50.0

100.0

1 2 3 4 5 6

Pe

rce

nt

Hospital




Figure 4. Proportion of women with a caesarean section performed from ≥37 to <39 weeks' gestation among low-risk women having a repeat caesarean section at term in Ontario, by hospital, Jan 1 - March 31, 2013 (Q4)

*Note: the results should be interpreted with caution since for Q4 only 92 hospitals data are available. This limitation applies to all levels of data (Provincial and hospital). The missing values include “no data” and “not acknowledged’’. No data refers to hospitals that either didn’t have any births for that period, or if the records did not meet the inclusion criteria.


Across Ontario during the 2012/12 fiscal year, approximately half of all elective repeat

caesarean deliveries at term were performed before 39 weeks ‘gestation in both the third

quarter (53.5%) and the fourth quarter (46.8%).

There is large variation in the hospital specific ERCS rates. In Q4, 18 level I hospitals

and one level III hospital had 0% of all elective repeat caesarean, term deliveries that

were performed before 39 weeks gestation. For hospitals with rates higher than 0%, the

rates ranged from ranging from 20% to 100% in q4 of 2012/13 (Figure 4). The rate

variation was similar in almost all level of care hospitals (Figures 1-3), with a slightly

narrower range in level III hospitals, where one hospital reported a rate of 0% and the

remaining hospital rates varied from 36% to 79%.

The variation in Q3 was similar to the variation seen in Q4 (however no figures are

presented for this quarter).

0.0

50.0

100.0

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 85 87 89 91 93

Pe

rce

nt

Hospital



Proportion of women who were induced with an indication of post-dates and were less than 41 weeks’ gestation at delivery Indicator description The number of women who were induced with an indication

for induction of labour of post-dates (>41 weeks gestation) and were actually less than 41 weeks' gestation (less than or equal to 40 weeks + 6 days gestation), expressed as a percent of the total number of women who were induced with

an indication for induction of labour of post‐dates (in a given time and place).

Relevance/Rationale

Based on SOGC guidelines16 induction of labour is indicated

when the benefits of vaginal delivery outweigh the maternal and fetal risks of induction. There are a number of indications for induction; however one of the most common indications for induction is post term pregnancy. It is also associated with potential risks, which includes increased risk of operative vaginal delivery, C section, uterine rapture, etc. Inductions in the absence of medical indications are considered elective.17

SOGC recommends that elective induction is associated with potential complications and should be undertaken after considering the risks and establishing accurate gestational age. The rate of induction in the Province was 25% in 2009/10 (BORN). The proportion of women who were <41 weeks of gestational age at delivery among women who were induced and had a post-dates indication for induction of labour was 18% in 2009/1018.

BORN Ontario reports induction rates as one of its key performance indicators on its hospital dashboard.

Reporting tool/product Quality Monitor (new) BORN dashboard and Provincial reports

Attribute Appropriate

Type Core and Process measure

External Alignment BORN reports; Provincial Council for Maternal and Child Health

Accountability Hospital and Primary Care

Calculation Numerator Number of women who were induced with an indication of post-dates and were less than 41 weeks' gestation at delivery Inclusion: If included as part of the denominator and had <= 40weeks+6days gestation

Denominator Total number of women who were induced with an indication of post-dates

16 Joan Crane. SOGC Clinical Practice Guideline. Induction of labour at term. No 107 August 2001 17 KTA Evidence Summary. What is known about the maternal and newborn risks of elective induction of women at term. Evidence

summary No 10 18 Perinatal Health Report 2009–2010 Erie St. Clair and South West — LHINs 1 & 2, August 2001


Inclusion: Indication for induction of labour of post-dates need not be the primary indication for induction of labour, it can be any indication for induction. Records will be included for this indicator if 'Fetal | Post-dates' is selected for 'All indications for induction of labour', regardless if any additional indications are selected for this multi-select data element.

All indications of Fetal/Post-dates, including any combination with other conditions

Induced labour


BORN Information System (BIS) data elements. For this indicator, values for type of birth are derived from the Birth Mother encounter, unless a different value was entered in the Birth Child encounter, in which case the value from the Birth Child encounter is used. The BORN Information System (BIS) collects data on every birth and young child in the province from Data is collected from a number of sources including:

Prenatal Screening laboratories

Hospitals (labour, birth, and early newborn care information including NICU admissions)

Midwifery Groups (labour, birth, and early newborn care information)

Specialized antenatal clinics (information about congenital anomalies)

Newborn screening laboratory

Prenatal screening and newborn screening follow-up clinics

Fertility clinics

Data are collected and reported through a variety of mechanisms including HL7, batch upload, manual data entry along with standard and analytical reports.


Reported quarterly by BORN Reporting hospital data are shown only if data have been acknowledged for submission for a given month.

Levels of comparability Provincial Facility PCMCH Level of care Summary of maternal levels of care definitions19 (for more details see http://www.pcmch.on.ca/publications-resources/clinical-practice-guidelines) Level 1: GREATER THAN OR EQUAL TO 36 WEEKS AND 0 DAYS (Includes 1a and 1b levels of care) –Delivery for women with low maternal and neonatal risk including no significant medical

19Provincial Council of Maternal and Child health. Standardized Maternal and Newborn levels of care definitions. July 2011.

Accessed at: http://www.pcmch.on.ca/publications-resources/clinical-practice-guidelines





diseases or risk factors. Women between 36 + 6 days and 36 + 0 days only if spontaneous preterm labour and with the absence of any other fetal maternal complications. For all other cases less than 37 weeks consultation or transfer is recommended. Operative vaginal deliveries are undertaken only when low risk and a backup plan is in place. The level 1b may care for uncomplicated dichorionic twin pregnancies greater than or equal to 36 weeks and 0 days. Level 2: GREATER THAN OR EQUAL TO 34 WEEKS AND 0 DAYS (Includes 2a, 2b and 2c levels of care): In addition to the care above hospitals with this designation can provide care to women carrying a fetus with minor anomalies. Low-to-moderate maternal risk experiencing low risk medical/obstetrical complications where SGA (small for gestational age) is not suspected. May care for uncomplicated dichorionic twin pregnancies. If less than 36 weeks and 0 days consider consultation and transfer. Level 3: ANY GESTATIONAL AGE OR WEIGHT Care as above plus high risk maternal and/or neonatal care; high maternal risk and/or complex medical, surgical and/or obstetrical complications requiring complex multidisciplinary and subspecialty critical care at any gestational age. High fetal risk complications such as diagnosis of congenital malformations Neonatal intensive care services as per Neonatal Scopes of Services document. On-site adult intensive care unit services available.


Less than 5% (BORN dashboard benchmark)

Target Source BORN Ontario

Limitations Across time (quarterly) In the current data there are about 10% missing values


N/A


SOGC Clinical Practice Guidelines. Induction of labour at term. No. 107,August 2001 BORN Evidence Summary No 10. March 2011


Current performance

Provincial rate Oct 1 - Dec 31, 2012

(Q3) Jan 1 - Mar 31,

2013 (Q4)

Proportion of women who were induced with an indication of post-dates and were less than 41 weeks’ gestation at delivery 26.6% 25.9%

Note: MND (maternal Newborn Dashboard launched November 19, 2012) Of 106 eligible hospitals data for 14 hospitals were not available (had not been acknowledged) for Q4

Figure 1. Proportion of women who were induced with an indication of post-dates and

were less than 41 weeks' gestation at delivery by maternal level of care I (Ia and Ib)

hospital, Jan 1 - March 31, 2013

0.0

50.0

100.0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

la lb

Pe

rce

nt

Hospital




were less than 41 weeks' gestation at delivery by maternal level of care II (IIa,IIb and IIc)

hospital, Jan 1 - March 31, 2013


were less than 41 weeks' gestation at delivery by maternal level of care III hospital, Jan 1

- March 31, 2013

0.0

50.0

100.0

1 2 3 4 5 6 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1 2 3 4 5 6 7 8 9 10 11

lla llb llc

Pe

rce

nt

Hospital

0.0

50.0

100.0

1 2 3 4 5 6

Pe

rce

nt

Hospital





were less than 41 weeks' gestation at delivery by hospital, Jan 1 - March 31, 2013

Note: The Q4 results should be interpreted with caution; out of 106 hospitals there were only 13 hospitals with no

data available. This limitation applies to all levels of data (Provincial and hospital). No data refers to hospitals that

either didn’t have any births for that period, or if the records did not meet the inclusion criteria.

Statement of Results:

Across Ontario in 2012/13 about one fourth of women who were induced with an

indication of post-dates were less than 41 weeks' gestation at delivery in Q3 (26.6%) and

in Q4 (25.9%).

There is large variation in induction rates at less than 41 weeks gestation. In Q4, 22 level

I hospitals and one level II hospital had 0% of women who were induced at less than 41

weeks gestation with an indication of post-dates. For hospitals with rates higher than

0%, the rates ranged from ranging from 2% to 100% in q4 of 2012/13 (Figure 4). The

rate variation was 9% to 100% for level I hospitals, 4% to 72% for level II hospitals and

2% to 27.3% for level III hospitals.

The variation in Q3 was similar to the variation seen in Q4 (however no figures are

presented for this quarter).

0.0

50.0

100.0

1 3 5 7 9 1113 1517 1921 2325 2729 313335 3739 4143 4547 4951 5355 5759 6163 6567 6971 7375 7779 8183 8587 8991 93

Per

cen

t

Hospital



Influenza immunization coverage among adults 65 years of age and older Indicator description

Proportion of people 65 years of age and older who have had an influenza vaccine for the current influenza season. The APHEO Influenza Vaccination Core Indicator includes the following specific indicators related to seniors:

Influenza vaccination coverage for those 65 years and older with no chronic condition

Influenza vaccination coverage for those 65 years and older with a chronic condition

Direction of improvement: increase Frequency of reporting: intermittently reported by Statistics Canada (see “reporting tool/product” section below).


Adults and children with certain chronic diseases, persons 65 years of age and older, children 6 to 59 months of age, pregnant women and Aboriginal peoples are at high risk for influenza-related complications


Statistics Canada reporting of influenza immunization:

Influenza immunization 2008

The effect of universal influenza immunization on vaccination rates in Ontario, 2006


Type Context and process indicator

External Alignment

Quality Monitor; Potential PCPM alignment; Quality Improvement Plans (Primary Care); M-SAA

Accountability Primary Care, Long-term Care and Home Care

Calculation Numerator1

Weighted number of people aged 65 years and older with no chronic condition who had a flu shot in past year

Weighted number of people aged 65 years and older with a chronic condition who had a flu shot in past year

Denominator1 Weighted total number aged 65 years and older


Canadian Community Health Survey (CCHS)

Data elements used: o Have you ever had a flu shot? o When did you have your last flu shot? o Do you have asthma? o Do you have chronic bronchitis? o Do you have emphysema? o Do you have chronic obstructive pulmonary disease

(COPD)? o Do you have diabetes? o Do you have heart disease? o Do you have cancer? o Do you suffer from the effects of a stroke?

Data collection method: national, telephone-based, population-level health survey Data availability:

Years available:

http://www.apheo.ca/index.php?pid=172

http://www.statcan.gc.ca/pub/82-625-x/2010001/article/11105-eng.htm

http://www.statcan.gc.ca/ads-annonces/82-003-x/pdf/4225222-eng.pdf

http://www.statcan.gc.ca/ads-annonces/82-003-x/pdf/4225222-eng.pdf


o CCHS Core Content (i.e., available for all health regions in Canada): 2000/2001; 2003; 2005; 2007/2008; 2009/2010;2011/2012;

Geography: o public health unit

Alternative data source: Rapid Risk Factor Surveillance System (RRFSS)

Approximately half of Ontario health units participate in RRFSS, a telephone-based, population-level health survey conducted in Ontario by the Institute for Social Research. No provincial sample is available.

RRFSS data have traditionally been used by health units to produce flu immunization results, as data are traditionally more timely than CCHS data.


CCHS

“Flu shot” module is core content (i.e., collected by all health regions in Canada)

ongoing telephone survey

data released annually


Public health units are encouraged to use the APHEO Core Indicators for population health reporting.


Public Health Agency of Canada: 80% for seniors ≥65 and adults <65 years of age with high risk conditions

Target Source Public Health Agency of Canada

Limitations Self-reported survey data

Surveys only those seniors that are community-dwelling, limiting representativeness

Data is not from a population registry


Age and sex standardized for 2011 overall population only for the following stratifications (i.e. not chronic condition cohort):

1. LHIN 2. Age (12-17, 18-64, 65+) (sex-adjusted only) 3. Sex (age-adjusted only) 4. Income 5. Rural/urban 6. Immigrant status (3 definitions) 7. Education (restrict to 25+ years of age)


Comments


Current performance Figure1. Percent of the population aged 65+ reporting having received a flu shot in the past year, 2001-2011

Figure2. Percent of the population aged 65+ reporting having received a flu shot in the past year by LHIN, 2011

2001 2003 2005 2007 2008 2009 2010 2011

Crude rate 73.73 74.59 77.89 75.19 72.22 71.85 68.45 67.78

Crude rate (chronic conditions) 78.1 77.8 81.0 78.0 74.5 74.8 71.3 69.6

0

50

100

Per

cent

age

PHAC target = 80%

Overall ESC SW WW HNHB CW MH TC C CE SE CH NSM NE NW

Standardized rate 69.0 72.3 69.1 74.6 73.2 63.3 59.4 58.3 76.5 69.0 73.0 74.8 68.1 65.9 70.0

69.072.3

69.1

74.6 73.2

63.3

59.4 58.3

76.5

69.0

73.074.8

68.165.9

70.0

0

50

100PHAC target = 80%


Table1. Percent of the population aged 65+ reporting having received a flu shot in the past year by population characteristics, 2011


Sex

Female 68.5 65.15 71.97

Male 69.94 66.79 73.19

Age

65-74 61.34 58.13 64.69

75-84 78.35 75.05 81.76

85+ 74.89 66.33 84.26

Income quintile

Q1 66.76 62.23 71.53

Q2 70.73 66.87 74.75

Q3 62.46 56.08 69.37

Q4 72.45 67.42 77.76

Q5 76.78 71.19 82.69

Rural/urban

rural 67.6 63.65 71.73

urban/non-rural 69.17 66.53 71.89

Immigration

1 Born in Canada 72.89 70.54 75.3

2 Over 10 years 63.27 58.37 68.47

3. 0-9 years 43.18 23.78 72.05

Education

1 Less than high school 65.21 60.5 70.19

2 High school graduation 70.51 65.2 76.13

3 Post-secondary graduation 71.77 69.01 74.61

*for calculating the p values the overall rates of the subgroups were used as a reference population.


In 2011 one third of the population aged 65 and older did not receive the annual

influenza vaccination. Over time, since 2001 the rate has varied from 67.8% to 77.9%

and was the highest in 2005 and the lowest in 2011. Consistently, the immunization

rates were slightly higher in people aged 65 and older with chronic conditions.

The influenza vaccination rates in the population aged 65 and older for 2011 varied

significantly by the age of the population and immigration status. Those aged 75 and

older were more likely to be immunized than younger adults and people who were born

in Canada had higher immunization rates than those who had been in Canada for 10 or

more years. There was no variation in flu vaccination rates by gender, place of

residence and education. Population residing in the highest income neighbourhoods had

significantly higher vaccination rates compared to the provincial rates.

The rates varied across the LHINs as well, ranging from 58% in the Toronto Central

LHIN to 77% in the Central LHIN.


2-dose measles immunization coverage among 7-year-olds Indicator description

This indicator measures the proportion of 7-year-olds who have received 2 valid doses of measles-containing vaccine on or before their 7th birthday. Valid doses refer to doses of measles-containing vaccine that were given in accordance with the following guidelines: the first dose delivered on or after the first birthday and with a minimum of 4-6 weeks between doses, depending on the vaccine product used. Direction of Improvement: Increase (or stable if immunization coverage target has been achieved) Frequency of reporting: reported annually at both a provincial level and at a Public Health Unit (PHU)-specific level within Ontario in the annual immunization report for school pupils (note: data at the public health unit level are not publicly available). This report has been published by Public Health Ontario (PHO) since 2012, and by the Ontario Ministry of Health and Long-Term Care (MOHLTC) prior to 2012. The Public Health Agency of Canada (PHAC) assesses immunization coverage, including 2 dose measles immunization coverage at age seven, through the Childhood National Immunization Coverage Survey (CNICS), which is typically conducted every two years. The sampling frame supports reporting at a national level only and the results are often challenging to access in the public domain. The most recent data from the NICS that is publicly-available is from the 2004 survey. Few provinces make their immunization coverage data publicly available; British Columbia is one exception and it updates its provincial and regional estimates on an annual basis. Notes:

The immunization database that supports the assessment of immunization coverage among school pupils in Ontario is currently in a state of transition. Since the early 1990s, this data has been captured in the Immunization Records Information System (IRIS) which will be replaced by the immunization module within the Pan-Canadian Communicable Disease Surveillance and Management Information Technology application (Panorama), over the course of 2013 and 2014 by all 36 PHUs in Ontario.


Measles is the most communicable vaccine-preventable disease. As a consequence, it requires very high levels of immunity within the population to effectively prevent outbreaks. The level at which measles vaccine coverage is adequate to prevent transmission of measles virus is between 96% and 99%. Indigenous measles transmission was declared to be eliminated from the Region of the Americas in 2002. In order to maintain Canada’s elimination status, high immunization coverage is essential to prevent


the transmission of measles when importations of disease from measles-endemic countries occur. Ontario has strong legislation to support high immunization coverage against measles. Under the Immunization of School Pupils Act7, Ontario students must provide either appropriate documentation of immunization against six designated disease, which include measles, or provide a statement of exemption (religious/conscientious or medical), or else risk school suspension.

Reporting tool/ product

Public Health Ontario

Summary of the immunization coverage report for school pupils, 2010/11 school year. Available at: http://www.publichealthontario.ca/en/DataAndAnalytics/Documents/2012_November_PHO_Monthly_Report.pdf

Attribute Focussed on population health

Type: Process and Core indicator

External Alignment

Primary Care Performance Measurement; Public Health Ontario; Public Health Agency of Canada

Accountability Primary Care / Ministry / Public Health

Calculation Numerator: The number of children who have received 2 valid doses of measles-containing vaccine on or before their 7th birthday

Denominator: The number of 7 year-old-children within the population of Ontario in the year in which immunization coverage is assessed. Note: the source of the denominator data varies, based on the data source and/or methodology used for the calculation of immunization coverage


Immunization Records Information System (IRIS)

Data custodian: Individual Medical Officers of Health (MOHs) for each of Ontario’s 36 PHUs

o Immunization coverage reports, which include a 2 dose measles immunization coverage report for 7-year-olds, are made available to PHO in the form of an aggregate report containing a numerator and denominator only. These aggregate reports are provided upon request to PHO, acting as an agent of the MOHLTC to conduct the transferred surveillance function of immunization coverage assessment.

Data collection method: o Under the ISPA, Ontario MOHs must maintain a record of

immunization for all school pupils within their jurisdiction and conduct an assessment of immunization at least annually. As part of this process, immunization records are collected at the time of school enrollment and entered into IRIS. These records form the basis for the numerator.

o Each PHU receives student demographic information for schools located within its geographic boundaries, from publicly-funded school boards and independent schools, either electronically or manually and this forms the basis

http://www.publichealthontario.ca/en/DataAndAnalytics/Documents/2012_November_PHO_Monthly_Report.pdf



for the denominator used for the assessment of immunization coverage in IRIS.

o Data availability within the IRIS application o Theoretically starting in 1992 to August 2013. o Notes: Data on students aged 18 years and older is

archived and is not available for in-application reports. PHU vary with respect to data archiving practices.

o Ontario Public Health Units will cease their use of IRIS over the period of August 2013 to late 2014. All data within IRIS will be migrated to the Panorama application.

o Level of aggregation The smallest level of aggregation is at the PHU-level.

PHU-specific estimates can be aggregated to provide provincial estimates

Immunization Module within the Panorama application

Data custodian: Individual Medical Officers of Health for each of Ontario’s 36 PHUs

o In-application reports within the Panorama application are anticipated to include a two dose measles immunization coverage estimate, for select birth years (birth cohorts). This requires confirmation as the business rules for the generation of reports within the Panorama application are still to be confirmed. If this report is not confirmed, than an alternative approach to assessing immunization coverage using data exported from the Panorama application will be pursued.

Data collection method: o The data collection method is unchanged (please see

notes above under IRIS data source) o Data availability within the Panorama application

o Ontario Public Health Units will implement the Panorama immunization module over the period of August 2013 to August 2014. All IRIS data will be migrated to the Panorama application. However, the staggered implementation may pose some challenges with respect to the continuity of coverage assessment activities and comparability of estimates between IRIS and Panorama.

o Level of aggregation Using in-application reports, the smallest level of

aggregation is likely to be at the school or school-board level, but PHO does not plan to publicly report data at this level.

If data is migrated out of the Panorama application for subsequent analysis, this would permit additional analyses where coverage could be estimated and reported by additional classifications (ie. By LHIN, urban/rural setting, etc.)



Data are entered on a continual basis into the IT system (IRIS or in the future, Panorama) as immunization information is received.

Immunization coverage assessment is currently conducted on an annual basis by PHO.


PHU-specific estimates can be compared

Temporal trends in provincial immunization coverage can be reviewed, although the change in the IT system from IRIS to Panorama may create challenges in continuity and comparability

Inter-provincial comparisons are possible, where immunization coverage is publicly-reported

International comparisons are also possible, although the methodology for coverage assessment (i.e. survey, registry, administrative billing data) will vary


The Canadian target is to “achieve and maintain measles immunization with a second dose by the seventh birthday in 99% of children by the year 2000”.

The Standards, Practice and Accountability (SPA) branch of the MOHLTC has not identified a measles-containing vaccine coverage target as part of its accountability agreements with PHUs

Limitations As noted above, the transition from IRIS to Panorama may pose challenges with respect to the continuity of coverage assessment


No adjustment is currently conducted


Attaining high 2 dose measles vaccine coverage is an essential component of Canada’s measles control strategy. National standards for the reporting of immunization coverage, includes assessment of immunization coverage at age 7-years-of-age. The World Health Organization (WHO) recommends that for countries aiming for measles elimination, that >95% immunization coverage with two doses of measles-containing vaccine should be achieved.

Comments

Statement of Results (no data figures were available)

For the 2011/12 school year, 2 dose measles vaccine coverage was 86.2% among 7-

year-olds and 94.2% among 17-year-olds

For the 2011/12 school year, 2 dose measles vaccine coverage among 7-year-olds in

British Columbia ranged from 80 to 98% by Health Service Delivery Area. No provincial

estimate is available.

The most recent NICS was conducted in 2011, but its results have not been publicly-

reported to date. The most recent NICS findings that are available in the public domain

are from the 2004 survey, which in Canada reported a 2 dose measles vaccine coverage

of 79% among 7-year-olds.


1-dose immunization coverage among 13 year-old students for quadrivalent meningococcal conjugate vaccine (MCV4) Indicator description

This indicator measures the proportion of 13 year olds who have received 1 dose of the quadrivalent meningococcal conjugate (MCV4) vaccine on or before their 13th birthday. In Ontario, there is a school-based delivery platform for this vaccine, administered by Ontario Public Health Units (PHUs). Direction of Improvement: Increase (or stable if immunization coverage target has been achieved) Frequency of reporting: reported annually at both a provincial level and at a PHU-specific level within Ontario in the annual immunization report for school pupils1. This report has been published by Public Health Ontario (PHO) since 2012, and by the Ontario Ministry of Health and Long-Term Care (MOHLTC) prior to 2012. Of note, the report by PHO in 20122 did not include MCV4 coverage because of data quality concerns (see ‘Data source’ section below). Notes:

The immunization coverage report for school pupils, an annual surveillance report produced by PHO is disseminated to Ontario Medical Officers of Health, but is not made publicly available. Instead, a summary which includes provincial-level immunization coverage estimates is published within a surveillance report that is publicly accessible through Public Health Ontario’s website3. As noted above, the first report produced by PHO did not include an assessment of MCV4 vaccine coverage because of data quality concerns (see ‘Data source’ section below).

The immunization database that supports the assessment of immunization coverage among school pupils in Ontario is currently in a state of transition. Since the early 1990s, this data has been captured in the Immunization Records Information System (IRIS) which will be replaced by the immunization module within the Pan-Canadian Communicable Disease Surveillance and Management Information Technology application (Panorama), over the course of 2013 and 2014 by all 36 PHUs in Ontario.


Invasive meningococcal disease (IMD) typically presents as an acute febrile illness, which rapidly progresses to include features of meningitis and, or septicemia. Mortality among IMD cases is approximately 10% and 10-20% of survivors will have long term complications which can include neurologic disabilities, hearing impairment and amputations.4 There are various serogroups of Neisseria meningitidis, the etiologic agent of IMD. Most, but not all, are vaccine-preventable. Ontario has two vaccination programs for IMD: a toddler-based program which involves 1 dose of meningococcal C conjugate vaccine at 12 months of age and an adolescent program which


delivers one dose of MCV4 to grade 7 students. Ontario’s school-based IMD program was first implemented in 2005 using the meningococcal C conjugate vaccine and since 2009 has used MCV4. The requirement for only a single dose of MCV4 vaccine makes the assessment of immunization coverage more straightforward, as compared to school-based programs requiring multiple doses (HPV and Hepatitis B), and those with a single-sex focus (HPV).


Public Health Ontario

Summary of the immunization coverage report for school pupils, 2010/11 school year. (Note-MCV4 vaccine coverage was not reported for 2010/11 school year) Available at: http://www.publichealthontario.ca/en/DataAndAnalytics/Documents/2012_November_PHO_Monthly_Report.pdf


Type: Core and Process indicator

External Alignment

Public Health Ontario (PHO)

Accountability Primary Care, Ministry of Health, Public Health

Calculation Numerator The number of Ontario students who have received 1 valid dose of MCV4 on or before the age of 13. A valid dose is defined within the current system of IRIS5 as having been administered after the age of 11 years.

Denominator The number of 13 year-olds enrolled in a public or private school in the province of Ontario, in the year in which immunization coverage is assessed. Note: the source of the denominator data varies, based on the data source and,or methodology used for the calculation of immunization coverage when making comparisons across data systems, provinces, and countries


Immunization Records Information System (IRIS)

Data custodian: Individual Medical Officers of Health (MOHs) for each of Ontario’s 36 PHUs

o Immunization coverage reports, which include an MCV4 vaccine coverage report, are made available to PHO in the form of an aggregate report containing a numerator and denominator only. These aggregate reports are provided upon request to PHO, acting as an agent of the MOHLTC to conduct the transferred surveillance function of immunization coverage assessment.

o There are some limitations with the IRIS system with regards to the assessment of immunization coverage for MCV4, as the system cannot differentiate between meningococcal C conjugate and MCV4. However, recent validation work using the number of publicly-funded MCV4 doses distributed to Ontario PHUs, suggests that the report in IRIS provides a reasonable approximation of MCV4 coverage.

Data collection method:




o Under the ISPA6, Ontario MOHs must maintain a record of immunization for all school pupils within their jurisdiction and conduct an assessment of immunization at least annually. As part of this process, immunization records are collected at the time of school enrollment and entered into IRIS. These records form the basis for the numerator.

o Each PHU receives student demographic information for schools located within its geographic boundaries, from publicly-funded school boards and independent schools, either electronically or manually and this forms the basis for the denominator used for the assessment of immunization coverage in IRIS.

o Data availability within the IRIS application o The adolescent and toddler meningococcal immunization

programs began in Ontario in 2005 year. Data availability in IRIS for meningococcal vaccine programs extend from 2005 to August 2013 for all 36 PHUs.

o Over the course of August 2013 to late 2014, all immunization data within IRIS will be migrated to the Panorama application.

o Level of aggregation The smallest level of aggregation is at the PHU-level.

PHU-specific estimates can be aggregated to provide provincial estimates

Immunization Module within the Panorama application (forthcoming)

Data custodian: Individual Medical Officers of Health for each of Ontario’s 36 PHUs

o In-application reports within the Panorama application are anticipated to include a one dose MCV4 coverage estimate, for select birth years (birth cohorts). This requires confirmation as the business rules for the generation of reports within the Panorama application are still to be confirmed. If this report is not confirmed, an alternative approach to assessing immunization coverage using data exported from the Panorama application will be pursued.

Data collection method: o The data collection method is unchanged (please see

notes above under IRIS data source) o Data availability within the Panorama application

o Ontario Public Health Units will implement the Panorama immunization module over the period of August 2013 to August 2014. All IRIS data will be migrated to the Panorama application. However, the staggered implementation may pose some challenges with respect to the continuity of coverage assessment activities and comparability of coverage estimates between the IRIS and Panorama systems.

o Level of aggregation


Using in-application reports, the smallest level of aggregation is likely to be at the school or school-board level, but PHO does not plan to publicly report data at this level.

If data is migrated out of the Panorama application for subsequent analysis, this would permit additional analyses where coverage could be estimated and reported by additional classifications (ie. By LHIN, urban/rural setting, etc.)


Data are entered on a continual basis into the IT system (IRIS or in the future, Panorama) as immunization information is received.

Immunization coverage assessment is currently conducted on an annual basis by PHO.


PHU-specific estimates can be compared

Temporal trends in provincial immunization coverage can be reviewed, although the change in the IT system from IRIS to Panorama may create challenges in continuity and comparability. Furthermore, temporal trends must also be interpreted in light of the change in the vaccine product used in Ontario for the school-based IMD program.

Inter-provincial comparisons are possible, where this immunization coverage is publicly-reported and where the MCV4 product is also used

International comparisons are limited by variations in the IMD immunization strategy (target age group, and vaccine product used)


The Canadian coverage target for meningococcal C conjugate vaccine was set at 90% to be achieved by 20127. A target specific to MCV4 has not been expressed as many provinces and territories continue to use meningococcal C conjugate for their adolescent programs.

The Standards, Practice and Accountability (SPA) branch of the MOHLTC has identified MCV4 vaccine coverage as part of its accountability agreements with PHUs.

Target Source Public Health Agency of Canada (PHAC)

Limitations As noted above, the transition from IRIS to Panorama may pose challenges with respect to the continuity of coverage assessment


No adjustment is currently conducted


Canada’s National Advisory Committee’s recommendations on the vaccines to protect against IMD are found within the Canadian Immunization Guide8 and its Advisory Committee Statements.4

Comments


Current performance (no data figures are available)

For the 2011/12 school year, provincial MCV4 coverage among the cohort of children

born in 1999 (i.e., turned 13 years of age in 2012) was 84.4%.1

References

1. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Immunization

coverage report for Ontario’s school-based programs: 2011-12 school year and exploring

the impact of expanded eligibility programs on immunization coverage (2007-08 to 2010-11

school years). Toronto, ON: Queen’s Printer for Ontario; 2013.

2. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Immunization

coverage report for school pupils. 2010/11 school year. Toronto, ON: Queen’s Printer for

Ontario; 2012.

3. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Summary of

the immunization coverage report for school pupils, 2010/11 school year. In: Monthly

infectious diseases surveillance report. 2012;1(12):1-17. Available at:

http://www.publichealthontario.ca/en/DataAndAnalytics/Documents/2012_November_PHO_

Monthly_Report.pdf

4. National Advisory Committee on Immunization. Update on the use of quadrivalent meningococcal conjugate vaccines. CCDR. 2013;39:1-40.

5. Ontario Ministry of Health and Long-Term Care. IRIS immunization logic: Eligible, due and overdue guidelines. Toronto, ON: Immunization Policy & Programs Section, Public Health Policy & Programs Branch, Public Health Division; April 2012.

6. Immunization of School Pupils Act, R.S.O. 1990.

7. Public Health Agency of Canada. Final report on outcomes from the national consensus conference for vaccine-preventable diseases in Canada. CCDR March 2008;34:S2.

8. Public Health Agency of Canada. Canadian Immunization Guide, Evergreen edition. Meningococcal Vaccine. Available at: http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-meni-eng.php



http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-meni-eng.php

http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-meni-eng.php