hospital care indicators - health quality ontario (hqo) · 2016. 3. 30. · hospital care...

Common Quality Agenda DRAFT - DO NOT CIRCULATE 1

Hospital Care Indicators


Hospital Care Indicators

There are 23 Common Quality Agenda indicators that are relevant to the hospital care sector,

the largest of all sectors. Accountability for 12 of these is specific to hospital care organizations;

an additional 11 indicators have shared accountability with other sectors.

Hospital care indicators Accountability Target Target source

Percentage of hip and knee replacements completed within target by priority level (E) (CD)

Hospital 182 days (provincially set)

Provincial government

Percentage of patients discharged to inpatient rehabilitation following the index stroke admission (N) (CD)

Hospital 42% (set by SEQC); year over year = 10%

SEQC

Percentage of hospitalized stroke patients who are admitted to a stroke unit (N) (CD)

Hospital 87.5% (set by SEQC); year over year = 10%

SEQC

Percentage of complex continuing care (CCC) residents with a new stage 2 or higher pressure ulcer in the last three months (E) (CD)

Hospital 1.6% HQO benchmarking

Percentage of complex continuing care (CCC) residents who fell in the last 30 days (E) (CD)

Hospital 5%; 10% year over year relative reduction

HQO benchmarking

Percentage of patients who would definitely recommend hospital to family and friends -inpatient -ED (E) (CD)

Hospital 70.6% (ED) – 5% relative improvement year over year 81.8% (inpatient) – 5% relative improvement year over year

HQO benchmarking

Percentage of STEMI patients with acute coronary syndrome whose door to balloon time was within provincial (CCN) benchmark (<90 minutes if presenting to PCI hospital; <120 minutes if presenting to non-PCI hospital). (N) (CD)

Hospital 90% for patients presenting to PCI hospitals 80% of patients presenting to non-PCI hospitals

CCN (guidelines based)

Percentage of procedures completed within target time period for patients designated as: urgent; semi; elect • Coronary artery bypass graft (CABG) • Percutaneous coronary intervention (PCI) • Angiography (E) (CD)

Hospital Wait times as set by CCN RMWT – PCI / Angio -Urgent (7 days) -Semi-urgent (14 days) -Elective (28 days) RMWT (CABG) -Urgent (14 days) -Semi-urgent (42 days) -Elective (90 days)

Provincial government with CCN


Wait times for cancer consult and surgery - % within target for cancer surgery; - wait time for radiation treatment (ready to treat to treat); - wait time for systemic treatment -----referral to consult -----consult to treatment (E) (CD)

Hospital 90th percentile wait time for cancer surgery = 14, 28, 84 days depending on priority Wait times for radiation - ready to tx to tx = 1, 7 or 14 days depending on priority Systemic therapy: Referral to consult = 67% within target values Consult to treatment = 85% within target values

Provincial government with CCO

Hospital-acquired C. diff infection (CDI) rate per 1000 patient days (E) (PH)

Hospital 10-20% year over year Try to get below 0.3

Expert consultation

90th percentile length of stay in ED (E) (PH)

Hospital (Ministry set benchmark) 90% of patients who are either low acuity or who are not admitted should have a LOS < 4hours 90% of patients who are either high acuity or who are admitted should have a LOS < 8hours


Prevalence of physical restraint use for mental health and addictions patients in hospital (N) (MH)

Hospital 0% (50% relative reduction year over year)

Expert consultation

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


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


% (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) (R) (CD)

Hospital/Primary Care/Home Care

10% year over year for CHF and COPD; stroke goal is to keep below 10% (current performance = 8.6%); Confirming asthma DM AMI targets

Expert consultation (Note SEQC 2012 report indicates stroke 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 between 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

Home care wait time : - time from inpatient discharge - time from community referral (E) (PH)

Hospital/Home Care

Hospital to HC wait time

No target set


Percent of Hip/Knee Replacements Completed within Target by Priority Level Indicator description

This is the percent of patients who met the access targets from when a patient and surgeon decide to proceed with surgery (decision-to-treat) until when the actual procedure is completed. The access targets are as follows for each of the priority levels:

Priority 2: 42 days

Priority 3: 84 days

Priority 4: 182 days

Relevance/ Rationale

Hip/knee replacement is one of high priority areas to reduce wait times. Collecting and reporting accurate and up-to-date data on wait times allow better decision making and increase accountability.

Reporting tool/product

Quality Monitor annual report

Attribute Accessible

Type Process and core indicator

External Alignment

HQO Quality Based Procedures; Ontario’s Action Plan for Health Care (Access); H-SAA; May also align with Health Links; Ministry Quarterly Report

Accountability Hospital

Calculation Numerator Number of patients whose surgery wait times is within the access targets. (See wait times calculation & access targets below.)

Wait time (in days) = "treatment" date minus "decision to treat" date

The wait time is calculated for each patient who received treatment within the most current time period. Access targets:

Priority 2: 42 days

Priority 3: 84 days

Priority 4: 182 days

Denominator All hip or knee replacement surgeries meeting the inclusion/exclusion criteria below. Inclusion Criteria:

All closed wait list entries with procedure dates within date range;

Patient was 18 years or older on the day the procedure was completed.

Exclusion Criteria: Procedures no longer required. Procedures assigned as Priority 1 level. Wait list entries identified by hospitals as data entry errors.

Other Criteria: If patient unavailable dates fall outside the Decision to Treat Date

up to Procedure Date, the patient unavailable dates are not


deducted from the patient's wait days. These are considered data entry errors.

Data source / data elements

Wait Times Information System (WTIS), CCO;

Hospitals submit their information electronically directly to WTIS;

Several activities ensure data accuracy and its compliance with established reporting guidelines for WTIS data. Please refer to the following website for details: http://www.health.gov.on.ca/en/pro/programs/waittimes/surgery/data.aspx#2

Reported at overall hospital facility, LHIN, and provincial levels.

Timing and frequency of data release

Monthly, quarterly and yearly data are requested from CCO; and yearly data are reported in QMonitor reports

Levels of comparability

Across time; Facility and LHIN level comparisons

Targets and/or Benchmarks

Hip/ Knee Replacement 42 days – priority 2 84 days – priority 3 182 days – priority 4

Target Source Provincial Wait Times Strategy

Limitations Small volumes: small number of cases within a certain reporting period may have a big impact on the result, and thus makes it difficult to draw conclusions about what should be expected

Other Factors Affecting Wait Times: There are factors that affect wait times that do not relate to a hospital’s efficiency, to a particular doctor or the availability of resources. They include :

o Patient Choice – a patient with a non-life-threatening condition may decide to delay treatment for personal or family reasons to a more convenient time.

o Patient Condition – a patient’s condition may need to improve before the surgery or exam takes place.

o Follow-up Care – a patient who has an existing condition may be pre-booked for a follow-up treatment or exam a long time in advance.

o Treatment Complexity – a patient with special requirements may need specific equipment or a certain kind of facility and there is a delay until these can be scheduled.

Right now, there is no way to capture all of these possible factors in the information that hospitals are reporting. However, the provincial Wait Time Information System (WTIS) will collect information about when patients are not available for treatment. Although these factors may have a significant effect on the wait time for an individual patient, overall wait times are still a good reflection of the current situation for a typical patient at that hospital.

http://www.health.gov.on.ca/en/pro/programs/waittimes/surgery/data.aspx#2



Adjustment (risk, age/sex standardization)

Not adjusted

Guidelines, SOPs, Evidence for best practice

n/a

Current performance

Figure1. Percent of hip replacements completed within target time by priority level,

FY2008/09 - 2011/12, Ontario

2008/09 2009/10 2010/11 2011/12

Total Volume (cases) 11292 11886 12174 12531

Priority 2 (42 days) 62% 63% 62% 66%

Priority 3 (84 days) 67% 68% 66% 67%

Priority 4 (182 days) 86% 90% 87% 85%

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Figure2. Percent of hip replacements completed within target time by priority level and LHIN, FY2011/12

Figure3. Percent of hip replacements completed within target time by facility, Priority level 2, FY2011/12

Note: Facilities with “NV” and “NA” are excluded from figure

ESC SW WWHNH

BCW MH TC C CES SE CH NSM NE NW

Priority 2 (42 days) 100% 67% 71% 56% 100% 86% 69% 89% 66% 77% 48% 75% 18% 89%

Priority 3 (84 days) 88% 49% 71% 61% 55% 77% 72% 77% 67% 66% 69% 65% 48% 84%

Priority 4 (182 days) 92% 79% 80% 78% 86% 93% 93% 95% 93% 95% 67% 95% 82% 83%

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Facility as per hip replacement figures

Performance target for priority level 2 = 42 days




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Performance target for priority 3 = 84 days




Figure6. Percent of knee replacements completed within target time by priority level,

FY2008/09 - 2011/12, Ontario

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2008/09 2009/10 2010/11 2011/12

Total Volume (cases) 20550 21186 21396 22968

Priority 2 (42 days) 60% 62% 60% 64%

Priority 3 (84 days) 63% 65% 62% 60%

Priority 4 (182 days) 82% 88% 86% 80%

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Figure7. Percent of knee replacements completed within target time by priority level and LHIN, FY2011/12

* For priority level 2, those LHINs have no data due to no or low volume during the reporting period.

ESC SW WWHNH

BCW* MH* TC C CE SE CH NSM NE NW*

Priority 2 (42 days) 91% 75% 70% 56% 73% 95% 61% 65% 46% 73% 27%

Priority 3 (84 days) 82% 39% 64% 53% 68% 76% 67% 73% 59% 60% 53% 67% 42% 67%

Priority 4 (182 days) 91% 69% 65% 67% 85% 86% 90% 91% 94% 94% 63% 95% 70% 73%

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Figure8. Percent of knee replacements completed within target time by facility, Priority

level 2, FY2011/12


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Figure9. Percent of knee replacements completed within target time by facility, Priority level 3, FY2011/12


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Performance target for priority 3 =84 days


Figure10. Percent of knee replacements completed within target time by facility, Priority level 4, FY2011/12


Statement of results

Hip Replacements

The volume of hip replacements has increased by more than 10% between 2008/09 and

2011/12. The time trends for the percent of procedures completed within target has

varied by priority level. The percent of urgent hip replacements (priority level 2)

completed within the 42 days target increased from 62% to 66% over the past four

years. The percent of semi-urgent (level 3) hip replacements completed within the 84

days target has remained relatively stable. The percent completed within target for

elective (level 4) hip replacements increased between 2008/09 to 2009/10, and since

then has decreased.

There was wide variation across LHINs for all priority levels in fiscal year 2011/12 (see

Figure 2). Overall, Erie-St. Clair LHIN had the best performance among all LHINs.

There was less facility level variation in the percent of elective cases completed within

target compared with the variation seen for semi-urgent and urgent cases. In 2011/12,

there were six facilities where less than 50% of urgent cases were completed within

target and 12 facilities for semi-urgent cases within target. Facility level variation for

elective cases was narrower—the percent of elective cases completed within target was

between 40% and 100%, and only 3 facilities had less than 50% completed within target.

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Knee Replacements

The volume of knee replacements has increased by more than 10% between 2008/09

and 2011/12. The trend over time in the percent of knee replacements completed within

target has varied by priority level. The percent of urgent knee replacements (priority level

2) completed within the 42 days target increased from 60% to 64% over the past four

years. The percent of semi-urgent (level 3) and elective (level 4) knee replacements

completed within target have slightly decreased over the same time period.

There was wide variation across LHINs for all priority levels in fiscal year 2011/12 (see

Figure 7). Overall, Erie-St. Clair LHIN and Central LHIN had better performance

compared to other LHINs.

There was facility level variation for all priority levels. In 2011/12, for example, the

percent of semi-urgent cases (level 3) completed within target was between 11% and

100%.


Percent of stroke patients discharged to inpatient rehabilitation following an acute stroke hospitalization Indicator description

In many cases, stroke patients should be discharged from an acute stroke hospitalization to inpatient rehabilitation to ensure full recovery potential is achieved


(Rationale taken from Canadian Best Practice Recommendations for Stroke Care http://www.strokebestpractices.ca/index.php/stroke-rehabilitation/stroke-rehabilitation-unit-care-2/) “There is strong and compelling evidence in favour of admitting patients with moderate and severe stroke to a geographically defined stroke rehabilitation unit staffed by an interprofessional team. Death and disability are reduced when post-acute stroke patients receive coordinated, interprofessional evaluation and intervention on a stroke rehabilitation unit. For every 100 patients receiving organized inpatient interprofessional rehabilitation, an extra five return home in an independent state.”


Qmonitor; Stroke Evaluation and Quality Committee Report

Attribute Effective

Type Process indicator and core indicator

External Alignment

Quality Based Procedures condition-specific indicator H-SAA; Ontario Stroke Audit


Calculation Numerator Stroke Patients (Most Responsible Diagnosis ICD10 code = I60, I61, I63, I64) Discharge Disposition not equal to 07 (dead) in the DAD and linking them to the NRS. Admitted and classified RCG=1 in the same fiscal year as the DAD discharge

Denominator For each fiscal year take the first stroke hospitalization discharge of a unique patient. Stroke Patients (Most Responsible Diagnosis = I60 (subarachnoid haemorrhage), I61 (intracerebral haemorrhage), I63 (cerebral infarction), I64 (stroke not specified)) discharged disposition not equal 07 (died) Excludes: 1. ICD-10-CA Diagnostic codes I60.8 (other subarachnoid hemorrhage), I63.6 (cerebral infarction due to cerebral venous thrombosis, nonpyogenic) 2. Discharge disposition = died (07) 3. Age is less than 18 4. Two different exclusions are applied depending on its use:

a) Individuals with missing LHIN (used for SEQC report for provincial rates) or

b) Individuals with missing subLHIN (used for SEQC report for benchmarking)

http://www.strokebestpractices.ca/index.php/stroke-rehabilitation/stroke-rehabilitation-unit-care-2/

http://www.strokebestpractices.ca/index.php/stroke-rehabilitation/stroke-rehabilitation-unit-care-2/



NRS and CIHI-DAD


Data are released annually in December and available as of 2003.


LHIN (using patient’s postal code to assign to LHIN, i.e., LHIN performance is the proportion of patients that live in the LHIN that received inpt rehab following an acute stroke inpatient stay)


42.3% based on target values set by the SEQC and reported in the Ontario Stroke Evaluation Report 2012.1 This target was confirmed in consultations with ICES and Ontario Stroke Registry 10% year-over-year relative improvement based on recommendations from ICES

Target Source SEQC and expert consultation

Limitations Only looks at stroke patients admitted into the NRS in the same FY as the DAD discharge therefore the numerator does not capture those patients discharged at the end of the FY from the DAD database. Nor does it capture those patients that received inpatient rehab in facilities that do NOT report to the NRS Unable to exclude patients who had mild strokes

Adjustment (risk, age/sex standardization

Stratified by sex, age group, income quintile, rural/urban, LHIN and subLHIN Risk adjusted using age and gender (indirect standardization)


Canadian Best Practice Recommendations for Stroke Care http://www.strokebestpractices.ca/index.php/stroke-rehabilitation/delivery-of-inpatient-stroke-rehabilitation-2/

Comments Ontario Stroke Evaluation Report 2012: Prescribing System Solutions to Improve Stroke Outcomes (exhibit 3.4) http://www.ices.on.ca/webpage.cfm?site_id=1&org_id=68&morg_id=0&gsec_id=0&item_id=7543&type=report Ontario Stroke Evaluation Report 2013: Spotlight on Secondary Stroke Prevention and Care (exhibit 5.3) http://www.ices.on.ca/file/Stroke-Report-2013_Accessible.pdf * The OSN reports a LHINs performance using a patient-based analysis. Postal-code of patient is used to assign patient to their LHIN. *Multiply by 100 to present as a percent

1 The benchmarks referenced in the Ontario Stroke Evaluation Reports are recalculated annually using the ABC methodology

and facility/sub-LHIN data. For benchmarking methodology, see Weissman et al. Journal of Evaluation in Clinical Practice 1999; 5(3): 269-81. The Ontario Stroke Evaluation Report 2013 provides an updated benchmark of 42.6%

http://www.strokebestpractices.ca/index.php/stroke-rehabilitation/delivery-of-inpatient-stroke-rehabilitation-2/

http://www.strokebestpractices.ca/index.php/stroke-rehabilitation/delivery-of-inpatient-stroke-rehabilitation-2/

http://www.ices.on.ca/webpage.cfm?site_id=1&org_id=68&morg_id=0&gsec_id=0&item_id=7543&type=report


http://www.ices.on.ca/file/Stroke-Report-2013_Accessible.pdf


Current Performance

Note: Graphs are generated using adjusted rates and exclusion 4a (Individuals with missing LHIN information are

excluded)

Figure 1: Percent of patients discharged to inpatient rehabilitation following the index stroke admission, per fiscal year, excluding missing LHINs

Data source: NRS & CIHI-DAD, provided by ICES

27.8 28.229.0

30.0 29.831.1 31.0 30.8

31.5

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Performance Target = 42.3%Target relative year-over-year improvement = 10%


Figure 2: Percent of stroke patients discharged to inpatient rehabilitation following the index stroke admission in fiscal year 2011/12 by LHIN, excluding missing LHINs


36.4

33.4

30.9 31.1

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Figure 3: Percent of stroke patients discharged to inpatient rehabilitation following the index stroke admission in fiscal year 2011/12 by subLHIN, excluding missing LHINs


Table 1: Percent of stroke patients discharged to inpatient rehabilitation following their index stroke admission in fiscal year 2011/12, by patient characteristics (excluding patients with missing LHIN)

Variable Category Adjusted rate

per 100 Adjusted 95%

LCL Adjusted 95%

UCL

Sex

F 31.55 30.26 32.83

M 31.55 30.35 32.74

Age

18-45 20.94 16.97 24.91

46-65 33.03 31.37 34.7

66-75 33.81 31.95 35.67

76-85 33.3 31.67 34.92

85+ 26.01 23.84 28.19

Income Quintile

1st (lowest) 32.52 30.68 34.36

2nd 31.62 29.71 33.53

3rd 30.87 28.83 32.9

4th 31.02 29.02 33.01

5th (highest) 31.35 29.3 33.4

Rural

N 31.92 30.98 32.86

Y 29.11 26.69 31.52

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Performance Target = 42.3%Target relative year=over-year improvement = 10%


Statement of Results

The age, sex-adjusted percent of hospitalized stroke patients who were discharged to

inpatient rehabilitation increased from 27.8% in 2003/04 to 31.5% in 2011/12 (Figure 1).

The percent of hospitalized stroke patients who were discharged to inpatient

rehabilitation showed a 15% difference between the best performing LHIN (Northwest

LHIN; 38.9%) and the worst performing LHIN (Central LHIN; 24.0%) in 2011/12 (Figure

2). The sub-LHIN variation was also large: of the 97 sub-LHIN regions, the 10th

percentile adjusted rate was 16.5% and the 90th percentile adjusted rate was 41.5%

(Figure 3, data values not shown).

There were statistically significant differences in inpatient rehabilitation rates by age, but not by

sex, neighbourhood income quintile or rural/urban status (Table 1). In 2011/12, there tended to

be smaller proportions of the youngest (18-45 year olds; 20.9%) and oldest (85+ year olds;

26.0%) stroke patients who were discharged to inpatient rehabilitation compared to those

between the ages of 46-85 (33.0% to 33.8%). Patients who lived in rural areas (29.1%) were

slightly less likely to be admitted to inpatient rehabilitation than those living in urban areas

(31.9%); however this difference was not significant.


Percent of stroke and transient ischemic attack (TIA) patients admitted to a stroke unit during their inpatient stay Indicator description

All hospitalized stroke / TIA patients should be admitted to a stroke unit for acute stroke management for improved outcomes.

Relevance/Rationale

There is strong evidence that the use of stroke care units improve outcomes of stroke patients who are hospitalized. Research has shown that stroke care units can decrease the likelihood of disability and death by as much as 30%.

http://strokebestpractices.ca/wp-content/uploads/2013/05/CSBP-Taking-Action-Resource-OVERVIEW_EN_22May13F.pdf

This indicator was recommended for performance measurement in the Quality-Based Procedures: Clinical Handbook for Stroke (http://www.hqontario.ca/Portals/0/Documents/eds/clinical-handbooks/stroke-130425-en.pdf)


QMonitor; Stroke Evaluation and Quality Committee Report

Attribute Effective

Type: Process indicator and core indicator

External Alignment

Quality Based Procedures; H-SAA; Ontario Stroke Audit; Stroke Evaluation and Quality Committee Report


Calculation Numerator Number of stroke or TIA inpatients >= 18 years of age treated on an acute stroke unit at any time during hospital stay

[HC_Admitted] = Stroke Unit OR [D_StrokeUnit] = Yes

Denominator All patients >= 18 years of age admitted to an acute care facility in Ontario with a diagnosis of stroke or TIA (ICD-10-CA codes I60 (excluding 160.8), I63 (excluding I63.6), I64, H34.1, I61 and G45 (excluding G45.4))

[FD=DCDiagnosis] = stroke or TIA [D_AdmitSame] = yes Exclusion

1. Age is less than 18 2. Inhospital stroke [SE_inHospitalStroke] = yes


Ontario Stroke Audit 2010/11 Note: for subsequent years, we will be able to use DAD - As of FY2012/13 stroke unit data element is mandatory in the Discharge Abstract Database (DAD) Stroke unit admission is determined according to the fifth character (Y, N, 8) of variables, “Project1~Project5”. Y=Yes, N=No, 8=Facility does not have a designed stroke unit.


Data are available biennially in February for data from Ontario Stroke Audit



http://www.hqontario.ca/Portals/0/Documents/eds/clinical-handbooks/stroke-130425-en.pdf

http://www.hqontario.ca/Portals/0/Documents/eds/clinical-handbooks/stroke-130425-en.pdf


Data available annually through Ontario Stroke Network or hospitals can generate as often as they like through their decision support team.

Data are available as of 2002 in the Ontario Stroke Audit and as of 2012/13, Stroke unit admission will be captured in the DAD


Data are available at the level of the facility


87.5% based on target values set by the SEQC and reported in the Ontario Stroke Evaluation Report 2012.2 This target was confirmed in consultations with ICES and Ontario Stroke Registry. 10% year-over-year relative improvement based on recommendations from ICES

Target Source SEQC and expert consultation

Limitations Ontario Stroke Audit is biennial and includes a sample of charts; the sampling strategies differ by year


Sampling strategies differ by year: Ontario Stroke Audits in 2002/03, 2004/05, 2008/09 were conducted on a random sample of 20% of all eligible cases, with oversampling performed at low-volume institutions (fewer than 33 annual visits or admissions for stroke or TIA) where each contributed a minimum of 10 cases and at District Stroke Centres where each contributed a minimum of 50 cases. Ontario Stroke Audit in 2010/11 was conducted based on a population-based sampling strategy that included:

100% sample of all cases from Regional, Enhanced, and District Stroke Centres;

100% sample of all cases seen at the non-designated hospitals where Telestroke consultations are initiated;

30% random sample of all cases from non-designated hospitals that have >100 adult stroke/TIA cases per year, 30 random adult charts from hospitals that have 33-99 adult stroke/TIA separations per year and, 10 random adult charts from hospitals that have <33 adult stroke/TIA separations per year

Weighting: To account for oversampling at certain institutions, results were weighted based on hospital volume and the number of charts sampled. The weight assigned to a record was inversely proportional to the probability of that record being selected for inclusion in the study. By using weights in the analyses, an estimate that applied to the entire population of discharge records was obtained. Adjustment:

2 The benchmarks referenced in the Ontario Stroke Evaluation Reports are recalculated annually using the ABC methodology

and facility/sub-LHIN data. For benchmarking methodology, see Weissman et al. Journal of Evaluation in Clinical Practice 1999; 5(3): 269-81. The benchmark in the Ontario Stroke Evaluation Report 2013 is the same as 2012 (87.5%)


Weighted, adjusted rates were calculated using an indirect standardization methodology: weighted risk adjusted rate for a subgroup = weighted crude rate for that subgroup/weighted predicted rate* overall weighted crude rate. The predicted rate and overall weighted crude rate were generated by running a survey logistic regression model with age and gender. The confidence interval for the weighted adjusted rate was from 1000 iteration bootstraps. Indicator results are stratified by: sex, age group, income quintile, Ontario Stroke System hospital designation, LHIN and institution


Canadian Best Practice Recommendations for Stroke Care http://www.strokebestpractices.ca/index.php/acute-stroke-management/stroke-unit-care-2/

Comments Ontario Stroke Evaluation Report 2012: Prescribing System Solutions to Improve Stroke Outcomes (exhibit 2.4) http://www.ices.on.ca/webpage.cfm?site_id=1&org_id=68&morg_id=0&gsec_id=0&item_id=7543&type=report

http://www.strokebestpractices.ca/index.php/acute-stroke-management/stroke-unit-care-2/

http://www.strokebestpractices.ca/index.php/acute-stroke-management/stroke-unit-care-2/




Current performance3

Figure1. Percent of stroke patients admitted to a stroke unit during their inpatient stay per fiscal year, weighted adjusted rates, Ontario, FY 2002/03, FY 2004/05, FY 2008/09, FY2010/11

Data Source: Ontario Stroke Audit Acute, provided by ICES Note: Acute Ontario Stroke Audits are conducted biennially. The sampling strategy differs between the earlier years (2002/03, 2004/05, and 2008/09) and the most recent audit (2010/11). Results for 2006/07 are not available.

3 Note: The graphs and table are generated using weighted adjusted rates. The weighted adjusted rates differ from

the weighted crude rates by at most 1%, but the adjusted confidence limits are wider than the crude confidence limits. The characteristics with significantly different percents of patients admitted to stroke unit (e.g., hospital designation) are the same for weighted crude and adjusted results.

2002/03 2004/05 2006/07 2008/09 2010/11

Weighted Adjusted Rate 2.8% 18.1% 29.4% 38.1%

0.0%

50.0%

100.0%

Pe

rce

nt



Figure2. Percent of stroke patients admitted to a stroke unit during their inpatient stay, weighted adjusted rates, stratified by LHIN, FY2010/11; Data Source: Ontario Stroke Audit Acute, provided by ICES


Weighted Adjusted Rate 59.8% 43.4% 41.2% 26.7% 16.4% 34.6% 38.1% 37.9% 31.1% 48.8% 50.4% 23.4% 40.0% 69.4%

0%

50%

100%P

erc

en

t



Figure3. Percent of stroke patients admitted to a stroke unit during their inpatient stay, weighted adjusted rates, stratified by institution with a stroke unit, FY2010/11; Data Source: Ontario Stroke Audit Acute, provided by ICES

Note: A) There were 35 institutions identified as having stroke units based on Appendix E Institutional Resources for Stroke in Ontario, 2011/124. There were an additional three institutions identified as having a stroke unit in the appendix that were not within the data provided by the Ontario Stroke Audit (Windsor Regional Hospital (Western), University Health Network (Western), and Mackenzie Richmond Hill Hospital). B) The first eight institutions have a rate of 0%. Six are non-designated stroke centres and 2 are district stroke centres.

4 Ontario Stroke Evaluation Report 2013: Spotlight on stroke prevention and care

0%

50%

100%

Pe

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nt

Non-designated District stroke centre Regional stroke centre Enhanced district stroke centre



Table1. Percent of stroke patients admitted to a stroke unit during their inpatient stay, weighted adjusted rates, by age group, sex, income quintile, rural/urban, and OSS Hospital Designation, FY2010/11; Data Source: Ontario Stroke Audit Acute, provided by ICES

Weighted adjusted rate

(%) 95% LCL

(%) 95% UCL

(%) Variable Stratification

Age 18-45 37.4% 33.0% 41.9%

46-65 37.9% 36.1% 39.6%

66-75 39.4% 37.3% 41.7%

76-85 38.2% 36.5% 40.2%

85+ 37.6% 35.5% 39.7%

Sex Female 38.3% 37.2% 39.3%

Male 38.3% 37.2% 39.3%

Income quintile 1st (Lowest) 38.4% 36.0% 40.7%

2nd 38.2% 35.9% 40.5%

3rd 38.0% 35.6% 40.6%

4th 36.9% 34.5% 39.3%

5th (Highest) 39.8% 37.2% 42.5%

Rural/ Urban Urban 39.6% 38.5% 40.8%

Rural 30.2% 27.9% 32.7%

OSS Hospital Designation

Regional Stroke Centre 63.9% 62.3% 65.5%

Designated Stroke Centre 63.3% 61.6% 65.0%

Non-designated 7.0% 5.8% 8.2%


The biennial Acute Ontario Stroke Audit (OSA) results show that the weighted adjusted

percent of hospitalized stroke patients who were admitted to a stroke unit during their

inpatient stay has increased from 3% in 2002/03 to 38% in 2010/11 (Figure 1).

There is significant LHIN variation in the weighted adjusted rate of stroke patients

admitted to a stroke unit, ranging from 16% (Central West LHIN) to 69% (North West

LHIN) (Figure 2).

The weighted adjusted rate of hospitalized stroke patients who were admitted to a stroke

unit during their inpatient stay does not vary by age, gender, or neighbourhood income

quintile, but does vary significantly by rurality (Table 1). Patients living in urban Ontario

represent approximately 85% of hospitalized stroke patients. The patients who lived in

urban Ontario were more frequently admitted to a stroke unit compared to patients who

lived in rural Ontario, with rates of 40% and 30%, respectively (Table 1).

There were approximately 13 000 stroke patients hospitalized in regional stroke centres

(4 124 patients), designated stroke centres (2 918 patients) or non-designated stroke

centres (5 733 patients). Thirty eight institutions have stroke units: 25 stroke units are in

regional, enhanced district, or district stroke centres and 13 stroke units are in non-

designated stroke centres. Over 60% of the patients hospitalized in stroke centres were


admitted to a stroke unit; however, only 7% of patients hospitalized in non-designated

stroke centres were admitted to stroke units (Table 1).

Even after limiting to hospitals with stroke units, there was institutional variation in the

percent of hospitalized stroke patients admitted to stroke units, ranging from 0% to 90%

(Figure 3). Eleven of the institutions with stroke units admitted 0-15% of stroke patients

to stroke units, 16 of the institutions admitted 40-70% of stroke patients to stroke units,

and 8 of the institutions admitted 75-90% of stroke patients to stroke units.


Percent of complex continuing care (CCC) residents with new stage 2 or higher pressure ulcer in the last three months Indicator description

This indicator measures the proportion of CCC patients that developed a new stage 2 or higher pressure ulcer in a three-month period.


This is an important indicator because the development of pressure ulcers increases a patient’s risk of serious infection and can have a negative impact on independence and mental health.


CIHI e-reporting portal to data submitters

Attribute Safe

Type Outcome and core indicator

External Alignment

QIP- Acute care sector


Calculation Numerator Residents who had a new pressure ulcer at stages 2 to 4 on their target assessment

Denominator CCC Residents with at least 2 valid assessments, excluding those with stage 2 to 4 pressure ulcers on their prior assessment


The indicators are derived from RAI-MDS 2.0 through CIHI’s Continuing Care Reporting System (CCRS), a reporting system that contains demographic, administrative and clinical information for residents from residential care and hospital-based continuing care facilities across Canada

Data elements used: o M2a Stage of Pressure Ulcer o Prev_M2a Stage of Pressure Ulcer

CIHI reported the facility level quarterly data on e-reporting tool. Data submitters can access their data. HQO has access as well through data portal.


Data updated by CIHI on e-reporting tool every quarter

LHIN level and provincial data were available through data request


Across time; by LHIN and facility (facility data are on CIHI portal; need CIHI permission for public reporting);


QIP Benchmark: 1.6%

Target Source HQO benchmarking process (2012) + expert consultation

Limitations While rolling four quarter averages stabilize the rates from quarter-to-quarter variations, especially for smaller facilities, it is makes it more difficult to detect true quarterly improvements


Risk adjustment at two levels:

Adjusted at individual resident level using logistic regression: Individual covariates

o Age younger than 65 o Personal Severity Index: Subset 1: Diagnoses


o More dependence in toileting o Resource Utilization Group (RUG) Cognitive

Impairment

Adjusted at facility level using direct standardization

Case Mix Index


N/A

Comments Incidence indicators are calculated using two assessments in order to capture change from one quarter to the next. One assessment is from the fiscal quarter of interest (“target” assessment) and the second assessment is from the previous quarter (“prior” assessment). The general inclusion criteria for assessments to be included in the incidence indicators are: o Assessment was the latest assessment in the quarter o Assessment was carried out more than 92 days from

Admission Date o Assessment was not an admission full assessment o There was an assessment in the previous quarter o There are 45-165 days between the target and prior

assessments

Rolling four-quarter average: The indicator is evaluated every quarter and calculated based on the rolling average of the four previous fiscal quarters (12 months). This methodology is used because events are relatively rare in smaller facilities.


Current performance

Figure1.Percent of CCC residents with new stage 2 or higher pressure ulcers in the last 3

months, Ontario, April to June 2010—January to March 2013

Apr-Jun

2010

Jul-Sep2010

Oct-Dec2010

Jan-Mar2011

Apr-Jun

2011

Jul-Sep2011

Oct-Dec2011

Jan-Mar2012

Apr-Jun

2012

Jul-Sep2012

Oct-Dec2012

Jan-Mar2013

Has a new stage 2 to 4 pressure ulcer 2.4% 2.4% 2.4% 2.3% 2.2% 2.1% 2.1% 2.2% 2.0% 2.2% 2.3% 2.3%

0.0%

5.0%

10.0%

Pe

rce

nt

Performance target = 1.6%


Figure2. Percent of CCC residents with new stage 2 or higher pressure ulcers in the last

3 months, Ontario, January to March 2013, by LHIN


The risk-adjusted percent of CCC residents with new stage 2 or higher pressure ulcers

in the last 3 months was 2.3% between January and March, 2013. The rate has

fluctuated between 2.0 and 2.5% since the first quarter of 2010 (see Figure1).

There was wide variation in the rate of new pressure ulcer among CCC patients across

LHINs. Based on the data from January to March, 2013, the LHIN specific rates ranged

from1.1% in the Mississauga Halton LHIN to 5.4% in the Erie St. Clair LHIN (see

Figure2).


Has a new stage 2 to 4 pressure ulcer 5.4% 3.3% 1.7% 3.3% 2.4% 1.1% 1.1% 2.9% 4.0% 2.0% 1.4% 2.3% 3.1% 3.0%

0.0%

5.0%

10.0%

Pe

rce

nt

Performance target = 1.6%


Percent of complex continuing care(CCC) residents who have fallen in the last 30 days

Indicator description

This indicator measures the proportion of CCC patients who have fallen in the previous 30 days.


This is an important indicator because patients may experience serious consequences after a fall. It may lead to injuries and increase patients care needs and thus have negative impacts on the health care system.


CIHI e-reporting tool to data submitters

Attribute Safe


External Alignment

QIP- Acute care sector


Calculation Numerator Residents who had a fall in the last 30 days recorded on their target assessment

Denominator CCC Residents with valid assessments


The indicators are derived from RAI-MDS 2.0 through CIHI’s Continuing Care Reporting System (CCRS), a reporting system that contains demographic, administrative and clinical information for residents from residential care and hospital-based continuing care facilities across Canada

Data elements used: o J4a Fell in past 30 days

CIHI reported the facility level quarterly data on e-reporting tool. Data submitters can access their data. HQO has access through data portal as well.


Data updated by CIHI on e-reporting tool every quarter

LHIN level and provincial data were available through data request


Across time; by LHIN and facility (facility data are on CIHI portal; need CIHI permission for public reporting);


QIP Benchmark: 5%; Ten percent relative decrease year over year.

Target Source HQO benchmarking process (2012) + expert consultation

Limitations While rolling four quarter averages stabilize the rates from quarter-to-quarter variations, especially for smaller facilities, it is makes it more difficult to detect true quarterly improvements

Adjustment (risk, age/sex standardization):

Risk adjustment at two levels:

Adjusted at individual resident level using logistic regression: Individual covariates

o Age younger than 65 o Not totally dependent in transferring o Locomotion problem o Personal Severity Index: Subset 2: Non-Diagnoses o Any wandering o Unsteady gait/cognitive impairment

Adjusted at facility level using direct standardization Stratification

Case Mix Index



n/a

Comments Prevalence indicators are measured at one point in time and use a single assessment in their calculation. The general inclusion criteria for assessments to be included in the prevalence indicators are:

o Assessment was the latest assessment in the quarter

o Assessment was carried out more than 92 days from admission date

o Assessment was not an admission full assessment

Rolling four-quarter average: The indicator is evaluated every quarter and calculated based on the rolling average of the four previous fiscal quarters (12 months). This methodology is used because some events are relatively rare in smaller facilities.

Current performance

Figure1.Percent of CCC residents who had fallen in the past 30 days, Ontario, April to

June 2010—January to March 2013

Apr-Jun

2010

Jul-Sep2010

Oct-Dec2010

Jan-Mar2011

Apr-Jun

2011

Jul-Sep2011

Oct-Dec2011

Jan-Mar2012

Apr-Jun

2012

Jul-Sep2012

Oct-Dec2012

Jan-Mar2013

Has fallen 9.7% 10.2% 10.3% 9.9% 9.3% 8.3% 8.4% 9.1% 9.4% 9.7% 9.9% 10.3%

0.0%

12.5%

25.0%

Pe

rce

nt

Performance target = 5.0%Year over year relative reduction=10%


Figure2. Percent of CCC residents who had fallen in the past 30 days, by LHIN, Ontario,

January to March 2013


The risk-adjusted percent of CCC residents who had fallen in the past 30 days was

10.3% between January and March, 2013. The rate has fluctuated over the past three

years between 8.3% - 10.3%. It increased slightly in the first three quarters of 2010/11,

and then started decreasing. The lowest rate in the past three year was observed in July

to September, 2011, and since then it has increased again (see Figure 1).

There was wide LHIN-variation in the rate of falls among CCC residents. The LHIN

specific rates ranged from 3.2% in the Mississauga Halton LHIN to 13.8% in the South

East LHIN (see Figure2) during the period Jan-Mar, 2013.

ESC SW WWHNH

BCW MH TC C CE SE CH NSM NE NW

Risk Adjusted Percentage 8.6% 11.3% 6.8% 13.4% 7.6% 3.2% 7.3% 13.1% 8.6% 13.8% 4.5% 7.5% 11.0% 11.9%

0.0%

12.5%

25.0%P

erc

en

tPerformance target = 5.0%Year over year relative reduction=10%


Percent of respondents who would definitely recommend the emergency department (ED) to family and friends

Indicator description Survey question (NRC Picker): Would you recommend this ED to family and friends?

- Yes, definitely - Yes, probably - No

Better quality is associated with a higher score. The indicator is reported yearly in the QMonitor.

Relevance/Rationale

It is crucial to learn from patients’ perspective about the quality of services provided by hospitals. The NRC-picker survey helps the hospitals to measure and improve patient-centered care in ED.


QMonitor; OHA/ NRC-Picker

Attribute Patient-centered

Type: Outcome and core indicator

External Alignment QIP- acute care sector; OHA reporting; May also align with Health Links


Calculation Numerator Number of survey respondents who choose Yes, definitely

Denominator Number of survey respondents


NRC-Picker Survey, provided by OHA, available every fiscal year


Fiscal year


Across time; By hospital


QIP benchmark is 70.6%; Five percent year over year relative improvement

Target source HQO benchmarking process (2012) + expert consultation

Limitations Self-reported patient satisfaction; prone to survey–related biases


Crude percent reported


N/A


Current performance

Figure1. Percent of respondents who would definitely recommend this emergency

department to family and friends in Ontario, FY2006/07- FY2011/12

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

ED 56.3 57.3 56.8 57.7 58.2 58.7

0

50

100

Perc

en

t

Performance target = 70.6% Year over year relative improvement = 5%


Figure2. Percent of respondents who would definitely recommend this emergency

department to family and friends by hospital in Ontario, FY2010/11

Table1. Facility-level distribution of percent of respondents who would definitely

recommend this emergency department to family and friends in Ontario, FY2010/11


In 2011/12, almost six in ten patients (59%) indicated that they would definitely

recommend the ED in which they received care. This indicator has improved slightly, but

significantly5 since 2009/10.

Among Ontario hospitals who had administered an NRC Picker Canada Acute Care

Patient Experience Survey in 2010/11, there was wide variation in satisfaction rates

ranging from 37% to 86% of patients who would recommend their hospital ED to friends

and family.

5 Statistically significant differences are calculated at 95% confidence level and results are provided by OHA.

0

50

100

Pe

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nt

Hospital

10th percentile Median 90thpercentile


Min 5th

Percentile

10th

Percentile

25th

Percentile Median

75th

Percentile

90th

Percentile

95th

Percentile Max

36.9 40.8 44.4 51.4 60.9 68.3 77.1 80.8 86.3


Percent of respondents who would definitely recommend this hospital to family and friends (inpatient care) Indicator description Survey question:

Would you recommend this hospital to family and friends? - Yes, definitely - Yes, probably - No

Better quality is associated with a higher score. The indicator is reported yearly in the QMonitor.

Relevance/Rationale

It is crucial to learn from patients’ perspective about the quality of services provided by hospitals. The NRC-picker survey helps the hospitals to measure and improve patient-centered care in hospital.


QMonitor; OHA/NRC-Picker

Attribute Patient-centered


External Alignment QIP- acute care sector; OHA reporting May also align with Health Links


Calculation Numerator Number of survey respondents who choose “Yes, definitely”

Denominator Number of survey respondents


NRC-Picker Survey, provided by OHA, available every fiscal year


Fiscal yearly


Across time; By hospital


QIP Benchmark is 81.8%; Five percent year over year relative improvement

Target source HQO benchmarking process (2012) + expert consultation

Limitations Self-reported patient satisfaction; prone to survey–related biases


Crude percent reported


N/A


Current performance

Figure1. Percent of respondents who would definitely recommend this hospital to family

and friends (for inpatient care) in Ontario, FY2006/07-2011/12

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

Inpatient 72.3 72.3 72.3 73.7 73.1 73.2

0.0

50.0

100.0

Pe

rce

nt



Figure2. Percent of respondents who would definitely recommend this hospital to family

and friends (for inpatient care) by hospital in Ontario, FY2010/11

Table1. Facility-level distribution of percent of respondents who would definitely

recommend this hospital to family and friends in Ontario, FY2010/11

Min 5th

Percentile

10th

Percentile

25th

Percentile Median

75th

Percentile

90th

Percentile

95th

Percentile Max

49.0 60.0 63.1 67.7 74.5 80.4 85.5 89.2 92.5


In 2011/12, approximate seven in 10 patients (73%) indicated that they would definitely

recommend the hospital in which they received care as an inpatient. This indicator has

improved slightly, but significantly6 since 2009/10.

Among Ontario hospitals who had administered an NRC Picker Canada Acute Care

Patient Experience Survey in 2010/11, there was wide variation in satisfaction rates

ranging from 49% to 93% of patients who would recommend their hospital for inpatient

care to friends and family.

6 Statistically significant differences are calculated at 95% confidence level and results are provided by OHA.

0.0

50.0

100.0

Pe

rce

nt

Hospital

10th percentile Median90thpercentile



Door to Balloon time for patients with ST elevated Myocardial Infarction (STEMI) Indicator description

This indicator measures the time between first presentation to the hospital (or EMS) and the time to primary percutaneous coronary intervention (balloon insertion/inflation) for patients who are able to reach a treating hospital within the recommended timeframe.

Relevance/Rationale

STEMIs require timely treatment to prevent death or severe morbidity. STEMIs are treated through the restoration of blood flow in the coronary artery through two reperfusion modalities, one of which is PCI or mechanical reopening of arteries using insertion and inflation of a balloon. According to ACC/AHA guidelines, STEMI patients should have a door-to balloon time of less than 90 minutes when presenting to a PCI capable hospital and 120 minutes when presenting to a non-PCI hospital to ensure the best outcomes.


Cardiac Care Network of Ontario (CCN), QMonitor (Information drawn from “Recommendations for Best-Practice STEMI Management in Ontario, June 2013, CCN)

Attribute Effective

Type Core and Process indicator

External Alignment Cardiac Care Network Reporting; Canadian Cardiovascular Society; Ontario Action Plan for Health Care.


Calculation Numerator: Percent of patients who received PCI for STEMI

Denominator: STEMI patients who were able to be treated in a PCI capable hospital within the recommended time frame (90 minutes for direct presentation to PCI capable hospital or 120 minutes for patients presenting to non-PCI hospitals)


CCN; data are available to hospitals directly and Cardiac Care Network hospitals are required to report


Data are available on a monthly basis


Hospital and trending over time


% of patients within target door-to-balloon time: Patients who are transferred by EMS or admitted directly to PCI capable hospital = 90% Patients admitted to non-PCI hospitals = 80%

Target source Ontario Wait times Strategy and CCN

Limitations Difficult to establish what the true denominator should be; patients who cannot make it to a PCI hospital or who are treated with lytic drugs (needle) are not included in denominator.


Describe all recommended reporting and methods (e.g., risk adjustment, age/sex adjustment, crude reporting). if age and sex adjusted, specify standard population


ACA/AHA and CCS guidelines for time to treatment


Comments Indicator reported by CCN as a measure of timeliness Time to primary PCI Door-to-balloon time (D2B) EMS arrival at patient to balloon time (E2B)

a) For walk-in patients arriving at PCI Centre: 90 minutes b) For patients arriving at Referring Hospital: 120 minutes c) For EMS with field ECG to cath lab: 90 minutes (target)

No data are presented at this time


Percent of angiography completed within recommended maximum waiting time (RMWT) by urgency level

- Urgent Semi-urgent - Elective

Indicator description This indicator measures the proportion of patients that require angiography and receive it within the recommended maximum wait time, based on their urgency level (urgent, semi-urgent, and elective). A higher rate is associated with a better performance. The indicator is reported in CCN wait time report and is reported annually in QMonitor.

Relevance/Rationale

Reporting cardiac wait times is an important part of being open and accountable about how well Ontario is doing in reducing wait times for the procedure. It is also an important tool to help hospitals monitor and manage the services they provide to patients in these areas.


QMonitor; CCN Wait time reports


Type Process and Core indicator

External Alignment MOH wait time website reports quarterly 90th percentile wait time data for all cardiac procedures (provincial, LHIN and hospital level) Cardiac Care Network, Canadian Cardiovascular Society; Ontario Wait Times, Ministry Quarterly Report; Ontario Action Plan for Health Care


Calculation Numerator Number of angiography procedures completed within RMWT (stratified by urgency level)

Denominator All adult angiography procedures that are done within Ontario's 18 member hospitals Inclusion:

1. Static (month-end) Data 2. Must be onlisted and offlisted as that procedure:

Onlisted and offlisted refers to being put on the waiting list. Once a patient sees a specialist (cardiologist, cardiac surgeon) and that physician accepts the patient for a procedure (CATH, PCI, CABG) they are “onlisted” to the wait list. Once the patient receives their treatment and the procedure is over the patient is “offlisted” from the wait list (because the treatment is done).

Note: excludes patients who die before they receive their procedures

3. Ontario patients with valid OHIP 4. Takes into account up to one DART* per patient

*DART stands for Dates Affecting Readiness to Treat. It means that a wait list clock is paused because the patient asked the physician to pause it.

If a patient has two DARTs, the second one will not be counted.



CCN cardiac registry, WTIS, provided by CCN Monthly data are available from Apr 2007 to Nov 2012 Fiscal yearly data are available from 2007/08 to 2011/12.


Data are requested from CCN every year for QMonitor report. Monthly and fiscal year data are available


Across time, by LHIN; by institution


RMWT -Urgent (7 days) -Semi-urgent (28 days) -Elective (84 days)

Target Source Ontario Wait Times Strategy (and CCN)

Limitations n/a


Crude rate – process indicator, does not need to be adjusted


n/a

Comments

Current performance

Figure1. Percent of angiography completed within RMWT by urgency level, FY2007/08-

2011/12

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

Urgent (7 days) 86 87 87 87 90

Semi-urgent (28 days) 74 74 71 71 77

Elective(84 days) 99 99 99 98 98

0

50

100

Pe

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nt


Figure2. Percent of angiography completed within RMWT by urgency level and by LHIN,

FY2011/12

Note: LHINs with blank values do not have any cardiac centres.


In FY2011/12, 90% of urgent, 77% of semi-urgent and 98% of elective patients waiting

for angiography had their procedures completed within the maximum recommended wait

time (see Figure1). The percent completed within RMWT for patients designated as

elective and urgent has been reasonably consistent over time; and for the semi-urgent

group, after a slight decrease between 2008/09 to 2010/11, it has improved from 71% to

77%.

There was variation across LHINs in the percent of patients who underwent angiography

within the target wait time for all three urgency levels. The rates ranged from 64%

(Champlain LHIN) to 98% (Central East and North East LHIN) for urgent patients, from

41% (Champlain LHIN) to 98% (Central East LHIN) for semi-urgent patients and from

91% (HNHB LHIN) to 100% in five LHINs (South West, Mississauga Halton, Toronto

Central, Central and Central East LHINs) for elective patients (Figure 2). Erie St. Clair

and North Simcoe Muskoka LHINs do not have cardiac centres and so did not have data

for this indicator.

ESC SW WWHNH

SCW MH TC C CE SE CH NSM NE NW

Urgent (7 days) 89 97 86 97 97 93 94 98 87 64 98 79

Semi-urgent (28 days) 87 68 49 92 91 81 97 98 70 41 84 68

Elective(84 days) 100 99 91 99 100 100 100 100 99 92 95 95

0

50

100

Pe

rce

nt


Percent of percutaneous coronary intervention (PCI) completed within recommended maximum waiting time (RMWT) by urgency level

- Urgent - Semi-urgent - Elective

Indicator description This indicator measures the proportion of patients that require a PCI and receive it within the recommended wait time, based on their urgency level (urgent, semi-urgent, elective). A higher rate is associated with better performance. The indicator is reported in CCN wait times report and is reported annually in QMonitor.

Relevance/Rationale








Calculation Numerator Number of PCI completed within RMWT (stratified by urgency level)

Denominator All adult PCI that are done within Ontario's 18 member hospitals Inclusion:

5. Static (month-end) Data 6. Must be onlisted and offlisted as that procedure :


exclude patients who die before they receive their procedures)





CCN cardiac registry, WTIS, provided by CCN Monthly data are available from Apr 2007 to Nov 2012


Fiscal yearly data are available from 2007/08 to 2011/12.




Across time, by LHIN, by institution




Limitations n/a




n/a

Comments

Current performance

Figure1. Percent of PCI completed within RMWT by urgency level, FY2007/08-2011/12

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

Urgent 90 90 91 91 91

Semi-Urgent 89 88 82 85 89

Elective 98 98 97 98 98

0

50

100

Pe

rce

nt


Figure2. Percent of PCI completed within RMWT by urgency level and by LHIN, FY2011/12


In FY2011/12, approximately nine out of ten patients waiting for PCI had their

procedures completed within the recommended maximum wait time for patients at the

urgent and semi-urgent level; 98% of patients who were designated as elective

underwent PCI within the recommended wait time (see Figure1).The percent of PCIs

completed within target has been stable for urgent and elective levels over the past four

years. For semi-urgent level, there was a slight decline in 2009/10 in the percent of

patients completed within the recommended maximum wait time, but it has increased

back to the 2007/08 level in the most recent year.

There was variation across LHINs in the percent of patients who underwent PCI within

the recommended maximum wait time for all three urgency levels. The rates ranged

from 71% (Champlain LHIN) to 100% (Waterloo Wellington, Central West and North

East LHINs) for urgent patients, from 63% (Champlain LHIN) to 100% (South East and

North East LHINs) for semi-urgent patients and from 89% (Champlain LHIN) to 100% in

5 LHINs (South West, Mississauga Halton, Central, Central East and North East LHINs)

(Figure 2). Erie St. Clair and North Simcoe Muskoka LHINs do not have cardiac centres

and so did not have data for this indicator.

ESC SW WWHNH


Urgent (7 days) 98 100 99 100 94 88 99 93 98 71 100 75

Semi-urgent (28 days) 98 98 87 93 81 98 96 100 63 100 88

Elective(84 days) 100 95 99 93 100 98 100 100 94 89 100 97

0

50

100P

erc

en

tP

erc

en

t


Percent of coronary artery bypass graft (CABG) completed within recommended maximum waiting time (RMWT) by urgency Indicator description

This indicator measures the proportion of patients that require CABG surgery and receive it within the recommended wait time, based on their urgency level (urgent, semi-urgent, and elective). A higher rate is associated with a better performance. The indicator is reported in Cardiac Care Network (CCN) wait time report and is reported annually in QMonitor.

Relevance/Rationale








Calculation Numerator Number of CABG surgeries completed within RMWT (stratified by urgency level)

Denominator All adult CABG surgeries that are done within Ontario's 18 member hospitals Inclusion:

9. Static (month-end) Data 10. Must be onlisted and offlisted as that procedure :


exclude patients who die before they receive their procedures)





CCN cardiac registry, WTIS, provided by CCN Monthly data are available from Apr 2007 to Nov 2012


Fiscal yearly data are available from 2007/08 to 2011/12.




Across time; by LHIN, by institution




Limitations n/a




n/a

Comments

Current performance

Figure1. Percent of CABG completed within RMWT by urgency level, FY2007/08-2011/12

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

Urgent (14 days) 74 78 79 84 85

Semi-urgent (42 days) 87 90 87 90 90

Elective(90 days) 94 96 95 96 97

0

50

100

Pe

rce

nt


Figure2. Percent of CABG completed RMWT by urgency level and by LHIN, FY2011/12

Note: LHINs with blank values do not have cardiac centres.


In 2011/12, 85% of urgent patients, 90% of semi-urgent patients and 97% of patients

designated as elective urgency had their CABG surgery completed within the

recommended wait time (see Figure 1). The percent completed within targets has

improved for all urgency levels compared to 2007/08 rates.

There was variation across LHINs in the percent of patients who underwent CABG

surgery within the target wait time for all three urgency levels. The rates ranged from

82% (Toronto Central LHIN) to 93% (South West LHIN) for urgent patients, from 83%

(South East LHIN) to 100% (North East LHIN) for semi-urgent patients and from 94%

(Central LHIN) to 100% (Waterloo Wellington and North East LHINs) (Figure 2). Five

LHINs (Erie St. Clair, Central West, Central East, North Simcoe Muskoka and North

West LHINs) do not have cardiac centres that perform CABG surgeries and so did not

have data for this indicator.

ESC SW WWHNH


Urgent (14 days) 93 87 87 84 82 87 90 78 84

Semi-urgent (42 days) 91 94 92 88 91 90 83 77 100

Elective(90 days) 98 100 97 98 97 94 96 98 100

0

50

100P

erc

en

t


Percent of Cancer Surgeries Completed within Target by Priority level Indicator description

This is the percent of patients who met the access targets from when a patient and surgeon decide to proceed with cancer surgery until when the actual cancer procedure is completed. The access targets are as follows for each of the priority levels:

Priority 2: 14 days

Priority 3: 28 days

Priority 4: 84 days


The Ontario government has put a plan in place to increase access and reduce wait times for major health services. These include: cancer surgery, cardiac procedures, cataract surgery, hip and knee replacements, general surgery, paediatric surgery and MRI and CT exams. Ontario's plan has 4 goals :

Significantly increase the number of procedures to reduce the backlog that has developed over the last decade.

Invest in new, more efficient technology such as MRI machines and longer hours of operation.

Standardize best practices for both medical and administrative functions in order to improve patient flow and efficiency.

Collect and report accurate and up-to-date data on wait times to allow better decision making and increase accountability.

Reporting Ontario surgical, diagnostic wait times on this website is an important part of the Ontario government’s commitment to being open and accountable about how well we are doing in reducing wait times for key health services. It is also an important tool to help hospitals monitor and manage the services they provide patients in these areas. Text taken from Ontario Wait Times website (http://www.health.gov.on.ca/en/pro/programs/waittimes/surgery/default.aspx)


Quality Monitor



External Alignment

Condition-specific alignment H-SAA 2012-13 indicator MLPA 2012/13 extension Ministry Quarterly Report


Calculation Numerator Number of patients whose cancer surgery wait times is within the access targets. (See wait times calculation & access targets below.) Wait times calculation:


Wait times are measured in days. Wait time = "treatment" date minus "decision to treat" date. The wait time is calculated for each patient who received treatment within the most current time period, for a particular service area and hospital. Using these individual wait times, there are three other calculations: median wait time, average wait time and 90 per cent completed within. Access targets:

Priority 2: 14 days

Priority 3: 28 days

Priority 4: 84 days

Inclusion/exclusion: See inclusion and exclusion criteria as defined in the “denominator” section of the template.

Denominator All cancer surgeries meeting the inclusion/exclusion criteria below. Inclusion Criteria:

All closed wait list entries with cancer procedure dates within date range.

Patients that are 18 years and older on the day the procedure was completed.

Treatment Cancer procedures only. Procedures classified as "NA" are currently included.

Exclusion Criteria:

Diagnostic, Palliative and Reconstructive cancer procedures.

Procedures on Skin - Carcinoma, Skin-Melanoma, and Lymphomas.

Procedures no longer required. Procedures assigned as Priority 1 level. Wait list entries identified by hospitals as data entry errors. Diagnostic imaging cases classified as specified date

procedures (SDP) or timed procedures. SDP cases are excluded from MRI and CT wait time information as of January 1, 2008.

Other Criteria:

If patient unavailable dates fall outside the Decision to Treat Date up to Procedure Date, the patient unavailable dates are not deducted from the patient's wait days. These are considered data entry errors.


Wait Times Information System data requested from Cancer Care Ontario


Data is available on a monthly, quarterly and annual basis.



This is available at the facility, LHIN and provincial.


CCO Performance Target is to have 90% of patients seen within each access target. (See “Access Targets” under the “Numerator” section). (Source: CSQI, Figure 2; http://www.csqi.on.ca/cms/one.aspx?portalId=258922&pageId=273257#.UhdlEz8R7b0)

Target Source Ontario Wait Times Strategy (and Cancer Care Ontario)

Limitations The intent of the data collection is to have the wait time for a patient undergoing an operation where cancer is a real possibility. In some cases, it is only after surgery that a negative result is known. Some reported wait time data for cancer surgery includes data for surgeries where there are benign or non-cancerous tumours. The Ministry of Health and Long-Term Care is working with the surgical community to have more accurate reporting of surgical treatment data involving “intentional” and “patient unavailable” wait times either by :

Subtracting the "patient unavailable dates" from the overall wait time.

Entering the “decision to treat date” as the date when the patient is first recovered from treatment.

For detailed limitations, see: http://www.health.gov.on.ca/en/pro/programs/waittimes/surgery/data.aspx#5 Many cancer surgery procedures are the same as the procedures for benign (non-cancerous) conditions, and the same doctors perform both cancer surgery and non-cancer surgery. As a result, almost every hospital in Ontario performs at least a few cancer surgeries every year. However, the hospitals with smaller numbers of cancer procedures may not have a formal cancer program or specialize in cancer surgery. A number of these smaller hospitals do not report their wait time data to WTIS. Text adapted from the Comprehensiveness of Cancer Surgery Reporting: http://www.health.gov.on.ca/en/pro/programs/waittimes/surgery/data.aspx#4


Not risk adjusted.


N/A

Comments Since April 1, 2006, reports on :






Genitourinary cancers no longer include prostate cancers. Prostate cancers are reported separately.

Head and neck cancers no longer include thyroid and endocrine cancers. These cancers are reported separately.

Thoracic cancers no longer include esophageal cancers. Esophageal cancers are reported under gastrointestinal cancers.

Text taken from the Comprehensiveness of Cancer Surgery Reporting: http://www.health.gov.on.ca/en/pro/programs/waittimes/surgery/data.aspx#4

Current Performance

Figure1. Percent of cancer surgeries completed within target time by priority level and

fiscal year, 2008/09 – 2011/12

Source: WTIS, provided by CCO

2008/09 2009/10 2010/11 2011/12

Total Volume 42285 44517 45760 46142

Priority 2 54% 55% 62% 68%

Priority 3 68% 69% 70% 74%

Priority 4 88% 90% 90% 91%

0

25000

50000

0%

50%

100%

Vo

lum

e

Pe

rce

nt

Total Volume Priority 2 Priority 3 Priority 4

Performance Target = 90%




Figure2. Percent of cancer surgeries completed within target time by priority level and

LHIN, Fiscal Year 2011/12

Source: WTIS, provided by CCO

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

Priority 2 91% 54% 70% 62% 83% 80% 76% 86% 57% 48% 75% 54% 58% 52%

Priority 3 82% 62% 84% 68% 69% 81% 72% 92% 81% 69% 69% 82% 59% 80%

Priority 4 97% 81% 98% 83% 95% 89% 90% 98% 97% 92% 90% 93% 90% 98%

0%

50%

100%

Pe

rce

nt

Priority 2

Priority 3

Priority 4



Figure3. Percent of cancer surgeries completed within target time by facility, Priority 2, Fiscal Year 2011/12

Source: WTIS, provided by CCO Note: Facilities with “NV” and “NA” are excluded from figure.

0%

50%

100%

Pe

rce

nt





0%

50%

100%

Pe

rce

nt






Ontario’s performance target is for 90% of all cancer surgeries to be completed within

their priority access targets. In 2011/12, elective cancer surgeries (priority level 4) met

this wait time performance target with 91% of cases completed within the access target

of 84 days. For urgent (priority level 2) and semi-urgent (priority level 3) cancer surgery

cases, 68% and 74% of surgeries were completed within their respective access targets

of 14 and 28 days.

While the volume of cancer surgeries has increased by 10% between 2008/09 and

2011/12, the percent of cancer surgeries completed within target time has either

remained relatively stable or improved, depending on the priority level. The percent of

urgent cancer surgeries (priority level 2) completed within the 14 day target showed an

absolute increase of 14% (54% to 68%), the largest improvement observed of the three

priority levels. Semi-urgent (level 3) and elective (level 4) cancer surgeries showed

absolute improvements of 6% and 3%, respectively. It is important to note that the

baseline performance for these two priority levels was higher than for urgent cancer

0%

50%

100%

Pe

rce

nt



surgeries; as such, there was more room for improvement on this indicator for urgent

cases.

There was less facility-level variation in the percent of elective cases completed within

target compared to semi-urgent and urgent cases. In 2011/12, there were eight facilities

where less than 50% of urgent cancer cases were completed within target and 10

facilities where more than 90% of urgent cases were completed within target. Facility

level variation for elective cases is narrower—the percent of elective cases completed

within target was between 69% and 100% across all facilities.


Wait Times for Radiation Treatment “Ready to Treat to Treatment” Indicator description

The percent of patients that are seen within the ‘ready to treat to treatment’ wait time target. “Targets for this interval vary from 1 to 14 days depending on the priority category, which is determined based on the patient’s condition” (http://www.csqi.on.ca/by_patient_journey/treatment/wait_times_for_radiation_treatment/#.Uea7-G1t7ZM)


Why is this important to patient care? Better outcomes, reduced patient stress

Radiation treatment shrinks tumours, destroys cancer cells and/or provides relief from cancer symptoms, including for palliative reasons at end of life. (See Prostate Cancer – End of Life.)

Some cancers are more aggressive and should be treated more quickly, while others are slow growing and do not need immediate attention.

To ensure the best outcomes from radiation treatment, the wait time should be as short as reasonably possible5.

Treating patients within the recommended timeframes also spares patients from additional stress.

Unavoidable delays, such as patient preferences for referrals, contribute to a proportion of patients who do not meet the target.

Wait times serve as a gauge for how well the cancer system is working. They provide valuable insight when distributing existing resources and planning for future services.

5 Chen Z, King W, Pearcey R, Kerba M, Mackillop WJ. The relationship between waiting time for radiotherapy and clinical outcomes: a systematic review of the literature. Radiotherapy and Oncology. 2008; 87:3-16. Text taken from CSQI (http://www.csqi.on.ca/by_patient_journey/treatment/wait_times_for_radiation_treatment/#.Uea7-G1t7ZM)


2011 Quality Monitor


Type: Process and core indicator

External Alignment

Condition Specific Alignment Cancer System Quality Index (CSQI) Integrated Cancer Program Operating Funding Agreement & Regional Performance Scorecard


Calculation

Numerator Total number of patients within ready to treat to treatment wait time of 1, 7 and 14 days (depending on priority category)

http://www.csqi.on.ca/by_patient_journey/treatment/wait_times_for_radiation_treatment/#.Uea7-G1t7ZM


http://www.csqi.on.ca/cms/one.aspx?portalId=258922&pageId=274150





Priority Category

Clinical Conditions Target Wait Time in

calendar days

1

Patients who have an immediately life-threatening condition (e.g., neurological compromise with cord

compression, superior vena caval syndrome), which is expected to be treated on an emergent

basis.

1

2

Patients who are not considered emergent, but, in the opinion of the treating physician, the treatment should start within one week. This category would include, for example, very aggressive tumours and

some palliative cases.

7

3 All patients who, in the opinion of the treating

physician, do not meet the criteria of category I or II.

14

See denominator for inclusion/exclusion criteria.

Denominator Total number of patients with a valid treatment date during the reporting time period Inclusion Criteria:

Radiation Ready to Treat to Treatment patients are those patients with both a valid ready to treat and treatment date receiving treatment at the cancer centre.

Only new treatments for a particular disease site are included

Exclusion Criteria: Diagnosis site not between ‘C00’ and ‘D49’ Treatment date is null Ready to treat date is null Ready to treat date is greater than treatment date

Other Criteria:

If patient unavailable dates fall outside the Decision to Treat Date up to Procedure Date, the patient unavailable dates are not deducted from the patient's wait days. These are considered data entry errors.


Activity Level Reporting, provided by Cancer Care Ontario


Data are available monthly, quarterly and annually.


This is available at the Regional Cancer Centre and Provincial-Level (including only RCCs).


Targets are at 1, 7 and 14 days depending on priority category. Cancer Care Ontario Annual 2012/13 Target for percent of patients within target wait time is 87% (source: CSQI, Figure 4; http://www.csqi.on.ca/cms/one.aspx?portalId=258922&pageId=272930#4-27-4)

Target Source Cancer Care Ontario

http://www.csqi.on.ca/cms/one.aspx?portalId=258922&pageId=272930#4-27-4

http://www.csqi.on.ca/cms/one.aspx?portalId=258922&pageId=272930#4-27-4


Limitations The Ready to Treat to Treatment activity presented in this report is limited to treatment activity provided within the Regional Cancer Centres.

Data for the 2 intervals referral to consult and ready to treat to treatment are available only from April 2007 onwards.

Only new radiation patients are included (excludes re-Juravinski (Hamilton) has experienced ALR data submission issues since June 2012, low volumes are observed from October to December 2012


Not risk adjusted.


N/A

Comments

Current Performance

Figure1. Radiation wait times: Percent of patients that are seen within the ready to treat

to treatment wait time target, FY06/07 to FY11/12

Source: ALR, provided by CCO

Figure2. Radiation wait times: Percent of patients that are seen within the ready to treat

to treatment wait time target by RCC, FY11/12

54.4%

58.4%

70.4%

78.3%

83.5%85.1%

0%

50%

100%

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

Per

cen

t

CCO Annual 2012/13 Target = 87%




The percent of patients who were seen within the ready-to-treat-to-treatment wait time

target increased by 31 percentage points between 2006/07 (54%) and 2011/12 (85%).

Cancer Care Ontario has set a program target of 87%. Although the province is near the

program target, variation between the Regional Cancer Centres continues to exist. Close

to 100% of patients at the Carlo Fidani Peel RCC had treatment within the target wait

times (1, 7 and 14 day, depending on priority level), but only one third of patients at the

Ottawa Hospital and Windsor Regional RCCs met the same targets.

91.8%

99.4%

90.6%

85.9%

75.3%

89.4% 89.1% 88.7% 89.4%

94.1%

84.1%

90.8%

68.0% 67.0%

0%

50%

100%P

erc

en

t



Wait Times for Systemic Treatment “Referral to Consult” Indicator description

The percent of patients that are seen within the referral to consult wait time target for systemic therapy, where target = 14 days.


Why is this important to Ontarians? The clinical and patient-centred perspective

To get the best outcomes from chemotherapy and spare patients from additional stress, treatment should be given within a reasonable time frame.

The two time intervals measured here are segments of the overall patient journey from diagnosis to the start of chemotherapy.

Studies suggest that adjuvant chemotherapy is effective up to 12 weeks after surgery for early stage breast cancer, and 8 weeks after surgery for Stage III colorectal cancer.3,4 (See Wait Times from Surgery to Adjuvant Chemotherapy .)

A recently published report suggests that for every 4-week delay in treatment for colorectal cancer, there is a significant decrease in disease-free and overall survival.5

A barometer for the health of the cancer system Wait times serve as an important barometer for how well the

cancer system is working. New cancer drugs and new combinations of drugs, combined

with the growing number of cancer patients referred for treatment, are boosting demand for chemotherapy in Ontario.

By monitoring wait times data, the province can distribute existing resources and plan for future services more effectively and accurately.

Waits during the time interval referral to consult are affected by the availability of medical oncologists.

Ensuring patients who could benefit from a consult with a medical oncologist are being referred is another important measure. (See Consultation with a Medical Oncologist .)

3Lohrisch C, Paltiel C, Gelmon K, Speers C, Taylor S, Barnett J, Olivotto IA. Impact on survival of time from definitive surgery to initiation of adjuvant chemotherapy for early-stage breast cancer. Journal of Clinical Oncology. 2006; 24(30):4888-4894. 4 Des Guetz G, Nicolas P, Perret G, Morere J, Uzzan B. Does delaying adjuvant chemotherapy after curative surgery for colorectal cancer impair survival? A meta-analysis. European Journal of Cancer. 2010; 46(6):1049-1055.

Text taken from CSQI (http://www.csqi.on.ca/cms/One.aspx?portalId=258922&pageId=272694#.UhOoHz8R7b0)




Type: Process and core indicator



http://www.csqi.on.ca/cms/One.aspx?portalId=258922&pageId=272694



External Alignment

Condition Specific Alignment; Cancer System Quality Index (CSQI); Integrated Cancer Program Operating Funding Agreement & Regional Performance Scorecard


Calculation Numerator Total number of patients within Referral to Consult target wait time of 14 days

See denominator for inclusion/exclusion criteria.

Denominator Total number of patients with a valid consult date during the reporting time period

Inclusion Criteria: Systemic Referral to Consult patients are those patients with

both a valid Referral and Consult Date receiving a Consult at the Regional Cancer Centre.

Only new consults for a particular disease site are included Exclusion Criteria:

Diagnosis site not between ‘C00’ and ‘D49’ Consult date is null Referral date is null Referral date is greater than Consult date




Data is available monthly, quarterly and annually.




CCO has an annual 2012/13 target of 67% (Source: CSQI, Figure 3; http://www.csqi.on.ca/cms/one.aspx?portalId=258922&pageId=272694#.UebwmW1t7ZM)


Limitations Data for the 2 intervals referral to consult and ready to treat to treatment are available only from April 2007 onwards.

Only new systemic patients are included (excludes re-treats)


Not risk adjusted.


N/A

Comments

http://www.csqi.on.ca/cms/one.aspx?portalId=258922&pageId=272694#.UebwmW1t7ZM

http://www.csqi.on.ca/cms/one.aspx?portalId=258922&pageId=272694#.UebwmW1t7ZM


Current Performance

Figure1. Systemic wait times: Percent of patients seen within Referral-to-Consult wait

time target (14) days, FY06/07 to FY 11/12


44.7%46.5%

48.9%50.3%

58.1%59.9%

0%

50%

100%

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

Pe

rce

nt



Figure2. Systemic wait times: percent of patients seen within Referral-to-Consult wait

time target (14 days), FY11/12, by RCC



The percent of patients who were seen within the 14 day referral-to-consult target

improved from 45% in 2006/07 to 60% in 2011/12.

Cancer Care Ontario has set a program target to have 67% of patients seen within the

14 day referral-to-consult target. In 2011/12, there were large variations across the 14

Regional Cancer Centres (RCCs), ranging from 45% in the Ottawa Hospital RCC to 86%

in the R.S. McLaughlin Durham Regional Cancer Centre. In all, five RCCs (Carlo Fidani,

Grand River Regional, R.S. McLaughlin Durham Regional, Regional Cancer Care

Northwest and Windsor Regional) reached the target of 67% in 2011/12.

64.1%

80.8%

71.2%

65.6%

50.8%

57.7%

47.7%

85.9%

77.2%

51.3%

56.2%

62.7%

45.1%

73.0%

0%

50%

100%

Pe

rce

nt



Wait Times for Systemic Treatment “Consult to Treatment” Indicator description

The percent of patients that are seen within the consult-to-treatment wait time target for systemic therapy (28 days)


Why is this important to Ontarians?

The clinical and patient-centred perspective To get the best outcomes from chemotherapy and spare

patients from additional stress, treatment should be given within a reasonable time frame.

The two time intervals measured here are segments of the overall patient journey from diagnosis to the start of chemotherapy.

Studies suggest that adjuvant chemotherapy is effective up to 12 weeks after surgery for early stage breast cancer, and 8 weeks after surgery for Stage III colorectal cancer.3,4 (See Wait Times from Surgery to Adjuvant Chemotherapy .)

A recently published report suggests that for every 4-week delay in treatment for colorectal cancer, there is a significant decrease in disease-free and overall survival.5

A barometer for the health of the cancer system Wait times serve as an important barometer for how well the

cancer system is working. New cancer drugs and new combinations of drugs, combined

with the growing number of cancer patients referred for treatment, are boosting demand for chemotherapy in Ontario.

By monitoring wait times data, the province can distribute existing resources and plan for future services more effectively and accurately.

Waits during the time interval referral to consult are affected by the availability of medical oncologists.

Ensuring patients who could benefit from a consult with a medical oncologist are being referred is another important measure. (See Consultation with a Medical Oncologist .)

3Lohrisch C, Paltiel C, Gelmon K, Speers C, Taylor S, Barnett J, Olivotto IA. Impact on survival of time from definitive surgery to initiation of adjuvant chemotherapy for early-stage breast cancer. Journal of Clinical Oncology. 2006; 24(30):4888-4894. 4 Des Guetz G, Nicolas P, Perret G, Morere J, Uzzan B. Does delaying adjuvant chemotherapy after curative surgery for colorectal cancer impair survival? A meta-analysis. European Journal of Cancer. 2010; 46(6):1049-1055.

Text taken from CSQI (http://www.csqi.on.ca/by_patient_journey/treatment/wait_times_for_systemic_treatment__chemotherapy_/)







http://www.csqi.on.ca/cms/One.aspx?portalId=258922&pageId=272694


http://www.csqi.on.ca/by_patient_journey/treatment/wait_times_for_systemic_treatment__chemotherapy_/

http://www.csqi.on.ca/by_patient_journey/treatment/wait_times_for_systemic_treatment__chemotherapy_/


External Alignment

Condition Specific Alignment Cancer System Quality Index (CSQI) Integrated Cancer Program Operating Funding Agreement & Regional Performance Scorecard


Calculation

Numerator Total number of patients within consult-to-treatment wait time of 28 days (see denominator for inclusion/exclusion criteria.)

Denominator Total number of cases with a valid Treatment Date during the reporting period.

Inclusion Criteria: Systemic Consult to Treatment patients are those patients with

both a valid Consult and Treatment Date receiving treatment at a Regional Cancer Centre.

Only new consults for a particular disease site are included

Exclusion Criteria: Diagnosis site not between ‘C00’ and ‘D49’ Consult date is null Referral date is null Referral date is greater than Consult date




Data are available monthly, quarterly and annually.




CCO Annual 2012/2013 Target is 85%.(source: CSQI, Figure 4; http://www.csqi.on.ca/by_patient_journey/treatment/wait_times_for_systemic_treatment__chemotherapy_/#.UhOmoj8R7b0)


Limitations Data for the 2 intervals referral to consult and ready to treat to treatment are available only from April 2007 onwards.

Only new systemic patients are included (excludes re-treats)


Not risk adjusted


N/A

Comments

http://www.csqi.on.ca/by_patient_journey/treatment/wait_times_for_systemic_treatment__chemotherapy_/#.UhOmoj8R7b0

http://www.csqi.on.ca/by_patient_journey/treatment/wait_times_for_systemic_treatment__chemotherapy_/#.UhOmoj8R7b0


Current Performance

Figure1. Systemic wait times: percent of patients seen within consult-to-treatment wait

time target (28 days), FY06/07 to FY11/12


70.7%72.2% 71.1%

72.2% 71.4%73.2%

0%

50%

100%

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

Pe

rce

nt



Figure2. Systemic wait times: percent of patients that are seen within consult-to-

treatment wait time target of 28 days by RCC, FY11/12



The percent of patients who were seen within the consult-to-treatment wait time target of

28 days has not changed substantially from 2006/07 (71%) to 2011/12 (73%).

The program target set by Cancer Care Ontario is that 85% of patients should begin

treatment within 28 days of the first consultation. In 2011/12, none of the 14 Regional

Cancer Centres (RCCs) reached the 85% target. Variation across RCCs was relative

small and performance on this indicator ranged from 66% (Regional Cancer Care

Northwest) to 78% (Windsor Regional Cancer Centre and R.S. McLaughlin Durham

Regional Cancer Centre).

69.5%

76.0% 76.4%73.8%

76.4%72.9%

67.3%

77.9%

65.5%

72.4% 71.8%

76.6%

71.3%

78.4%

0%

50%

100%

Pe

rce

nt



Hospital-acquired C.difficile infection (CDI) rate per 1000 patient days

Indicator description This rate represents the incidence rate of nosocomial CDI associated with the reporting facility per 1000 inpatient days. A lower rate is associated with better performance. This indicator is reported annually in the QMonitor.

Relevance/Rationale

C. difficile is a leading cause of healthcare associated diarrhea. Infection acquired in a hospital is an unnecessary waste of healthcare resources and suffering for patients, and can sometimes result in death.


QMonitor; Patient Safety Website

Attribute Safe


External Alignment HQO patient safety public reporting; QIP – Acute care sector; HSAA indicator; Ministry Quarterly Report


Calculation Numerator Total number of new nosocomial (i.e. hospital acquired) CDI Cases Inclusion criteria: 1. All publicly funded hospitals 2. Inpatient beds 3. Laboratory-confirmed CDI cases (i.e. confirmation of a positive toxin assay (A/B) for Clostridium difficile together with diarrhea OR visualization of pseudomembranes on sigmoidoscopy or colonoscopy, or histological/pathological diagnosis of pseudomembranous colitis) 4. New nosocomial case associated with the reporting facility defined as - the infection was not present on admission (i.e., onset of symptoms > 72 hours after admission) or the infection was present at the time of admission but was related to a previous admission to the same facility within the last 4 weeks and the case has not had CDAD in the past 8 weeks. Exclusion criteria: 1. Patients less than 1 year of age

Denominator Total number of inpatient days Inclusion criteria: 1. All publicly funded hospitals 2. Inpatient beds Exclusion criteria: 1. Patients less than 1 year of age


Self Reporting Initiative (SRI), provided by the MOH


Data are available each month. Fiscal year data available upon special data request to MOH



Across time, by hospital, by hospital type


Not able to set a target through HQO benchmarking process; Please refer to the Ranking Analysis Table at http://www.hqontario.ca/Portals/0/Documents/qi/qip-benchmark-update-en.pdf Target: 10% relative reduction year over year.

Target Source Relative reduction target: set through expert consultation

Limitations Data are self-reported by hospitals.


Crude rate


n/a

Comments The following cases are not included in the rate calculation: 1.New nosocomial case associated with other health care facilities The infection was present on admission (i.e., onset of symptoms < 72 hours after admission) and the patient was exposed to another health care facility (including LTC) other than the reporting facility within the last 4 weeks and the case has not had CDAD in the past 8 weeks. 2. New case associated with a source other than a health care facility or unknown/indeterminate source The infection was present on admission (i.e., onset of symptoms < 72 hours after admission) and the patient was not exposed to any health care facility (including LTC) within the last 4 weeks or the source of infection cannot be determined and the case has not had CDAD in the past 8 weeks.

http://www.hqontario.ca/Portals/0/Documents/qi/qip-benchmark-update-en.pdf

http://www.hqontario.ca/Portals/0/Documents/qi/qip-benchmark-update-en.pdf


Current performance

Figure1. Hospital-acquired C.diff infection rate per 1000 patient days, FY 2009/10-2011/12

Figure 2. Hospital-acquired C.diff infection rate per 1000 patient days by hospital, FY

2011/12

2009/10 2010/11 2011/12

Cdiff (Rate per 1,000 patient days) 0.29 0.30 0.35

0.00

0.60

1.20

Rat

e p

er 1

,000

pat

ien

t d

ays

Year over year relative reduction = 10%

0.00

0.60

1.20

Rat

e pe

r 1,

000

patie

nt d

ays

Hospital

10th Percentile Median 90th Percentile



Table1. Hospital-level distribution of hospital-acquired C.diff infection rate per 1000

patient days in Ontario, FY2011/12

Min 5th

Percentile

10th

Percentile

25th

Percentile Median

75th

Percentile

90th

Percentile

95th

Percentile Max

0.00 0.00 0.00 0.01 0.19 0.42 0.62 0.81 1.09

Table2. Hospital-acquired C.diff infection rate per 1000 patient days in Ontario by

hospital type, 2012


The CDI rate has increased from 0.29 per 1000 patient days in 2009/10 to 0.35 per 1000

patient days in 2011/11 (20% increase). There were about 500 more cases detected in

2011/12 compared to 2010/11. Switching to a more sensitive testing method might be a

contributing factor to the increased rate.

In 2011/12 there was large variation in CDI rates across hospitals; from 0 infections per

1000 patient days in more than 10 percent of hospitals to a high of greater than 1

infection per 1000 patient days. Almost 30% of hospitals had higher CDI rates than the

provincial rate (0.35 per 1000 patient days).

Hospital

Type

Acute

Teaching

Hospitals

CCC & Rehab

Hospitals

Large

Community

Hospitals

Mental

Health

Hospitals

Small

Community

Hospitals

Case count 1246 156 1998 6 70

Rate per

1000 patient

days

0.50 0.10 0.40 0.01 0.14


90th percentile ED length of stay (LOS) for high or low complexity patients Indicator description

This indicator measures the maximum amount of time in which nine out of ten high and low complexity patients have completed their ED visits. High and low complexity patients refer to the group of patients assigned with CTAS level 1 to 3, and CTAS level 4 to 5, respectively. Lower value of this indicator is associated with a better performance. The indicator is reported yearly in the QMonitor.


Long ED wait times are inconvenient and, in some cases, negatively affect a patient’s health. Spending a long time in the waiting room, or on hallway stretchers waiting for admission, can also compromise comfort and privacy.


QMonitor



External Alignment

QIP: acute care sector; HSAA; Ministry Quarterly Report


Calculation LOS is calculated based on the following: LOS in HOURS = (Date/Time Patient Left ED) OR (Disposition Date/Time) - (Registration Date/Time) OR (Triage Date/Time).

Use Date/Time Patient Left ED when Visit Disposition = 06 to 09;

Use Disposition Date/Time when Visit Disposition = 01 to 05 or 10 to 15.

If Date/Time for either is missing use the other Date/Time.

Use Registration Date/Time when: Triage Date/Time is > Registration Date/Time or does not contain a valid date/time value.

Use Triage Date/Time when: Registration Date/Time >=Triage Date/Time; or does not contain a valid date/time value.

If both Date/Time Patient Left ED and Disposition Date/Time do not contain valid value or both Triage Date/Time and Registration Date/Time do not contain valid value then ED LOS is equal to Null.

Inclusion criteria: Case Type = Emergency Visits (Unscheduled) Exclusion criteria: Triage (CTAS) level is unknown


National Ambulatory Reporting System (NACRS), Health Data Server, 2008/09 to 2011/12, Apr 2008/09 to Jun 2012/13, provided by MOHLTC


Data are released monthly and fiscal yearly.


By fiscal year; By LHINs; by institution (not available for 2011/12 data), By patient complexity group (High vs. Low)


Ministry’s targets: 1. 90% of patients with minor or uncomplicated conditions (low

complexity, i.e. CTAS 4 or 5, and not admitted) should have a total ED LOS no more than 4 hours

2. 90% of patients with complex conditions (admitted and non-admitted, high complexity, i.e. CTAS 1, 2, 3 or admitted, low complexity) should have a total LOS no more than 8 hours


Please see the details on ministry ED wait time website: http://www.health.gov.on.ca/en/pro/programs/waittimes/edrs/targets.aspx

Target source Ontario Wait Times Strategy

Limitations


Crude


N/A

Comments The indicator we report here is not aligned with Ministry reported wait times; it does not account for admission status (Ministry reports the following two categories:

admitted and non- admitted high complexity (CTAS 1, 2 or 3)

non-admitted low complexity (CTAS 4 or 5)

Current performance

Figure1. 90th percentile ED length of stay for high and low complexity patients,

FY2008/09-2011/12

Note: The indicator as reported is not aligned with performance targets as it does not account for admission status

2008/09 2009/10 2010/11 2011/12

High Complexity 12 11.6 11.5 10.9

Low Complexity 4.7 4.6 4.4 4.3

0

7.5

15

Ho

urs

Performance targets forNon-admitted high complexity and all admitted = 8 hoursNon-admitted low complexity = 4 hours

http://www.health.gov.on.ca/en/pro/programs/waittimes/edrs/targets.aspx


Figure2. 90th percentile ED length of stay for high and low complexity patients LHIN,

FY2011/12

Note: The indicator as reported is not aligned with performance targets as it does not account for admission status


The 90th percentile length of stay for ED patients has decreased slightly though

consistently over the past 3 years for both high and low complexity patients (Figure 1).

As illustrated in Figure 2, for high complexity patients, South West LHIN (8.3 hours) had

the shortest wait time and Central West LHIN (12.5 hours) had the longest. Low

complexity patients waited the longest in Toronto Central LHIN EDs (5.1 hours) and

shortest in the Central LHIN (3.7 hours).


High Complexity 10.5 8.3 10.1 11.6 12.5 11.6 12.3 11.9 11.1 9.3 11.8 9.6 9.7 9.3

Low Complexity 4.4 3.9 4.8 4.3 3.9 3.8 5.1 3.7 4.3 4.1 5.0 4.0 4.1 3.8

0.0

7.0

14.0

Ho

urs

Performance targets forNon-admitted high complexity and all admitted = 8 hoursNon-admitted low complexity = 4 hours


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


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


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

Target Source Expert consultation

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

0.0

125.0

250.0

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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

0.0

125.0

250.0

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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

175.0

350.0

Sta

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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

Variable Stratification

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



0.0

175.0

350.0S

tan

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10

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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


0.0

50.0

100.0

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0.0

50.0

100.0

Sta

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ized

rate

per

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Table1. Standardized Hospitalization Rate for Diabetes, 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 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


0.0

50.0

100.0

Sta

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00

,00

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0.0

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100.0

Sta

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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


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.


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

25.0

50.0

Perc

en

t

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

0.0

25.0

50.0

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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).

0.0

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Hospital

10th percentile Median 90th percentile



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.7 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.8


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

7 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 8 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

r 1

00

FT

Es

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


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

0.0

25.0

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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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ESC SW WWHNH



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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

50.0

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

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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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rce

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



0.0

25.0

50.0P

erc

en

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

50.0

Pe

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


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

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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

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

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

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100

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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

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

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

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100

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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


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 definitions9 (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

9Provincial 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)

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100.0

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la Ib

Pe

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nt

Hospital

Performance target = 11%


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

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0.0

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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

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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

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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 guidelines10 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.11

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 2009/1012.

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

10 Joan Crane. SOGC Clinical Practice Guideline. Induction of labour at term. No 107 August 2001 11 KTA Evidence Summary. What is known about the maternal and newborn risks of elective induction of women at term. Evidence

summary No 10 12 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 definitions13 (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

13Provincial 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

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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

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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

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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



Wait Time for home care services – discharge or application date to service initiation (stratified by referrals from the acute setting and referrals from the community) Indicator description Number of days from the hospital discharge date/application date

to the first non-case management (CM) service for clients whose home care referral source was a hospital or the community

Relevance/Rationale

“It is important that individuals with chronic conditions or complex needs who need home care services are provided with care as soon as possible. Delays in service could mean that clients experience an abrupt decline in their condition and could require immediate medical assistance or admission to hospital.”

(Text from Home Care Public Reporting Website)

Reporting tool/ product


Home Care Public Reporting website

Attribute Access

Type: Process; core indicator

External Alignment Potential Alignment: Health Links; M-SAA Action Plan for Seniors; Ministry Quarterly Report

Accountability Home care and Hospital

Calculation Numerator The median, mean, and 90th percentile wait time in days for:

a) Time from HC referral (appdate) to first non-case management HC service visit (all home care services) for those referred from community (denominator 1a)

b) Time from Hospital Discharge to first non-case management HC service visit (all home care services) for those referred from hospital (denominator1b)

c) Time from ED Discharge to first non-case management HC service visit (all home care services) for those referred from ED (denominator 1c)

Note: Censor wait times to home care services (all home care services) >30 days (i.e., remove clients with wait times < 0 days or > 30 days) Exclude:

1. Standard Exclusions (Refer to Master Document) 2. Death date precedes application date 3. Age at application date > 120 years 4. Missing service date 5. First service date precedes application date 6. Not in denominator (i.e. not defined as long stay / acute

home care client) Referral location:

Referral from Hospital CIHI-DAD hospitalization in which HCD Episodes var appdate falls within the time period between acute care admission and {discharge + 7 days}


CIHI-DAD var admdate <= HCD Episodes var appdate <= {CIHI-DAD var ddate + 7 days}

Else Referral from Community Identification of first home care services:

Earliest Servdate from HCD Services file, EXCLUDING HCD Services var service in (10, 14, 15, 99), corresponding to home care application (as defined above) (link to HCD Services table where episodeid=episodeid from application record) Exclude: Service in (10, 14, 15, 99) 10 - CASE MANAGEMENT 14 - PLACEMENT SERVICES 15 - RESPITE 99 - OTHER

Denominator New referrals to home care (see definition), in a given quarter

Stratified by referral from a: 1a) community setting 1b) inpatient hospital setting 1c) ED hospital setting


Home Care Database (HCD), CIHI-DAD and NACRS from ICES The volume, 10th, 50th, 90th percentiles and mean are requested from ICES.


This indicator is available quarterly and annually from ICES.


This is available at the provincial and CCAC level; comparable over time and LHIN /CCAC.


Targets/benchmarks are not available

Target source N/A

Limitations There could be wait lists in place in some CCACs which would affect the number of days since the clients will not be counted until the service is delivered. Each case is reported under the fiscal year and quarter in which the client received their first home care service. Approximately 3% of records per fiscal year are dropped due to invalid (less than zero) or implausible (over a year) wait times. This indicator censors wait times exceeding 30 days for those referred from the community, which may not be appropriate. The M-SAA version of this indicator removes this restriction and only excludes wait times > 365 days.



Not risk adjusted


N/A

Comments The re-alignment of the 42 CCACs to the 14 Local Health Integration Network (LHIN) CCACs took place as of January 1, 2007. From fiscal year 2007/08 and onward, complete years of data were reported under the new 14 CCAC boundaries.

Current performance

Figure1. Wait times: Number of days within which 90% of clients receive their first home

care service after discharge from inpatient hospital setting or application from

community, 2006/07 – 2011/12

Data source: HCD, CIHI-DAD and NACRS, provided by ICES

Apr-

Jun

Jul-Sep

Oct-

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

Community 15 15 15 15 15 14 15 15 15 15 16 14 14 14 14 14 13 13 13 13 13 12 13 12

Inpatient hospital 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 6

0

10

20

Days


Figure2. Wait times: Number of days within which 90% of clients receive their first home

car service after discharge from inpatient hospital setting or application from community,

2011/12

Data source: HCD, CIHI-DAD and NACRS, provided by ICES


In 2011/12, almost 530,00014 Ontarians received in-home health care services through

Ontario’s 14 Community Care Access Centres. Nine out of ten clients who applied for home

care services from the community waited 12 days or less to receive their first home care

service visit, while those who were referred from the hospital or emergency department had

a 90th percentile wait time of 6 and 7 days, respectively. Since 2006/07, wait times have

improved for clients referred from the community, but not for clients referred from the

hospital or emergency department.

The 90th percentile wait time for those referred from the community varies across CCACs,

from 7 days (Erie St. Clair, Hamilton Niagara Haldimand Brant, Central and Mississauga

Halton CCACs) to 16 days (Toronto Central CCAC). The variation in wait times should be

reduced to ensure that clients who require home care services have equal access to these

services regardless of where they live in Ontario. However, it is worth noting that these wait

times are not risk adjusted; therefore, one should use caution when interpreting the

differences in wait times between CCACs. For instance, it is possible that some CCACs

have a higher proportion of acute home care clients, who often receive nursing services

within the first 1-4 days of referral.

Variation in wait time for clients referred from an inpatient hospital is relatively minor, ranging

from 4 days to 7 days (see graph above).

14 “Healthcare Indicator Tool | Health Data Branch Web Portal,” accessed January 29, 2013, https://hsimi.on.ca/hdbportal/hit


Community 7 11 15 7 7 7 16 14 11 13 10 14 14 12

Inpatient hospital 4 5 6 5 7 6 7 6 7 7 7 7 7 6

0

10

20

Da

ys