Good news about difficult decisions: the Canadian approach to hospital cost control.
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Biomedical subjects
L L Roos
Publications and source records attributed to L L Roos.
Organizing the present, looking to the future: an online knowledge repository to facilitate collaboration.
BACKGROUND: Comprehensive data available in the Canadian province of Manitoba since 1970 have aided study of the interaction between population health, health care utilization, and structural features of the health care system. Given a complex linked database and many ongoing projects, better organization of available epidemiological, institutional, and technical information was needed. OBJECTIVE: The Manitoba Centre for Health Policy and Evaluation wished to develop a knowledge repository to handle data, document research Methods, and facilitate both internal communication and collaboration with other sites. METHODS: This evolving knowledge repository consists of both public and internal (restricted access) pages on the World Wide Web (WWW). Information can be accessed using an indexed logical format or queried to allow entry at user-defined points. The main topics are: Concept Dictionary, Research Definitions, Meta-Index, and Glossary. The Concept Dictionary operationalizes concepts used in health research using administrative data, outlining the creation of complex variables. Research Definitions specify the codes for common surgical procedures, tests, and diagnoses. The Meta-Index organizes concepts and definitions according to the Medical Sub-Heading (MeSH) system developed by the National Library of Medicine. The Glossary facilitates navigation through the research terms and abbreviations in the knowledge repository. An Education Resources heading presents a web-based graduate course using substantial amounts of material in the Concept Dictionary, a lecture in the Epidemiology Supercourse, and material for Manitoba's Regional Health Authorities. Confidential information (including Data Dictionaries) is available on the Centre's internal website. RESULTS: Use of the public pages has increased dramatically since January 1998, with almost 6,000 page hits from 250 different hosts in May 1999. More recently, the number of page hits has averaged around 4,000 per month, while the number of unique hosts has climbed to around 400. CONCLUSIONS: This knowledge repository promotes standardization and increases efficiency by placing concepts and associated programming in the Centre's collective memory. Collaboration and project management are facilitated.
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Coronary angiography and bypass surgery in Manitoba and the United States: a first comparison.
OBJECTIVE: To compare the appropriateness of use of coronary angiography (CA) and bypass surgery (CABS) in the early 1980s in one Canadian hospital and several American hospitals using explicit case-based criteria. Procedure rates were much lower in Canada during this period. SUBJECTS: Canadian subjects, 502 Manitoba residents undergoing CA at one hospital in 1981-82 were tracked forward to determine whether and when they underwent CABS. CA comparisons were made with 351 Canadian patients aged 55 years or older; 1677 American CA patients aged 65 years or older and were drawn in 1981 from three hospitals. Two hundred and forty-five patients undergoing CABS within 12 months of CA made up the Canadian sample. American CABS patients were sampled from three hospitals during 1979-82. Manitoba patients assigned to medical treatment after CA were also appraised. METHODS: Criteria were derived by an American panel of clinicians following a Delphi process; indications were rated appropriate, equivocal and inappropriate. A trained abstractor reviewed charts and assigned ratings. Results of exercise electrocardiograms were not available in the Manitoba data set, hence sensitivity analyses were performed to determine how differing proportions of positive exercise electrocardiograms might affect the Manitoba results. RESULTS: Even assuming only 50% of treadmill tests were positive in the Manitoba sample, the proportion of inappropriate CA was lower in Manitoba than for the American hospitals: 9% versus 15 to 18%. For CABS, only one of the three comparison American hospitals approached the Manitoba hospital level of appropriateness. CONCLUSIONS: In the early 1980s, there was more appropriate use of CA and CABS in a Manitoba hospital compared with several American hospitals. Many Canadian patients undergoing CA and treated medically met American indications for appropriate use of CABS. Whether this represents underprovision of necessary care remains uncertain.
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