Jaakkimainen L, Upshur REG, Klein-Geltink JE, Leong A, Maaten S, Schultz SE, Wang L, editors. Primary Care in Ontario: ICES Atlas. Toronto: Institute for Clinical Evaluative Sciences; 2006.

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Source

• Jaakkimainen L, Upshur REG, Klein-Geltink JE,
  Leong A, Maaten S, Schultz SE, Wang L, editors.
  Primary Care in Ontario ICES Atlas. Toronto
  Institute for Clinical Evaluative Sciences 2006.

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Table of Contents
Slides

• Background
• Primary care...4
• Cervical and colorectal cancer screening.
  .6
• Methodology
• Cervical cancer screening........
  8
• Colorectal cancer screening...........
  ............9
• Key Findings
• Cervical cancer screening......10
  
• Colorectal cancer screening...17
• Interpretive Cautions.............................
  .............................................24

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BackgroundPrimary Care in Ontario

• Primary care is the foundation of many health
  care systems globally. Primary care is considered
  to be health care provided by a medical
  professional that is a patients first point of
  entry into the health system.
• Research evidence indicates that health outcomes
  for populations are better in those jurisdictions
  that have more integrated primary care.
• In November 2006, the Institute for Clinical
  Evaluative Sciences (ICES) released Primary Care
  in Ontario ICES Atlas. The goal of this release
  was to provide descriptive information about
  patterns of primary care utilization between
  1992/93 and 2002/03.
• The Atlas also provided cross-sectional
  descriptive information about Ontarians receiving
  primary care services. A number of themes were
  addressed, one of which was indicators of primary
  care using administrative data (Chapter 12).

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Background (contd)Primary Care in Ontario

• Indicators that were measured
• Preventive care indicators rates of cervical and
  colorectal cancer screening and childhood
  vaccinations
• Chronic disease management indicators diabetes
  mellitus (DM), congestive heart failure (CHF) and
  asthma care
• An acute disease management indicator acute low
  back pain care and
• A continuity of care indicator measuring the
  relational continuity of care received by
  patients with a General Practitioner (GP)/Family
  Practitioner (FP) in Ontario.
• As more recent data become available, these
  indicators are being updated and released in
  phases accordingly.

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Background (contd)Cervical Cancer Screening

• Among Ontario women aged 20 to 49 years old,
  cervical cancer is the second most common type
  of cancer, after breast cancer.
• The disease lends itself well to screening
  programs. The Papanicolaou (Pap) test is a
  recognized screening measure for cervical cancer
  and is commonly used as an indicator of primary
  care performance in developed countries.
• Cervical screening rates were estimated among
  screen-eligible women 20 to 69 years of age.
  Rates were also examined by socioeconomic status
  using Statistics Canadas PCCF.
• Age-standardized rates were reported using the
  2006/07 cervical cancer screening cohort.

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Background (contd)Colorectal Cancer Screening

• Colorectal cancer is the second leading cause of
  cancer death and the second most common cancer
  diagnosed in Ontario.
• It is suggested that early detection through
  regular screening may be associated with a 90
  cure rate.
• There are several options available for screening
  average risk men and women starting at age 50,
  including fecal occult blood test (FOBT),
  colonoscopy, sigmoidoscopy and barium enema. In
  Ontario, FOBT has been recommended as the primary
  screening tool for those who are at average risk
  for colorectal cancer.
• Rates of colorectal cancer screening (which
  included FOBT, colonoscopy, sigmoidoscopy or
  barium enema in the past two years) were
  estimated among screen-eligible adults between 50
  and 74 years of age. Rates were also examined by
  socioeconomic status using STCs PCCF.
• Rates of colorectal cancer screening were age-
  and sex-standardized to the 2006/07 colorectal
  cancer screening cohort.

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MethodologyCervical Cancer Screening

• Inclusion criteria
• All women between the ages of 20 and 69 years
  alive in Ontario on April 1 for fiscal years
  2004/05, 2005/06 and 2006/07 (3 cohorts) were
  identified using the Registered Persons Database
  (RPDB).
• OHIP billings were examined over a three-year
  period inclusive (e.g., April 1, 2002 to March
  31, 2005 for the first cohort) in order to
  identify women who underwent a Papanicolaou (Pap)
  test within that time frame.
• Pap smears were captured using OHIP laboratory
  codes G365, G394, L713 or L812. During an annual
  health exam visit, a procedure code for a Pap
  test may not be billed.
• Exclusion criteria
• Women who were not eligible for OHIP at any point
  during the study period.
• Women who died prior to the end of each of the
  study years in each cohort (i.e., March 31, 2005,
  2006 or 2007).
• Women who had a previous diagnosis of cervical
  cancer.
• Women who had undergone a hysterectomy prior to
  or during the study period.

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Methodology (contd)Colorectal Cancer Screening

• Inclusion criteria
• All Ontarians between the ages of 50 and 74 years
  alive on April 1 for fiscal years 2004/05,
  2005/06 and 2006/07 (3 cohorts) were identified
  using the Registered Persons Database (RPDB).
• OHIP billings were examined over a two-year
  period for each cohort to identify individuals
  who underwent at least one colorectal cancer
  screening investigation, including FOBT, rigid
  or flexible sigmoidoscopy, single or double
  contrast barium enema and colonoscopy.
• Exclusion criteria
• Persons not eligible for OHIP benefits at any
  point during the study periods individuals who
  died prior to the end of any of the study years
  (i.e., March 31, 2005, 2006 or 2007) individuals
  who had a previous diagnosis of colorectal cancer
  and/or inflammatory bowel disease or individuals
  who underwent a colorectal investigation within
  the five years prior to April 1 for each of the
  fiscal years.

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Key FindingsCervical Cancer Screening

• Cervical cancer screening rates in Ontario
• The number of screening tests increased by
  approximately 5 between 2004/05 (over 2.4
  million tests) and 2006/07 (over 2.5 million
  tests).
• Overall, 65 of eligible women between 20 and 69
  years of age in Ontario in the 2006/07 cohort had
  at least one Pap test over the three-year period.
  Screening rates remained relatively stable over
  the three cohorts.
• Approximately 70 of women between 30 and 39
  years of age received at least one Pap test over
  the three-year period from April 1, 2004 to March
  31, 2007. This proportion fell with increasing
  age to 51 in women between 60 and 69 years of
  age. A similar pattern was observed for the two
  earlier cohorts.
• Although women 60 to 69 years of age had the
  lowest rates of cervical cancer screening, this
  age group showed the greatest increase in rates
  (7) over time compared to their younger
  counterparts.
• Rates of cervical cancer screening increased
  steadily with increased neighbourhood income.

11
Age-specific rates of cervical cancer screening
per 100 women aged 20 to 69, Ontario, 2006/07
12
Age-adjusted rates of cervical cancer screening
per 100 women aged 20 to 69, by neighbourhood
income quintile, Ontario, 2006/07
13
Key Findings (contd)Cervical Cancer Screening

• Cervical cancer screening rates among the LHINs
• There was some variation across the LHINs in the
  proportion of eligible women receiving at least
  one Pap test. For example, in the most recent
  cohort (2006/07) cervical cancer screening rates
  ranged from 61 in the North East and North West
  LHINs to almost 69 in the Champlain LHIN.
• The range in rates across the LHINs for cervical
  cancer screening was similar for all three
  cohorts (2004/05, 2005/06 and 2006/07).
• Across the LHINs, rates of cervical cancer
  screening increased steadily with increasing
  neighbourhood income. This was consistent for all
  three cohorts.

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Age-adjusted rates of cervical cancer screening
per 100 women aged 20 to 69, 2006/07 by Local
Health Integration Network (LHIN) in Ontario
15
Age-specific rates of cervical cancer screening
per 100 women aged 20 to 69, 2006/07 LHIN 11
(Champlain) vs. Ontario
16
Age-adjusted rates of cervical cancer screening
per 100 women aged 20 to 69, by neighbourhood
income quintile, 2006/07 LHIN 11 (Champlain) vs.
Ontario
17
Key Findings (contd)Colorectal Cancer Screening

• Colorectal cancer screening rates in Ontario
• The annual number of colorectal cancer screening
  procedures performed in Ontario increased by 44
  between 2004/05 (approximately 552,000 colorectal
  cancer screening investigations) and 2006/07
  (approximately 796,000 colorectal cancer
  screening investigations).
• Approximately 34 of screen eligible Ontarians
  between 50 and 74 years of age received a
  colorectal cancer screening test over a two-year
  period from 2006/07 to 2007/08. This represents a
  40 increase in comparison to those who underwent
  a colorectal cancer screening test during the
  two-year period from 2004/05 and 2005/06 where
  the proportion was 24.
• Colorectal cancer screening rates were generally
  higher among persons aged 60-69 years and lowest
  among those aged 50-59.
• Overall, women were more likely to have a
  colorectal cancer screening procedure than men.
  However, men aged 70-74 years were more likely to
  undergo colorectal cancer screening than their
  female counterparts.
• Rates of colorectal cancer screening increased
  steadily with increasing neighbourhood income.
  The disparity between individuals living in the
  poorest neighbourhoods and wealthiest
  neighbourhoods decreased over time.

18
Age- and sex-specific rates of colorectal cancer
screening per 100 population aged 50 to 74,
Ontario, 2006/07
19
Age- and sex-adjusted rates of colorectal cancer
screening per 100 population aged 50 to 74, by
neighbourhood income quintile, Ontario, 2006/07
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Key Findings (contd)Colorectal Cancer Screening

• Colorectal Cancer Screening Rates among the
  LHINs
• For the most recent colorectal cancer screening
  cohort (2006/07), rates of colorectal cancer
  screening ranged from 28 in the North West LHIN
  to 38 in the Central and Champlain LHINs.
• All LHINs experienced an increase in rates of
  colorectal cancer screening between 2004/05 and
  2006/07, ranging from an increase of 29 in the
  North West LHIN to 51 in the South East LHIN.
• In 2006/07, about half of the LHINs (8 of 14)
  were within 10 of the Ontario rate (33.7) for
  colorectal cancer screening.
• Rates of colorectal cancer screening by
  neighbourhood income were generally similar to
  that observed at the provincial level. Adults
  living in the wealthiest neighbourhoods (highest
  income quintile, Q5) were more likely to undergo
  colorectal cancer screening than those living in
  the poorest neighbourhoods (lowest income
  quintile, Q1).

21
Age- and sex-adjusted rates of colorectal cancer
screening per 100 population aged 50 to 74,
2006/07 by Local Health Integration Network
(LHIN) in Ontario
22
Age- and sex-specific rates of colorectal cancer
screening per 100 population aged 50 to 74,
2006/07 LHIN 11 (Champlain) vs. Ontario
23
Age- and sex-adjusted rates of colorectal cancer
screening per 100 population aged 50 to 74, by
neighbourhood income quintile, 2006/07 LHIN 11
(Champlain) vs. Ontario
24
Interpretive Cautions

• LHIN-level analyses were based on the LHIN where
  the patient lived, which may not be the same as
  the LHIN where the procedure/imaging was
  performed.
• Variation in rates of cervical cancer screening
  may be attributable to patient-, physician- and
  system-level factors. Examples of patient-level
  factors include knowledge and attitudes regarding
  cervical cancer and socio-demographic
  characteristics such as lower education,
  non-English language and ethnic background.
  Physician- and system-level factors may include
  missed opportunities to perform or recommend
  screening during a womans contact with her
  health care provider, lack of regular health care
  and an inability to access screening services.
• Cervical cancer screening rates may be
  underestimated due to physician practice (e.g.,
  Pap tests performed during an annual health exam
  visit or gynecological consultation and not
  billed separately) or Pap tests performed
  in-hospital and billed instead, under hospital
  global budgets.

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Interpretive Cautions (contd)

• Limitations in the use of administrative data to
  capture colorectal screening rates include the
  ability to ascertain whether a procedure was
  performed for screening or diagnostic reasons. In
  some instances, barium enema or colonoscopy may
  be utilized for other reasons and not just for
  cancer (e.g., other intestinal disorders).
• Services including colonoscopy and sigmoidoscopy
  provided outside the OHIP fee-for-service (FFS)
  system are not adequately captured with the
  current administrative data.
• Physician billings for FOBTs may also include
  single samples obtained by digital rectal
  examination during an office visit, which do not
  meet the current recommendation of taking three
  separate samples.
• Processing of screening FOBT kits completed in
  primary care physicians office that were not
  billed by the physicians may have resulted in
  some underreporting of colorectal cancer
  screening.