Mythbusters Jenn Thornhill, M.Sc., BJH Senior Advisor, Knowledge Summaries 17 October 2008 Using...

Mythbusters

Jenn Thornhill, M.Sc., BJHSenior Advisor, Knowledge Summaries

17 October 2008

Using evidence to debunk popular myths in Canadian healthcare

Overview• About CHSRF • About Canada’s

healthcare “systems” – key features

• About Mythbusters – key examples & lessons learned

http://www.dolighan.com/ July 30, 2004

About us• Publicly-funded, not-for-profit organization• Registered charity under the Canadian

Corporations Act (1997)• $100M endowment • $15-16M annual operating budget• Board of Trustees (14) – regional reps; researchers

and decision makers• New President and CEO, Maureen O’Neil

Our Vision & Mission• Our vision is a strong Canadian healthcare system

that is guided by solid, research-informed management and policy decisions.

• Our mission is to support evidence-informed decision-making in the organization, management and delivery of health services through funding research, building capacity and transferring knowledge.

CHSRF 2007-2011• A focus on enabling organizations that are

predisposed to using evidence, and disseminating innovation

• Products that are more responsive to the needs of decision makers

• Increasing differentiation from the granting councils• A shift along the spectrum of conceptual versus

instrumental use

What do we really do?

Canada – an Overview

• ~ 10M km2 land area• 31.6M people (2006)• 10 provinces and 3 territories• Discrepancies between:

– urban and rural/remote areas– east/west – north/south

• major economic centres: Toronto, Montreal and Vancouver

Sept 13, 2004

Canadian Healthcare Systems• 1947 (Saskatchewan): national and provincial components of current

Medicare system introduced – public financing, private delivery

• Hospitals are private, NFP; physicians mainly self-employed and FFS; but increasingly salaried employees

• Current system covers medically necessary hospital and physician services for all Canadians in 10 provinces and 3 territories

• Federal role: oversight of Canada Health Act; transfer payments to P/Ts; healthcare services for federal prisons, armed forces, and aboriginal people

• Provincial role: manage services through provincial health insurance plans with federal transfer payments; majority of healthcare funds raised through taxation

• 70% of healthcare expenditures are publicly funded; 30% private

Healthcare in Canada (cont’d)• Five principles underlying the Canada Health Act (1984): universality,

public administration, portability, accessibility, and comprehensiveness• Private insurance/physicians cannot offer services for which there is

public health insurance coverage• Supplementary private insurance offered by most employers• 9.8% of GDP (2005) spent on healthcare (average within G7)• Approx. 36% of P/T budgets spent on health • Regionalization within P/Ts – local responsiveness• Strong public support for healthcare system, but concerns exist

Mythbusters (2000+)

“. . . healthcare ‘zombies’ – ideas, or positions, that often appear, on first blush to be

‘common sense’ (or are widely held beliefs) but under which

there turns out to be embarrassingly little research

evidence.”Barer, M. 2005. Evidence, Interests and Knowledge Translation: Reflections of an Unrepentant Zombie Chaser. Healthcare Quarterly; 8(1): 46-53.

To every complex problem there is a simple answer: Neat, plausible, and wrong.

- H.L.

Mencken

Ex I – Private-sector Care• Public healthcare covers

“medically necessary” hospital and physician services

• Public sector accounts for 70% of total healthcare spending; Private accounts for 30%

• Most insurance schemes forbid doctors from offering services that are offered under the public insurance plan

May 9, 2005

Framing of privatization – the myths• Canada (like communist Cuba and N. Korea) disallows

private payment for healthcare• Parallel private systems reduce wait times• For-profit ownership of facilities improves efficiency• Healthcare costs are spiraling out of control*• User fees stop consumer waste• NEW: Activity-based funding will ensure that money

follows the patient – better quality; rewards and penalties for hospital performance

Privatization – the players (for)• Recent growth in investor-owned

medical clinics and DI facilities

• June 2005, historic Supreme Court of Canada case (“Chaoulli decision”)

• CMA – “Medicare Plus”

• Right-wing think tanks (i.e., Fraser Institute)

• Federal gov`t largely criticized for its absenteeism in enforcing CHA June 11, 2005

Privatization – the players (against)• Canadian Doctors for Medicare & Médecins Québécois

pour le Régime Public • Canadian Union of Public Employees – launched a

campaign to “Tell Tony Clement to keep health care public”

• Council of Canadians• Coalition Solidarité Santé

Ex II – Financial Sustainability• Discussing this topic is “the national pastime”

• Framing of the issue: – Medicare is a monopsony, with no competition,

therefore, costs remain perpetually high. – Public funding and administration cannot meet the

needs of an aging population

Financial Sustainability• Total health spending as a share of GDP is comparable

to elsewhere

• Increases are moderate

• Real cost drivers fall outside of Medicare

• Declining tax base; but Canadians are willing to pay higher taxes

Ex III – Physician Brain Drain

-100

0

100

200

300

400

500

600

700

1970 1976 1982 1988 1994 2000 2006

Year

Nu

mb

er

Doctors leaving Canada

Doctors returning to Canada

Net loss

Doctors leaving for U.S.

Physician Migration, 1970–2006

Canadian Institute for Health Information. Scott's Medical Database (SMDB). 2000-2007. Supply, Distribution and Migration of Canadian Physicians, 1999-2006.

“More Doctors More Care”

• CMA’s ad campaign 2008

Canadian Medical Association. 2008. www.moredoctors.ca

The News Headlines • Maclean’s. 2008, January 3 - The doctor crisis | Five

million Canadians are currently without a family doctor - and things are only getting worse

• Maclean’s. 2008. March 17 – Fixing a doctor crisis

• CBC DocZone. 2008, January 19 - Desperately Seeking Doctors

The problem: Supply?• No, but there are problems

“Why does it feel like we have a physician shortage? If it is true that an increasingly sever shortage has been developing since the mid-1990s, it must be a shortage of physicians’ services, not of physicians per se, perhaps reflecting declining average clinical workload per physician.”Chan B. 2002. From perceived surplus to perceived shortage: What happened to Canada’s Physician Workforce in the 1990s? Ottawa: Canadian Institute for Health Information.

Ex IV – Aging population (2002)• Fact: the proportion of Canadians over 65 is increasing.• Fact: the elderly need more medical services than

younger people. • The real issue is with changes in the number and

nature of medical services for elderly patients; Also, it’s actually healthy seniors who have driven the most significant increases in healthcare use

• Is intensified care for healthy elderly people appropriate and necessary?

In healthcare, less maybe more• Inspired by Ivan Illich’s (Austrian philosopher, social critic,

historian) Medical Nemesis (1976); Hypothesized: The greatest threat to mankind is healthcare

• Roemer’s Law: “A built hospital bed is a filled hospital bed”

• Dartmouth Atlas Project: examines geographical variations in care

Key Messages• Most myths originate from the same place – the critics

of Medicare• As such, myths are created and debunked through

ongoing political posturing and positioning of the issues.

• The CHSRF is well-positioned to confront these myths given our bias for the best-available evidence.

Lessons Learned for writing Mythbusters

Mythbusters Teaching ResourceI. Spotting the MythII. Searching for

EvidenceIII. Writing the SummaryIV. Adding Visual AppealV. Undergoing ReviewVI. Sharing Evidence-

Informed Messages

Mythbusters as a teaching toolSummaries are used:• as course readings;• as samples of KT strategies;• to inform class

discussions/seminars;• to inform the development of

a curriculum module.

CHSRF. Summer 2007. Links; 10(2): 8.

Knowing your audience

It’s useful to think of all audiences as ‘decision-makers’ since ‘decisions’ arewhat might be improved with researchevidence.”

- Reardon et al., 2006

Knowing your audience

Storytelling

Why are stories important?

A single narrative is as powerful as any health care intervention; it is the one language that all of us - health care

worker and lay person - share... a single narrative can change the way we live our lives, practice our art, and even

reform our policies. When we don't tell our stories, our experiences... can disappear forever. So can the possibility

of a more relevant and meaningful kind of health care.

Chen, P.W. 2008. Narrative Matters: “Stories beyond the box.” Health Affairs; 27 (4): 1148-53.

Getting to the point“What the story is about involves the context (the background, facts, and people involved); the point of the story is the main theme, the thread that connects each part of the story, or the ‘so what’ factor.”

Roberts M. 2006. Finding a story’s focus. www.concernedjournalists.org/node/474

Relying on Opinion Leaders• Opinion leaders disseminating and implementing “best evidence” is

one innovative method that holds promise as a strategy to bridge know-do gaps.

• When it comes to encouraging change, opinion leaders’ views have greater sway than other people’s constructive criticism.

• Identifying opinion leaders can take a lot of work and be hard to validate, but when they are found they can boost the amount of research being used in everyday practice.

G. Doumit, M. Gattellari, J. Grimshaw, and M.A. O’Brien. 2007. “Local opinion leaders: Effects on professional practice and health care outcomes.” Cochrane database of systematic reviews.

Should the Drug Industry Use Key Opinion Leaders?

British Medical Journal 336(7658)June 2008

Drug marketing: Key opinion leaders: independent experts or drug representatives in disguise? (Ray Moynihan)

Measuring impact

Thornhill J., Neeson J. & Clements D. 2008. Myths, “Zombies” and “Damned Lies” Plague Canadian Healthcare Systems. What’s a Researcher to Do? Healthcare Quarterly; 11(3): 14-15.

ImplementationHow do we move from distribution (passive) to dissemination (active) to implementation (most active)?

Thank You

jennifer.thornhill@chsrf.ca

www.chsrf.ca

Aug 18, 2005