UBC Faculty Research and Publications

Planning for renewal : mapping primary health care in British Columbia Watson, Diane E.; Krueger, Hans; Mooney, Dawn; Black, Charlyn, 1954- Jan 31, 2005

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Planningfor RenewalMapping Primary Health Care in British ColumbiaJanuary 2005 2CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWAL“Planning for Renewal: Mapping Primary Health Care in British Columbia” was produced by:Centre for Health Services and Policy ResearchThe University of British Columbia426-2194 Health Sciences MallVancouver, BC, Canada V6T 1Z3Tel: (604) 822-1949Fax: (604) 822-5690Email: enquire@chspr.ubc.caDiane Watson, Dawn Mooney, and Charlyn Black are all based at the Centre for Health Services and Policy Research.Hans Krueger is principal of H. Krueger & Associates, Inc. You can download this publication from our website at www.primary-care.chspr.ubc.ca. This publication is protected by copyright. It may be distributed for educational and non-commercial use, provided the Centre for Health Services and Policy Research is credited.  iJANUARY 2005Table of ContentsABOUT CHSPR           iiACKNOWLEDGEMENTS iiiEXECUTIVE SUMMARY ivCHAPTER 1: INTRODUCTION 1CHAPTER 2:  ABOUT THIS REPORT 2CHAPTER 3: PRIMARY HEALTH CARE CONTEXTS  6Population density 7Population growth  Website/CD only Population structure Website only Older adults 9Older adults living alone Website/CD only Children and adolescents Website/CD onlyPremature mortality 17Potential years of life lost  Website/CD onlyInfant mortality Website/CD onlyChildren at risk Website/CD onlySocioeconomic risk 25CHAPTER 4: PRIMARY HEALTH CARE INPUTS 32Expenditures on general practice services 33Supply of general practice providers 41Location of general practice providers 49Supply of nurses Website/CD onlyCHAPTER 5: PRIMARY HEALTH CARE OUTPUTS - PHC AND RELATED SERVICES 54Access to general practice services 55Emergency room visits 63Home-based professional services 71Home support services 79Diabetes 87Congestive heart failure 95CHAPTER 6: PRIMARY HEALTH CARE OUTCOMES 102CHAPTER 7: A FIRST GLANCE AT EQUITY IN THE DISTRIBUTION OF PHC SERVICES   103CHAPTER 8: CONCLUSIONS 116DEFINITIONS AND TECHNICAL NOTES 118APPENDIX 1: GENERAL PRACTICE PROFILES 126APPENDIX 2: DENOMINATOR POPULATION WEBSITE/CD ONLYREFERENCES 133 iiCENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALAbout CHSPRThe Centre for Health Services and Policy Research (CHSPR) is an independent research centre based at the University of British Columbia. CHSPR’s mission is to stimulate scientifi c enquiry into issues of health in population groups, and ways in which health services can best be organized, funded and delivered. Our researchers carry out a diverse program of applied health services and population health research under this agenda.CHSPR aims to contribute to the improvement of population health by ensuring our research is relevant to contemporary health policy concerns and by working closely with decision makers to actively translate research fi ndings into policy options. Our researchers are active participants in many policy-making forums and provide advice and assistance to both government and non-government organizations in British Colum-bia (BC), Canada and abroad. CHSPR receives core funding from the BC Ministry of Health Services to support research with a direct role in informing policy decision-making and evaluating health care reform, and to enable the ongoing develop-ment of the BC Linked Health Database. Our researchers are also funded by competitive external grants from provincial, national and international funding agencies. Much of CHSPR’s research is made possible through the BC Linked Health Database, a valuable resource of data relating to the encounters of BC residents with various health care and other systems in the province. These data are used in an anonymized form for applied health services and population health research deemed to be in the public interest.CHSPR has developed strict policies and procedures to protect the confi dentiality and security of these data holdings and fully complies with all legislative acts governing the protection and use of sensitive information. CHSPR has over 30 years of experience in handling data from the BC Ministry of Health and other profes-sional bodies, and acts as the access point for researchers wishing to use these data for research in the public interest.For more information about CHSPR, please visit www.chspr.ubc.ca.    iiiJANUARY 2005All projects of this size and complexity rely on the talents and contributions of many dedicated people. Numerous colleagues at the Centre for Health Services and Policy Research (CHSPR) have contributed to this endeavour. Our thanks go to Heidi Matkovich and Sabrina Wong for their time and editorial talents throughout this project; Nino Pagliccia for analysis related to primary health care expenditure patterns; Jennifer Bow for early work on map interpretation and documentation; and James Hughes for the design and management of the online version of this report. Bob Prosser of the Vancouver Coastal Health Authority also assisted in assessing the categorization methodology used in this report.Our CHSPR colleagues Kim McGrail and Peter Schaub deserve particular acknowledgment for developing the mapping templates used in this report to profi le geographic patterns of health and health care in British Columbia. This report builds on the fi rst and second editions of the British Columbia Health Atlas produced by CHSPR.The BC Ministry of Health Services provided funding to support this project under the Primary Health Care Transition Fund. At the Ministry, special thanks are extended to Marian Knock, Carol Myron and Anne Ardiel. Vicki Farrally must be acknowledged for her role as chair of the province’s evaluation working group for primary health care. Members of this group offered numerous insights that guided the selection and interpre-tation of the profi les in this report.This report relies primarily on information derived from other organizations. All analysis and interpretation, and any errors, are the sole responsibility of the authors. Diane E. Watson, PhD MBAFaculty, CHSPRHans Krueger, MSc PhD (Cand.)H. Krueger & Associates Inc.Dawn Mooney, BAGeographer, CHSPRCharlyn Black, MD ScDDirector, CHSPRJanuary 2005Acknowledgements  ivCENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALPrimary health care (PHC) is the foundation of Canada’s health care system. For most people, PHC is their fi rst point of contact with the health care system, often through a family physician. It is where short-term health issues are resolved and the majority of chronic health conditions are managed. It is also where health promotion and education efforts are undertaken, and where patients in need of more specialized services are linked to secondary care. Over the last decade, there has been a signifi cant focus on transforming the delivery of PHC in Canada. In British Columbia, the government has committed to investing at least $74 million between 2002 and 2006 to “strengthen family practice and reduce pressure on the acute care sys-tem; improve health care delivery and health outcomes; and provide patients with a wider range of options for accessing services at the local level.”In September 2003, British Columbia’s Ministry of Health Services contracted with CHSPR to build capac-ity to conduct province-wide, system-level performance measurement and evaluation research about PHC. This is the second report in this three-year research program and was developed in response to the urgent need for information relevant to planning for PHC renewal. This document contains selected profi les only: the full collec-tion of profi les, data tables and additional appendices are available on our website ( www.primary-care.chspr.ubc.ca) and the included CD.The goal of this project was to quickly compile a snapshot of the PHC system in British Columbia—and the health of its users—to inform policy and planning for the renewal of this sector. We created a set of profi les to refl ect different facets of the PHC system, drawing primarily on information from readily available sources, but also conducting some important new analytic work. Each indicator, or profi le, was mapped to advance our under-standing of geographic variation and distribution across the province’s six health authorities, 16 health service delivery areas, and 89 local health areas, and presented in a way to illustrate the relationship between health status and PHC services use. Accompanying data tables (website/CD only) provide supplemental information.As a collection, the profi les contained in this report will enable health system planners to better understand demographic, socioeconomic and health profi les of the population; temporal changes in population size; the level of supply and geographic distribution of PHC provid-ers; patterns of delivery and use of PHC services; and the responsiveness of these services to variations in the distribution of health status. This report illuminates the many challenges for planning PHC renewal in the province. For example, there is tremendous diversity in the contexts in which the PHC system operates:•   Diversity in demographic structure, population health status and socioeconomic conditions across regions in the province require that services be tailored to meet local needs. •   Variations in population density have direct implica-tions for planning and managing requirements for dispersion in supply of PHC services.  •   Historic patterns and future projections of population growth necessitate temporal shifts in the supply of PHC services. There are substantial fi nancial and human resource invest-ments in PHC: •   British Columbians spent roughly $665 million in 2000/01 ($164 per capita) on general practice services.•   An estimated 3,558 full-time equivalent general prac-tice providers, the majority of whom are physicians engaging in general practice, serviced British Colum-bia in 2000/01. Supply varied across local health areas, with an average of 8.7 general practice providers for every 10,000 people. •   British Columbia had approximately 94 nurses for every 10,000 people in 2000. There was no readily available information on the count or location of Executive Summary vJANUARY 2005nurses who provide PHC services; CHSPR is planning future work in this area. There is much to learn about the patterns of use and delivery of PHC services:•   Eighty-four per cent of British Columbians received general practice services in either their own or adjacent local health areas in 2001/02. •   British Columbians made approximately 964,187 visits to emergency rooms in 1999, a rate of 275 visits for every 1,000 people. This is likely to be an underes-timate because of limited data sources. •   British Columbians received approximately 218 home visits for every 1,000 people from publicly funded nurses, physiotherapists or occupational therapists in 2001/02.•   British Columbians used approximately 1,764 hours of publicly funded home support services for every 1,000 people in 2001/02.•   Physicians identifi ed approximately 4.74% of British Columbians as diabetic in 2001/02. The proportion of diagnosed diabetics that received recommended clinical services varied by the type of service and across health regions. •   Physicians identifi ed approximately 1.66% of British Columbians with congestive heart failure in 2001/02. The proportion of people with diagnosed congestive heart failure that received recommended clinical treat-ments varied by the type of intervention and across health regions. As identifi ed in A Results-Based Logic Model for Primary Health Care, primary health care is responsible for a number of different outcomes. Immediate (or direct) outcomes are those for which this sector is most respon-sible, and include maintaining or improving the work life of the PHC workforce; increasing knowledge about health and health care among the population; reducing the risk, duration and effects of acute and episodic condi-tions; and, reducing the risks and effects of continuing health conditions. Primary health care has a lesser degree of infl uence over intermediate and fi nal outcomes. Inter-mediate outcomes include acceptability with health care, appropriateness of place and provider, health care system effi ciency, and health system equity. Final outcomes include a sustainable health care system; improvement and/or maintenance of functioning, resilience and health for individuals; and improvement in the level and distribu-tion of population health status.One of the foremost expectations Canadians hold of their health system is that care will be delivered to those most in need. Equity simply refl ects the effectiveness of the health system in distributing services to populations on the basis of need. The PHC sector contributes to health system equity directly through its responsibility for equi-table distribution of care within the sector, and indirectly through its control over referrals and hospital admissions. In this report, we take a fi rst glimpse at the level of equity of British Columbia’s PHC system by looking more closely at the association between population health status, or need for health care (as measured by premature mortality rate), and a number of key PHC profi les.The degree of equity in the allocation of PHC services seems to depend on the type of services in question. While expenditures on general practice services appear to be equitably distributed across local health areas, use of emergency rooms and home-based care do not appear to be associated with population health status. Importantly, our analyses suggest that general practice services, home-based care and emergency room utiliza-tion work in synchrony to respond to the needs of local health areas with varying population health status. When combined, expenditures on this collection of PHC services refl ecting different types of care—general practice, emergency rooms and home-based care—show a strong association with population health status. This indicates that PHC needs may be met by relying on different mixes of PHC services, depending on, for example, underlying population health status, demographic structure, and regional variation in supply of different types of services. viCENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALIn planning for PHC renewal, these analyses highlight the critical importance of looking at multiple facets of the PHC system when making assessments of allocation equity, and shed light on local variability in need for care, supply of services, access and utilization. Our report also points to the absolute requirement for comprehensive data: we were, for example, able to fully detail expenditures on general practice services using multiple funding sources, a methodological advance with particular signifi cance for further PHC research in BC. This report contributes a few small, though important, pieces of the PHC puzzle and provides an important starting point for planning for PHC renewal. We have provided a fi rst glance at the supply and utilization of PHC services, and the level of equity in the distribution of PHC resources across the province. However, there is still much to learn about the health of British Columbians and the many facets of their PHC system, and much work to be done to improve the administrative data infrastructure in British Columbia—particularly in relation to data from alternative funding sources—for PHC planning and evaluation. CHSPR is committed to this agenda and looks forward to developing a comprehensive picture of the attributes and qualities of the PHC system in British Columbia as we progress through our research program. 1JANUARY 2005Primary health care (PHC) is the foundation of Canada’s health care system. For most people, it is the fi rst point of contact with the health care system, often through a family physician. It is also where patients in need of more specialized services are linked to secondary care. PHC is where short-term health issues are resolved and the majority of chronic health conditions are managed. It is also where health promotion and education efforts are undertaken. Physicians, dieticians, home care workers, nurses, occupational therapists, physiotherapists, phar-macists, social workers, and other health care workers all deliver PHC services.Canadians care about their health and take great pride in their health care system. We have come to expect convenient access to high quality health services based on need. Although most Canadians (70%) are satisfi ed with the quality of health care, fewer are content with current access to care in the community.1 In British Columbia (BC), 12% of residents report diffi culties accessing fi rst contact care.2 But despite reporting an erosion in overall confi dence in their health care system, Canadians remain open to a wide variety of initiatives to improve the current situation, and strongly support the notion that research will contribute to the pace of innovation in health care and evidence-based decision-making.3Over the last decade, there has been a signifi cant focus on transforming the delivery of PHC in Canada. Federal and provincial governments have made considerable invest-ments toward PHC renewal through the Health Transition Fund (1997), the Primary Health Care Transition Fund (2000), and the First Ministers’ Accord on Health Care Renewal (2003). Between 1997 and 2003, federal invest-ments designed to stimulate change and support evaluative research in this sector exceeded $1 billion. In British Columbia, the government has committed to investing at least $74 million between 2002 and 2006 to “strengthen family practice and reduce pressure on the acute care system; improve health care delivery and health outcomes; and provide patients with a wider range of options for accessing services at the local level.”4 The province’s plan for PHC renewal is based upon a strategic partnership with BC’s regional health authorities, which will receive the majority of this funding to help accelerate and expand sustainable PHC initiatives to respond to local challenges. The remaining portion of this funding is being used to support province- and system-wide initiatives.In September 2003, the BC Ministry of Health Services contracted with CHSPR to build capacity to conduct province-wide, system-level performance measurement and evaluation research about PHC. This three-year research program will produce a results-based logic model to guide the development of a PHC information system (released September 2004); develop a PHC administrative data-based system enabling temporal, geographic, provider-based, and population-based analyses; provide advice to inform PHC data collection at provincial and health authority levels; and deliver timely information and insights on the state of PHC in British Columbia to provincial stakeholders. This is the second report in this research program and was developed in response to the urgent need for information relevant to planning for PHC renewal. In 2005, we will release additional reports describing patterns of popula-tion morbidity, and the delivery and use of PHC services across the province. While this report contributes a few small, though important, pieces of the PHC puzzle, as we continue our research it will become increasingly possible to develop a comprehensive picture of the attributes and qualities of the PHC system in British Columbia. Chapter 1: Introduction 2CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALThis is the second report in CHSPR’s three-year PHC research program. The goal of this project was to quickly compile a snapshot of the PHC system in British Colum-bia—and the health of its users—to inform policy and planning for the renewal of this sector. We drew primarily on information from readily available sources, but also conducted some important new analytic work to provide a fi rst glance at the patterns of delivery and responsiveness of PHC services. Each indicator, or profi le, was mapped to advance our understanding of geographic variation and distribution, and presented in a way to illustrate the relationship between health status and PHC services use.Logic model framework As part of our overall PHC research program, we have developed a results-based logic model5 for primary health care that describes the contexts, inputs, activi-ties, outputs and outcomes of this sector. A logic model identifi es the linkages between the activities of a policy, program or initiative and the achievement of its outcomes. Our model was designed using the Treasury Board of Canada framework,6 policy analysis, research evidence, and broad consultation. It is intended to guide the devel-opment of a PHC information system for the province, and aims to focus and unify evaluative efforts by enabling diverse stakeholders to work from a shared conceptual foundation and lexicon. We have used the logic model in structuring this report to establish a solid base for the overall research pro-gram. The profi les presented here are grouped into PHC contexts, inputs, outputs, and outcomes. PHC contexts include population characteristics and contextual factors that can infl uence external outcomes. PHC inputs include the fi scal, material and human resources necessary to carry out activities. PHC activities are the primary link in the chain through which outcomes are achieved, and can be categorized into policy/governance, manage-ment and clinical activities and decisions. PHC outputs include health promotion, preventive, screening, curative, rehabilitative, palliative and supportive services to target groups or populations. PHC outcomes can be immediate, intermediate or fi nal, and collectively represent “results for British Columbians.” A more detailed discussion of each category of profi les is provided throughout the report.Premature mortality rate frameworkA second feature of this report is the use of premature mortality rate (PMR) as an ordering framework for all relevant PHC profi les. A key aspect of planning for PHC renewal is to understand how well the current system responds to the needs of the populations it serves. We have chosen premature mortality rate—generally rec-ognized as the best indicator of population health sta-tus7,8,9,10—as the central measure of need for health care. As a measure of need, low population health status (high PMR) suggests that health care services use should be higher, while high population health status (low PMR) predicts lower use of health care services.11 Premature mortality rate is fully profi led in Chapter 3. For all other profi les, values for PMR are used to rank order local health areas. For example, Fraser Health Authority (and its component local health areas) is ordered at the top of each bar chart in all profi les because it has the lowest value for PMR of all health authorities. This allows each PHC profi le to be easily benchmarked to health status, helping to inform judgements about the responsiveness of PHC to the need for health care. The association of health status with health care services use is explored in greater depth for key PHC profi les in Chapter 7. About the PHC profi lesThe majority of profi les mapped in this report are based on readily available data from the BC Ministry of Health Services, BC Stats, the BC Vital Statistics Agency, and Statistics Canada. Any limitation associated with a particular data source has therefore been carried forward into our analyses. For example, the supply of nurses could only be profi led as a general count rather than a specifi c overview of nurses providing PHC because  available data do not readily identify the type of services these providers deliver. We were also unable to develop a Chapter 2:  About this report 3JANUARY 2005profi le of general practice provider group practices due to the lack of readily available information about practice relationships between providers.  However, ongoing research has allowed us to increase the robustness of the data used for a number of profi les. First, as initially detailed in the British Columbia Health Atlas (2nd edition),12 CHSPR’s calculation of premature mortality rates also includes out-of-province deaths of BC residents not otherwise captured in the provincial data. This has a signifi cant effect on areas of the province that border Alberta.Second, the profi le for expenditures on general practice services has been improved by the addition of Alternative Payments Program and primary health care organiza-tion data to Medical Services Plan (MSP) fee-for-service billing claims. While more work needs to be done to fi ne-tune this profi le, this is a signifi cant development toward analysis of local health areas with heavy reliance on services funded outside the MSP. A special mention must also be made of our decision to introduce new terms to defi ne PHC providers and the services they deliver. Researchers and analysts in the province have historically, and correctly, used the terms “general practitioners” and/or “family physicians” when referring to physicians who hold these specialty desig-nations. But these terms have also been used to refer to physicians who predominantly bill for general practice services: these physicians may hold designations in pedi-atrics, internal medicine or other specialties. In this report, we use terms tied closely to the methodol-ogy used to construct the provider-related profi les. Gen-eral practice providers describes physicians defi ned by type-of-practice methodology and may therefore include physicians who hold specialty designations other than general practitioner or family physician. This term also includes providers who deliver PHC services through service organizations that do not bill fee-for-service. Gen-eral practice services are defi ned by fee item specialty methodology and are an indication of expenditures in a particular fee category, irrespective of the specialty des-ignation of the provider who billed for the services. PHC services delivered by service organizations that do not bill fee-for-service are also included.These defi nitions are by nature still emerging and we will be developing and refi ning them further throughout our research program. However, a core theme is our desire to distinguish providers on the basis of the way they actually practice. More detail on the provider-related profi les is provided in Appendix 1.MethodsThe majority of profi les presented in this report are mapped in the standard format used for the BC Health Atlas, which uses BC’s sub-provincial geographic bound-aries for health services planning and delivery: fi ve13 health authorities—Fraser, Vancouver Island, Vancouver Coastal, Interior and Northern; sixteen health service delivery areas; and eighty-nine local health areas, the smallest unit of analysis.14 This report presents population-based analyses, where services, when measured, are attributed to individuals based on where they live rather than where they may have received that care. This approach is especially important in assessing the responsiveness of the primary health care system, as geographic profi les accurately represent varia-tions in the way residents of different areas of the prov-ince access and use services. Denominator populations were determined using data from PEOPLE 2815, BC Stats, unless otherwise noted.Values are categorized using the natural breaks (Jenks) methodology with a pre-set number of fi ve categories. In most situations where only one local health area fell into a category by itself, the outlier value was removed, the natural breaks were recalculated, and the outlier value as-signed to the relevant category.More detailed information about the methods used throughout this report is available in Defi nitions and techni-cal notes. 4CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALUnderstanding the profi lesThe majority of the profi les in this report are mapped according to the same eight-page format used in the BC Health Atlas. Our interpretation is limited to notable highs, lows and variability within and across health authorities, in recognition of the need for local knowledge of geographic peculiarities and underlying trends.Page one of each profi le presents a choropleth map of British Columbia (1), including an inset of the Vancouver area and the southern tip of Vancouver Island (2). The map depicts the 89 local health areas and uses higher-contrast borders (3) to show health authority boundaries. The legend (4) in the lower left corner includes a modifi ed histogram showing the minimum and maximum values of the profi le, the break-points between data classes, and the number of local health areas that fall into each of the fi ve classes. A description of the profi le (5) is also provided, including data sources and any known limitations.Page two displays similar information in two different chart forms. The vertical “line and dot” chart (6) is designed for easy comparability of the distribution of values between local health areas within and across each health authority. Each circle represents a local health area within its given health authority (7). The overall value for the health authority (8) and the province (9) are marked.The bar chart (10) retains the grouping of local health areas within health authorities, ordered from top to bottom on the basis of increasing premature mortality rate (declining health status). Haphazard ordering for a given profi le indicates low association with premature mortality rate. If the values for a given profi le increase with premature mortality rate, bars on the chart will increase in size from top to bottom.  5JANUARY 2005Page three displays data at the health service delivery area level. A cartogram (11) is used for understanding differences in health status or health care services use in areas where there is an uneven pattern of settlement. Circles are sized according to population size and coloured to refl ect the health service delivery area value for the given profi le, a weighted average of the local health area values. The circles rest on a stylized map of British Columbia, which provides a general sense of the geographic location of each of these areas. A vertical “line and dot” chart (12) and a bar chart (13) display the health service delivery area and health authority values for the given profi le. The relevance, province-wide variability, and any geographic trends of the profi le are noted (14).Pages four though eight provide specifi c information for each of the fi ve health authorities, including a choropleth map (15), cartogram (16), and a table of local health area values (17). Because of their size and geographic arrange-ment, the Vancouver Coastal and Vancouver Island health authority maps are drawn in perspective view—as if you were standing at the southern part of the region and looking northwest. Notable highlights for each health authority are discussed (18). 6CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALChapter 3: Primary Health Care Contexts To design a PHC system responsive to the needs of various communities, it is important to understand the demographic and health characteristics of the population, as well as contextual factors that could affect the need, demand and use of health care. Profi les in this section provide information on population density, population growth, demographics, and health status. The socioeconomic risk index and children at risk index (developed by BC Stats) are included as indica-tors of the important social and economic contexts that infl uence the health and health care use of populations. This section contains profi les of:PROFILE DATA SOURCE* AVAILABLEDemographicsPopulation density 2001 Statistics Canada p. 7-8 Population age and gender structure 2001 Statistics Canada Website onlyPopulation growth 1991-2001 BC Stats Website/CD onlyOlder adults (percentage of population aged 65+) 2001 BC Stats p. 9-16Older adults living alone (percentage of population aged 65+ living alone)2001 Statistics Canada Website/CD onlyChildren and adolescents (percentage of population aged 0-19)2001 BC Stats Website/CD onlyHealth statusPremature mortality (rate per 1,000 population) 1996-2000 CHSPR p. 17-24Potential years of life lost index 1997-2001 BC Vital Statistics Agency Website/CD onlyInfant mortality (rate per 1,000 live births) 1997-2001 BC Vital Statistics Agency Website/CD onlySocial and economic contextsChildren at risk index 1997-2002 BC Stats Website/CD onlySocioeconomic risk 1997-2002 BC Stats p. 25-31A number of profi les relevant to PHC contexts are also available in the BC Health Atlas (2nd ed.):•   Life expectancy (1997-2001)•   Age-standardized mortality rate (1996-2000)•   High users of physician services (2000/01) •   Population of the dominant centre in each local health area (2001)†•   Average annual rate of population growth (1996-2001)†•   Urbanization rate (2001)†•   Dependency ration (2001)†*For full details of profi le methodology and data sources, refer to Definitions and technical notes.†Details provided in Section 1.3 Health authority demographics (BC Health Atlas) 7POPULATION DENSITY PROVINCE-WIDEPHC CONTEXTS - DEMOGRAPHY 8POPULATION CENTRES PROVINCE-WIDE 9OLDER ADULTS PROVINCE-WIDEPHC CONTEXTS - DEMOGRAPHY 10OLDER ADULTS LOCAL HEALTH AREAS 11OLDER ADULTS HEALTH SERVICE DELIVERY AREAS 12OLDER ADULTS FRASER 13OLDER ADULTS VANCOUVER COASTAL 14OLDER ADULTS VANCOUVER ISLAND 15OLDER ADULTS INTERIOR 16OLDER ADULTS NORTHERN 17PREMATURE MORTALITY PROVINCE-WIDEPHC CONTEXTS - HEALTH STATUS 18PREMATURE MORTALITY LOCAL HEALTH AREAS 19PREMATURE MORTALITY HEALTH CENTRAL DELIVERY AREAS 20PREMATURE MORTALITY FRASER 21PREMATURE MORTALITY VANCOUVER COASTAL 22PREMATURE MORTALITY VANCOUVER ISLAND 23PREMATURE MORTALITY INTERIOR 24PREMATURE MORTALITY NORTHERN 25SOCIOECONOMIC RISK PROVINCE-WIDEPHC CONTEXTS - SOCIAL AND ECONOMIC 26SOCIOECONOMIC RISK LOCAL HEALTH AREAS 27SOCIOECONOMIC RISK FRASER 28SOCIOECONOMIC RISK VANCOUVER COASTAL 29SOCIOECONOMIC RISK VANCOUVER ISLAND 30SOCIOECONOMIC RISK INTERIOR 31SOCIOECONOMIC RISK NORTHERN 32CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALChapter 4: Primary Health Care InputsAll PHC systems rely on fi nancial, material and human resources to deliver care. Profi les in this section provide information on expenditures on primary health care services, and the supply and distribution of health care professionals who deliver these services. This section contains profi les of:PROFILE DATA SOURCE* AVAILABLEExpenditures on general practice services (per capita)2000/01 CHSPR (new analysis) p. 33-40Supply of general practice providers (rate of FTE providers per 10,000 population)2000/01 CHSPR (new analysis) p. 41-48Geographic location of general practice providers 2001/02 CHSPR (new analysis) p. 49-53Supply of nurses (crude rate per 10,000 population) 2000 CHSPR Website/CD only*For full details of profi le methodology and data sources, refer to Definitions and technical notes. 33EXPENDITURES ON GENERAL PRACTICE SERVICES PROVINCE-WIDEPHC INPUTS 34EXPENDITURES ON GENERAL PRACTICE SERVICES LOCAL HEALTH AREAS 35EXPENDITURES ON GENERAL PRACTICE SERVICES HEALTH SERVICE DELIVERY AREAS 36EXPENDITURES ON GENERAL PRACTICE SERVICES FRASER 37EXPENDITURES ON GENERAL PRACTICE SERVICES VANCOUVER COASTAL 38EXPENDITURES ON GENERAL PRACTICE SERVICES VANCOUVER ISLAND 39EXPENDITURES ON GENERAL PRACTICE SERVICES INTERIOR 40EXPENDITURES ON GENERAL PRACTICE SERVICES NORTHERN 41SUPPLY OF GENERAL PRACTICE PROVIDERS PROVINCE-WIDEPHC INPUTS 42SUPPLY OF GENERAL PRACTICE PROVIDERS LOCAL HEALTH AREAS 43SUPPLY OF GENERAL PRACTICE PROVIDERS HEALTH SERVICE DELIVERY AREAS 44SUPPLY OF GENERAL PRACTICE PROVIDERS FRASER 45SUPPLY OF GENERAL PRACTICE PROVIDERS VANCOUVER COASTAL 46SUPPLY OF GENERAL PRACTICE PROVIDERS VANCOUVER ISLAND 47SUPPLY OF GENERAL PRACTICE PROVIDERS INTERIOR 48SUPPLY OF GENERAL PRACTICE PROVIDERS NORTHERN 49LOCATION OF GENERAL PRACTICE PROVIDERS FRASER 50LOCATION OF GENERAL PRACTICE PROVIDERS VANCOUVER COASTAL 51LOCATION OF GENERAL PRACTICE PROVIDERS VANCOUVER ISLAND 52LOCATION OF GENERAL PRACTICE PROVIDERS INTERIOR 53LOCATION OF GENERAL PRACTICE PROVIDERS NORTHERN 54CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALChapter 5: Primary Health Care Outputs - PHC and Related ServicesPHC outputs represent the interface between British Columbians and care providers. This interface is often described as “access to health care”. Access has a number of different dimensions that relate to the process of obtaining care—availability, geographic proximity to care, affordability—and the receipt of certain types of care.Profi les in this section provide information on the patterns of use and delivery of primary health care and related services. The accessibility of primary health care is measured as the amount of general practice services people receive in their own or a geographically adjacent local health area. Information is also provided on the use of emergency rooms, home-based professional services and home support services. The delivery of recommended services to people with diabetes and congestive heart failure are profi led; and juxtaposed with information regarding the prevalence of these health conditions. These profi les provide a glimpse at the technical effectiveness of general practice services, which refers to how providers select and use effi cacious or recommended clinical tests, treatments and/or services for particular patients. This concept has also been popularized as evidence-based care16 and includes care otherwise considered legitimate by contemporary professional standards.This section contains profi les of:PROFILE DATA SOURCE* AVAILABLEAccess to general practice services (percentage of MSP-funded general practice services received in home or geographically-adjacent local health area)2001/02 CHSPR (new analysis) p. 55-62Emergency room visits (rate per 1,000 population) 1999 CHSPR p. 63-70Home-based professional services (nursing, physiotherapy, and occupational therapy visits per 1,000 population)2001/02 BC Ministry of Health Servicesp. 71-78Home support services (hours per 1,000 population)2001/02 BC Ministry of Health Servicesp. 79-86Diabetes (prevalence and receipt of recommended services)2001/02 BC Chronic Disease Managementp. 87-94Congestive heart failure (prevalence and receipt of recommended services) 2001/02 BC Chronic Disease Managementp. 95-101A number of profi les relevant to PHC contexts are also available in the BC Health Atlas (2nd ed.):•   Home support users (2000/01)•  Continuity of physician care (2000/01)*For full details of profi le methodology and data sources, refer to Definitions and technical notes. 55ACCESS TO GENERAL PRACTICE SERVICES PROVINCE-WIDEPHC AND RELATED SERVICES 56ACCESS TO GENERAL PRACTICE SERVICES LOCAL HEALTH AREAS 57ACCESS TO GENERAL PRACTICE SERVICES HEALTH SERVICE DELIVERY AREAS 58ACCESS TO GENERAL PRACTICE SERVICES FRASER 59ACCESS TO GENERAL PRACTICE SERVICES VANCOUVER COASTAL 60ACCESS TO GENERAL PRACTICE SERVICES VANCOUVER ISLAND 61ACCESS TO GENERAL PRACTICE SERVICES INTERIOR 62ACCESS TO GENERAL PRACTICE SERVICES NORTHERN 63EMERGENCY ROOM VISITS PROVINCE-WIDEPHC AND RELATED SERVICES 64EMERGENCY ROOM VISITS LOCAL HEALTH AREAS 65EMERGENCY ROOM VISITS HEALTH SERVICE DELIVERY AREAS 66EMERGENCY ROOM VISITS FRASER 67EMERGENCY ROOM VISITS VANCOUVER COASTAL 68EMERGENCY ROOM VISITS VANCOUVER ISLAND 69EMERGENCY ROOM VISITS INTERIOR 70EMERGENCY ROOM VISITS NORTHERN 71HOME-BASED PROFESSIONAL SERVICES PROVINCE-WIDEPHC AND RELATED SERVICES 72HOME-BASED PROFESSIONAL SERVICES LOCAL HEALTH AREAS 73HOME-BASED PROFESSIONAL SERVICES HEALTH SERVICE DELIVERY AREAS 74HOME-BASED PROFESSIONAL SERVICES FRASER 75HOME-BASED PROFESSIONAL SERVICES VANCOUVER COASTAL 76HOME-BASED PROFESSIONAL SERVICES VANCOUVER ISLAND 77HOME-BASED PROFESSIONAL SERVICES INTERIOR 78HOME-BASED PROFESSIONAL SERVICES NORTHERN 79HOME SUPPORT SERVICES PROVINCE-WIDEPHC AND RELATED SERVICES 80HOME SUPPORT SERVICES LOCAL HEALTH AREAS 81HOME SUPPORT SERVICES HEALTH SERVICE DELIVERY AREAS 82HOME SUPPORT SERVICES FRASER 83HOME SUPPORT SERVICES VANCOUVER COASTAL 84HOME SUPPORT SERVICES VANCOUVER ISLAND 85HOME SUPPORT SERVICES INTERIOR 86HOME SUPPORT SERVICES NORTHERN 87DIABETES PROVINCE-WIDEPHC AND RELATED SERVICES 88DIABETES LOCAL HEALTH AREAS 89DIABETES HEALTH SERVICE DELIVERY AREA 90DIABETES FRASER 91DIABETES VANCOUVER COASTAL 92DIABETES VANCOUVER ISLAND 93DIABETES INTERIOR 94DIABETES NORTHERN 95CONGESTIVE HEART FAILURE PROVINCE-WIDEPHC AND RELATED SERVICES 96CONGESTIVE HEART FAILURE HEALTH SERVICE DELIVERY AREAS 97CONGESTIVE HEART FAILURE FRASER 98CONGESTIVE HEART FAILURE VANCOUVER COASTAL 99CONGESTIVE HEART FAILURE VANCOUVER ISLAND 100CONGESTIVE HEART FAILURE INTERIOR 101CONGESTIVE HEART FAILURE NORTHERN 102CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALThere are a number of outcomes for which PHC is responsible. Immediate or direct outcomes are those for which this sector is most responsible. Immediate outcomes include: maintaining or improving the health of the PHC workforce; increasing knowledge about health and health care among the population; reducing the risk, duration and effects of acute and episodic conditions; and, reducing the risks and effects of continuing health conditions. PHC has a lesser degree of infl uence over intermediate and fi nal outcomes. Intermediate outcomes include acceptability of services; appropriateness of place and provider; health care system effi ciency; and health system equity and respon-siveness. One of the principal expectations Canadians hold of their health system is that care should be delivered to those most in need. That is, PHC will be distributed to populations in an equitable and responsive way. We have dedicated the fi nal chapter to describing the relationship between population health status (or need for health care), the supply of general practice providers, and the use of PHC and related services. To understand the responsiveness of PHC, we assessed whether lower (or higher) health status is related to higher (or lower) supply of providers, and higher (or lower) use of services.The role of PHC providers as gatekeepers to other health care sectors is one mechanism by which PHC infl uences many immediate and intermediate outcomes. For example, prescribing and referral patterns infl uence health care system effi ciency and responsiveness, as well as the appropriateness of place and provider. The following profi les, available in the BC Health Atlas (2nd ed.), offer a glimpse into health care sectors that are infl uenced indirectly by PHC services. •   Acute care days (2000/01)•   Hospital separations (2000/01)•   Specialist expenditures (2000/01)•   PharmaCare expenditures (2001)Chapter 6: Primary Health Care Outcomes 103JANUARY 2005The goal of this project was to quickly compile a snapshot of the primary health care (PHC) system in British Columbia—and the health of its users—to inform policy and planning for the renewal of this sector. As a collection, the profi les in this report will enable health system planners to better understand the demographic, socioeconomic and health characteristics of the popula-tion; temporal changes in population size; the level of supply and geographic distribution of PHC providers; and patterns of delivery and use of PHC and related services. These profi les, while generally drawing on existing data, provide important new perspectives on geographic variation and distribution, and signifi cantly, are presented for the fi rst time as a comprehensive collection. We used a results-based logic model to describe the contexts, inputs, activities, outputs and outcomes of the PHC sector, and to guide the selection of information included in this report. One of the foremost expectations Canadians hold of their health system is that care will be delivered to those most in need.1 Equity simply refl ects the effectiveness of the health system in distributing services to populations on the basis of their relative need for health care. People with greater need should receive proportionally more services, while individuals with similar needs should receive similar levels of care. The PHC sector contributes to health system equity directly through its responsibility for distribution of care within this sector, and indirectly through control over prescriptions, referrals and hospital admissions. In recognition of public expectations and policy objec-tives regarding equity in the distribution of health care, the provincial government introduced a revised funding formula for health authorities in 2002. The formula was designed, in part, to account for regional differences in the relative need for health care. Health authorities, however, do not fund the vast majority of general prac-tice providers in the province: most of these providers are remunerated on a fee-for-service basis through the Medical Services Plan. Other than work published in the BC Health Atlas (2nd ed.), little analysis has been done in the province to determine whether PHC services are being allocated to health regions on the basis of their relative need for this care. In this chapter, we take a fi rst glance at the level of equity in British Columbia’s PHC system by looking closely at the association between population health status, or need for health care (as measured by premature mortality rate), and the following key profi les:•   Supply of general practice providers •   Expenditures on general practice services •   Emergency room visits •   Home-based professional services•   Home support services•   Combined expenditures on PHC services     (a composite profi le)As outlined in Chapter 2, in this report we use premature mortality rate (PMR) as an indicator of population health status, and therefore, population health care service needs. Rather than viewing premature mortality as a health out-come (e.g. where higher health status could indicate more effective health care services), populations with higher PMR (low health status) are more likely to require more care. Determining the relative needs of different popula-tions and the optimal level of service use is problematic, however, as it relies on the capacity to measure need, to make judgments about the effectiveness of care and the capacity to benefi t from care, and to determine the right level of care.In this chapter we explore the relationship between PMR and the utilization of general practice services, emergency rooms and publicly-funded home-based care in more detail. We then combined this collection of PHC services to determine whether these services might work in synchrony to respond to the needs of local health areas with varying population health status.Chapter 7: A First Glance at Equity in theDistribution of Primary Health Care Services   104CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALMethodsIn this chapter, local health area values for each PHC profi le are graphed against PMR and represented as scatter plots, providing a general indication of the degree of association between supply/use of services and need for care. Trend lines illustrate the relationship between the two variables. Dashed trend lines represent the associa-tion between supply/use and need for care for all local health areas. Solid trend lines represents the association after excluding: (a) areas identifi ed as outliers, and/or (b) areas where services were known to be absent or close to zero (e.g. emergency rooms in remote areas). The level of association for both trend lines was calculated. Pearson correlation coeffi cients were used to assess the degree of association between each PHC profi le and PMR at the local health area. The Pearson correlation is a standard approach for measuring the nature and level of agreement between variables. Correlations were catego-rized into zero (or low) association, moderate association, strong association, or very strong association according to the scale shown below. Correlations were not weighted.17Table 1: Categorization of correlation coeffi cientsASSOCIATION PEARSON P ValueVery strong > 0.75 P < 0.05Strong 0.60-0.75 P < 0.05Moderate 0.40-0.59 P < 0.05No (or low) < 0.40 P > 0.05Bar charts are included for some profi les to provide an alternative visual representation of the association between supply/use and PMR. Local health areas are rank ordered from top to bottom on the basis of increasing PMR (declining health status) to enable comparison of use relative to health status.Supply of general practice providersSupply of general practice providers is fully profi led in Chapter 4. Data used to estimate the age/sex-standardized rate of full-time equivalent (FTE) general practice provid-ers per 10,000 population were obtained from Medical Services Plan (MSP) practitioner and billing fi les, Alterna-tive Payments Program fi les, and primary health care orga-nization fi les for 2000/01. MSP fee-for-service providers were estimated using type of practice methodology.  For the PHC system to be operating equitably, we would expect to see local health areas with low health status having a higher than expected supply of PHC providers to meet their additional needs. This would be displayed as a strong, positive association between PMR and supply of general practice providers.There is a moderate level of association between supply of general practice providers and PMR across the province (Figures 1 and 2). When the outlying local health areas of Vancouver Downtown Eastside and Vancouver Island West are excluded, the level of association remains moderate. A number of local health areas with low health status, such as Nisga’a, and the combined areas of Bella Coola/Central Coast and Snow Country/Stikine/Telegraph Creek, show a higher than expected rate of general practice pro-viders.In comparison, the local health areas of Vancouver Downtown Eastside and Vancouver Island West both have low health status, and a lower than expected supply of general practice providers. However, any interpretation of suffi ciency of supply requires simultaneous consider-ation of access to providers in adjacent local health areas. Consider that providers located in Vancouver Island West delivered only 18 percent of general practice services used by people residing in that area in 2001/02 (See Chapter 5:  Access to general practice services). Providers in geographically adjacent local health areas, primarily  105JANUARY 2005Campbell River, supplied an additional 34 percent of gen-eral practice services used by residents of that area. Expenditures on general practice servicesProfi ling the supply of general practice providers is based on the geographic location of providers and their prac-tices—it is a supply-based analysis. But, as illustrated for the local health areas of Vancouver Downtown Eastside and Vancouver Island West, any comprehensive interpreta-tion of service use requires a population-based analysis. In this type of analysis, services are attributed to individuals based on where they live rather than where services were delivered. Juxtaposing information about the supply of providers on the basis of their geographic location with information about how people in that area use services is important to PHC policy and planning. Consider the local health area of Vancouver Island West: a jurisdiction of approximately 2,500 people and a PMR of 4.10 (compared to the pro-vincial average of 2.81). The supply of general practice providers in this LHA (0.5 FTEs per 10,000 population) was much lower than the provincial average (8.7 FTEs per 10,000). But, expenditures on general practice services for this area ($182 per capita, after adjusting for age) were signifi cantly higher than the provincial average ($164 per capita). As noted earlier, general practice providers located outside Vancouver Island West delivered the majority of services received by people living in this local health area.Figure 1: Scatter plotillustrating the association between supply of general practice providers and premature mortality rate 106CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALFigure 2: Bar chart illustrating the association between supply of general practice providers and premature mortality rate 107JANUARY 2005Expenditures on general practice services are fully profi led in Chapter 4. Data used to calculate age-standardized rates of expenditures per capita were obtained from MSP fee-for-service expenditures, Alternative Payments Program fi les, and primary health care organization fi les for 2000/01. MSP fee-for-service expenditures were derived using the fee item specialty methodology.  For the PHC system to be operating equitably, we would expect to see local health areas with low health status us-ing more general practice services to meet their additional needs. This would be displayed as a strong, positive asso-ciation between PMR and expenditures on general practice services.There is a moderate level of association between expendi-tures on general practice services and PMR across the prov-ince (Figures 3 and 4). When the outlying local health area of Vancouver Downtown Eastside is excluded, a strong level of association results. The local health area of Vancouver Downtown Eastside displays both low health status and lower than expected ex-penditures on general practice services. This suggests that this population receives less general practice services than might be expected on the basis of demographics and health status, and therefore need. In comparison, many rural and remote local health areas with low health status—Nisga’a, Bella Coola/Central Coast,Figure 3: Scatter plot illustrating the association between expenditures on general practice services and premature mortality rate 108CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALFigure 4: Bar chart illustrating the association between expenditures on general practice services and premature mortality rate  109JANUARY 2005Snow Country/Stikine/Telegraph Creek, Upper Skeena—show higher expenditures than would be expected on the basis of health and demographic status. In the BC Health Atlas (2nd edition), no (or only a low level of) association was reported between general prac-titioner expenditures and PMR. Why do we then report a moderate to strong level of association between expendi-tures on general practice services and PMR? The most notable difference between the BC Health Atlas and this report is advancement in methodology that allowed our analysis to include general practice services expenditures made under the Alternative Pay-ments Program and primary health care organizations, in addition to MSP fee-for-service payments. The BC Health Atlas counted expenditures associated with fee-for-service physicians only. Indeed, in our own analysis, an assess-ment of just the fee-for-service portion of expenditures also showed no association with PMR, indicating the importance of including alternative payment sources when profi ling such measures for British Columbia. Emergency room visitsEmergency room visits are fully profi led in Chapter 5. Visit rates per 1,000 population were estimated in a previous CHSPR analysis using 1998/99 MSP fee-for-service physi-cian billing claims.  Visits to hospitals where ER physicians are paid through salary and sessional arrangements could Figure 5: Scatter plot illustrat-ing the association between ER visit rates and premature mor-tality rate, estimating ER visit rates in select local health areas on the basis of health status and demographic profi le 110CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALnot be identifi ed through the MSP data and were therefore excluded from analyses. This exclusion particularly affects Vancouver (data from Vancouver General Hospital and St. Paul’s Hospital are unavailable) and selected coastal and northern local health areas. Our analyses on general practice services and providers indicated the importance of including data from alterna-tive funding sources to properly calculate an association with PMR. We therefore conducted analyses to assess the signifi cance of the missing data for ER visits to our overall estimates of the association with PMR.An analysis of MSP fee-for-service data alone suggests a low level of association between ER use and PMR. We judge that eight local health areas in Vancouver and the north display low/under-reported ER visit rates due to alter-native funding arrangements. If we assume that population-based rates of ER use in these eight LHAs are at the provin-cial average, the level of association between ER visits and PMR remains low. However, if we assume that population-based rates of ER use in these eight LHAs are associated with the health status and demographic profi le of the area, the association between ER use and PMR becomes moderate. Figure 5 illustrates this scenario.Two local health areas—Powell River and Cariboo-Chilco-tin—display average health status and higher than expected ER visit rates. The use of ER services in these two areas is an interesting case study, as both record levels of supply of general practice providers and expenditures on general practice services as predicted on the basis of health sta-tus and demographic profi le. Health care administrators, practitioners and people who reside in or service these local health areas are best situated to identify why this might be. 111JANUARY 2005Figure 6: Scatter plot illustrating the association between home-based professional services and premature mortality rate Home-based professional services Home-based professional services include publicly-funded nursing, physiotherapy and occupational therapy and are often used by patients following discharge from a hospital, or by individuals who require assistance to maintain their independence at home. Data used to calculate age-standard-ized visit rates per 1,000 population were obtained from PURRFECT 8.1 for 2001/02. Home-based professional services are fully profi led in Chapter 5.For the PHC system to be operating equitably, we would expect to see local health areas with low health status having a higher than average use of home-based profes-sional services to meet their additional needs. This would be displayed as a strong, positive association between PMR and use of home-based professional services.There is no association between publicly-funded home-based professional service use and PMR across the prov-ince (Figure 6). When the outlying local health areas with few to zero visits are excluded, a moderate level of associa-tion results. These outlying local health areas of Telegraph Creek, Central Coast, Snow Country, Nisga’a, Vancouver Island West, Bella Coola and Stikine display both low health status and lower than expected visit rates. In contrast, Vancouver Downtown Eastside local health area displays the lowest health status across the province and one of the highest visit rates for home-based profes-sional services.  112CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALFigure 7: Scatter plot illustrating the association between home support services and premature mortality rateHome-based professional service use is also much higher than might be expected, based on population health status and age structure, for the local health area of North Thomp-son. Health care administrators, practitioners and people who reside in or service this local health area are best situ-ated to identify why this might be.Home support servicesHome support services are designed to enable individu-als with health problems to remain in their own homes for as long as possible and include personal assistance with daily activities such as bathing, dressing and grooming, as well as household tasks such as laundry, vacuuming and cooking. Data used to calculate age-standardized hours per 1,000 population were obtained from PURRFECT 8.1 for 2001/02. Like home-based professional services, this source includes only publicly-funded home support servic-es. Home support services are fully profi led in Chapter 5.For the PHC system to be operating equitably, we would expect to see local health areas with low health status hav-ing a higher than average use of home support services to meet their additional needs. This would be displayed as a strong, positive association between PMR and utilization of home support services.There is no association between utilization of publicly-funded home support services and PMR across the prov-ince (Figure 7). When the outlying local health areas with  113JANUARY 2005Figure 8: Scatter plot illustrating the association between com-bined PHC expenditures and premature mortality ratelittle to no utilization are excluded, a moderate level of association results. The outlying local health areas of Telegraph Creek, Central Coast, Snow Country, Nisga’a and Stikine display both low health status and lower than expected utilization rates. In contrast, Vancouver Downtown Eastside local health area displays the lowest health status across the province and one of the highest utilization rates of publicly-funded home support services. This is particularly interesting in light of this local health area’s lower than expected supply of gen-eral practice providers and expenditures on general practice services. This suggests that publicly-funded home-based services (home-based professional services and home support services) may serve as an alternative to physician-based care for this population.Utilization of home support services is also much higher that might be expected, based on population health status and age structure, for the local health area of Vancouver City Centre. Health care administrators, practitioners and people who reside in or service this local health area are best situated to identify why this might be.Combined expenditures on primary health careThese analyses highlight general trends, and notable anom-alies, in the levels of association between selected measures of PHC and PMR. A number of local health areas—the  114CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALnorthern local health areas of Nisga’a, Bella Coola/Central Coast, and Snow Country/Stikine/Telegraph Creek—record higher than expected levels of expenditures on general practice services and lower than expected use of emer-gency rooms and/or publicly-funded home-based services. Conversely, one local health area—Vancouver Downtown Eastside—displays lower than expected expenditures on general practice services and higher than expected use of publicly-funded home-based services. An important question is therefore:  “Are services provided by general practice, home-  based and emergency room providers being used interchangeably to address the health needs of certain  populations because of regional variation in service  type availability?”To explore this question further, we summed expenditures on general practice services, emergency room visits22 and publicly-funded home-based care (both home-based professional services and home support services)23 for each local health area, resulting in a measure of combined per capita expenditures on PHC. Because expenditures on emergency room visits and home-based care had to be estimated using an assumed dollar value, we conducted a sensitivity analysis to assess the extent of change in association by using a range of dollar values.24 Altering the amount used to calculate expenditures of emergency room visits and home-based care was shown to have little effect. The reason is that the prime determinant of combined expenditures is expendi-tures on general practice services. A sensitivity analysis was also conducted to assess the extent of change in association under different assumptions about emergency room visit rates in areas where rates had to be estimated because of funding from alternative sources.25 Again, altering these values was shown to have little effect on the measure of combined PHC expenditures. For the PHC system to be operating equitably, we would expect to see local health areas with low health status having a high level of combined PHC expenditures to meet their additional needs. This would be displayed as a strong, positive association between PMR and combined PHC expenditures.Remarkably, we see a strong association between com-bined PHC expenditures and PMR, with few outlying local health areas (Figures 8 and 9). Moreover, all areas (with one exception) with low health status have higher than expected expenditures on PHC. This analysis illus-trates the importance of considering the use of multiple types of services when making judgments about PHC system equity. Areas where equity in resource allocation may appear to be lacking—for example, through lower than expected use of home support services—may instead have their PHC needs met through heavier reliance on a different type of service, such as general practice services.  115JANUARY 2005Figure 9: Bar chart illustrating the association between combined PHC expenditures and premature mortality rate  116CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALChapter 8: ConclusionsThe degree of equity in the allocation of PHC services to populations of varying health status clearly depends on the type of services in question. When considered in isola-tion, general practice services in British Columbia appear to be equitably distributed to health regions in relation to their health status. This fi nding parallels results of analy-sis conducted in other Canadian jurisdictions.26,27,28,29 By comparison, publicly-funded home-based services do not seem to be equitably distributed to health regions relative to variation in the health status of geographic populations. This parallels results of analysis of home care use after inpatient care elsewhere in Canada.30  Importantly, our analyses suggest that general practice services, home-based care and emergency room services work in synchrony to respond to the different needs of local health areas across the province. At a glance, therefore, it would appear that resources allocated to a combined set of PHC services are equitably distributed to health regions in British Columbia in relation to variation in population health status. Another important fi nding relates to the supply of general practice providers and the utilization of general practice services in local health areas with low health status. The story differs depending on whether we consider the rural and remote northern local health areas, and the coastal region of Bella Coola/Central Coast, or whether we look at the densely populated local health area of Vancouver Downtown Eastside.  Rural and remote areas: Supply of general practice providers and use of general practice services in rural and remote local health areas, such as Nisga’a, Bella Coola/Central Coast, Snow Country/Stikine/Telegraph Creek and Upper Skeena, are higher than expected rela-tive to population health status and demographic struc-ture. Combined PHC expenditures were only slightly higher than expected but these areas had low utilization of home-based services and low use of emergency room services. The Canadian Institute for Health Information recently released comparative regional profi les that measure the count of general/family physicians per 100,000 popula-tion (2001 data). These profi les suggest that the northern rural health service delivery areas in British Columbia have crude rates between 91 and 129 general/family physicians per 100,000. By comparison, northern rural regions in Alberta have rates between 69 and 78 per 100,000. Rural regions in Manitoba have rates between 74 and 77 per 100,000. Rural north regions in Ontario have rates between 81 and 93 per 100,000. This sug-gests that strategies to recruit and retain physicians in rural and remote areas in British Columbia appear to be more successful, relative to other jurisdictions. Vancouver Downtown Eastside: Supply of general practice providers and use of general practice services in the local health area of Vancouver Downtown Eastside is lower than expected relative to population health status and demographic structure. Though this local health area had one of the highest utilization levels of publicly-funded home-based services, combined PHC expenditures were slightly lower than expected. CHSPR will continue to conduct work to better identify community-based PHC services and emergency room visits funded through the Alternative Payments Program that have not been included in this analysis. These analyses highlight the critical importance of looking at multiple types of services delivered through the PHC system when making assessments of allocation equity. Using just one or two measures of PHC services does not adequately portray regional variation in the mix of health care services use or the ways in which they are complementary. In addition, these analyses shed light on the importance of carefully tailoring approaches to renew PHC to suit local variations in patterns of service utilization.  117JANUARY 2005The need to operate with all possible information at hand applies equally to the underlying PHC data. The inclusion of data from alternative funding sources, such as the Alternative Payments Program, has an enormous impact on understanding the utilization of general practice services. We would like to construct a similarly compre-hensive picture for BC’s emergency rooms, which are likely to play an important PHC role in certain areas of the province. In planning for PHC renewal, we have provided a fi rst glance of the supply and utilization of PHC services, and the level of equity in the distribution of PHC resources, across the province. However, much work remains to be done to improve the administrative data infrastructure in British Columbia—particularly in relation to data from alternative funding sources—for PHC planning and evaluation. CHSPR is committed to this agenda and looks forward to developing a comprehensive picture of the attributes and qualities of the PHC system in Brit-ish Columbia as we progress through our program of research. 118CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALAccess to general practice servicesGeographic access to general practice services was determined by calculating the percentage of general prac-tice services that patients received in either their own or a geographically adjacent local health area. Data used for this profi le for 2001/02 were obtained from PURRFECT 8.1 (MSP referral patterns, LHA MSP referral reports). MSP services were identifi ed using the fee item specialty method-ology to count the number of services billed in the general practitioner category of the MSC payment schedule. Unlike the Expenditures on General Practice Services profi le, only MSP fee-for-service data from PURRFECT were used to calculate this profi le. Local health areas where more than 10% of general practice services were provided outside the FFS system were excluded from analysis: Vancouver Downtown Eastside (162), Bella Coola (49), Central Coast (83), Fernie (1), Queen Charlotte (50), Nisga’a (92), Snow Country (51), Stikine (87), Upper Skeena (53), and Telegraph Creek (94). Local health areas were considered geographically adjacent unless separated by a body of water with no connecting tun-nel or bridge. Data for the local health areas of Surrey/South Surrey (201/202) are not disaggregated in PURRFECT 8.1. For this profi le only, categorization did not rely directly on the Jenks optimization algorithm. Because the local health area of Vancouver Island West is such a strong outlier that it became the only value in the lowest category, we excluded this LHA when calculating the categories, then added it to the lowest class. Full derivation of this profi le is detailed in Appendix 1. Also see HEALTH BOUNDARIES; MEDICAL SERVICES PLAN; NATURAL BREAKS (JENKS) CATEGORIZA-TION; PURRFECT.Alternative Payments Program (APP)Eight thousand physicians are paid over $2.5 billion for health care services in BC.31 While the majority of physicians are paid under the Medical Services Plan fee-for-service system, about $300 million is paid through the Alternative Payments Program (APP), a compensation arrangement involving salary/sessional payments and service agreements. APP is typically used where fee-for-service payments may not guarantee physicians the fi nancial support or stability to provide needed care, such as for specialized and/or labour intensive services, or for services carried out in training hospitals or in less-populated areas. More information is pro-vided in Appendix 1. Also see MEDICAL SERVICES PLAN.CartogramCartograms are value-by-area maps drawn such that an area is proportional to the data it represents. Cartograms with health service delivery areas sized according to their population are provided in most profi les. Because BC has an uneven population distribution, cartograms provide important context to the choropleth maps. Proportional point symbols are also used: for our profi les, this symbol is a circle and is sized according to local health area population. These proportional circles are drawn using the Flannery method and are superimposed on the population cartogram. Also see CHOROPLETH MAPS; FLANNERY METHOD; HEALTH BOUNDARIES.Children and adolescents (Website/CD only)Percentage of the population aged 19 years or younger. Calculated at the local health area level for 2001 from PEOPLE 28. Children at risk index (Website/CD only)The children at risk index is calculated by BC Stats by assigning relative weights to various measures refl ecting socioeconomic and health issues considered relevant to chil-dren.32 The index is compiled from the following variables (including their relative weight), spanning up to fi ve years of data (1997-2002):VariableRelative weightYear of data% of children <19 on income assistance < 1 year 0.10 Sept 2002% of children <19 on income assistance >1 year 0.20 Sept 2002Children in care per 1,000 population 0-18 0.10 2002Infant mortality per 1,000 live births 0.20 1997-2001% below standard for grade 4 reading, writing & math 0.20 99/00-01/02Criminal charges per 1,000 population aged 12-17 0.20 1999-2001Children are defi ned as aged 19 years or younger. Denominator populations (2001) aged 19 years of younger were derived from PEOPLE 28. This index was calculated at the local health area only: no HSDA-level information is available.Vancouver and Surrey were not partitioned into their component local health areas in the BC Stats methodology. Additionally, BC Stats excluded the following LHAs in their index calculation due to small numbers: Vancouver Island West (84), Queen Charlotte (50), Snow Country (51), Central Coast (83), Stikine (87), and Telegraph Creek (94). Defi nitions and technical notes 119JANUARY 2005Since the completion of our analyses, BC Stats has released (March 2004) an updated 2003 version of their socioeconomic status rankings.33 Also see POPULATION; SOCIOECONOMIC RISK INDEX. Choropleth mapsChoropleth maps use colour to signify the values of the profi le being mapped. Colours are assigned to the unit of analysis—for example, the local health area—on the basis of the particular data category they fall into. Data are categorized using the natural breaks (Jenks) categorization methodology. Also see NATURAL BREAKS (JENKS) CATEGO-RIZATION.Congestive heart failure (CHF)Congestive heart failure (CHF) treatment prevalence was calculated from data for 2001/02 from BC Chronic Disease Management,34 an initiative of the BC Ministry of Health Services. Benefi ciaries insured under the MSP were assumed by BC Chronic Disease Management to have CHF if they had one or more acute inpatient hospital admissions, or two or more physician services within a year, where congestive heart failure was given as a diagnosis. These claims data include services provided by BC practitioners with medi-cal specialties 00 to 21, 23, 24, 28, 29, 33, 44, 47 and 48. Services paid by MSP and PHCOs only are included; APP and other payments are excluded.The all-age treatment prevalence for CHF was calculated by dividing the number of persons with diagnosed CHF in an area by the total population of that area. Data were avail-able at the health services delivery area level only because of the small number of affected individuals. Denominator populations (2001) were derived from PEOPLE 28. All-age treatment prevalence is reported as a crude rate and is not age- or sex-standardized.International guidelines recommend that patients with CHF be treated with drugs such as angiotensin-convert-ing enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARBs).35,36,37 ARBs are recommended when the patient presents with ACE-I or beta-blocker intolerance. Beta-blockers and digoxin may be added for some patients. Loop diuretics are commonly used to control fl uid overload. Spironolactone—another diuretic—is commonly recom-mended for severe congestive heart failure (ejection fraction <35%) if no renal failure is indicated. PharmaNet38 data were used to determine if patients with diagnosed congestive heart failure were receiving recom-mended drugs. Patients were fl agged for an indicator of the recommended services if they received two or more pre-scription medicines on different dates during the fi scal year. Medicines included: •   Angiotensin converting enzyme inhibitors (ACE inhibitors) (therapeutic classes 24080036, 24080028, 24040002, 24080029, 24080031, 24080034, 24080032);•   Angiotensin II receptor antagonists or blockers (ARBs) (therapeutic classes 24080042, 24080040, 24080041, 24080037, 24080043); •   Beta-blockers (therapeutic classes 24080010, 24080002); •   Digoxin (therapeutic class 24040004); •   Diuretics other than spirinolactone (therapeutic classes 40280014, 40280009, 40280006, 40280013, 40281003, 40281001, 40280019); and •   Spirinolactone (therapeutic class 40281002). Also see MEDICAL SERVICES PLAN; POPULATION, PRIMARY HEALTH CARE ORGANIZATIONS.DiabetesDiabetes treatment prevalence was calculated from data for 2001/02 from BC Chronic Disease Management),34 an initiative of the BC Ministry of Health Services. Benefi cia-ries insured under the MSP were assumed by BC Chronic Disease Management to have diabetes if they had one or more hospital admissions or two or more physician services within a year where diabetes was given as a diagnosis; or they had one or more PharmaNet claims for insulin, oral hypoglycaemics or glucose testing strips.39 The all-age treatment prevalence for diabetes was calculated by dividing the number of persons with diagnosed diabetes in an area by the total population of that area. Denominator populations (2001) were derived from PEOPLE 28. All-age prevalence is reported as a crude rate and is not age- or sex-standardized.The chronic complications associated with diabetes can be delayed or even prevented with appropriate self-management and clinical care.40,41 In BC, clinical practice guidelines42 for diabetic care recommend services including: •   two or more HbA1C tests during a year (MSP fee item 91745); •   at least one retinal eye exam per year (MSP fee items 2010, 2011, 2015, 2040, 2039, 2898, 2899); •   at least one urinary microalbumin test per year (MSP fee items 92396, 91985); and •   at least one serum lipid test every three years (MSP fee items 91375, 91780, 92350). 120CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALMSP fee-for-service physician billing claims data by date of service were used to determine if patients with diagnosed diabetes received a series of recommended services. Services provided by BC practitioners with medical specialties 00 to 21, 23, 24, 28, 29, 33, 44, 47 and 48, and paramedical specialties 38 and 39 were included. Only services paid by MSP were included. Adjacent local health areas were aggregated when less than fi ve general practice providers were located within a given local health area: Bella Coola/Central Coast (49/83); Cowichan/Lake Cowichan (65/66); Campbell River/Vancou-ver Island West (72/84); South Okanagan/Keremeos (14/16); Kootenay Lake/Nelson (6/7); Grand Forks/Kettle Valley (12/13); Upper Skeena/Smithers (53/54); Peace North/Fort Nelson (60/81); Terrace/Nisga’a (88/92); Queen Charlotte/Prince Rupert (50/52); Snow Country/Stikine/Telegraph Creek (51/87/94). In addition, data for the local health areas of Surrey/South Surrey (201/202) were not disaggregated.Receipt of recommended services data for the local health areas of Prince Rupert and Queen Charlotte were unreliable due to a known laboratory reporting error and were excluded from analysis. Also see MEDICAL SERVICES PLAN; POPULA-TION.Dissemination area (DA)The smallest standard geographic area for which all census data are disseminated. A dissemination area (DA) is a small, relatively stable geographic unit composed of one or more neighbouring blocks with a population of 400-700. DAs cover the entire territory of Canada.43 Emergency room visitsAn emergency room (ER) visit is defi ned as use of a hospital-based emergency department and is reported as an age/sex-standardized rate per 1,000 population. In the absence of a province-wide tracking system for emergency room services, the vast majority of visits are captured in MSP information on fee-for-service payments to physicians.CHSPR developed an ER visits indicator using data from 1998/99 MSP fee-for-service physician billing claims.44 This indicator relies on identifying all MSP services that occur in a hospital, excluding non-physician and non-emergency fee items and services associated with an inpatient stay, and excluding all billings with unknown age/sex/LHA. Visits to hospitals where ER physicians are paid through salary and sessional arrangements could not be identifi ed through the MSP data and were therefore excluded from analysis (detailed below).Results were validated against the BC Ministry of Health Services record of total ER visits. Approximately 83% of ER visits in BC were accounted for. However, it should be noted that the process of identifying all ER services is not well understood. There are several methods for billing ER services, and many physician specialties may be billing for ER services. A further complication is that not all emergency services occur in an ER.Visit rates per 1,000 population were age/sex-standardized using indirect standardization and fi ve year age groupings. Visit rates were then adjusted by removing excluded local health areas, assuming that age/sex-specifi c utilization remained the same after these exclusions. Denominator populations (2001) were derived from PEOPLE 28. The local health areas where hospitals paid through salary and sessional arrangements are located were excluded from the profi le mapping: Vancouver General Hospital (LHAs 161-166), St. Paul’s Hospital in Vancouver (LHAs 161-166); Bella Coola General (LHA 49), R.W. Large Memorial Hos-pital in Waglisla (LHA 83), and Wrinch Memorial Hospital in Hazelton (LHA 53). In addition, data for the local health areas of Surrey/South Surrey (201/202) were not disaggre-gated. Also see MEDICAL SERVICES PLAN; POPULATION. Expenditures on general practice servicesExpenditures on general practice services were reported as an age-standardized rate per capita. Data used to calculate expenditures on general practice services were obtained from PURRFECT 8.1 (MSP referral and utilization rates programs), 2000/01 Alternative Payments Program (primary care services) fi les and 2000/01 primary health care organi-zation fi les. MSP fee-for-service expenditures were derived using the fee item specialty methodology to count dollars on services billed in the general practitioner category of the MSC payment schedule. Denominator populations (2001) were derived from PEOPLE 27.Several local health areas were aggregated due to a recog-nized problem with the allocation of APP funds to specifi c local health areas at the expense of neighbouring regions. The affected LHAs are: Bella Coola/Central Coast (49/83); Snow Country/Stikine/Telegraph Creek (51/87/94). Data for the local health areas of Surrey/South Surrey (201/202) are not disaggregated in PURRFECT 8.1. Full derivation of this profi le is detailed in Appendix 1. Also see ALTERNA-TIVE PAYMENTS PROGRAM; MEDICAL SERVICES PLAN; PRIMARY HEALTH CARE ORGANIZATIONS; POPULATION; PURRFECT.  121JANUARY 2005Fee-for-service (FFS)A payment system for physician services where the pro-vider is paid for each service rendered, according to a set fee schedule. Also see MEDICAL SERVICES PLAN.Flannery methodThe Flannery method, also known as apparent-magnitude scaling, is a method for scaling the size of proportional point circles that more closely matches how their sizes are per-ceived. All proportional point circles have been increased by 12%.45 Also see CARTOGRAM.Health boundariesProvincial ministries of health defi ne geographic health regions as legislated administrative areas with health care service delivery responsibilities. The current sub-provincial health boundaries in British Columbia defi ne six health authorities, 16 health service delivery areas, and 89 local health areas. Five health authorities—Fraser, Vancouver Coastal, Vancouver Island, Interior, and Northern—are responsible for providing a range of services to geographi-cally defi ned sub-populations, from acute hospital care to home and community-based services. The sixth authority, the Provincial Health Services Authority, is responsible for highly specialized health care services and provincial programs and organizations and does not have a sub-pro-vincial population base. Each of the fi ve health authorities is comprised of three or four health service delivery areas, which in turn are divided into local health areas, which generally follow political and natural boundaries.Home-based professional servicesHome-based professional services include publicly-funded nursing, physiotherapy and occupational therapy, and can include assessment, treatment, consultation, referral and/or case management. Visit rates were reported per 1,000 popu-lation and were age-standardized using the indirect method and 20 age groups. Data were obtained from PURRFECT 8.1 for 2001/02 (Continuing care age-standardized utilization rates module), BC Ministry of Health Services. Total (Extended Care, Intermediate Care 1, 2, 3 and Personal Care) care levels were selected. Data for the local health areas of Surrey/South Surrey (201/202) are not disaggregated in PURRFECT 8.1. Denominator populations (2001) derived from PEOPLE 27. Also see HOME SUPPORT SERVICES; POPULATION; PURRFECT.Home support servicesHome support services are designed to enable individu-als with health problems to remain in their own homes for as long as possible and include personal assistance with daily activities such as bathing, dressing and grooming as well as household tasks such as laundry, cleaning and meal preparation. Like home-based professional services, this source includes only publicly-funded home support services. Utilization of home support is reported as hours per 1,000 population and was age-standardized using the indirect method and 20 age groups. Data were obtained from PURRFECT 8.1 for 2001/02 (Continuing care age-standardized utilization rates module), BC Ministry of Health Services. Total (Extended Care, Intermediate Care 1, 2, 3 and Personal Care) care levels were selected. Data for the local health areas of Surrey/South Surrey (201/202) are not disaggregated in PURRFECT 8.1. Denominator populations (2001) derived from PEOPLE 27. Also see HOME-BASED PROFESSIONAL SERVICES; POPU-LATION; PURRFECT.Infant mortality rate (IMR) (Website/CD only)Infant mortality is defi ned as any death occurring to a person within the fi rst year of life and is expressed as a rate per 1,000 live births. It is considered a general indicator of population health because it is related to the underlying health of the mother, public health practices, socioeconomic conditions and availability and use of appropriate health care by pregnant women and their children.Infant mortality rate was calculated by the BC Vital Statistics Agency based on fi ve years of aggregated date (1997-2001).32 Several local health areas were aggregated to provide more stable rates in thinly populated areas: Koote-nay Lake/Nelson (6/7); Grand Forks/Kettle Valley (12/13); Campbell River/Vancouver Island West (72/84); and Sti-kine/Telegraph Creek (87/94). Data for the local health areas of Surrey/South Surrey (201/202) were not disaggregated. Rates based on less than 200 live births were highlighted on the relevant health authority maps. International comparisons were available from the United States Bureau of the Cen-sus.46 Location of general practice providersThe geographic location of general practice providers was determined using type of practice methodology to identify general practice providers by MSP billing address. Data were obtained from the 2001/02 Medical Services Plan practitioner and billing fi les. Note that the Supply of General  122CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALPractice Providers profi le uses 2000/01 MSP data because of the requirement for consistency with combined data sources. This profi le uses more recent MSP data (2001/02). Popula-tion density is shown as persons per km2 by dissemination area from 2001 Census, Statistics Canada.In larger urban areas (the entirety of Fraser Health Author-ity, the Vancouver/Richmond/North Shore area, Victoria, Nanaimo, Kelowna, Vernon, Penticton, Kamloops, and Prince George), location was determined by six-digit postal code. In more rural areas, the map scale was unsuitable for mapping specifi c postal code locations. Location was instead determined by the town or city as identifi ed in the billing address. Where general practice provider location is mapped by postal code, circle sizes are range-graded for simplicity. Where general practice provider location is mapped by town, circle sizes vary in proportion to the number of providers, using Flannery scaling. This profi le does not include Alternative Payments Pro-gram or primary health care organization data. Areas which rely heavily on receipt of general practice services through the APP, such as most of the local health areas in the North-west health services delivery area, as well as the local health areas of Bella Coola and Central Coast, therefore appear to have very few general practice providers. Full derivation of this profi le is detailed in Appendix 1. Also see ALTERNATIVE PAYMENTS PROGRAM; DISSEMINATION AREA; FLANNERY METHOD; MEDICAL SERVICES PLAN; PRIMARY HEALTH CARE ORGANIZATIONS.Medical Services Commission (MSC)The Medical Services Commission (MSC)47 is responsible for managing the Medical Services Plan on behalf of the Government of British Columbia. The MSC must ensure that all BC residents have reasonable access to medical care, and is responsible for managing the provision and payment of medical services in an effective and cost-effi cient man-ner. The MSC includes representatives of government, the BCMA, and MSP benefi ciaries. Also see MEDICAL SER-VICES PLAN.Medical Services Plan (MSP)The Medical Services Plan (MSP)48 is the funding mechanism used in BC to insure medically required services provided by physicians and supplementary health care practi-tioners, laboratory services and diagnostic procedures. Under the MSP billing system, the BC government pays providers based on the number of procedures performed for each patient, a method referred to as fee-for-service. The Medical Services Plan payment fi les include fee-for-service payments to BC providers for services to BC and non-BC residents, and payments made on behalf of BC residents who obtained services in Quebec, the US, and other countries. Out-of-province payment data is partitioned separately and includes fee-for-service payments to out-of-province physicians for services to BC residents. When a BC resident receives services in another province (excluding Quebec), the other province bills back to BC ‘manually’—i.e. not through the standard claim submission process. The MSP is managed by the Medical Services Commission. More information is provided in Appendix 1. Also see ALTERNATIVE PAYMENTS PROGRAM; MEDICAL SERVICES COMMISSION. Natural breaks (Jenks) categorizationNatural breaks categorization uses the Jenks method, an optimization algorithm, to group data into classes of similar value. The algorithm forms groups that are internally homogeneous while assuring heterogeneity among classes. In situations where only one local health area fell into a category by itself, the outlier value was removed, the natural breaks were recalculated, and the outlier value assigned to the relevant category. Also see CHOROPLETH MAPS.Older adultsPercentage of the population aged 65 years or older. Calcu-lated at the local health area level for 2001 from PEOPLE 28. Also see OLDER ADULTS LIVING ALONE; POPULATION.Older adults living alone (Website/CD only)The percentage of the population aged 65 years or older (older adults) and living alone was calculated by dividing the number of older adults living alone in an area by the popula-tion of older adults in that area. Both numerator and denomi-nator were derived from the 2001 Census, Statistics Canada for this profi le (note difference with Older Adults profi le). Census estimates were derived from a 20% sample of households in the province (where one in every fi ve house-holds provides more detailed information to correct and extend general census results). Because this sample did not include individuals who lived in “collective dwellings” (e.g. lodgings, rooming houses, hotels, nursing homes, hospitals), this profi le is likely to underestimate the number of older adults living alone. For the 2001 Census, an estimated 48,690 people in BC lived in collective dwellings, of which 34,600 lived in health care and related institutions.49 Also see OLDER ADULTS; POPULATION. 123JANUARY 2005PopulationLocal health area denominator populations are derived from PEOPLE (Population Extrapolation for Organizational Planning with Less Error),15 BC Stats (unless otherwise stated). PEOPLE is developed from information provided by Statistics Canada and aims to correct for known census under-counting.50  Population counts and projections are updated on an annual basis with PEOPLE 28, providing population counts as of July 1st 2001, being the most current version. PEOPLE 28 was developed with information from the 2001 Census, Statistics Canada. 2001 Census data are used to calculate denominator popu-lations for three profi les: Population Density, Older Adults Living Alone and Location of General Practice Providers. Also see Appendix 2 (Website/CD only).Population densityPopulation density was mapped using dissemination area data from the 2001 Census, Statistics Canada. One dot equals one hundred residents. Population fi gures are given for all urban areas in BC with a population greater than 2,000. Urban areas, as defi ned by Statistics Canada, have a minimum population concentration of 1,000 persons and a population density of at least 400 persons per km2.Because most of the Lower Mainland is treated as one urban area (Vancouver), it was divided into its component census subdivision (CSD) populations. A CSD is defi ned as a municipality or area deemed to be equivalent to a munici-pality for statistical reporting purposes, such as an Indian reserve.51 CSD populations were not used for the entire province because they are often misleading. For instance, a large part of a municipal population could be rural or semi-rural. Urban area population fi gures more accurately refl ect the actual populations of towns and cities in BC. Also see DISSEMINATION AREA; POPULATION.Population growth (Website/CD only)Population growth was determined by calculating the percentage change in population size for each local health area between 1991 and 2001 from PEOPLE 28. Also see POPULATION.Projected population growth was calculated for the period 2001 to 2011, from PEOPLE 28. (Website/CD only).Potential years of life lost (PYLL) (Website/CD only)Potential years of life lost (PYLL) is calculated by summing the number of years of life ‘lost’ when a person dies before age 75 and gives a high weight to early deaths: a death at age 15 years adds 60 to the overall measure (75 minus 15), while a death at 74 years adds a value of only one (75 minus 74).The PYLL index is expressed as a ratio of a region’s observed PYLL to that which would be expected for the region if it had a pattern of early deaths consistent with that of the province overall. The provincial PYLL index equals 1.00. Values greater than 1.0 indicate a region has more deaths at younger ages (lower health status); values below 1.0 indicate fewer deaths at younger ages (higher health status).The PYLL index was calculated by the BC Vital Statistics Agency based on fi ve years of aggregated data (1997-2001).52 Several local health areas were aggregated to provide stable rates in thinly populated areas: Kootenay Lake/Nelson (6/7); Grand Forks/Kettle Valley (12/13); Campbell River/Vancouver Island West (72/84); and Stikine/Telegraph Creek (87/94). Data for the local health areas of Surrey/South Surrey (201/202) were not disaggregated. Premature mortality rate (PMR)The premature mortality rate (PMR) is calculated by dividing the number of deaths among people aged 0 to 74 in an area by the total population aged 0-74 in that area, and is reported as a rate per 1,000 population. PMR is based on mortality incidence annualized over 1996-2000, and is indirectly standardized to account for age/sex differences in populations. Mortality data was available from the BC Vital Statistics Agency. To this were added out-of-province deaths of BC residents, as identifi ed in hospital separations data from the BC Ministry of Health Services. Any deaths with unknown age, sex, or local health area were excluded. Denominator populations (2001) were derived from PEOPLE 28. Also see POPULATION.Primary health care (PHC)For most people, primary health care is the fi rst point of contact with the health care system, often through a family physician. It is also where patients in need of more special-ized services are linked to secondary care. PHC is where short-term health issues are resolved, the majority of chronic health conditions are managed, and where health promotion and education efforts are undertaken. It can involve a broad range of services such as screening, health information, examinations, vaccinations, prenatal care, home visits, nutritional counseling, drug dispensing, palliative care and mental health services. Physicians, dieticians, home care  124CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALworkers, nurses, occupational therapists, physiotherapists, pharmacists, social workers and other health care workers all deliver PHC services.Primary health care organizations (PHCOs)Primary health care organizations (PHCOs) were estab-lished in British Columbia in 1998, originally as primary care demonstration projects. PHCOs now operate as an integral part of the primary health care system in BC. More information is provided in Appendix 1.PURRFECTPURRFECT (Population Utilization Rates and Referrals for Easy Comparative Tables) is a BC Ministry of Health Services database that captures acute care, MSP, mental health and continuing care services.53 All data in PURRFECT is for the latest available fi ve-year period and does not include information for the current year to date. More information is provided in Appendix 1. Socioeconomic risk indexThe socioeconomic risk index is calculated by BC Stats by assigning relative weights to various measures refl ecting social and economic conditions.32 The index is intended only to fl ag regions that may be experiencing higher levels of socioeconomic stress relative to neighbouring areas. The index is compiled from the following variables (including their relative weight), spanning up to fi ve years of data (1997-2002):VariableRelative weightYear of dataHealth problems (20% of overall index)PYLL due to natural causes per 1,000 pop. 0.40 1997-2001PYLL due to external causes per 1,000 pop. 0.30 1997-2001PYLL due to suicide/homicide per 1,000 pop. 0.30 1997-2001Economic hardship (30% of overall index)% pop. 0-64 on income assistance < 1 year 0.25 Sept 2002% pop. 0-64 on income assistance > 1 year 0.50 Sept 2002% seniors receiving maximum guaranteed income supplement 0.25 2002Crime (20% of overall index)Serious violent crime rate per 1,000 pop. 0.35 1999-2001Serious property crime rate per 1,000 pop. 0.50 1999-2001Number of serious crimes per police offi cer 0.15 1999-2001Education concerns (20% of overall index)% pop. 25-54 without completed post-secondary 0.40 2001% 18-year olds who did not graduate 0.30 99/00-01/02Mathematics 12 provincial exam non-completion 0.10 99/00-01/02% below standard for grade 4 reading, writing & math 0.10 99/00-01/02Children at risk (5% of overall index)% of children <19 on income assistance < 1 year 0.10 Sept 2002% of children <19 on income assistance > 1 year 0.20 Sept 2002Children in care per 1,000 pop. 0-18 0.10 2002Infant mortality per 1,000 live births 0.20 1997-2001% below standard for grade 4 reading, writing & math 0.20 99/00-01/02Criminal charges per 1,000 pop. aged 12-17 0.20 1999-2001Youth at risk (5% of overall index)% youth 19-24 on income assistance < 1 year 0.20 Sept 2002% youth 19-24 on income assistance > 1 year 0.40 Sept 2002% 18-year olds who did not graduate 0.20 99/00-01/02Total serious crime rate per 1,000 pop. 0.20 1999-2001Denominator populations (2001) were derived from PEOPLE 28. This index was calculated at the local health area only: no HSDA-level information is available.Vancouver and Surrey were not partitioned into their component local health areas in the BC Stats methodology. Additionally, BC Stats excluded the following LHAs in their index calculation due to small numbers: Queen Charlotte (50), Snow Country (51), Central Coast (83), Vancouver Island West (84), Stikine (87), and Telegraph Creek (94).Since the completion of our analyses, BC Stats has released (March 2004) an updated 2003 version of their socioeconomic status ranking.33 Also see CHILDREN AT RISK INDEX; POPULATION. Supply of general practice providers Supply of general practice providers is reported as an age/sex-standardized rate of full-time equivalent (FTE) general practice providers per 10,000 population. Data used to estimate the supply of general practice providers were obtained from 2000/01 Medical Services Plan practitioner and billing fi les, 2000/01 Alternative Payments Program fi les and 2000/01 primary health care organization fi les. MSP fee-for-service providers were estimated using type of practice methodology to identify provider specialty and FTE contribution. Denominator populations (2001) were derived from PEOPLE 28. Several local health areas were aggregated due to a recog-nized problem with the allocation of APP funds to specifi c local health areas at the expense of neighboring regions. The affected LHAs are: Bella Coola/Central Coast (49/83); Snow Country/Stikine/Telegraph Creek (51/87/94). Full derivation of this profi le is detailed in Appendix 1. Also see ALTERNA-TIVE PAYMENTS PROGRAM; MEDICAL SERVICES PLAN; PRIMARY HEALTH CARE ORGANIZATIONS; POPULATION.  125JANUARY 2005Supply of nurses (Website/CD only)Supply of nurses is reported as a crude rate of nurses per 10,000 population. Registered nurses, registered psychiatric nurses, and licensed practical nurses are included. Data on the number of nurses was derived from Inventory Update 2000: A Regional Analysis of Health Personnel in the Prov-ince of British Columbia.54 Denominator populations (2000) were derived from PEOPLE 28. The majority of nurses work in acute health care rather than primary health care. Acute health care facilities are shown sized by weighted cases, which are used as a measure of resource intensity and include total inpatient, surgical day care and rehabilitation service activity. Information on the relative acuity, severity and complexity (all age groups) is used to weight cases. Only hospitals with more than 1,000 weighted cases are included. Data on weighted cases for 2000 was derived from PURRFECT 7.1 (Hospital compara-tive reports 3.10). Vancouver and Surrey were not partitioned into their component local health areas in this methodology.  126CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALPrimary health care (PHC) is often thought of as a profes-sional discipline (e.g. family physician, nursing), a loca-tion of care (e.g. walk-in clinic or emergency room), or, as we consider it for the purposes of our research program, a service function. When profi ling PHC it is important to clearly identify whether the measure is based on service type, provider type and/or location of care. For this report we made a deliberate decision to move away from the terms typically used to describe general practitioners and/or family physicians. Researchers and analysts in the province have historically, and correctly, used these terms when referring to physicians who hold these specialty designations. But these terms have also been used to refer to physicians who predominantly bill for services in the general practice section of the BC Medical Services Commission (MSC) payment schedule. These physicians may hold designations in pediatrics, internal medicine or other specialties. In this report, we have profi led services funded through three sources:•   fee-for-service payments made through the BC Medi-cal Services Plan (MSP);•   primary care services funded through the BC Alterna-tive Payments Program (APP); and •   primary care services funded through primary health care organizations (PHCOs).Expenditures attributed to the latter two funding arrange-ments may relate to PHC services provided by both physicians and other health care professionals. This, and ongoing work in our research program, has convinced us of the need for a new lexicon to profi le PHC in British Columbia. This report takes the fi rst step by introducing new terms tied closely to the methodology we used to defi ne PHC providers and the services they deliver:General practice providers: Defi ned by physician type of practice, on a “head-count” basis, and may include other health care providers funded by the APP and/or PHCOs. (See Supply of general practice providers; Loca-tion of general practice providers.)General practice services: Defi ned by fee item spe-cialty, on a “dollar” basis. (See Expenditures on general practice services; Access to general practice services.)We specifi cally chose NOT to use “family physicians” or “family physician services” in these profi les. Both type of practice and fee item specialty methodologies identify physicians based on the types of services they deliver, rather than their specialty designation. In this and future CHSPR reports relating to PHC, we will reserve the term “family physician” to describe providers identifi ed using the most recent registered specialty methodology. This methodology is not used in the profi les in this report. These defi nitions are by nature still emerging and we will be developing and refi ning them further throughout our research program. However, a core theme is our desire to distinguish physicians on the basis of the way they actually practice, and to use the term “general practice providers” when a profi le includes both physicians who have a general practice and other PHC providers. We know that the methodology used to measure PHC ser-vices and providers substantively infl uences the fi ndings, and therefore the policy implications, of our research. Future CHSPR reports will further refi ne and defi ne the PHC lexicon in British Columbia, to improve communi-cation in the policy, practice and research community and our understanding about the province’s PHC system. Background information on types of methodology and physician payment in British Columbia is detailed below, followed by a description of the approach used for each general practice profi le.  Appendix 1: General practice profi les 127JANUARY 2005Identifying physicians Physician specialties can be identifi ed in a number of ways. The most familiar methodology is by most recent registered specialty (MRRS), as designated by the physician’s most recent specialty registration with the MSP. This is a self-reported measure of each physician’s licensure and registration status. This methodology is not used in this report, but more information is provided below on how this methodology compares to type of practice. In contrast, type of practice (TOP) is a methodology that uses physician billing information to categorize each physician based on the way they actually practice. For example, a physician could report their MRRS as a family physician, but may actually have a billing pattern more closely representing emergency medicine. He or she would be identifi ed as an emergency medicine physician by type of practice, despite their registered status as a family physician. By comparison, a physician could report their MRRS as pediatrics, but may actually have a billing pattern more closely representing a general practice physi-cian. He or she would be identifi ed as a general practice physician by type of practice, despite their registered status as a pediatrician. BC’s MSP uses the TOP method-ology for creating practitioner profi les.55 Fee item specialty is a third type of methodology that identifi es different types of services. All services covered under the MSP are identifi ed by particular fee items in the MSC payment schedule used by fee-for-service physi-cians. These fee items are grouped into broad categories and different types of physicians are said to “own” a section for the purposes of fee negotiations. For example, fee item “0532 electrocardiogram and interpretation for children under 2 years of age” is owned by specialty 14-paediatrics. Specialty 00-family physicians own fee items in the “general practice” category. This “owner-ship”, however, does not imply exclusive billing: any practitioner billing under the MSP can bill any applicable fee item. The use of fee item specialty methodology, therefore, captures all billings in a particular category of the MSC payment schedule, regardless of the type of physician who provided those services. PURRFECT, a BC Ministry of Health Services database uses fee item specialty methodology to identify services provided by general practitioners, even though these services may be delivered by physicians who have other MRRS specialty designations.  For the purposes of this report, the important difference between TOP and fee item specialty is that TOP starts by looking at physicians and how they bill, and then decides how they should be categorized based on their billing pat-tern. We describe this as a “head-count” basis and there-fore include these physicians when identifying “general practice providers.” Fee item specialty, however, starts by looking at the dollars spent in a particular category of the MSC payment schedule, rather than at the physicians who bill these dollars. We describe this as a “dollar” basis and therefore include these expenditures when calculating “general practice services.”Sources of physician payment data in British ColumbiaA number of different methods of physician payment are used in British Columbia. The majority of BC physicians are paid under the MSP fee-for-service system. However, a number of physicians are paid on a salaried/sessional basis under the APP. The APP also funds service agree-ments with organizations, from which physicians and other providers receive remuneration. Examining physi-cian supply and expenditure using only MSP data can lead to under-estimates for particular areas of the province (e.g. rural and remote) and or particular services (e.g. emergency room services) that rely more heavily on the APP. We have invested signifi cant time and energy into developing a methodology that captures all available pay-ment data for relevant profi les. The results are presented in this report for the fi rst time.  128CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALMSP fee-for-service: The majority of BC physicians are paid on a fee-for-service basis under the MSP. Fee-for-service physicians are paid a specifi c fee for each service provided for each patient, and physician income from this source ultimately depends on the number and types of services he or she provides. In this report, we commonly refer to fee-for-service data simply as MSP data. Data on MSP fee-for-service payments to physicians can be obtained directly from MSP practitioner and billing fi les (which include most recent registered specialty as well as type of practice identifi ers for each physician), or through PURRFECT (which uses fee item specialty methodology to calculate physician expenditures). APP: Alternative payments are used to remunerate physi-cians who receive salary and sessional payments, and to fund service organizations that may hire physicians and other health care providers. The APP is administered from within the BC Ministry of Health Services.  •   Sessional payments: Sessional payments are time-based rather than service-based. Sessional fees are negotiated between the BC Medical Association and the MSC.  •   Service agreements: Under a service agreement, APP funds an agency that then contracts or directly employs individual physicians (or a mix of health care practitioners) for the delivery of services. Service agreements are the most common method of payment under the APP.•   Salaried payments: This type of funding arrangement remunerates salaried physicians.Data on all types of APP payments to physicians and service organizations are obtained directly from the APP.PHCOs: Primary health care organizations were estab-lished in British Columbia in 1998. Originally primary care demonstration projects, PHCOs are now an integral part of the primary health care system. In 2000/01, payments of $4,068,630 outside of the MSP fee-for-ser-vice system and APP were made to primary health care organizations, as indicated at Table 1. Data on PHCO encounters are obtained directly from the BC Ministry of Health Services. Table 1: Summary of payments to primary health care organizations (by local health area location) to 2002/03LHA 1999/2000 2000/2001 2001/2002 2002/2003Langley (35) $789,917 $1,549,386 $1,853,873 $1,906,846Kamloops (24) $401,383 $672,396 $830,051 $1,094,554Vancouver – Midtown (165) $258,340 $704,603 $940,164 $1,003,856Vancouver – City Centre (161) $368,137 $817,236 $1,020,289 $1,178,272Greater Victoria (61) $162,504 $325,008 $374,177 $594,766Agassiz-Harrison (76) - - - $745,532TOTAL $1,980,281 $4,068,630 $5,018,555 $6,523,825Notes: Values in 2002/03 were obtained during year-end calculations. Values for prior years were obtained by summing level two adjustments. Some payments many have been made outside the claims system. 129JANUARY 2005Expenditures on general practice           services profi leThis profi le includes MSP fee-for-service expenditures, APP-funded primary care services, and payments made to PHCOs. MSP fee-for-service expenditures were derived using the fee item specialty methodology to count dol-lars spent on services billed in the general practitioner category of the MSC payment schedule. These three data sources are compiled to develop a comprehensive profi le and reported as per capita expenditures on general practice services.Data source: PURRFECT (2000/01)PURRFECT is a BC Ministry of Health Services database that captures acute care, MSP, mental health and continu-ing care services. PURRFECT aggregates MSP services based on all fee items owned by a given physician specialty. Data used to calculate expenditures on services billed from the general practice category of the MSC pay-ment schedule were obtained from PURRFECT 8.1 (MSP referral and utilization rates programs), using the general practitioner (0) category. This category includes general practitioners (0), public health and community medicine (21) and occupational medicine (23). In 2000/01, general practice service expenditures identifi ed through MSP bill-ing totaled $649 million; the latter two groups billed just $4,469 dollars of this amount.The PURRFECT MSP referral application provides utili-zation rates and detailed client and physician referral pat-terns by year and geo-region. Referral analysis is based on the patient’s place of residence (patient local health area) and physician’s billing address (practice local health area) as recorded by MSP. Expenditure amounts include the paid amount, Northern isolation allowance, rollback, fee item rollback and interest. Only fee-for-service payments made through the MSP are identifi ed. Midwife, WCB and ICBC claims, services to non-residents and out-of-prov-ince payments to BC residents are all excluded. Crude rates are age-standardized using indirect standardization using 20 age groups.We converted the age-standardized rate per 1,000 popu-lation provided by PURRFECT into a per capita rate. Age-standardization was based on PEOPLE 27 (2001) population counts. The per cent difference between the crude rate and the age-standardized rate was calculated to estimate the effect of age-standardization. Data sources: Alternative Payments Program and PHCO (2000/01)To capture the general practice services provided outside the MSP, we used data from the APP, and PHCO fi les provided by the BC Ministry of Health Services.From the APP, all dollars allocated to programs desig-nated as “primary care” were included, with the exception of the dollars allocated to the Canadian Red Cross. In 2000/01, $12,234,323 was paid to primary care programs through the APP, of which $340,116 was for the Canadian Red Cross. In 2000/01, payments of $4,068,630 were made to PHCOs (see Table 1).We assumed that APP “primary care” and PHCO services were utilized by patients living in the LHA to which pay-ments have been designated (exceptions detailed below).CHSPR profi le using combined data sourcesThe crude rate of expenditures on general practice ser-vices per capita was calculated based on the sum of MSP data from PURRFECT, APP “primary care”, and PHCO payments assigned to each local health area, divided by the size of the population of that local health area. Denominator populations were derived from PEOPLE 27.To age-standardize the crude rates, we used the indirect method based on expenditures related to MSP-based general practice services by age using 20 age categories. The impact of age-standardizing for each local health area was determined as a percentage increase or decrease. This measure of change was then applied to APP and PHCO  130CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALcrude estimates to convert them to age-standardized expenditures per capita. Several local health areas were aggregated due to a recog-nized problem with the allocation of APP funds to specifi c local health areas at the expense of neighbouring regions. The affected LHAs are Bella Coola/Central Coast (49/83); Snow Country/Stikine/Telegraph Creek (51/87/94). Sur-rey/South Surrey (201/202) are also aggregated because, as previously discussed, PURRFECT 8.1 does not disag-gregate their data into separate local health areas. In 2000/01 age-standardized expenditures for general practice services in British Columbia were approximately $665 million or $164 per capita.Access to general practice services profi leThis profi le measures the utilization of general practice services using fee item specialty methodology to count services billed in the general practice category of the MSC payment schedule. However, this profi le uses a single data source only—MSP fee-for-service data from PURRFECT 8.1 (MSP referral patterns and LHA MSP referral rates, 2001/02 data). (See Expenditures on General Practice Services profi le for details.) APP and PHCO data are not included. Geographic access to general practice services is reported as a percentage of general practice services that patients received in either their own or a geographically adjacent local health area. Local health areas where more than 10% of general practice services were provided outside the FFS system were excluded from analysis. Local health areas were considered geographically adjacent unless separated by a body of water with no connecting tunnel or bridge. In British Columbia in 2001/02, 66% of general prac-tice services were provided to patients in their own local health area and an additional 19% in a geo-graphically adjacent area. Overall, 84% of general practice services were provided in patients’ own or a geographically adjacent local health area. Supply of general practice providers profi leThis profi le measures the supply of general practice providers using type of practice methodology to estimate MSP fee-for-service providers on the basis of the type of services they deliver. Estimates of providers who receive funds through the APP and PHCOs are also included. Theses three data sources are compiled to develop a com-prehensive profi le and reported as an age/sex-standardized rate of full-time equivalent (FTE) general practice provid-ers per 10,000 population.Data source: MSP practitioner and billing fi les (2000/01)Type of practice methodology is used to identify provider practice patterns. To count the number of MSP provid-ers, we identifi ed physicians who had a BC postal code, received remuneration in the period, and had a type of practice entitled general practice (type of practice code 00). For the purposes of this report, we did not include physicians with other primary care-relevant type of prac-tice designations. For example, physicians assigned to the type of practice groups entitled “GP-Alternative Payments at 50%+”, “GP-Miscellaneous” or “PHCO physician” (type of practice codes 61, 55, and 63 respectively) were not included in this MSP-based analysis. CHSPR will profi le and release information about the number of physi-cians with these types of practice in 2005. The type of practice designation, and the full-time equivalent contribution that each provider makes is used to estimate the supply of fee-for-service provid-ers. Full-time equivalent status is a workload value that ranks providers relative to their peers on the basis of practice income. This methodology for calculating FTEs is dictated by the Health Canada defi nition.56 The bench-mark values for FTE calculation were derived from, and applied to, the study population described here. Unlike the  131JANUARY 2005Health Canada methodology, the benchmark values were calculated using information from all doctors rather than just those who billed in all four quarters in the period. Paid services provided to BC residents were included, and remuneration for services to out-of-province patients was excluded. Data source: Alternative Payments Program and PHCO (2000/01)To capture the involvement of general practice provid-ers paid outside the MSP, we used data from the APP, and PHCO fi les provided by the BC Ministry of Health Services. From the APP, all dollars allocated to primary care service agreements were included, with the exception of the dollars allocated to the Canadian Red Cross (see Expendi-tures on General Practice Services profi le for details). The number of FTE general practice providers receiving funds from this source was then estimated by dividing the APP dollar amount allocated to each local health area by the average dollar value of one FTE as calculated using the MSP billings in British Columbia in 2000/01. Since APP funds service organizations, these expenditures are used to remunerate providers and, potentially, to fund other expenses such as travel. Therefore, our estimates of FTE providers in local health areas with a high proportion of APP expenditures (such as in the north) may overestimate supply. The magnitude of overestimation is related to the extent that APP expenditures are not used for remunera-tion.    In 2000/01, payments of $4,068,630 were made to PHCOs (see Expenditures on General Practice Services profile for details). The number of FTE general practice providers receiving funds from this source was then estimated by dividing the PHCO dollar amount allocated to each local health area by the average dollar value of one FTE as calculated using the MSP billings in British Columbia in 2000/01. CHSPR profi le using combined data sourcesThe crude rate of FTE general practice providers per 10,000 population was calculated based on the sum of FTEs derived from MSP practitioner and billing fi les (fee-for-service physicians), APP “primary care” programs, and PHCO payments for each local health area, divided by the size of the population of that local health area. Denominator populations were derived from PEOPLE 28 (2001).To age- and sex-standardize the crude rates, we used the indirect method based on the utilization of MSP-based general practice services by age and gender using 20 age categories. The impact of age- and sex-standardizing for each local health area was determined as a percentage increase or decrease. This measure of change was then applied to APP and PHCO crude estimates to convert them to age- and sex-standardized rates per 10,000 population. Several local health areas were aggregated due to a recog-nized problem with the allocation of APP funds to specifi c local health areas at the expense of neighbouring regions. The affected LHAs are Bella Coola/Central Coast (49/83); Snow Country/Stikine/Telegraph Creek (51/87/94). There were an estimated 3,852 general practice providers and 3,558 FTE general practice provid-ers in British Columbia in 2000/01, resulting in an age/sex-standardized rate of 8.67 FTE general practice providers per 10,000 population. Location of general practice providers profi leThis profi le determines the location of general practice providers using type of practice methodology to identify physicians by MSP billing address. This profi le uses a single data source only—MSP practitioner and billing fi les, 2001/02 data. Note that only general practice providers, not FTE general practice providers, were identifi ed. Also, this profi le uses more recent MSP data, compared to the  132CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALSupply of General Practice Service Providers profi le, which uses 2000/01 MSP data for consistency in the combined data sources. APP and PHCO data are not included. This results in clear under-estimates of the geographic location of general practice providers in areas that rely heavily on receipt of primary care services through the APP, such as most of the local health areas in the Northwest health services delivery area, and the local health areas of Bella Coola and Central Coast. Geographic location of general practice providers is reported using the billing address from the MSP practi-tioner fi le. In large urban areas, location was determined by six-digit postal code. In more rural areas, location was determined by the town or city identifi ed in the billing address. 133JANUARY 20051 Pollara Research. Health care in Canada survey: retrospec-tive 1998-2003 [monograph on the Internet].  Toronto: Pollara Inc.; 2003 [cited2004 Aug 10]. Available from: http://www.mediresource.com/e/pages/hcc_survey/pdf/HCiC_1998-2003_retro.pdf 2 In British Columbia, 89% report having a family physician, 12% report diffi culty accessing fi rst contact care, and 9% report diffi culty accessing routine care. Sanmartin C, Gendron F, Berthelot JM, Murphy K. Access to health care services in Canada, 2003 [monograph on the Internet]. Ottawa: Statistics Canada; 2004 [cited 2004 Aug 30]. Avail-able from: http://www.statcan.ca/english/freepub/82-575-XIE/2003001/pdf/report.pdf 3 Pollara Research. Health care in Canada survey, 2003 [monograph on the Internet]. Toronto: Pollara Inc.; 2003 [cited 2004 Jul 6]. Available from: http://www.mediresource.com/e/pages/hcc_survey/pdf/2003_hcic.pdf 4 BC Ministry of Health Services [homepage on the Internet]. Victoria (BC): BC Ministry of Health Services [updated 2004 Mar1; cited 2004 Aug 30]. Primary Health Care Transition Fund; [about 1 screen]. Available from: http://www.healthser-vices.gov.bc.ca/phc/aboutphctf.html  5 Watson DE, Broemeling A, Reid RJ, Black C. A results-based model for primary health care. Laying an evidence-based foundation to guide performance measurement, monitoring and evaluation. Vancouver (BC): Centre for Health Services and Policy Research, University of British Columbia; 2004. Report. No.: CHSPR 04-19. Available from http://www.chspr.ubc.ca/chspr/pdf/chspr04-19.pdf 6 Treasury Board of Canada. Results for Canadians: a management framework for the government of Canada [monograph on the Internet]. Ottawa: Treasury Board of Canada Secretariat; c2000 [cited 2004 Jan 20]. Available from: http://www.tbs-sct.gc.ca/res_can/dwnld/rc_e_pdf.pdf 7 Birch S, Eyles J. Needs-based planning of health care: a critical appraisal of the literature. Hamilton, ON: Centre for Health Economics and Policy Analysis, McMaster University; 1991. Report No.: 91-5. 8 Eyles J, Birch S, Chambers S, Hurley J, Hutchison B. A needs-based methodology for allocating health care resources in Ontario, Canada: development and an applica-tion. Soc Sci Med 1991;33(4):489-500. 9 Kyffi n, RGE, Goldacre MJ, Gill M. Mortality rates and self reported health: database analysis by English local authority area. BMJ. 2004;329(7471):887-888. 10 In addition to this substantial body of literature, recent research published by the Centre for Health Services and Policy Research further explores and supports the choice of PMR to profi le population health in British Columbia. See: McGrail KM, Schaub P, Black C. The British Columbia Health Atlas. 2nd ed. Vancouver (BC): Centre for Health Services and Policy Research, University of British Colum-bia; 2004. Report. No.: CHSPR 04:12. Available from: http://www.health-atlas.chspr.ubc.ca11 This differs from thinking about health status as an outcome, where, for example, higher health status might be the result of more effective health care services use.12 McGrail K, Schaub P, Black C. The British Columbia Health Atlas. 2nd ed. Vancouver (BC): Centre for Health Services and Policy Research, University of British Columbia; 2004 [cited 2004 Sep 9]. Report. No.: CHSPR 04:12. Available from: http://www.health-atlas.chspr.ubc.ca13 The sixth health authority, the Provincial Health Services Authority, is responsible for highly specialized health care services and provincial programs and organizations and does not have a sub-provincial population base.14 More information on BC health boundaries and health authority structure is available in: McGrail KM, Schaub P, Black C. The British Columbia Health Atlas. 2nd ed. Vancou-ver (BC): Centre for Health Services and Policy Research, University of British Columbia; 2004. Report. No.: CHSPR 04:12. Available from: http://www.health-atlas.chspr.ubc.ca15 For more information on PEOPLE, visit: BC STATS [homep-age on the Internet]. Victoria (BC): BC STATS, Ministry of Management Services; c2004 [updated 2004 Aug 25; cited 2004 Aug 30]. Population Projections; [about 1 screen]. Available from: http://www.bcstats.gov.bc.ca/data/pop/pop/popproj.htm16 Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Rich-ardson WS. Evidence based medicine: what it is and what it isn’t [editorial]. BMJ: 1996;312(7023):71-2.17 For reasons described in: Frohlich N, Carriere KC, Potvin L and Black C. Assessing socioeconomic effects on different sized populations: to weight or not to weight? J Epidemiol Community Health 2001;55(12):913-920.18 Refer to Appendix 1 for more detailed methodology and references.19 Refer to Appendix 1 for more detailed methodology and references.20 Refer to Defi nitions and technical notes for more detailed methodology and references.21 CHSPR will be releasing a report in 2005 that more thor-oughly explores use of PHC and related services (e.g. emergency room services) through the use of administrative data regarding fee-for-service and alternative payments.22 Per capita age/sex-standardized emergency room visit rates were multiplied by $100 to estimate per capita expenditures on this type of PHC service. Emergency room visit rates for References 134CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHP LANN I NG  FOR  R ENEWALlocal health areas that receive funding for these services from alternative sources were estimated on the basis of the demographic and health status of the local health area population. 23 Per capita age-standardized home-based professional services visit rates were multiplied by $50 to estimate per capita expenditures on this type of PHC service; per capita age-standardized home support service hours were multiplied by $25 to estimate per capita expenditures. 24 Assessments of per capita expenditures on emergency room and home-based services were increased and decreased by 60% and the level of association between combined services and PMR remained strong. 25 Local health areas in which emergency room visit rates were likely to be under-reported due to funding through alternative sources were assigned visit rates equal to: (a) the provincial average, or (b) expected use on the basis of health status and demographic structure. 26 Dunlop S, Coyte PC, McIsaac W. Socio-economic status and the utilisation of physicians’ services: results from the Canadian National Population Health Survey. Soc Sci Med 2000;51(1):123-133. 27 Frohlich N, Fransoo R, Roos N. Health services use in the Winnipeg Regional Health Authority: variations across areas in relation to health and socioeconomic status. Health Care Manag Forum 2000;51(1 Winter Suppl):9-14. 28 McIsaac W, Goel V, Naylor CD. Socio-economic status and visits to physicians by adults in Ontario. Canada. J Health Serv Res Policy 1997;2(2):94-102. 29 Watson DE, Bogdanovic B, Heppner P, Katz A, Reid RJ, Roos R. Supply, availability and use of family physicians in Winnipeg 1991-2001. Winnipeg (MB): Manitoba Centre for Health Policy, University of Manitoba; 2003. 30 Coyte PC, Young W. Regional variations in the use of home care services in Ontario, 1993/95. CMAJ 1999;161(4):376-80. 31 Auditor General of British Columbia. Alternative payments to physicians: a program in need of change [monograph on the Internet]. Victoria (BC): Offi ce of the Auditor General of British Columbia; 2003 [cited 2004 May 7]. Available from: http://www.bcauditor.com/PUBS/2003-04/Report4/HealthAl-ternative.pdf  32 BC STATS. British Columbia regional socio-economic indicators: methodology. November 1999, Updated June 2002 [monograph on the Internet]. Victoria (BC): BC STATS, Ministry of Management Services; 2002 [cited 2003 Nov] Available at: http://www.bc.stats.gov.bc.ca/data/sep/method.pdf33 BC STATS [homepage on the Internet]. Victoria (BC): BC STATS, BC Ministry of Management Services [updated 2004 May 7; cited 2004 May 7]. Socio-economic indices - local health areas (LHAs); [about 2 screens]. Available from: http://www.bcstats.gov.bc.ca/data/sep/i_lha/lha_main.htm34 BC Chronic Disease Management [homepage on the Internet]. 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