Comparing Canada’s health-care system with other countries, Part 4: Clinical Performance and Quality

The first three blog posts of this series documented Canada’s relative scarcity of key medical resources, its mixed performance in terms of the volume of care and surgical services, and poor performance on measures of timely access to these resources in comparison to other countries with universal health-care systems. In part four of this series, we examine the relative quality and clinical performance of Canada’s health-care system.

Our annual comparison of health system performance includes 12 indicators of quality and clinical performance. These indicators are separated into five groups: primary care, acute care, mental health, cancer care and patient safety. While lower rates are preferable for certain indicators, the performances of countries on each indicator are ordered such that a rank of 1 indicates superior performance on all indicators.

Also, the indicators examined do not measure the incidence of disease among the population of a country but rather the respective health-care system’s ability to effectively deliver care. For example, hospital admission rates for asthma are not included since these may largely reflect genetic and environmental factors. On the other hand, the age-sex standardized mortality rates (per 100 patients) within 30 days after admission to a hospital for an acute myocardial infarction (otherwise known as a heart attack) is included as these rates are more directly linked to the quality of care provided for a given prevalence of disease.

Primary Care
For primary care, the report includes rates of lower extremity amputation related to diabetes. While the relative prevalence of diabetes depends on a number of social and environmental factors, amputation of the lower extremity is considered a preventative complication that reflects the quality of care provided. Unfortunately, Canada performed statistically worse than the average, ranking 19th out of 24 countries for its performance on this measure (6.9 per 100,000).

Acute Care
The annual report also includes four measures on the quality of acute care. Canada reports 93.1 per cent of hip fracture surgeries initiated within 48 hours after admission to a hospital—better than the OECD average (81.5 per cent)—ranking 6th best out of 22 countries. Canada also reported lower rates (4.6 per 100 patients) of in-hospital mortality within 30 days after an acute myocardial infarction (AMI), ranking 9th best (out of 27) in terms of performance. However, Canada’s rates for stroke-related mortality within 30 days of admission were statistically no different than the OECD average. For hemorrhagic stroke, Canada ranked 17th out of 27 countries (23.6 per 100 patients) and 17th out of 27 countries (7.5 per 100 patients) for ischemic stroke. So while Canada performed above the average for the first two indicators, the country performed around the average for indicators related to stroke mortality.

Indicator	Rank (1=best)	Rate*	Average for High-Income Universal Health Care Countries
Diabetes lower extremity amputation (Age-sex standardised rate per 100 000 population; 15 years old and over)	19th out of 24	6.9 w	5.7
Hip-fracture surgery initiated within 48 hours after admission to the hospital (Crude rate per 100 patients; 65 years old and over)	6th out of 22	93.1	81.5
Admission-based AMI 30 day in-hospital mortality (Age-sex standardised rate per 100 patients; 45 years old and over)	9th out of 27	4.6 b	6.1
Admission-based Hemorrhagic stroke 30 day in-hospital mortality (Age-sex standardised rate per 100 patients; 45 years old and over)	17th out of 27	23.6 a	21.9
Admission-based Ischemic stroke 30 day in-hospital mortality (Age-sex standardised rate per 100 patients; 45 years old and over)	17th out of 27	7.5 a	7.3
Breast cancer (five year net survival, 2010-2014, female, 15 years old and over, age-standardised survival %)	5th out of 26	88.6 b	85.7
Cervical cancer (five year net survival, 2010-2014, female, 15 years old and over, age-standardised survival %)	11th out of 26	67.3 a	66.8
Colon cancer (five year net survival, 2010-2014, 15 years old and over, age-standardised survival %)	8th out of 26	67 b	63.9
Rectal cancer (five year net survival, 2010-2014, 15 years old and over, age-standardised survival %)	6th out of 26	67.1 b	63.0
Obstetric trauma vaginal delivery with instrument, 2019 (Crude rate per 100 vaginal deliveries, female, 15 years old and over)	20th out of 20	16.3	5.4
Obstetric trauma vaginal delivery without instrument, 2019 (Crude rate per 100 vaginal deliveries, female, 15 years old and over)	20th out of 20	3.4	1.5
In-patient suicide among patients diagnosed with a mental disorder (Age-sex standardised rate per 100 patients; 15 years old and over)	12th out of 18	0.06 a	0.06

*Note: w = statistically worse than average; b = statistically better than average; a = not statistically different from average

Mental Health
The report also includes a single measure of clinical performance related to mental health outcomes where its performance was not statistically different from the average. Specifically, Canada reports 0.06 per in-patient suicides among 100 patients diagnosed with a mental health disorder, ranking 12th out of 18 in terms of performance.

Cancer Care
Unfortunately, data on cancer survival rates from the OECD have not been updated recently. However, it’s still insightful to examine Canada’s performance using data for the five-year period between 2010 and 2014. Overall Canada performed better than the average on three (breast, colon and rectal) out of four indicators for cancer care. For breast cancer, Canada ranked 5th best out of 26 countries with a survival rate of 88.6 per cent (statistically better than the average). For colon and rectal cancer, Canada ranked 8th and 6thout of 26 countries at 67 per cent and 67.1 per cent survival respectively (statistically better than the average). However, for cervical cancer Canada ranked 11th out of 26 countries with a five-year net survival rate of 67.3 per cent (statistically no different than the average).

Patient Safety
Finally, there’s patient safety. Made up of two indicators measuring obstetric trauma during birth, Canada performed poorly on both. Canada reported the highest rate of obstetric trauma during a vaginal delivery with (16.3 per cent) and without (3.4 per cent) an instrument—ranking last in terms of performance (20th out of 20 countries with available data).

Canada clearly has mixed performance when we examine these indicators of the quality of care and services provided. Out of 12 indicators, Canada performed well on five while performing average or below average on seven—despite being the second-highest spender (as a percentage of GDP) among high-income OECD countries with universal coverage.

In the next and final addition to this series, we’ll summarize the main findings of our four-part analysis of Canada’s health-care system compared to other high-income universal health-care countries.