Michael Wolfson and David Castle
The federal government has just offered the provinces and territories substantial new funding to address the obvious failings in Canada’s health care sector. They have also rightly coupled reform with major improvements in health data collection, including the need for new and better indicators to measure progress. As Prime Minister Justin Trudeau has repeatedly said, “What gets measured gets done.”
But as with all data, the devil is in the details.
What exactly are health outcomes? Are they the same as health indicators? How will they be measured, and how can we ensure they are reported meaningfully and transparently for all Canadians? And most importantly: Will new health data meaningfully improve health care for Canadians?
In health care, for example, indicators can include the percentages of Canadians who have access to a family care team and the number of new family care practitioners; in fact, these are two of the indicators specified by the federal government. But while these are valuable, neither measures a health outcome. Instead, these indicators provide information on volume and accessibility for a key input in health care, namely primary care.
To the extent that these indicators can provide more detail – for example, by ethnicity or socioeconomic status, which should be essential lenses – they can shed light on important issues of equity and timeliness of health care. And as these indicators are tracked over time, they can provide a partial picture of whether health care is improving.
But health-outcome measures go beyond indicators and require more detailed kinds of data.
A health outcome needs to consider a patient’s health status both before and after an intervention, such as a knee replacement or cataract surgery. It’s not just the waiting lists that matter; we also need to know how often a knee replacement has to be redone within a short period of time, or how frequently a cataract surgery fails to improve vision as much as anticipated.
Regularly measuring these kinds of health outcomes is fundamental to learning how well different parts of health care are performing, and whether we are receiving quality health care in the most cost-effective manner.
So how does this understanding of outcomes align with the federal government’s proposed “indicators” and data initiatives requirement? Short answer: we don’t know.
Provinces and territories have control over what health care data are routinely collected. For example, if we really want to know about health outcomes related to primary care, we first need to understand the various ways primary care is currently delivered – whether by solo fee-for-service doctors, or by teams, which include nurse practitioners as well as physicians who are remunerated by capitation, or some other model.
There is enough variety in primary care delivery across Canada that it should be possible to learn what works best by careful and probing comparisons across and within jurisdictions.
We then need to follow samples of individuals over time, to track which mode of primary care organization has patients with fewer illnesses, fewer hospitalizations and longer lives.
It is only with these kinds of longitudinal, person-level data that we’ll be able to produce evidence on which we can base valid indicators of health outcomes and connect them to jurisdictions’ current and evolving ways of providing primary care to their residents.
Will the provinces collaborate, agree on standardized definitions and, with federal financial support, make the investments needed so these critical data become available?
The federal government’s wording on this is ambiguous: “To access their share of the federal funding, including the guaranteed 5 per cent growth top-up payments to the CHT, for the next five years, provincial and territorial governments are asked to commit to improve how health information is collected, shared, used and reported to Canadians to promote greater transparency on results.”
Is this general statement merely cajoling, or is the federal government actually waving a serious fiscal stick? That will ultimately dictate the data outcome because past decades of federal initiatives have repeatedly shown that if Ottawa fails to wield meaningful fiscal penalties, the momentum on serious health care reform is bound to face disappointment.
Michael Wolfson is a former assistant chief statistician at Statistics Canada and an adjunct professor in the faculties of medicine and law at the University of Ottawa.
David Castle is professor of public administration at the University of Victoria. They both served on the Expert Advisory Group of the Pan-Canadian Health Data Strategy convened by the Public Health Agency of Canada.