The ICES Practice Atlas 2Nd Edition

The ICES Practice Atlas 2nd Edition

PatternsPatterns ofof HealthHealth Care Care inin OntarioOntario

INSTITUTE FOR CLINICAL EVALUATIVE SCIENCES IN ONTARIO Patterns of Health Care in Ontario

The ICES Practice Atlas 2nd Edition

Editors Vivek Goel J. Ivan Williams Geoffrey M. Anderson Paula Blackstien-Hirsch Cathy Fooks C. David Naylor

INSTITUTE FOR CLINICAL EVALUATIVE SCIENCES IN ONTARIO Published by The Canadian Medical Association

Cover design by Laura Benben – Graphic Designer, ICES and Jonathan Paul, Freelance Graphic Designer

Interior design and Page Layout by Laura Benben – Graphic Designer, ICES and Lawrence Stevenson, Informatics Officer, ICES

Printed by National Printers (Ottawa) Inc.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the proper written permission of the publisher.

Canadian Cataloguing in Publication Data

The ICES practice atlas: patterns of health care in Ontario

2nd ed Published for the Institute for Clinical Evaluative Sciences in Ontario

First edition published under title: Patterns of health care in Ontario

Includes bibliographical references and index ISBN 0-920169-79-1

1. Medical care – Utilization – Ontario. I. Goel, Vivek II. Canadian Medical Association III. Institute for Clinical Evaluative Sciences in Ontario IV. Title: Patterns of health care in Ontario

RA 450.05134 1996 362 P09713 C96-900575-X

How to cite the ICES Practice Atlas:

The production of the ICES Practice Atlas was a collaborative venture. Accordingly, to give credit to individual authors, please cite individual chapters using chapter authors and title, in addition to editors and book title. For example, for Chapter 5: Naylor CD, DeBoer DP, Total Hip and Knee Replacement, Variations in Selected Surgical Procedures and Medical Diagnoses by Year and Region. In Goel V, Williams JI, Anderson GM, Blackstien-Hirsch P, Fooks C, Naylor CD (eds). Patterns of Health Care in Ontario. The ICES Practice Atlas. 2nd edition (Ottawa: Canadian Medical Association, 1996) 54-63.

Additional copies are available from: Membership Services Canadian Medical Association 1867 Alta Vista Dr. Ottawa, Ontario K1Y 3Y6

Telephone: 1-800-663-7336, ext 2307 Table of Contents

Chapter 1 Introduction ...... 1 Vivek Goel, Cathy Fooks Chapter 2 Indicators of Health Determinants and Health Status ...... 5 Vivek Goel, Karey Iron, J. Ivan Williams Chapter 3 An Overview of Trends in the Use of Acute Care Hospitals, Physician and Diagnostic Services, and Prescription Drugs ...... 27 Geoffrey M. Anderson, Ben Chan, Judy A. Carter, Tami Axcell Chapter 4 The Use of Acute Care Hospitals, Physician and Diagnostic Services, and Prescription Drugs in Ontario's Health Planning Regions ...... 43 Geoffrey M. Anderson, Tami Axcell, Ben Chan, Judy A. Carter Chapter 5 Variations in Selected Surgical Procedures and Medical Diagnoses by Year and Region Introduction ...... 51 C. David Naylor Total Hip and Knee Replacement ...... 54 C. David Naylor, Donald P. DeBoer

i Chapter 5 Variations in Selected Surgical Procedures and Medical Diagnoses by Year and Region (Cont’d) Cholecystectomy ...... 64 Marsha M. Cohen, Wendy Young Primary and Incidental Appendectomy ...... 70 C. David Naylor, Donald P. DeBoer, Roderick P. Hernandez Lens Extraction ...... 80 C. David Naylor, Ralf Buhrmann, Donald P. DeBoer Carotid Endarterectomy ...... 85 Teresa To, Daryl S. Kucey, Michelle Tran Abdominal Aortic Aneurysm Repair ...... 90 Teresa To, Daryl S. Kucey, C. David Naylor, Michelle Tran Procedures for Peripheral Vascular Disease ...... 95 Teresa To, Daryl S. Kucey, Michelle Tran Coronary Artery Bypass Grafting ...... 99 C. David Naylor, Donald P. DeBoer Common Conditions Considered Sensitive to Ambulatory Care (Asthma and Congestive Heart Failure) ...... 104 Geoffrey M. Anderson Dilatation and Curettage ...... 111 Susan E. Bronskill, Marsha M. Cohen Hysterectomy ...... 116 Marsha M. Cohen, Wendy Young Radical Prostatectomy ...... 126 Teresa To, Laurence H. Klotz, Neill A. Iscoe, Michelle Tran Orchidectomy ...... 130 Teresa To, Neill A. Iscoe, Laurence H. Klotz, Michelle Tran Transurethral Resection of the Prostate ...... 135 C. David Naylor, Donald P. DeBoer Chapter 6 Patient Origin and Market Share – Tools to Assist with Hospital Planning ...... 147 Alan Ruth, Donald P. DeBoer Chapter 7 Hospital-specific Information: Cesarean Section, Appendectomy, Breast Cancer Surgery, and Complications After Laparoscopic Cholecystectomy Introduction ...... 169 Paula Blackstien-Hirsch Cesarean Section ...... 170 Geoffrey M. Anderson, Tami Axcell Primary and Incidental Appendectomy ...... 177 C. David Naylor, Roderick P. Hernandez, Donald P. DeBoer Breast Cancer Surgery ...... 183 Vivek Goel, Neill A. Iscoe, Carol Sawka

ii Chapter 7 Hospital-specific Information: Cesarean Section, Appendectomy, Breast Cancer Surgery, and Complications After Laparoscopic Cholecystectomy (Cont’d) Complications After Laparoscopic Cholecystectomy ...... 187 Marsha M. Cohen, Wendy Young Chapter 8 Patterns of Hospitalization ...... 197 Antoni S. H. Basinski, Marc-Erick Thériault Chapter 9 Trends in Physician Fee-for-service Billing Patterns ...... 247 Ben Chan, Geoffrey M. Anderson Chapter 10 Mental Health: Levels of Need and Variations in Service Use in Ontario Introduction ...... 265 Paula Goering, Elizabeth Lin Mental Health Needs ...... 266 Elizabeth Lin, Paula Goering Mental Health Expenditures ...... 269 Paula Goering, Elizabeth Lin OHIP Utilization ...... 271 Elizabeth Lin, Paula Goering, Ben Chan Inpatient Utilization ...... 274 Paula Goering, Elizabeth Lin, Donald P. DeBoer Chapter 11 Pediatric Health Service Utilization OHIP Fee-for-service Billings for Children ...... 287 Teresa To, Warren J. Mclsaac, William Feldman, Paul T. Dick, Michelle Tran Hospitalization Among Children in Ontario ...... 290 Teresa To, William Feldman, Paul T. Dick, Warren J. McIsaac, Michelle Tran Small Area Variation Analysis General Approach Teresa To ...... 293 Circumcision Teresa To, William Feldman, Paul T. Dick, Michelle Tran ...... 294 Myringotomy With the Insertion of Ventilation Tubes Teresa To, Peter C. Coyte, William Feldman, Paul T. Dick, Michelle Tran ...... 297 Tonsil and Adenoid Surgery Teresa To, William Feldman, Paul T. Dick, Michelle Tran ...... 300 Hospitalization for Childhood Asthma Teresa To, Paul T. Dick, William Feldman, Michelle Tran ...... 307 Hospitalization for Gastroenteritis Teresa To, William Feldman, Paul T. Dick, Michelle Tran ...... 309

iii Chapter 12 Patterns of Use of Specific Drugs in the Elderly: Antidepressants, Antibiotics and Drugs to be Avoided in the Elderly ...... 323 Geoffrey M. Anderson, Judy A. Carter Chapter 13 Conclusions and Reflections ...... 329 C. David Naylor, Vivek Goel Appendix I A Summary of Studies on the Quality of Health Care Administrative Databases in Canada ...... 339 J. Ivan Williams, Wendy Young Electronic Edition Electronic Atlas Tables ...... 347

Index Listings ...... 349

iv Contributors

Practice Atlas Contributors Geoffrey M. Anderson Ben Chan Institute for Clinical Evaluative Sciences Institute for Clinical Evaluative Sciences Clinical Epidemiology Unit, Sunnybrook Health Departments of Health Administration and Science Centre Preventive Medicine & Biostatistics, University of Toronto Canadian Institute for Health Information Marsha M. Cohen Department of Health Administration, Institute for Clinical Evaluative Sciences University of Toronto Clinical Epidemiology Unit, Sunnybrook Health Tami Axcell Science Centre Institute for Clinical Evaluative Sciences Department of Health Administration, University of Toronto

Antoni S. H. Basinski Peter C. Coyte Institute for Clinical Evaluative Sciences Department of Health Administration, University of Toronto Clinical Epidemiology Unit, Sunnybrook Health Institute for Clinical Evaluative Sciences Science Centre Donald P. DeBoer Departments of Preventive Medicine & Biostatistics and Institute for Clinical Evaluative Sciences Family & Community Medicine, University of Toronto Paul T. Dick Susan E. Bronskill Division of General Pediatrics, Hospital for Sick Children Institute for Clinical Evaluative Sciences Department of Pediatrics, University of Toronto Ralf Buhrmann William Feldman Department of Opthalmology, Dana Centre for Preventive Ophthalmology, Johns Hopkins University Division of General Pediatrics, Hospital for Sick Children Departments of Pediatrics and Preventive Medicine & Judy A. Carter Biostatistics, University of Toronto Institute for Clinical Evaluative Sciences Cathy Fooks Institute for Clinical Evaluative Sciences

v Vivek Goel C. David Naylor Institute for Clinical Evaluative Sciences Institute for Clinical Evaluative Sciences Department of Preventive Medicine & Department of Medicine and the Clinical Epidemiology Unit Biostatistics,University of Toronto and Health Care Research Program, Sunnybrook Health Clinical Epidemiology Unit, Sunnybrook Health Science Centre and the University of Toronto Science Centre Alan Ruth Paula Goering Institute for Clinical Evaluative Sciences Health Systems Research and Clinical Epidemiology Unit, Department of Health Administration, University of Toronto Clarke Institute of Psychiatry President, HEALTHCOR Department of Psychiatry, Faculty of Nursing, Institute of Medical Sciences, University of Toronto Carol Sawka Division of Medical Oncology, Toronto Sunnybrook Roderick P. Hernandez Regional Cancer Centre Institute for Clinical Evaluative Sciences Clinical Epidemiology Unit, Sunnybrook Health Science Centre Karey Iron Institute for Clinical Evaluative Sciences Institute for Clinical Evaluative Sciences Department of Medicine, University of Toronto Neill A. Iscoe Toronto Sunnybrook Regional Cancer Centre Marc-Erick Thériault Institute for Clinical Evaluative Sciences Clinical Epidemiology Unit, Sunnybrook Health Science Centre Teresa To Institute for Clinical Evaluative Sciences Institute for Clinical Evaluative Sciences Department of Medicine, University of Toronto Department of Preventive Medicine & Biostatistics, University of Toronto Laurence H. Klotz Clinical Epidemiology Unit, Sunnybrook Health Department of Surgery, Division of Urology, Science Centre Sunnybrook Health Science Centre Toronto Sunnybrook Regional Cancer Centre Michelle Tran Department of Surgery, University of Toronto Institute for Clinical Evaluative Sciences

Daryl S. Kucey J. Ivan Williams Department of Surgery and Clinical Epidemiology Unit, Institute for Clinical Evaluative Sciences Sunnybrook Health Science Centre Clinical Epidemiology Unit, Sunnybrook Health Department of Surgery, University of Toronto Science Centre Institute for Clinical Evaluative Sciences Department of Family & Community Medicine, Graduate Department of Community Health, Institute for Medical Elizabeth Lin Science, Graduate Department of Nursing Science, Health Systems Research and Clinical Epidemiology Unit, University of Toronto Clarke Institute of Psychiatry Wendy Young Department of Psychiatry, University of Toronto Institute for Clinical Evaluative Sciences Warren J. McIsaac Institute for Clinical Evaluative Sciences Family Medicine Centre, Mount Sinai Hospital Department of Family Medicine, University of Toronto

vi Exhibits & Appendices

Chapter 2 Exhibit 2.10: Number of Hours and Days with Moderate, Poor or Very Poor Air Quality by Monitoring Indicators of Health Determinants and Site, Health Planning Region and District Health Health Status Council in Ontario, 1994 ...... 16 Exhibit 2.1: Canadian and International Health Indicators Exhibit 2.11: Selected Health-related Practices for People and Human Development Index, 1995 ...... 6 12 Years and Over by Sex and Ontario Health Planning Region, 1994 ...... 17 Exhibit 2.2: Main Demographic Indicators for the Industrialized (OECD) Countries, 1995 ...... 7 Exhibit 2.12: Health Status Indicators by Sex and Ontario Health Planning Region ...... 19 Exhibit 2.3: Expenditures by OECD Countries on Health Care – 1992 and Growth from 1982 to 1992 ...... 9 Exhibit 2.13: Age/Sex-specific Rates per 100,000 Population for Leading Chronic Health Problems Exhibit 2.4: Recent Demographic Indicators for the in Ontario, 1994 ...... 20 Canadian Provinces and Territories ...... 10 Exhibit 2.14: Age/Sex-specific Rates per 100,000 Population Exhibit 2.5: Selected Community Health Profile Indicators, for Leading Causes of Hospitalization Ontario Ministry of Health, 1995 ...... 11 in Ontario, 1994 ...... 22

Exhibit 2.6: Ontario Population Distribution by Exhibit 2.15: Age/Sex-specific Rates per 100,000 Population Age and Sex, 1994 ...... 12 for Leading Causes of Hospital Days of Stay and Accompanying Average Lengths of Stay Exhibit 2.7: Population Projections (millions) by (ALOS) in Ontario, 1994 ...... 22 Age and Sex in Ontario, 1991-2011 ...... 12 Exhibit 2.16: Age/Sex-specific Rates per 100,000 Population Exhibit 2.8: Population Distribution by Age Group and, for Leading Causes of Death in Ontario, 1992 . . .23 Ontario Health Planning Region, 1994 ...... 13 Exhibit 2.17: Age/Sex-specific Percentages for Exhibit 2.9: Demographic, Social and Economic Indicators Leading Causes of Loss of Life Potential (LLP) by Ontario Health Planning Region ...... 14 in Ontario, 1992 ...... 23

vii Chapter 3 Chapter 4 An Overview of Trends in the Use of Acute Care The Use of Acute Care Hospitals, Physician and Hospitals, Physician and Diagnostic Services, Diagnostic Services, and Prescription Drugs in and Prescription Drugs Ontario’s Health Planning Regions Exhibit 3.1: Ontario Ministry of Health Total Operating Exhibit 4.1: Boundaries for Ontario Health Planning Expenditures, 1984/85, 1989/90 and Regions Compared with Boundaries Defined 1994/95 ($ billion) ...... 28 by Referral Patterns to Tertiary Care Hospitals ...... 45 Exhibit 3.2: Trends in Hospital Utilization for Inpatient Acute Care and Day Surgery in Ontario, Exhibit 4.2: Separation Rates from Acute Care Hospitals 1984/85 - 1994/95 ...... 29 for Residents of Ontario Health Planning Regions, 1994/95 ...... 46 Exhibit 3.3: Trends in Age/Sex-adjusted Inpatient Separation Rates per 1,000 Population by Exhibit 4.3: Estimated per Capita Expenditures for Type of Case in Ontario, 1984/85 - 1994/95 . . . .30 Acute Care Hospital Use by Residents of Ontario Health Planning Regions, 1994/95 . . . . .47 Exhibit 3.4: Trends in Age/Sex-adjusted Inpatient Days of Care per 1,000 Population by Type of Case Exhibit 4.4: OHIP Fee-for-service and Non-fee-for-service in Ontario, 1984/85 - 1994/95 ...... 30 Expenditures per Capita by Ontario Health Planning Region, 1994/95 ...... 48 Exhibit 3.5: Trends in Inpatient Separation Rates per 1,000 Population by Age Group in Ontario, Exhibit 4.5: Ontario Drug Benefit Program per Capita 1984/85 - 1994/95 ...... 31 Expenditures by Category of Drug and Ontario Health Planning Region, 1994/95 ...... 49 Exhibit 3.6: Trends in Inpatient Days of Care per 1,000 Population by Age Group in Ontario, Exhibit 4.6: Estimated per Capita Expenditures for 1984/85 - 1994/95 ...... 31 Acute Care Hospitals, Physician Services and Drugs for the Elderly by Ontario Exhibit 3.7: Trends in OHIP Physician Fee-for-service Health Planning Region, 1994/95 ...... 50 Billings in Ontario, 1989/90 - 1994/95 ...... 33

Exhibit 3.8: Actual OHIP Billings by Fee Code Category in Ontario, 1989/90 - 1994/95 ...... 34 Chapter 5

Exhibit 3.9: OHIP Billings for Top 20 Diagnostic and Variations in Selected Surgical Procedures and Therapeutic Procedures in Ontario, 1994/95 . . . .35 Medical Diagnoses by Year and Region Exhibit 3.10: OHIP Expenditures in Ontario by Year for Exhibit 5.1: Overall and Age/Sex-adjusted Hip and Knee Top 20 Laboratory Services ...... 36 Replacement Rates per 100,000 Population 20 Years and Over in Ontario, Exhibit 3.11: Total Ministry of Health Price-adjusted per 1985/86 - 1994/95 ...... 55 Capita Billings by Age and Sex in Ontario, 1989/90 and 1994/95 ...... 37 Exhibit 5.2: Overall and Age/Sex-specific Hip Replacement Rates per 100,000 Population 20 Years and Exhibit 3.12: OHIP Billings by Fee Code Category and Over in Ontario, 1985/86 - 1994/95 ...... 55 Age Group in Ontario, 1994/95 ...... 38 Exhibit 5.3: Overall and Age/Sex-specific Knee Replacement Exhibit 3.13: Ontario Drug Benefit Program Drug Rates per 100,000 Population 20 Years and Ingredient Expenditures for People 65 Years Over in Ontario, 1985/86 - 1994/95 ...... 55 and Older in Ontario, 1990/91 - 1994/95 ...... 39 Exhibit 5.4: Age/Sex-adjusted Hip Replacement Rates Exhibit 3.14: Ontario Drug Benefit Program Formulary per 100,000 Population 20 Years and Over per Capita Expenditures on Subcategories of by DHC Area of Patient Residence in Ontario, Cardiovascular Drugs for People 65 Years and 1992/93 - 1994/95 (SARV map) ...... 57 Older in Ontario, 1990/91 - 1994/95 ...... 40 Exhibit 5.5: Age/Sex-adjusted Hip Replacement Rates Exhibit 3.15: Ontario Drug Benefit Program per Capita per 100,000 Population 20 Years and Over Expenditures on Formulary and Non-formulary by DHC Area of Patient Residence in Ontario, Gastrointestinal Drugs for People 65 Years and 1989/90 - 1994/95 (SARV table) ...... 58 Older in Ontario, 1990/91 - 1994/95 ...... 41 Exhibit 5.6: Age/Sex-adjusted Knee Replacement Rates Exhibit 3.16: Ontario Drug Benefit Program Expenditures per 100,000 Population 20 Years and Over for Acid Reducing Agents for People 65 Years by DHC Area of Patient Residence in Ontario, and Older in Ontario, 1990/91 - 1994/95 ...... 42 1992/93 - 1994/95 (SARV map) ...... 59

viii Exhibit 5.7: Age/Sex-adjusted Knee Replacement Rates Exhibit 5.21: Age/Sex-adjusted Incidental Appendectomy per 100,000 Population 20 Years and Over Rates per 100,000 Population (all ages) by by DHC Area of Patient Residence in Ontario, DHC Area of Patient Residence in Ontario, 1989/90 - 1994/95 (SARV table) ...... 60 1989/90 - 1994/95 (SARV table) ...... 77

Exhibit 5.8: Overall and Age/Sex-adjusted Cholecystectomy Exhibit 5.22: Age/Sex-adjusted Diagnostic Accuracy Rates per 100,000 Population 20 Years and Rates for Appendectomy per 100,000 Over in Ontario, 1985/86 - 1994/95 ...... 65 Population (all ages) by DHC Area of Patient Residence in Ontario, 1992/93 - 1994/95 Exhibit 5.9: Overall and Age/Sex-specific Cholecystectomy (SARV map) ...... 78 Rates per 100,000 Population 20 Years and Over in Ontario, 1985/86 - 1994/95 ...... 65 Exhibit 5.23: Overall and Age/Sex-specific Lens Extraction Rates per 100,000 Population 50 Years and Exhibit 5.10: Age/Sex-adjusted Cholecystectomy Rates Over in Ontario, 1991/92 - 1994/95 ...... 80 per 100,000 Population 20 Years and Over by DHC Area of Patient Residence in Ontario, Exhibit 5.24: Age/Sex-adjusted Lens Extraction Rates 1992/93 - 1994/95 (SARV map) ...... 66 per 100,000 Population 50 Years and Over by DHC Area of Patient Residence in Ontario, Exhibit 5.11: Age/Sex-adjusted Cholecystectomy Rates 1993/94 - 1994/95 (SARV map) ...... 81 per 100,000 Population 20 Years and Over by DHC Area of Patient Residence in Ontario, Exhibit 5.25: Age/Sex-adjusted Lens Extraction Rates 1989/90 - 1994/95 (SARV table) ...... 67 per 100,000 Population 50 Years and Over by DHC Area of Patient Residence in Ontario, Exhibit 5.12: Percentage of Laparoscopic vs. Open 1991/92 - 1994/95 (SARV table) ...... 82 Cholecystectomies in Ontario, 1989/90 - 1994/95 ...... 68 Exhibit 5.26: Overall and Age/Sex-specific Carotid Endarterectomy Rates per 100,000 Exhibit 5.13: Overall and Age/Sex-specific Positive Population 20 Years and Over in Ontario, Primary Appendectomy Rates per 100,000 1981/82 - 1994/95 ...... 85 Population (all ages) in Ontario, 1989/90 - 1994/95 ...... 71 Exhibit 5.27: Overall and Age/Sex-adjusted Carotid Endarterectomy Rates per 100,000 Exhibit 5.14: Overall and Age/Sex-specific Negative I Population 20 Years and Over in Ontario, Appendectomy Rates per 100,000 Population 1981/82 - 1994/95 ...... 86 (all ages) in Ontario, 1989/90 - 1994/95 ...... 71 Exhibit 5.28: Age/Sex-adjusted Carotid Endarterectomy Exhibit 5.15: Overall and Age/Sex-specific Negative II Rates per 100,000 Population 20 Years Appendectomy Rates per 100,000 Population and Over by DHC Area of Patient Residence (all ages) in Ontario, 1989/90 - 1994/95 ...... 72 in Ontario, 1989/90 - 1994/95 (SARV table) . . . . .87

Exhibit 5.16: Overall and Age/Sex-specific Incidental Exhibit 5.29: Age/Sex-adjusted Carotid Endarterectomy Appendectomy Rates per 100,000 Population Rates per 100,000 Population 20 Years (all ages) in Ontario, 1989/90 - 1994/95 ...... 72 and Over by DHC Area of Patient Residence Exhibit 5.17: Age/Sex-adjusted Positive Primary in Ontario, 1992/93 - 1994/95 (SARV map) . . . . .88 Appendectomy Rates per 100,000 Population Exhibit 5.30: Overall and Age/Sex-specific Abdominal (all ages) by DHC Area of Patient Residence in Aortic Aneurysm Repair Rates per 100,000 Ontario, 1992/93 - 1994/95 (SARV map) ...... 73 Population 20 Years and Over in Ontario, Exhibit 5.18: Age/Sex-adjusted Positive Primary 1989/90 - 1994/95 ...... 90 Appendectomy Rates per 100,000 Population Exhibit 5.31: Age/Sex-specific Abdominal Aortic Aneurysm (all ages) by DHC Area of Patient Residence in Repair Rates per 100,000 Population 50 Years Ontario, 1989/90 - 1994/95 (SARV table) ...... 74 and Over in Ontario, 1989/90 - 1994/95 ...... 90

Exhibit 5.19: Age/Sex-adjusted Negative I Appendectomy Exhibit 5.32: Age/Sex-adjusted Abdominal Aortic Aneurysm Rates per 100,000 Population (all ages) by Repair Rates per 100,000 Population 20 Years DHC Area of Patient Residence in Ontario, and Over by DHC Area of Patient Residence in 1989/90 - 1994/95 (SARV table) ...... 75 Ontario, 1989/90 - 1994/95 (SARV map) ...... 91

Exhibit 5.20: Age/Sex-adjusted Negative II Appendectomy Exhibit 5.33: Age/Sex-adjusted Abdominal Aortic Aneurysm Rates per 100,000 Population (all ages) by Repair Rates per 100,000 Population 20 Years DHC Area of Patient Residence in Ontario, and Over by DHC Area of Patient Residence in 1989/90 - 1994/95 (SARV table) ...... 76 Ontario, 1992/93 - 1994/95 (SARV map) ...... 92

ix Exhibit 5.34: Overall and Age/Sex-specific Peripheral Exhibit 5.47: Age/Sex-adjusted Asthma Hospitalization Vascular Surgery Rates per 100,000 Rates per 100,000 Population 20 Years and Population 20 Years and Over in Ontario, Over by DHC Area of Patient Residence 1989/90 - 1994/95 ...... 95 in Ontario, 1992/93 - 1994/95 (SARV map) . . . .108

Exhibit 5.35: Age/Sex-specific Peripheral Vascular Surgery Exhibit 5.48: Age/Sex-adjusted Asthma Hospitalization Rates per 100,000 Population 50 Years and Rates per 100,000 Population 20 Years and Over in Ontario, 1989/90 - 1994/95 ...... 95 Over by DHC Area of Patient Residence in Ontario, 1989/90 - 1994/95 (SARV table) . . . .109 Exhibit 5.36: Age/Sex-adjusted Peripheral Vascular Surgery Rates per 100,000 Population 20 Years and Exhibit 5.49: Overall and Age-adjusted Dilatation and Over by DHC Area of Patient Residence in Curettage Rates per 100,000 Women 20 Years Ontario, 1992/93 - 1994/95 (SARV map) ...... 96 and Over in Ontario, 1991/92 - 1994/95 . . . . .111

Exhibit 5.37: Age/Sex-adjusted Peripheral Vascular Surgery Exhibit 5.50: Overall and Age-specific Dilatation and Rates per 100,000 Population 20 Years and Curettage Rates per 100,000 Women 20 Years Over by DHC Area of Patient Residence in and Over in Ontario, 1991/92 - 1994/95 . . . . .112 Ontario, 1989/90 - 1994/95 (SARV table) ...... 97 Exhibit 5.51: Age-adjusted Rates of Dilatation and Exhibit 5.38: Overall and Age/Sex-specific Coronary Artery Curettage per 100,000 Women 20 Years Bypass Rates per 100,000 Population 20 Years and Over by DHC Area of Patient Residence and Over in Ontario, 1985/86 - 1994/95 ...... 99 in Ontario, 1992/93 - 1994/95 (SARV map) . . . .113

Exhibit 5.39: Overall and Age/Sex-specific Coronary Artery Exhibit 5.52: Age-adjusted Dilatation and Curettage Bypass Rates per 100,000 Population 20 Years Rates per 100,000 Women 20 Years and Over in Ontario, 1985/86 - 1994/95 . . . . .100 and Over by DHC Area of Patient Residence in Ontario, 1992/93 - 1994/95 (SARV table) . . . .114 Exhibit 5.40: Age/Sex-adjusted Coronary Artery Bypass Rates per 100,000 Population 20 Years and Exhibit 5.53: Overall and Age-adjusted Hysterectomy Rates Over by DHC Area of Patient Residence per 100,000 Women 20 Years and Over in Ontario, 1992/93 - 1994/95 (SARV map) . . . .101 in Ontario, 1985/86 - 1994/95 ...... 117

Exhibit 5.41: Age/Sex-adjusted Coronary Artery Bypass Exhibit 5.54: Overall and Age-specific Hysterectomy Rates Rates per 100,000 Population 20 Years and per 100,000 Women 20 Years and Over Over by DHC Area of Patient Residence in Ontario, 1985/86 - 1994/95 ...... 117 in Ontario, 1989/90 - 1994/95 (SARV table) . . . .102 Exhibit 5.55: Age-adjusted Hysterectomy Rates per Exhibit 5.42: Overall and Age/Sex-specific Congestive 100,000 Women 20 Years and Over by Heart Failure Hospitalization Rates per DHC Area of Patient Residence in Ontario, 100,000 Population 20 Years and Over 1992/93 - 1994/95 (SARV map) ...... 118 in Ontario, 1985/86 - 1994/95 ...... 104 Exhibit 5.56: Age-adjusted Hysterectomy Rates per Exhibit 5.43: Overall and Age/Sex-adjusted Asthma 100,000 Women 20 Years and Over by Hospitalization Rates per 100,000 Population DHC Area of Patient Residence in Ontario, 20 Years and Over in Ontario, 1989/90 - 1994/95 (SARV table) ...... 119 1985/86 - 1994/95 ...... 105 Exhibit 5.57: Relative Change in Age-adjusted Exhibit 5.44: Overall and Age/Sex-specific Asthma Hysterectomy Rates by Indication for DHC Hospitalization Rates per 100,000 Population Area of Patient Residence in Ontario, from 20 Years and Over in Ontario, 1989/90 - 1991/92 to 1992/93 - 1994/95 . . . . .120 1985/86 - 1994/95 ...... 105 Exhibit 5.58: Percentage of Hysterectomies Performed Exhibit 5.45: Age/Sex-adjusted Congestive Heart Failure as Subtotal, Vaginal (VH), Laparoscopically- Hospitalization Rates per 100,000 Population assisted Vaginal (LAVH), Total Abdominal 20 Years and Over by DHC Area of Patient (TAH) and Other in Ontario, Residence in Ontario, 1992/93 - 1994/95 1989/90 - 1994/95 ...... 120 (SARV map) ...... 106 Exhibit 5.59a: Percentage of Hysterectomies Performed Exhibit 5.46: Age/Sex-adjusted Congestive Heart Failure as Total Abdominal Hysterectomy for Hospitalization Rates per 100,000 Population Women 20 Years and Over by DHC Area 20 Years and Over by DHC Area of Patient of Patient Residence in Ontario, 1994/95 Residence in Ontario, 1989/90 - 1994/95 (SARV map) ...... 121 (SARV table) ...... 107

x Exhibit 5.59b: Percentage of Hysterectomies Performed Appendix A5.1: Procedures/Diagnoses and as Vaginal Hysterectomy for Women Canadian Clasification of Procedure (CCP) 20 Years and Over by DHC Area of Patient and International Classification of Diseases Residence in Ontario, 1994/95 (SARV map) . . . .122 Diagnosis Codes - 9th Revision (ICD-9) . . . . .141

Exhibit 5.60: Percentage of Hysterectomies Performed Appendix A5.2: Excluded Cases and Missing Data by as Subtotal, Vaginal (VH), Laparoscopically- Procedure/Diagnosis for Ontario ...... 143 assisted Vaginal (LAVH), Total Abdominal (TAH) and Other by DHC Area of Patient Appendix A5.3: Summary of Rate Variations for Residence in Ontario, 1994/95 (SARV table) . . . .123 Surgical Procedures ...... 146

Exhibit 5.61: Overall and Age-specific Radical Prostatectomy Rates per 100,000 Men 50 Years and Over Chapter 6 in Ontario, 1989/90 - 1994/95 ...... 126 Patient Origin and Market Share – Tools to Assist Exhibit 5.62: Overall and Age-adjusted Radical Prostatectomy Rates per 100,000 Men 50 Years and Over With Hospital Planning in Ontario, 1989/90 - 1994/95 ...... 126 Exhibit 6.1: Hierarchy of Standard Geographic Boundaries for Ontario ...... 148 Exhibit 5.63: Age-Adjusted Radical Prostatectomy Rates per 100,000 Men 50 Years and Over Exhibit 6.2: Market Share Contours for Obstetrical by DHC Area of Patient Residence in Ontario, Separations for Hospitals Located 1989/90 - 1994/95 (SARV table) ...... 127 Within the Metropolitan Toronto District Health Council Area, 1994/95 ...... 150 Exhibit 5.64: Age-adjusted Radical Prostatectomy Rates per 100,000 Men 50 Years and Over Exhibit 6.3: Market Share Contours for Hospitals in the by DHC Area of Patient Residence in Ontario, Rideau Valley District Health Council Area – 1992/93 - 1994/95 (SARV map) ...... 128 Acute Myocardial Infarction Separations, 1994/95 ...... 152 Exhibit 5.65: Overall and Age-specific Orchidectomy Rates per 100,000 Men 50 Years and Over Exhibit 6.4: Comparison of Drive Time and Straight in Ontario, 1989/90 - 1994/95 ...... 130 Line Distance Methodologies for Calculating Service Areas Around Oshawa General Exhibit 5.66: Overall and Age-adjusted Orchidectomy Hospital, 1994/95 ...... 154 Rates per 100,000 Men 50 Years and Over in Ontario, 1989/90 - 1994/95 ...... 130 Exhibit 6.5: Patient Origin and Market Share Considerations for Obstetrical Separations Exhibit 5.67: Age-adjusted Orchidectomy Rates per at Leamington District Memorial Hospital, 100,000 Men 50 Years and Over by DHC Area 1994/95 ...... 155 of Patient Residence in Ontario, 1992/93 - 1994/95 (SARV map) ...... 132 Exhibit 6.6: Comparison of Hospital Service Areas for Inpatient Asthma Separations in the Exhibit 5.68: Age-adjusted Orchidectomy Rates per Huron/Perth District Health Council Area . . . . .157 100,000 Men 50 Years and Over by DHC Area of Patient Residence in Ontario, Exhibit 6.7: Average Distance Travelled by 1989/90 - 1994/95 (SARV table) ...... 133 Diagnosis/Procedure in Ontario, 1994/95 . . . . .156

Exhibit 5.69: Overall and Age-specific Transurethral Exhibit 6.8: Average Distance Travelled for Acute Resection of the Prostate Rates per 100,000 Myocardial Infarction and Hip Replacement Men 50 Years and Over in Ontario, by District Health Council in Ontario, 1985/86 - 1994/95 ...... 135 1994/95 ...... 158

Exhibit 5.70: Overall and Age-adjusted Transurethral Exhibit 6.9: Location of Patient Treatment Site in Relation Resection of the Prostate Rates per 100,000 to Whether the Closest Hospital was In – or Men 50 Years and Over in Ontario, Outside of the DHC of Patient Residence – 1985/86 - 1994/95 ...... 136 Acute Myocardial Infarction Separations in Ontario, 1994/95 ...... 159 Exhibit 5.71: Age-adjusted Transurethral Prostatectomy Rates per 100,000 Men 50 Years and Over Exhibit 6.10: Location of Patient Treatment Site in Relation by DHC Area of Patient Residence in Ontario, to Whether the Closest Hospital was In – or 1992/93 - 1994/95 (SARV map) ...... 137 Outside of the DHC of Patient Residence – Hip Replacement Separations in Ontario, Exhibit 5.72: Age-adjusted Transurethral Resection of the 1994/95 ...... 160 Prostate Rates per 100,000 Men 50 Years and Over by DHC Area of Patient Residence in Ontario, 1989/90 - 1994/95 (SARV table) ...... 138

xi Exhibit 6.11: Location of Patient Treatment Site in Relation Exhibit 7.8: Diagnostic Accuracy and Perforation to Whether the Closest Hospital was In – or Rate, In-hospital Death Rate and Average Outside of the DHC of Patient Residence – Length of Hospital Stay (ALOS) for Women Average Distance Travelled, Acute Myocardial and Men with Acute Appendicitis in Infarction Separations in Ontario, Ontario, 1989/90 - 1994/95 ...... 178 1994/95 ...... 161 Exhibit 7.9: Range of Appendectomy Outcomes Within Exhibit 6.12: Location of Patient Treatment Site in Relation Each Quintile in Ontario, to Whether the Closest Hospital was In – or 1992/93 - 1994/95 ...... 178 Outside of the DHC of Patient Residence – Average Distance Travelled, Hip Replacement Exhibit 7.10: Hospital Classifications for Appendectomy Separations in Ontario, Outcomes in Ontario, 1992/93 - 1994/95 . . . . .179 1994/95 ...... 162 Exhibit 7.11: Diagnostic Accuracy Rate for Appendix A6.1: Diagnosis/Procedure Codes and Appendectomies by District Health Council Number of Records Included ...... 165 of Patient Residence in Ontario, 1992/93 - 1994/95 ...... 182 Appendix A6.2: Postal Code Definition and Considerations for Use ...... 166 Exhibit 7.12: Breast Conserving Surgery (BCS) Proportion by Hospital in Ontario, Appendix A6.3: Residence Code (Municipal Code) 1991/92 vs. 1994/95 ...... 184 Definition and Considerations for Use . . . . .166 Exhibit 7.13: Breast Conserving Surgery Appendix A6.4: Drive Time Methodology ...... 167 Proportions by Hospital in Ontario, 1994/95 ...... 185 Appendix A6.5: Software Used for the Production of Chapter 6 ...... 167 Exhibit 7.14: Rate of Bile Duct Injury and Conversion Rate from Laparoscopic to Open Procedure by Number of Procedures Performed per Chapter 7 Hospital in Ontario, 1993/94 and 1994/95 . . . .188 Hospital-specific Information: Cesarean Section, Exhibit 7.15: Rate of Bile Duct Injury by Hospital, by the Number of Procedures Performed, Appendectomy, Breast Cancer Surgery, and in Ontario, 1994/95 ...... 189 Complications After Laparoscopic Exhibit 7.16: Rate of Conversion from Laparoscopic Cholecystectomy to Open Cholecystectomy by Hospital, by the Exhibit 7.1: Indication–Level Rates for Cesarean Section . . . .170 Number of Procedures Performed, in Ontario, 1994/95 ...... 190 Exhibit 7.2: Trends in Deliveries, Cesarean Sections and Cesarean Section Rates in Ontario, Appendix A7.1: Selection of Cases, Definition of 1984/85 - 1994/95 ...... 171 Indications and Calculation of Rates for Cesarean Sections ...... 193 Exhibit 7.3: Cesarean Section Rates Attributed to Different Indications in Ontario, Appendix A7.2: Appendectomy – Odds Ratios for 1984/85, 1989/90 and 1994/95 ...... 171 Perforation and In-hospital Death and Linear Regression Coefficients for Length Exhibit 7.4: Cesarean Section Rates by Nursery Level of Hospital Stay in Ontario, in Ontario, 1993/94 and 1994/95 1992/93 - 1994/95 ...... 194 (Combined) ...... 172 Appendix A7.3: Appendectomy – Odds Ratios for Exhibit 7.5: Distribution of Repeat Cesarean Section In-hospital Death and Linear Regression Rates and Cesarean Sections Attributable Coefficients for Length of Hospital Stay to Dystocia and Fetal Distress by Nursery Level in Ontario, 1992/93 - 1994/95 ...... 194 in Ontario, 1993/94 and 1994/95 (Combined) ...... 172 Appendix A7.4: Procedure Codes Used for Breast Conserving Surgery and Cholecystectomy Exhibit 7.6: Cesarean Section Rates Attributable to Analyses ...... 195 Different Indications, in Ontario Hospitals with Over 300 Deliveries, Classified by Nursery Level in Ontario, 1993/94 and Chapter 8 1994/95 (Combined) ...... 173 Patterns of Hospitalization Exhibit 7.7: Cesarean Section Rates in Ontario Hospitals, Classified by Nursery Level, 1993/94 and Exhibit 8.1: Length of Stay for Medical Cases by 1994/95 ...... 175 Diagnosis for Teaching Hospitals in Ontario, 1992/93 - 1994/95 ...... 209

xii Exhibit 8.2: Length of Stay for Medical Cases by Exhibit 8.19: Total Length of Stay for a Single Episode Diagnosis for Medium-sized Hospitals in of Illness Among Institutions for Hip and Ontario, 1992/93 - 1994/95 ...... 210 Knee Replacement and Cerebrovascular Accident for Teaching Hospitals in Ontario, Exhibit 8.3: Length of Stay for Medical Cases by 1993 and 1994 ...... 233 Diagnosis for Smaller-sized Hospitals in Ontario, 1992/93 - 1994/95 ...... 211 Exhibit 8.20: Unplanned 30 Day Readmission Rates for Selected Medical Diagnoses for Teaching Exhibit 8.4: Length of Stay for Medical Cases by Hospitals in Ontario, 1993 and 1994 ...... 234 Hospital for Teaching Hospitals in Ontario, 1992/93 - 1994/95 ...... 212 Exhibit 8.21: Unplanned 30 Day Readmission Rates for Selected Medical Diagnoses for Medium- Exhibit 8.5: Length of Stay for Medical Cases by sized Hospitals in Ontario, 1993 and 1994 . . . .235 Hospital for Medium-sized Hospitals in Ontario, 1992/93 - 1994/95 ...... 213 Exhibit 8.22: Unplanned 30 Day Readmission Rates for Selected Medical Diagnoses for Smaller- Exhibit 8.6: Length of Stay for Medical Cases by sized Hospitals in Ontario, 1993 and 1994 . . . .237 Hospital for Smaller-sized Hospitals in Ontario, 1992/93 - 1994/95 ...... 215 Exhibit 8.23: Unplanned 30 Day Readmission Rates for Selected Surgical Diagnoses for Teaching Exhibit 8.7: Length of Stay for Surgical Cases by Hospitals in Ontario, 1993 and 1994 ...... 239 Procedure for Teaching Hospitals in Ontario, 1992/93 - 1994/95 ...... 217 Exhibit 8.24: Unplanned 30 Day Readmission Rates for Selected Surgical Procedures for Medium- Exhibit 8.8: Length of Stay for Surgical Cases by sized Hospitals in Ontario, 1993 and 1994 . . . .240 Procedure for Medium-sized Hospitals in Ontario, 1992/93 - 1994/95 ...... 218 Exhibit 8.25: Unplanned 30 Day Readmission Rates for Selected Surgical Procedures for Smaller- Exhibit 8.9: Length of Stay for Surgical Cases by sized Hospitals in Ontario, 1993 and 1994 . . . .242 Procedure for Smaller-sized Hospitals in Ontario, 1992/93 - 1994/95 ...... 219 Exhibit 8.26: Relation Between Readmission Rate and Adjusted Hospital Average Length of Stay, Exhibit 8.10: Length of Stay for Surgical Cases by 1993 and 1994 ...... 203 Hospital for Teaching Hospitals in Ontario, 1992/93 - 1994/95 ...... 220 Exhibit 8.27: Readmission Within 30 Days of Discharge from Acute Care Hospital for Acute Exhibit 8.11: Length of Stay for Surgical Cases by Myocardial Infarction in Ontario, Hospital for Medium-sized Hospitals in 1993 and 1994 ...... 203 Ontario, 1992/93 - 1994/95 ...... 221 Exhibit 8.28: Readmission of Newborns to Hospital Exhibit 8.12: Length of Stay for Surgical Cases by Within 14 Days of Birth by Birthweight and Hospital for Smaller-sized Hospitals in Neonatal Length of Stay (All Causes) in Ontario, 1992/93 - 1994/95 ...... 223 Ontario, 1992/93 - 1994/95 ...... 204

Exhibit 8.13: Day Surgery Rates by Procedure for Exhibit 8.29: Readmission of Newborns to Hospital Teaching Hospitals in Ontario, Within 14 Days of Birth by Birthweight and 1992/93 - 1994/95 ...... 225 Neonatal Length of Stay (Jaundice) in Exhibit 8.14: Day Surgery Rates by Procedure for Ontario, 1992/93 - 1994/95 ...... 204 Medium-sized Hospitals in Ontario, Exhibit 8.30: Readmission of Newborns to Hospital 1992/93 - 1994/95 ...... 226 Within 14 Days of Birth by Birthweight and Exhibit 8.15: Day Surgery Rates by Procedure for Neonatal Length of Stay (All Causes Except Smaller-sized Hospitals in Ontario, Jaundice) in Ontario, 1992/93 - 1994/95 ...... 205 1992/93 - 1994/95 ...... 227 Exhibit 8.31: Readmission of Newborns to Hospital Exhibit 8.16: Day Surgery Rates by Hospital for Within 14 Days of Birth by Birthweight and Teaching Hospitals in Ontario, Neonatal Length of Stay by Calendar Month 1992/93 - 1994/95 ...... 228 (Jaundice) in Ontario, 1992/93 - 1994/95 . . . . .205

Exhibit 8.17: Day Surgery Rates by Hospital for Appendix A8.1: Medical Conditions: Inclusion/Exclusion Medium-sized Hospitals in Ontario, Criteria and Adjustments ...... 244 1992/93 - 1994/95 ...... 229 Appendix A8.2: Surgical Procedures: Inclusion/Exclusion Exhibit 8.18: Day Surgery Rates by Hospital for Criteria and Adjustments ...... 245 Smaller-sized Hospitals in Ontario, 1992/93 - 1994/95 ...... 231

xiii Chapter 9 Chapter 10 Trends in Physician Fee-for-service Billing Patterns Mental Health – Levels of Need and Variations in Exhibit 9.1: Major Policy Changes Affecting OHIP in Service Use in Ontario Ontario, 1989/90 - 1994/95 ...... 248 Exhibit 10.1: Age/Sex-specific Weighted Proportions of Exhibit 9.2: Description of OHIP Physician Activity Mental Disorder, Reported Disability and Measures ...... 251 Self-rated Mental Health Status in Ontario, 1990 ...... 268 Exhibit 9.3: OHIP Billings and Actual Gross Payments to Physicians in Ontario, 1989/90 - 1994/95 Exhibit 10.2: Percentage with Mental Health “Need” for ($ billion) ...... 252 People 15 to 64 Years by Ontario Health Planning Region, 1990 ...... 269 Exhibit 9.4: OHIP Billings and Gross and Net Payments per Physician in Ontario, 1989/90 - 1994/95 ...... 252 Exhibit 10.3: Total Expenditures on Mental Health Services in Ontario, 1992/93 ...... 270 Exhibit 9.5: Number of Active Physicians in Ontario, 1989/90 - 1994/95 ...... 253 Exhibit 10.4: Per Capita Expenditures on Mental Health Services by Ontario Health Planning Region, Exhibit 9.6: Growth in OHIP Billings and Price-adjusted 1992/93 ...... 270 Billings by Fiscal Quarter, 1989/90 - 1994/95 ...... 253 Exhibit 10.5: Mental Health Billings and per Capita Billings by Age and Sex in Ontario, Exhibit 9.7: Physician Supply and Billings by Specialty 1994/95 ...... 272 (1994/95) and Percent Change (1989/90 - 1994/95) in Ontario ...... 254 Exhibit 10.6: OHIP Billings for Mental Health and Physician Supply by Ontario Health Planning Exhibit 9.8: OHIP per Capita Billings, Average Billings Region, 1992/93 ...... 273 per Physician and Physician Supply in Ontario, 1994/95, and Percent Change, Exhibit 10.7: Per Capita OHIP Billings for Mental Health 1989/90 - 1994/95 ...... 255 by Ontario Health Planning Region, 1992/93 ...... 273 Exhibit 9.9: Number of GP/FPs per 10,000 Population, Average Billings per Physician and Price- Exhibit 10.8: Trends in Patient Days for Mental Health adjusted Billings per Capita by District Services per 100,000 Population in Ontario, Health Council in Ontario, 1994/95 ...... 256 1992/93 - 1994/95 ...... 275

Exhibit 9.10: Percentage of Physicians by Age, Sex and Exhibit 10.9: Patient Days per 100,000 Population by Ontario Health Planning Region, 1994/95 . . . . .257 Ontario Health Planning Region, Provincial Psychiatric Hospitals and Other Facilites, Exhibit 9.11: Proportion of Women in Medicine by 1992, 1993, and 1994 ...... 275 Ontario Health Planning Region, 1989/90 - 1994/95 ...... 258 Exhibit 10.10: Provincial Psychiatric Hospital Utilization by Ontario Health Planning Region, Exhibit 9.12: Physician Billings by Age, Sex and Ontario 1992, 1993, and 1994 ...... 277 Health Planning Region, 1994/95 ...... 259 Exhibit 10.11: Provincial Psychiatric Hospital Utilization Exhibit 9.13: Average OHIP Billings by Active Physician by Ontario Health Planning Region and Specialty and Age in Ontario, Admission Category, 1992, 1993, and 1994 . . . .277 1989/90 - 1994/95 ...... 259 Exhibit 10.12: Mental Health Utilization in Hospitals with Exhibit 9.14: Percentage of Physicians in Various Billing Psychiatric Units in Ontario, 1994/95 ...... 278 Ranges in Ontario, 1994/95 ...... 259 Appendix A10.1: OHIP Fee Schedule Codes Pertaining to Exhibit 9.15: Percentage of OHIP Billings for High-volume Mental Health Services ...... 282 Physicians by Ontario Health Planning Region, 1994/95 ...... 260 Appendix A10.2: Inpatient Mental Health Utilization ...... 284

Exhibit 9.16: Proportion of Billings in Each Fee Code Category by Specialty in Ontario, 1994/95 and Percentage Change Between 1989/90 and 1994/95 ...... 261

xiv Chapter 11 Exhibit 11.16: Proportion of Separations by Month for Myringotomy with Ventilation Tubes Pediatric Health Service Utilization Among Children 0 to 19 Years in Ontario, 1992/93 - 1994/95 ...... 298 Exhibit 11.1: Total Price-adjusted Billings to OHIP for Children 0 to 19 Years in Ontario, Exhibit 11.17: Age/Sex-adjusted Myringotomy with 1989/90 - 1994/95 ...... 288 Ventilation Tube Rates (inpatient and day surgery) per 1,000 Children 0 to 19 Years Exhibit 11.2: Price-adjusted per Capita OHIP Billings for by DHC Area of Patient Residence in Ontario, Children Under 20 Years in Ontario, 1992/93 - 1994/95 (SARV table) ...... 299 1989/90 - 1994/95 ...... 288 Exhibit 11.18: Age/Sex-adjusted Myringotomy with Exhibit 11.3: Total Price-adjusted Billings to OHIP for Ventilation Tube Rates (day surgery only) Children Under 1 Year in Ontario, per 1,000 Children 0 to 19 Years by DHC 1989/90 - 1994/95 ...... 289 Area of Patient Residence in Ontario, Exhibit 11.4: Total Price-adjusted Billings to OHIP for 1992/93 - 1994/95 (SARV table) ...... 300 Children 1 to 4 Years in Ontario, Exhibit 11.19: Age/Sex-adjusted Myringotomy with 1989/90 - 1994/95 ...... 289 Ventilation Tube Rates (inpatient and day Exhibit 11.5: Total Price-adjusted Billings to OHIP for surgery) per 1,000 Children 0 to 19 Years Children 5 to 14 Years in Ontario, by DHC Area of Patient Residence in Ontario, 1989/90 - 1994/95 ...... 289 1992/93 - 1994/95 (SARV map) ...... 301

Exhibit 11.6: Total Price-adjusted Billings to OHIP for Exhibit 11.20: Rate per 1,000 and Distribution by Age Group Female Children 15 to 19 Years in Ontario, for Tonsillectomy for Children 0 to 19 Years 1989/90 - 1994/95 ...... 291 in Ontario, 1991/92 - 1994/95 ...... 302

Exhibit 11.7: Total Price-adjusted Billings to OHIP for Exhibit 11.21: Age/Sex-adjusted Tonsillectomy Rates Male Children 15 to 19 Years in Ontario, (inpatient and day surgery) per 1,000 1989/90 - 1994/95 ...... 291 Children 0 to 19 Years by DHC Area of Patient Residence in Ontario, Exhibit 11.8: OHIP Billings by Age Group and Physician 1992/93 - 1994/95 (SARV table) ...... 303 Specialty in Ontario, 1994/95 ...... 291 Exhibit 11.22: Age/Sex-adjusted Tonsillectomy Rates Exhibit 11.9: Measures of Inpatient Hospital Utilization (inpatient and day surgery) per 1,000 Among Children in Ontario, Children 0 to 19 Years by DHC Area of 1992/93 - 1994/95 ...... 292 Patient Residence in Ontario, 1992/93 - 1994/95 (SARV map) ...... 304 Exhibit 11.10: Top Three Medical and Surgical Pediatric Hospitalization Rates per 1,000 by Major Exhibit 11.23: Age/Sex-adjusted Tonsillectomy Rates Clinical Category and Age Group in Ontario, (day surgery only) per 1,000 1992/93 - 1994/95 ...... 293 Children 0 to 19 Years by DHC Area of Patient Residence in Ontario, Exhibit 11.11: Provincial Trends in Circumcision Rates per 1992/93 - 1994/95 (SARV table) ...... 305 1,000 Male Infants Under 28 Days in Ontario, 1985/86 - 1994/95 ...... 294 Exhibit 11.24: Inpatient vs. Day Surgery Tonsillectomy Rates per 1,000 Children 0 to 19 Years Exhibit 11.12: Age-adjusted Circumcision Rates (inpatient only) in Ontario, 1992/93 - 1994/95 ...... 306 per 1,000 Male Infants Under 28 Days by DHC Area of Patient Residence in Ontario, Exhibit 11.25: Overall and Age/Sex-specific Asthma 1989/90 - 1994/95 (SARV table) ...... 295 Hospitalization Rates per 1,000 Children 0 to 19 Years in Ontario, Exhibit 11.13: Age-adjusted Circumcision Rates (inpatient only) 1985/86 - 1994/95 ...... 308 per 1,000 Male Infants Under 28 Days by DHC Area of Patient Residence in Ontario, Exhibit 11.26: Proportion of Separations by Month for 1992/93 - 1994/95 (SARV map) ...... 296 Asthma Among Children 0 to 19 Years in Ontario, 1992/93 - 1994/95 ...... 308 Exhibit 11.14: Overall and Age-specific Myringotomy with Ventilation Tube Rates per 1,000 Children Exhibit 11.27: Age/Sex-adjusted Asthma Hospitalization by Age Group in Ontario, Rates per 1,000 Children 0 to 19 Years 1991/92 - 1994/95 ...... 297 by DHC Area of Patient Residence in Ontario, 1989/90 - 1994/95 (SARV table) ...... 310 Exhibit 11.15: Age/Sex-specific Myringotomy with Ventilation Tube Rates per 1,000 Children 0 to 19 Years Exhibit 11.28: Age/Sex-adjusted Asthma Hospitalization in Ontario, 1992/93 - 1994/95 ...... 298 Rates per 1,000 Children 0 to 19 Years by DHC Area of Patient Residence in Ontario, 1992/93 - 1994/95 (SARV map) ...... 311

xv Exhibit 11.29: Overall Age/Sex-specific Gastroenteritis Exhibit 12.5: Percentage of People Age 65 and Older Hospitalization Rates per 1,000 Children in Ontario Exposed to Drugs That Should 0 to 19 Years in Ontario, be Avoided, 1985/86 - 1994/95 ...... 312 1990/91, 1992/93 and 1994/95 ...... 327

Exhibit 11.30: Proportion of Separations by Month for Gastroenteritis Among Children Chapter 13 0 to 19 Years in Ontario, 1992/93 - 1994/95 . . .312

Exhibit 11.31: Age/Sex-adjusted Gastroenteritis Conclusions and Reflections Hospitalization Rates per 1,000 Children Exhibit 13.1: Activities of an Ontario Health Services 0 to 19 Years by DHC Area of Patient Council ...... 337 Residence in Ontario, 1989/90 - 1994/95 (SARV table) ...... 314

Exhibit 11.32: Age/Sex-adjusted Gastroenteritis Appendix Hospitalization Rates per 1,000 Children Exhibit A.1: Summary of Canadian Studies Reviewing 0 to 19 Years by DHC Area of Patient Completeness of Demographic Data ...... 340 Residence in Ontario, 1992/93 - 1994/95 (SARV map) ...... 315 Exhibit A.2: Summary of Canadian Reabstraction Studies of Hospital Records ...... 341 Appendix A11.1: Major Clinical Categories (MCC) ...... 319 Exhibit A.3: Summary of Canadian Studies Comparing Appendix A11.2: Surgical Procedure/Medical Diagnosis, Diagnoses and Procedures Between Description and Canadian Classification Hospital Discharge Data and Another of Procedure (CCP) and International Source ...... 342 Classificaion of Diseases - Diagnosis Codes – 9th Revision (ICD-9) ...... 319 Exhibit A.4: Summary of Canadian Studies Comparing Diagnoses Between Hospital Discharge Data Appendix A11.3: Breakdown of Excluded Cases and and External Criteria ...... 343 Missing Data By Procedure for Ontario . . . . .320

Appendix A11.4: Summary of Health Services Provided to Children in Ontario, 1994/95 ...... 321

Appendix A11.5: Summary of Common Surgical Procedures for Children in Ontario, 1994/95 ...... 321

Appendix A11.6: Summary of Non-surgical Hospitalizations for Children in Ontario, 1994/95 ...... 321

Chapter 12 Patterns of Use of Specific Drugs in the Elderly Exhibit 12.1: Defined Daily Doses (DDD) for Antidepressants ...... 324

Exhibit 12.2: Number of Defined Daily Doses (DDD), Average Cost per DDD and per Capita Expenditures for Antidepressants for People 65 Years and Older in Ontario, 1990/91 and 1994/95 ...... 325

Exhibit 12.3: Exposure to Antidepressants Among People 65 Years and Older in Ontario, 1990/91 and 1994/95 ...... 325

Exhibit 12.4: Ontario Drug Benefit Prescriptions per Capita, Cost per Prescription and per Capita Expenditures for Antibiotics for People 65 Years and Older in Ontario, 1990/91, 1992/93 and 1994/95 ...... 326

xvi Acknowledgements

When it comes to producing a research publication of the members helped out by doing a final proofreading of all magnitude of the Practice Atlas, the old saying “many chapters. Alison Steeves of Sunnybrook Health Science hands make light work” takes on an entirely new meaning. Centre and the Communications Working Group contributed Without the involvement of “many hands” over the past key advice on communications strategies. PC Support and two years, publication of this second edition would have Solutions developed the software for the electronic Atlas been impossible. We would like to acknowledge the many and Kathryn Harvey ably prepared the executive summary people who helped bring this project to fruition. and electronic user's guide. We especially thank our talented group of ICES scientists, research coordinators, technical First, we would like to thank all our colleagues from both team and administrative support staff for their tremendous the Institute for Clinical Evaluative Sciences (ICES) and the efforts in producing this edition. A special thanks to Sunnybrook Clinical Epidemiology Program, whose hard Rebecca MacBride who assisted with additional word- work and dedication made this project possible. Thank you processsing tasks. Finally, an extensive review process for to Karey Iron who coordinated the early phase of the work the Atlas was made possible through the participation of and then moved on to coordinating the data for the numerous academic and clinical reviewers, and the ICES electronic edition. Thank you to Paula Blackstien-Hirsch, External Coordinating Committee (ECC). Their names are who took over as project coordinator in the fall of 1995 listed below. We apologize in advance for any unintentional and led the Atlas team through a very tight timeline and omissions and we take full responsibility for any errors provided editorial advice. A special thank you is extended in the text. to Laura Benben and Lawrence Stevenson, who took on the monumental task of design, layout and graphics in a very short time frame. Jonathan Paul also assisted with ICES External Reviewers design and layout. Thank you also to Cathy Fooks who guided We gratefully acknowledge the work of our external the production process and media relations, provided reviewers who reviewed one or more chapters. editorial advice and conducted numerous stakeholder briefings. Kathy Knowles Chapeskie and Cathy Cameron Isabel Barnes, Clarke Institute of Psychiatry assisted with copy editing and proofreading. Pam Slaughter Paul Brochu, Ontario Ministry of Health assisted with proofreading of the executive summary, and a number of research coordinators and technical team Jeanette Cochrane, Clarke Institute of Psychiatry

xvii Catherine Cornell, Scarborough General Hospital Dr. Verna Mai, Chair, Committee on Population Health

Janet Durbin, Clarke Institute of Psychiatry Dr. Michael McGuigan, Chair, Committee on Drugs and Pharmacotherapy Margaret Dwyer, Ontario Ministry of Health Dr. Raymond Osborne, Toronto-Sunnybrook Regional Hy Eliasoph, Joint Policy & Planning Committee Cancer Centre Secretariat Dr. Duncan Paterson, Barrie Dr. Robin J. Fairfull-Smith, Ottawa General Hospital Dr. Christopher Patterson, Chair, Section on Geriatrics Theresa Firestone, Ontario Ministry of Health Dr. Robin Richards, Chair, Section on Orthopaedic Surgery Dr. William Gnam, The Toronto Hospital Dr. Ronald Smuckler, Chair, Section on General and Dr. Martin Goldbach, Victoria Hospital Corporation Family Practice

Dr. Alan Goldbloom, Hospital for Sick Children Dr. Ann Spence, London

Dr. Jeffrey Gollish, The Orthopaedic & Arthritic Hospital Dr. Wilfred Steinberg, Toronto

Jessica Hill, Ontario Ministry of Health Dr. Wayne Tanner, Chair, Section on Cardiovascular Surgery

Dr. Robert Issenman, Children’s Hospital, Chedoke- Dr. Robert Williams, Chair, Committee on Hospitals McMaster Hospitals Dr. Ian Wilson, Chair, Committee on Child Welfare Dr. John Nkansah, Association of General Hospital Psychiatric Services Dr. James Wright, Hospital for Sick Children

Dr. William Orovan, St. Joseph’s Hospital, Hamilton

Dr. George Pasut, Ontario Ministry of Health ICES External Coordinating Committee (ECC)

Gloria Ringwood, Ontario Health Records Association The ECC reviewed all of the Atlas chapters and provided us with feedback on the policy implications of the work. Dr. Brian Rowe, Sudbury General Hospital

Dr. Hugh E. Scully, The Toronto Hospital Jackie Cooper, Institute for Work and Health (formerly from the Ontario Medical Association) Dr. Heather Shapiro, The Toronto Hospital Cathy Fooks (Chair), Institute for Clinical Evaluative Sciences Dr. Richard Swinson, Clarke Institute of Psychiatry Brad Graham, Ontario Ministry of Health Dr. Marie Truelove, Ryerson Polytechnic University Nora Ho, Ontario Ministry of Health Dr. Donald Wasylenki, Wellesley Hospital Paul Huras, Thames Valley District Health Council Dr. John Wedge, Hospital for Sick Children Natalie Rashkovan, Joint Policy & Planning Committee Caroline Yip, Ontario Ministry of Health Secretariat

Joanne Rolland, Simcoe County District Health Council

Ontario Medical Association Reviewers Ron Sapsford, Ontario Hospital Association

The Ontario Medical Association (OMA) asked a number Dr. Michael Thoburn, Ontario Medical Association of the clinical section and committee chairs to review relevant chapters of the Atlas. Their constructive input is ICES Communications Working Group greatly appreciated. The Working Group provided valuable communications Dr. Allan Abramovitch, Chair, Section on Urology expertise and planned the communication strategy for the Dr. Henry Barnett, University Hospital release of the ICES Practice Atlas. Individual members also Dr. Phillip Barron, Ottawa Civic Hospital assisted with drafting communications materials.

Dr. Andrew Braude, Chair, Section on Respiratory Disease Paula Blackstien-Hirsch, Institute for Clinical Evaluative Sciences Dr. Patrick Conlon, Past Chair, Section on Psychiatry John Court, Association of District Health Councils of Ontario Dr. John Deadman, Chair, Section on Psychiatry Cathy Fooks, Institute for Clinical Evaluative Sciences Dr. Fraser Fellows, St. Joseph's Hospital, London Elliot Gold, Ontario Ministry of Health Dr. George Hiraki, Toronto Jeff Henry, Ontario Medical Association Dr. Arnold Kravetz, Chair, Section on Ophthalmology Michael Moralis, Ontario Hospital Association Dr. Leo Mahoney, Chair, Committee on Breast Cancer Screening

xviii Michelle Noble, Faculty of Medicine, University of Toronto Canadian Medical Association

Alison Steeves (Chair), Sunnybrook Health Science Centre We would also like to acknowledge the contributions of Dr. Bruce Squires as a chapter reviewer and Carolyn Brown of the CMA Publications Office who provided us ICES Technical Team with copy editing and editorial advice. Debbie Rupert was The collective expertise of the ICES technical team made the CMA coordinator of the project. the Atlas possible. Team members provided methodologic support, data production and analysis, and general problem solving advice.

Mohammed Agha, Research Coordinator

Don DeBoer, Senior Biostatistician

Rod Hernandez, Programmer

Eileen Lee, Statistician

Doug Manuel, MSc Student, University of Toronto

Marc-Erick Theriault, Programmer/Analyst

Michelle Tran, Programmer/Analyst

Claus Wall, Manager

Keyi Wu, Programmer/Analyst

Exceptional systems support was provided by J-R Kidston and Colin Shepherd

Atlas Electronic Edition Team

Paula Blackstien-Hirsch

Don DeBoer

Dr. Vivek Goel (Chair)

Karey Iron

Lawrence Stevenson

Claus Wall

ICES Administrative Support

Administrative support was ably provided by members of the ICES Administrative Support group.

Margaret Brady

Wendy Cooke

Francine Duquette

Donna Hoppenheim

Rebecca MacBride

Eileen Patchett

Donna Polyak

Mona Shaw

xix xx Foreword

It wasn’t hard for me to accept the editors’ invitation to tonsillectomy and adenoidectomy. At the local level, write this foreword. As the President of the Board of hospitals used the ICES Practice Atlas to assess their Directors of the Institute for Clinical Evaluative Sciences patterns of practice, and many instituted internal reviews in Ontario (ICES), I have been delighted to oversee the and audits. Some common, problematic issues concerning development of this dynamic research organization. The the diagnostic and procedure codes, such as those for release of the second edition of the ICES Practice Atlas, appendectomy and breast-conserving surgery, were Patterns of Health Care in Ontario, marks the institute’s identified and communicated to all hospitals to improve continuing contribution to the Canadian experiment the quality of future data. called medicare. I anticipate that the response to the second edition of The response to the 1994 publication of the first ICES the ICES Practice Atlas will be even stronger. Like the Practice Atlas was overwhelming. ICES heard from hospital first edition, this new edition provides basic information administrators, clinical managers, community physicians, about the operation of the Ontario health care system. District Health Council planners and consumers from Readers will again have details about the health of their across the province. Whenever possible, ICES responded community, the amount of surgery being provided to to requests for speakers, further data analyses, technical residents of Ontario, differences in length of stay for assistance with methodology and general support for common admissions to Ontario hospitals, patterns of those following up on the specific findings for their drug prescribing for the elderly and trends in provincial institution or community. health expenditures over the last decade.

Did the first ICES Practice Atlas make a difference? At New information contained in the second edition is the the provincial level, the Ontario Ministry of Health and direct result of feedback from stakeholders about the the Ontario Medical Association established a working first edition and, I believe, meets the needs of our changing group to address regional variations in hysterectomy times. The Ontario health care community is in the middle rates. The College of Physicians and Surgeons of Ontario of a major financial transition. Restructuring is under and the Joint Policy and Planning Committee of the way across the province, and comparative information Ministry of Health and the Ontario Hospital Association about communities and institutions plays a vital role in sponsored a project to promote higher rates of outpatient the discussions.

xxi In addition to updating the information provided in the first edition of the ICES Practice Atlas, the 1996 edition covers new topics, such as physician billing patterns, the impact of length of stay on hospital readmissions and small area rate variations for common medical conditions considered sensitive to ambulatory care. Utilization and expenditure trends in mental health and pediatric services are an exciting addition to this edition. Another innovation in this edition is the provision of tabular information on diskette. Users can extract and compile information as desired.

The challenges faced by health care providers increase annually. With the release of this new ICES Practice Atlas, ICES continues to play a crucial role in helping health care managers and professionals deliver high quality health care. “You can’t manage what you can’t measure” may be an overworked phrase; however, the need for management and measurement has never been stronger.

It is up to all of us to respond to the information presented here and to act collectively to maintain high quality health care in Ontario.

Dr. John Evans

President, ICES Board of Directors and Chair, Torstar Corporation

xxii