A few changes for health care

Briefly:

• Eliminate pagers (replacement value: $375) in favour of secure hospital-issued mobile phones.
  
• Move to electronic medical records integrating primary and hospital/specialist-based care. Family physicians don't need to be sent entire inpatient charts, but they need to have access to them when relevant. The reverse goes for hospital-based physicians and other health care workers.
  
• How about handheld devices instead of print-outs of patient lists? What is not lacking is the technology so much as the integration of technology.
  
• More long-term care beds and rehab facilities (community and hospital-based). Far too many patients waiting for ALC or rehab languish in acute care wards that do not provide an ideal environment for them. And it's wasteful.
  
• Centralize referrals/wait lists to expedite investigations and follow-up. Triage these to determine who is waiting and why.

These's more, of course, but these are just random thoughts that've come up on my elective in the past few weeks. It's probably a good idea to hire more nurses too.

About that long form census...

It goes without saying that the Harper government's decision to eliminate the mandatory long-form census, replacing it with a voluntary survey, is beyond stupid. They claim that the mandatory survey is "coercive" and an invasion of privacy. Or something:

In a written statement Tuesday, Clement said the short-form census, which is still mandatory, will provide a sufficient demographic picture of the country.

"The government does not think it is necessary for Canadians to provide Statistics Canada with the number of bedrooms in their home, or what time of day they leave for work or how long it takes them to get there," Clement said. "The government does not believe it is appropriate to force Canadians to divulge detailed personal information under threat of prosecution."

Garneau argued Clement does not understand how scientific data is gathered or used, and that the census has to be mandatory to get responses from a wide variety of people. He said that information from the long-form census is essential for the development of sound government policies.

I'll leave aside the fundamental reasons why this is a stupid idea and address Clement's comments directly. First, it's worth noting that nothing in the census data will, in the end, reflect any individual information. Second, Clement's own examples seem rather important to me - commuting time, for example, is a rather good proxy for the likes of traffic congestion and patterns of daily movement. The question of where people work vs. where they live, and how far they must travel daily, is of pretty obvious relevance to urban planning, highway construction, public transit, and a host of social policy issues. I'm not sure what about such questions is overly "personal" either.

So what's the real problem? Well, while it's nice to think that a voluntary survey would achieve a sufficiently high response rate, this strikes me as doubtful. Currently the mandatory survey is sent to 20% of Canadian households (I presume these households are chosen randomly). The line from the government seems to be that a voluntary survey might reach a larger number of Canadians, and that this would be superior to the mandatory survey of 20%. This is, however, wrong. Any kind of survey of a population contains some element of sampling error. You can actually predict the size of this error by choosing an appropriate sample size. Now, 20% of Canadian households is a big sample. REALLY big. The sampling error implied by such a large sample is very small, so small in fact that increasing its size to 25% or even 50% of households will not make a significant difference. Happily, because this survey is mandatory, there is minimal non-response and so the results of the sampling are said to be "unbiased".

Unfortunately, a voluntary survey leads to an unpredictable degree of non-response bias in the results. Bias is a form of structural error in a statistic that cannot be eliminated by increasing the sample size (which is not important in this case anyhow). We can imagine that poor people (or wealthy ones) or anarchists or libertarians or contrarians or any other sort of socioeconomic or political group might be more or less likely to respond to a voluntary survey. That's bias. And it means that the results of the survey may not - and almost certainly will not - be representative or generalizable to the Canadian population. That's a demonstrably inferior survey sample - less reliable, less accurate, and in ways that are difficult to quantify. We can estimate sampling error fairly readily, but that does not hold for sampling bias, since it requires a great deal of information about the sources of bias. Of course, without the mandatory long-form survey, it seems unlikely we'd know why particular people failed to respond to a voluntary survey. Quite the catch 22.

So, Tony Clement, with respect to this:

“I am not saying it's every Canadian, but I am saying there are Canadians [who complained] and we should try to accommodate their concerns in a balanced way,” he said.

He added that he took the privacy concerns to Statistics Canada and asked they be incorporated into the next census. “They gave me options and we chose one of those options,” he said.

“This is a methodology that Statistics Canada offered to us and if it's good enough for Statistics Canada, it should be good enough for some of our critics.”

As I happen to know a number of statisticians, I'm rather skeptical that Statcan thinks this change is "good enough". At this point, I should note that indeed have some kind of degree: MMath (Statistics-Biostatistics) from Waterloo. I think that beats Tony's poli sci undergrad (I have one too) and law degree - at least insofar as these things go.

Random Things...

I haven't posted in a while, though the time since my last entry has gone by swiftly (briefly: conference in Mexico, an OSCE, population health project, and final exam for the year). I've been following a few issues lately with a fair degree of attention, though. Starting off, there's the matter of the 2010 Toronto mayoral race:

Outspoken councillor Rob Ford leads a new poll that evinces a splintered electoral race with two clear front-runners and an indecisive electorate.

A new Globeandmail/CTV/CP24/Nanos poll puts Mr. Ford in first place – but just barely, and well within the margin of error.

The poll shows that 17.8 per cent of 1,000 Torontonians said they would vote for Mr. Ford if the election was held immediately, giving him a tiny lead over former deputy premier and energy and infrastructure minister George Smitherman, with 15.9 per cent.

Almost 40 per cent of those would-be voters are still undecided – but this poll cements a two-horse race between Mr. Ford and Mr. Smitherman, a long-time front-runner after he left his provincial post to run.

Deputy Mayor Joe Pantalone garnered a 10.1 per cent result; 9 per cent of those polled said they’d vote for Rocco Rossi if the vote were held immediately. Councillor Giorgio Mammoliti got 2.5 per cent; Women’s Post publisher Sarah Thomson earned 5.8 per cent of votes.

I'm going to say right off that I hope to hell that Rob Ford doesn't win. I don't think he will, of course, as this poll probably represents the ceiling not the floor of his support. Other than riding a wave of discontent over the usual "waste and overspending" talking points, he doesn't seem to have any particular plans or vision for the city, at least, none that I can find on his laughably amateurish website. He apparently wants to scrap Transit City in favour of subways, i.e. replace a less costly more comprehensive plan with one that is an order of magnitude more expensive and much slower to construct. How he expects that to be paid for is anyone's guess.

The rest of the field is not altogether inspiring - Smitherman seems okay, but his plans are a bit fuzzy - and since I don't live in TO, it doesn't really impact me directly, but the success of our largest city ought to matter to Canadians. Halifax's transit issues, for example, are a microcosm of what faces Toronto. Traffic is ever worsening and most of the plans to remedy it are not sufficiently ambitious. It's too early to predict the outcome of the mayoral election; it remains to be seen where the large number of undecided voters ends up.

People in Toronto are Crazy

That's the only conclusion I can reach after reading this:

In his 29 years of ferrying people to Toronto Island, boat crew member Frank Corbin never saw passengers as agitated as they were this weekend. There was pushing, profanity and even punches thrown; at one point on Friday, the police had to be called in to help regulate the crowd.

Just blame it on the potent combination of unseasonably warm weather, a holiday weekend and thousands of Torontonians trying to get to Toronto Island.

That, and the fact that just one puny, puttering ferry was available to haul everyone across.

"It was very busy, much busier than normal," said Corbin, the first mate of Ongiara, the 220-passenger ferry. "We were not really prepared for the crowd, basically."

Lineups at the ferry docks stretched past the ticket gates as people waited for up to three hours before leaving dry land.

People became so frustrated they were rushing onto the boat or jumping queues.

At least one fist fight broke out Friday, Corbin said.

"(People were) very impatient," he said. "Rude to me, rude to the captain. They were swearing at the deckhand, calling him a lazy bum and using the f-word."

I don't blame people for being frustrated but... it's April 4th. They didn't plan on the temperature being 25 degrees and weren't ready for these crowds. That doesn't excuse the behaviour described above. And while they should finally build at least a pedestrian bridge (or two) to the Islands for precisely this reason, I can't imagine why so many people would be so set on going to Centre Island. It's not *that* great. I suppose people in TO are just starved for any contact with the lake... which doesn't really explain why Harbourfront is so underused half the time. In any case, ocean >>> lake.

Bad Ideas and Health Care Reform

Nope, I'm not going to be writing about Obama's recent success in passing health insurance reform. I'm cautiously optimistic about its impact, but those events have predictably brought up the subject of health care reform in Canada once again. As a general rule, newspaper columnists and pundits are not experts about anything and will typically provide - at best - some sort of conventional wisdom that doesn't bear scrutiny. David Olive's column about "five bright ideas to save the Liberal Party" is no exception. He posits, indeed, a health care "renaissance" as one such idea:

Skyrocketing health-care costs are a fixation of governments from Japan to France, all facing the same demographic challenge of an aging population as we do, but not content as we are in passively watching health-care costs gobble up 40 per cent of our economy by mid-century, likely sooner. Health care is perhaps the one major field most stubbornly resistant to reform in both quality (medical errors are rampant) and cost-efficiency. At least in its big cities, China is far ahead of North America in electronic medical records, which cut down on errors and costly duplication, and make “distance care” more practical.

As to the breadth of coverage, our imagined comprehensive Medicare coverage is anything but. It lacks the universal dental care of Britain and state-funded prescription-drug provision of France and Japan.

Just as caregivers have little incentive to rethink treatment, patients have little reason to adopt a healthier lifestyle of proper diet and fitness. A reinvented Medicare would impose means-testing and co-pays to provide that incentive. As part of that overhaul, universal care would be made truly comprehensive by embracing dental health and pharmacare extending beyond the seniors now receiving it.

Setting aside the general vagueness and lack of specifics in this "idea", it betrays both all-too-common simplistic thinking about these issues. Medical errors are rampant? I'd say they happen and are to a small extent unavoidable. As I wrote in the fall, there are numerous approaches to improve communication and cut down on errors, such as the addition of universal checklists to the OR. I'd hazard a guess that electronic medical records would play - at best - a small role in "cutting down" errors. We have many computer-based records systems as it stands, but in my admittedly limited experience paper charts are easier to flip through to find what you're looking for. I'm not sure where the duplication comes in either; if the past, oh, 30 years or so have shown anything, it's that computer infrastructure is expensive, high maintenance, and certainly not cheaper than paper.

Olive is quite right that we lack universal dental coverage (which I understand the UK doesn't have to the extent he implies) or prescription-drug provision... though drugs for certain chronic conditions and cancers are. He probably should have discussed drug costs in more detail, however, as if there's anything "unsustainable" (a common media refrain) about our system, it's drug costs - most of which are privately paid.

His last point is simply morally unjustifiable. On one hand, I'd say that good health is its own reward, and while there's no shortage of people who make bad choices (e.g. NEVER start smoking), there are many more whose jobs facilitate a sedentary lifestyle and it is a simple effect that people with low incomes and limited educations have the worst health outcomes. Another sizeable group of "frequent flyers" for health care suffer from genetic predispositions to different diseases. In short, Olive is advocating that sick people be punished for their poor health status, under the supposition that this will give them an "incentive"... not to be sick. I guess. I'm sure those with type 1 diabetes or rheumatoid arthritis would be happy to pay nominal co-pays if it would rid them of their conditions once and for all, but that's not how things work. I'm not aware that such incentives actually work anyhow, apart from having the documented effect of driving people with low incomes away from seeking health care. And that's a bad thing.

Toronto vs. Vancouver

Well, not really. Nothing seems to generate vapid columns about common Canadian stereotypes than Globe and Mail columnists writing about any larger city - usually one of Vancouver, Calgary, Toronto, Ottawa, or Montreal. But usually Vancouver, I tend to think. Unsurprisingly, these never fail to generate lots of snarky comments from online readers. But first the offending article:

Please do not misunderstand me: I am not about to do the eastern-Canadian, passive-aggressive, Toronto thing that Vancouverites hate, which is to decry Vancouver as a beautiful but empty-headed woman you long to sleep with and then can't wait to ditch so that you can talk about something other than the muscle tone of her thighs.

Vancouver has always been unspeakably beautiful, but the Olympics stand to launch it into the global stratosphere.

At that point the city will completely replace Toronto and Montreal and (really?) Ottawa, which actually has more residents than Vancouver, as the go-to city in the mind of the world, when the mind of the world thinks of Canada – especially the mind of Asia, which is going to control most of the money on the planet for the next 200 years.

Yes, Vancouver will be the go-to city in the "mind of the world". I wish I could make such a turn of phrase up myself. The author goes on to describe a code of etiquette for city employees which apparently caused something of an uproar (I guess Vancouverites react badly to the implication that they're clueless and socially awkward), but that doesn't really bear mentioning here. The amusing thing is that the online comments invariably take one of three forms - people slagging Toronto, others slagging Vancouver, and a third smaller group of people calling for peace in our time.

This post reflects none of those positions. However, I did find this comment rather amusing:

By the way, an anecdote about Toronto subways to balance things up. I worked there for 5 years and, forgive me, but I don't remember everyone chatting to each other on the subway. Being thoroughly miserable in public was the order of the day - every day.

This, of course, is entirely accurate. Toronto is a big anonymous city. Vancouver is not nearly as big, but just as anonymous. I have come to realize lately that I'm not a "big city" person. Not anymore at least. I really enjoy visiting for days or weeks at a time, but that's about all I can manage. Everything's too spread out, too big, and there are too many people everywhere all the time. For all the enjoyment I get hanging out in downtown TO, most of the city consists of strip malls, character-less, cookie-cutter suburbs, and big box outlets. Oh, and lots of new condos. That all look kinda the same.

Vancouver is generally prettier, up to and including its suburbs like Burnaby and Richmond, but it's an appallingly expensive place to live and the stark class divisions between different areas of the city persists. Lovely place to visit, but I already live near the ocean, less than a 5-10 minute walk to the harbour or to Point Pleasant Park. I live within a 20 minute walk of almost everything I need, and most things are closer: several grocery stores, most buildings at Dal, the hospitals, my bank, drug stores, an excellent selection of restaurants, and, of course, an HMV. Not that I buy much there lately. If I need to go a bit further afield, I've learned that the buses are certainly adequate, and there are always lots of cabs - not that walking is usually a problem, as even downtown is only 20 minutes away at most.

So, yes, I love Hali. But there is a cultural element to this too. I hadn't fully appreciated it until I spent a year in Waterloo, but Ontario is... different. Smaller cities there are friendlier, certainly, but I didn't find K-W to be appreciably less anonymous. If Nova Scotia is friendlier - and I think it is - it's also somewhat less open, and there is a vastly stronger sense of history than most places in Ontario (I think!). Vancouver is even more ephemeral. If Toronto feels like it's in a constant process of reinventing itself (to varying degrees of success), Vancouver seems ever focussed on its natural beauty, "lifestyle", and - currently - the all important Olympics. Nothing too substantive there, and little more than handwringing over some of the worst social problems in the country.

Now, Halifax is far from perfect. Traffic problems are ever worsening, parking and living on the peninsula are fairly expensive (fortunately I only do the latter), and the less said about the sewage treatment fiasco the better. But it's almost the perfect size for a city. We just need some way of getting people on and off the peninsula more efficiently and without having to use their own cars. One day perhaps. One day soon I'll go home to the Valley too. Rural (or small town) living is perhaps a topic for another post, though.

King Tut in TO

I've just noticed that an exhibition of King "Golden Pharaoh" Tutankamen artifacts is coming to the AGO this month and will be sticking around until April. Anyone else want to go? :)