Introduction

There are a range of sophisticated hospital-based procedures that are generally expected to be concentrated in a small number of acute care facilities. The Funded Accountability section of Manitoba Health expressed interest in defining a method of distinguishing these higher level, or tertiary, services from acute care hospital services, which may be expected to be provided at a broad range of hospitals in the province.

Tertiary Care Defined

A definition of tertiary care was created by the Joint Policy and Planning Committee (JPPC) of the Ontario Hospital Association*. In the JPPC model, hospital cases were categorized into four groups:


1. Quaternary care - requires highly specialized skills, technology and support services. One hospital would provide the majority of such services to residents of Metro and Greater Toronto areas;
   
2. Tertiary care - requires specialized skills, technology and support services. Tertiary services would be expected to be consolidated in a single delivery site for a planning region. Not all Metro Toronto hospitals would provide tertiary care;
   
3. Secondary care - provided by a specialist health care provisional usually after referral from a primary care physician; and
   
4. Primary care - basic hospital care. The Ontario committee ultimately combined quaternary and tertiary care into tertiary care for the purposes of their modeling, and this combined definition was adopted for the Manitoba simulation.

Tertiary Care and Case Mix Groups (CMGs)

The original tertiary definition in the JPPC model involved three criteria:


1. the magnitude of the CMG Resource Intensity Weight in a case group
   
2. the number of hospitals which provide care within a particular CMG
   
3. the proportion of patients within a CMG who have been referred to the facility from another service area.

CMGs were ranked separately on these three criteria and then given an overall ranking equivalent to the sum of the three individuals ranks. This preliminary list of tertiary CMGs was reviewed for face validity and internal consistency. Subsequent to this review, a number of decisions were made to reclassify a number of CMGs into the tertiary care category, including:

CMG 775 - Schizophrenia/other with ECT,
CMG 577 - Major Gynecological Procedure, Ovarian Cancer, and
CMG 10 - Neoplasm of nervous system.

The final list of tertiary CMGs contains 110 categories. This group was used in the Manitoba simulation, and includes categories such as heart lung transplant, liver transplant, craniotomy procedures, cystic fibrosis, cardiac pacemaker replacement/revision, eating disorders, low birth weight newborns and hip replacement.

The cases which are included in the tertiary list include many diagnoses and procedures which are treated or performed at many hospitals in Manitoba, not just in those facilities considered teaching hospitals.

Additionally, some of the tertiary CMGs are heterogeneous and contain a mixture of diagnoses or procedures. Only some may be tertiary or only tertiary at a given severity of the illness. For example, admissions for treatment of neoplasm of the nervous system, added to the tertiary list based on the reclassification review, were found at more than 30 Manitoba hospitals, many of them being small rural hospitals. It will be important to resolve the degree to which small rural hospitals provide tertiary level care versus palliative and supportive care for these patients.

The CMGs assigned to the tertiary level of care are available in the document: CMGs Assigned to Tertiary Care.