POPULIS:How's your health? It's a common question. But, when the question is directed towards the entire population of Winnipeg or Central Manitoba or Northern Manitoba, answering is far from easy. Then, when you start comparing the health of Winnipeggers with the health of Central or Northern Manitobans, and try to answer the larger question about the health of the entire province of Manitoba, answering is even more difficult. Since its inception in January 1991, the Manitoba Centre for Health Policy (MCHP) has been working on answering those questions.
the POPULATION HEALTH INFORMATION SYSTEM
Manitoba, April 1990-March 1993
To answer more precisely, the Centre has been developing the Population Health Information System (POPULIS) - an information "searchlight" - to examine data, asking questions not only about the health of Manitobans, but about the relationship of health to the use of health care services and to an individual's economic and social status. This report combines our earlier observations on these issues, then compares them with more recent findings to identify consistency of patterns and possible trends. With three years of data, it is our most complete answer to date about the state of Manitoba's health.
Manitoba is divided into eight health regions: Westman, Central, Eastman, Winnipeg, Parklands, Interlake, Norman, and Thompson. The Populis tracks the health status and health care services used by residents of these regions - based on where the users live, not on where they receive the care. To put that difference into perspective, consider that 20% of rural residents' contacts with physicians are with Winnipeg doctors, so reporting only on the times rural doctors were contacted would greatly underestimate how often rural residents saw a doctor. The Populis focusses on how the use of health care services produces health in the population and, from region to region, how equally the residents use those services. It also focusses on the effects that factors like education, unemployment and living conditions have on one's health, factors that are particulary telling in some regions.
Indicators of Health Status
One key indicator of health status is mortality rates. If people are living longer, it's an indication that they are healthier. Between 1990-91 and 1992-93, there were fewer deaths per 1000 among Manitobans aged 0-74 (fig. 1). This drop may cautiously be interpreted as a modest improvement in the health status of Manitobans. Consistent with the improvements in mortality rates, other commonly used measures suggested slightly improved health status over the three years. For example, the proportion of infants born with low birth weight dropped and mortality due to chronic disease also declined marginally.
However, any self-congratulations for this overall improvement is tempered by the fact that residents in some regions of the province are living much shorter lives than residents in other regions. Throughout this period, both the Norman and Thompson regions showed higher than average premature mortality among their residents. In 1992-93 the standardized mortality rates for people aged 0-74 in those regions were 41% and 57% higher than the provincial average, respectively. At the other extreme, Westman had a mortality rate 13% below the provincial average. These extremes underscore the strong relationship across all regions between mortality and the Socioeconomic Risk Index, a measure developed by the Centre. This index includes measures of high unemployment, high numbers of single parent households, low levels of education, low female participation in the work force, and low housing value. The higher a region's score on this index, the higher the death rate among its residents (fig.2).
The overall improvement in health status occurred during a period when the average number of visits to a physician (approximately 4.7 per year) decreased slightly across all regions. What is particularly worth noting is that despite Winnipeg having three times more physicians per person than some regions, there was a uniformly high percentage of individuals contacting a physician at least once a year, in all regions (fig.3). This is reassuring, both for the fact that Manitobans are making themselves available for diagnosis and treatment, and because it shows access to health care is similar for all - a strength of the Canadian system. In short, the universal access system appears to work well in Manitoba.
However, major differences in physician use were evident between Winnipeg and the rest of the province. In 1992-93, Winnipeg had nearly twice as many physicians than all the other regions combined and 16% more visits to a physician per 100 residents. Fifty-four percent of its physicians were specialists, compared to only 14% outside the city. Most interestingly, despite this high availability of specialists - such as pediatricians or internists - which should make referrals less necessary, Winnipeggers were much more likely to have a referral than their non-Winnipeg counterparts. The net effect of these differences was a cost per Winnipeg resident for physician services nearly 30% higher than the comparable cost for a non-Winnipeg resident-$123 vs. $94.
There is a pattern of physician use in Manitoba that is unsettling: the lower an area's social and economic status, the more primary care visits (to a general practitioner or a nursing station) there were (fig.4). At a glance, this could be viewed positively: the underprivileged are more likely to be ill, so these resources are most being used by those who need them most. But, when we recall that Manitoba's two northern regions, areas of low social and economic status, have the highest death rates by far in the province - despite relatively high access to primary care - the more negative implications are that high use of these services is not alleviating the persistence of bad health among the poor of this province.
Just as the poor were high users of physician services, so too, were they high users of hospital services. In general, residents of regions with low social and economic status, such as the Norman and Thompson Regions, made the heaviest use of hospitals for short stays. Given that they are generally in poorer health, we could see this as an appropriate response from a Canadian health care system that is working: those who most need hospital services are those who most use them. But this positive view is again overshadowed by the fact that despite high access to health care services - in this case hospitals - poorer health still persists among the disadvantaged people of Manitoba.
In 1992-93 there were also puzzling differences in hospital use between Winnipeg and the rest of the province. Winnipeg residents spent fewer days in hospital than non-Winnipeg residents for short stay hospitalizations but markedly more days in hospital for long stays (more than 60 days). Comparing 1992-93 with 1990-91, there was a 5% decline in short-stay hospital days per 1000 residents in Winnipeg, only a 0.5% decline outside of it. What's puzzling is not so much that Winnipeggers and non-Winnipeggers, particularly the five southern regions, used hospitals quite differently, but that they did so with no apparent health differences.
Interestingly, there was no consistent pattern between visits to a physician (including specialists) and less reliance on hospitals. Some might expect that areas where the use of doctors was high would also be areas of lower hospitalization, but such was not always the case. Winnipeg residents had the most physicians, the highest physician contact rate (overall and with specialists) and, as expected, the lowest rate of acute hospitalization in the province. But residents of Norman, who also made high use of physicians, had the highest rate of hospitalization. Westman residents, who had the best access to specialist care outside of Winnipeg, also had a relatively high hospitalization rate.
Nursing Home Use
While much attention is paid to use of physicians and hospitals, one of the most important parts of our health care system is nursing homes. In Manitoba, we currently spend $3,180 per elderly person (75 years or older) on nursing homes. Fully 13.2% of that elderly population live in nursing homes at a cost of approximately $27,000 per year. With the population of the elderly growing - 5.2% during the three years ending in 1992-1993 - nursing home care is becoming an even more important portion of our health care system.
While the elderly population increased 5.2%, the number of nursing home beds has also increased, by 3.1% (108 beds). The fact that there are fewer nursing home beds per elderly citizen likely explains the drop in nursing home use rates during the three year period. A comparison of those rates from region to region demonstrates that residents of Manitoba enjoy equal access to nursing home care. The number per 1000 population (excluding Norman and Thompson, where very small elderly populations make rates unstable) ranged from 124 in Parklands to 140 in Westman, suggesting that similar admission standards are being applied across the province.
Some of us will eventually spend some time in a nursing home and it will be a long stay: on average, about 4.1 years. It is reassuring to know that no matter where we live in this province, if we need this care, we have a relatively equal chance of getting it.Conclusions
How's Manitoba's health? On the whole, the news is good. Indications are that the health of Manitobans has, if anything, improved somewhat. As for the health care system, it seems to work well in Manitoba inasmuch as residents of every region have remarkably good access to physicians. In addition, regions whose residents have the poorest health are also those whose residents have the highest use of both primary care services and hospital services. Given the high level of their needs, the response by the health care system appears altogether fitting and appropriate.
But the news is not all good. Yes, Manitobans enjoy good access to physicians, but proportionately far too many of those physicians - in particular, specialist physicians - appear to be in Winnipeg. Yes, our system does provide a high level of care, particularly to residents of disadvantaged regions. However, the persistent health problems of Norman and Thompson residents raise a fundamental question about the role of the health care system in improving the health of the population: Is high use of health care the most efficient way to ensure good health?
We may have to start rethinking our approach. The old solution of putting more health care dollars into areas of high health risk may not be the best response, any more than building a clinic at an uncontrolled intersection is a good solution to traffic injuries. Stop signs are cheaper and likely more effective. The Population Health Information System, with its population-based, socioeconomic sensitivity makes clear the fact that health care services alone cannot treat the underlying social and economic problems creating poor health in parts of Manitoba. Perhaps we need more stop-sign thinking. Investing in better housing, cleaner water and more early care dollars. A closer focus on those problems and on social initiatives designed to generate good health across the entire population is in order.
Summary written by RJ Currie, based on the report: A Report on the Health Status, Socio-Economic Risk and Health Care Use of the Manitoba Population 1992-93 and Overview of the 1990-91 to 1992-93 Findings: by Norm Frohlich, Trevor Markesteyn and others
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