How Canada Compares Results From The Commonwealth Fund

How Canada Compares: Results From The Commonwealth Fund 2014 International Health Policy Survey of Older Adults Report January 2015

Production of this document is made possible by financial contributions from Health Canada and provincial and territorial governments. The views expressed herein do not necessarily represent the views of Health Canada or any provincial or territorial government. All rights reserved. The contents of this publication may be reproduced unaltered, in whole or in part and by any means, solely for non-commercial purposes, provided that the Canadian Institute for Health Information is properly and fully acknowledged as the copyright owner. Any reproduction or use of this publication or its contents for any commercial purpose requires the prior written authorization of the Canadian Institute for Health Information. Reproduction or use that suggests endorsement by, or affiliation with, the Canadian Institute for Health Information is prohibited. For permission or information, please contact CIHI: Canadian Institute for Health Information 495 Richmond Road, Suite 600 Ottawa, Ontario K 2 A 4 H 6 Phone: 613 -241 -7860 Fax: 613 -241 -8120 www. cihi. ca copyright@cihi. ca ISBN 978 -1 -77109 -336 -1 © 2015 Canadian Institute for Health Information How to cite this document: Canadian Institute for Health Information. How Canada Compares: Results From The Commonwealth Fund 2014 International Health Policy Survey of Older Adults. Ottawa, ON: CIHI; 2015. Cette publication est aussi disponible en français sous le titre Résultats du Canada : Enquête internationale de 2014 auprès des adultes âgés sur les politiques de santé du Fonds du Commonwealth. ISBN 978 -1 -77109 -337 -8

Table of contents Acknowledgements 4 About this report 5 Executive summary 7 Methodological notes 12 Access to care Timely access to care Cost as a barrier to health care 15 16 23 Caregiving and planning for end-of-life care Informal caregiving Planning for end of life and advanced age 29 30 33 Quality of care Patient-centred primary and specialist care Medication reviews Chronic condition management and disease prevention 38 39 44 48 Perception of health and health care 55 Appendix 60 Bibliography 70 3

Acknowledgements Core funding for The Commonwealth Fund 2014 International Health Policy Survey of Older Adults was provided by The Commonwealth Fund with co-funding from the following organizations outside of Canada: Haute Autorité de santé (France); Caisse nationale de l’assurance maladie des travailleurs salariés (France); BQS Institute for Quality and Patient Safety (Germany); the German Federal Ministry of Health; the Dutch Ministry of Health, Welfare and Sport; the Scientific Institute for Quality of Healthcare, Radboud University Nijmegen (the Netherlands); the Norwegian Knowledge Centre for the Health Services; the Swedish Ministry of Health and Social Affairs; the Swiss Federal Office of Public Health; the NSW Bureau of Health Information (Australia); and many other country partners. Within Canada, funding for an expanded Canadian sample was provided by the Canadian Institute for Health Information (CIHI), the Canadian Institutes of Health Research (CIHR), the Health Quality Council of Alberta, the Commissaire à la santé et au bien-être du Québec and Health Quality Ontario. Production of this document is made possible by financial contributions from Health Canada and  provincial and territorial governments. The views expressed herein do not necessarily represent the views of Health Canada or any provincial or territorial government. 4

About this report Health care is fundamentally about people, and the experience of patients is critical to understanding the performance of a health system. For the past decade, The Commonwealth Fund’s International Health Policy surveys have helped fill important information gaps through polls of patients and providers in 11 developed countries. The 2014 edition of this survey focused on the experience of people age 55 and older. The purpose of this companion report is to tell the Canadian story, and to highlight how experiences with health care vary across the country and relative to other countries. • For the first time, statistical testing has been performed to understand whether Canadian results are significantly different from the average of 11 Commonwealth Fund (CMWF) surveyed countries. – In bar graphs, an asterisk (*) indicates that Canadian results are statistically different. – Elsewhere in the report where national and provincial results are presented, significance testing is shown with the following colour codes: Above average • Same as average Below average Additional questions that were asked of only Canadian respondents are indicated throughout this report using a maple leaf. 5

About this report (cont’d) • In the body of the report, provincial results are compared with the international average of CMWF countries. In the appendix, provincial results are compared with the Canadian average. • Supplementary data tables with expanded questionnaire information are available as a free companion product online. • To provide additional context, this report also references information from CIHI, Statistics Canada and other sources. All other data is from the 2014 Commonwealth Fund International Health Policy Survey of Older Adults. 6

Executive summary Canada’s demographic realities are not unique. Understanding how to meet the growing health care needs of an aging population—and how to deliver high-quality care in a cost-efficient fashion—is a challenge that many other nations are trying to address. When comparing the experiences of older people in Canada with those of older people in other countries, this report shows significant variation across the country and mixed results overall. 7

Executive summary (cont’d) Access to care Timely access to primary and specialist care remains a significant challenge for older Canadians. • While almost all older Canadians (55 and older) have a regular doctor, 53% waited at least 2 days for care the last time they were sick or needed medical attention, and 25% waited at least 2 months to see a specialist. Canada had the longest waits for primary and specialist care of all 11 countries, and every province had significantly longer waits than the international average. • Half of older Canadians found it very or somewhat difficult to get medical care in the evenings and on weekends or holidays without going to the hospital emergency department (ED). Consequently, 37% of individuals responded that the last time they went to the ED, it was for a condition that could have been treated by their regular doctor. • While cost was not a barrier to medical services for most older Canadians, a significantly higher proportion (7%) than the average of countries said they were prevented from filling a prescription or skipped a medical dose because of the cost. For 15% of older Canadians, cost was also a barrier for dental care. 8

Executive summary (cont’d) Caregiving and planning for end-of-life care Older Canadians spent more time on average as informal caregivers; they also spent more time planning for their own end-of-life needs. • Almost 1 in 5 older Canadians provided care at least once a week to a person with an age-related problem. Nearly half of them (47%) provided care for at least 10 hours a week, a greater proportion than the international average (40%). • Nearly 1 in 4 (23%) Canadian caregivers needed help to provide care but did not receive it, and 34% said they had experienced distress, anger or depression while providing care. • Older Canadians were significantly more likely than older people in other countries to have discussions (61%) about their end-of life wishes or to have written plans (39%). 9

Executive summary (cont’d) Quality of care Generally, older Canadians reported having positive experiences with their providers that were on par with or better than the international average; however, continuity of care between providers can be improved. • Older Canadians were more likely on average to be encouraged to ask questions (70%) by their regular doctor and to be involved in treatment plans (79%) by their specialists than older people in other countries. • Most older Canadians were taking multiple medications, and they were significantly more likely to report having medication reviews (80%) with their care providers than the international average. • Older Canadians with chronic conditions were also more likely to have discussions about treatment goals (60%) and adopting healthy lifestyles (e. g. , diet, exercise) with their providers than older people in other countries. However, only 37% had a written plan to self-manage their conditions. • A higher proportion of older Canadians (13%) said that specialists did not have basic information or test results from their family doctor. Similarly, 25% said their family doctor did not seem to be informed and up to date about the specialist care they had received. These results varied widely across the country, however. 10

Executive summary (cont’d) Perceptions of health and health care While older Canadians were more likely to feel good about their health, they were not as optimistic about their health system. • Slightly more than half of older Canadians said their health was very good or excellent, which was significantly higher than the international average. • More than half also believed that fundamental changes are required to fix the health system. While perceptions of the health system had improved slightly in the previous 7 years, they were still among the lowest of reporting countries. 11

Methodological notes The 2014 Commonwealth Fund International Health Policy Survey of Older Adults randomly sampled the general population age 55 and older in 11 countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States. In Canada, interviews were conducted from March through May 2014 by Social Science Research Solutions (SSRS). There were 5, 269 respondents. CIHI and CIHR provided funding to ensure a minimum of 250 respondents in each province, allowing for provincial comparisons. Sample sizes were further increased in Quebec, Ontario and Alberta with funding from provincial organizations. The overall response rate in Canada was 28%. For a complete list of sample sizes and response rates from all countries surveyed, please see the accompanying methodology notes. Provinces and territories Number of interviews Percentage distribution Newfoundland Labrador 252 5% Prince Edward Island 261 5% Nova Scotia 258 5% New Brunswick 277 5% Quebec 1, 006 19% Ontario 1, 502 29% Manitoba 252 5% Saskatchewan 254 5% Alberta 953 18% British Columbia 250 5% Yukon 3 0% Northwest Territories 1 0% Nunavut 0 0% 5, 269 100% Total 12

Methodological notes (cont’d) Weighting of results The survey data for Canada was weighted within each of the 10 provinces by age, gender, level of education and knowledge of the official language. Additionally, data was subsequently weighted to reflect Canada’s geographic distribution, by provinces and territories. Population parameters for these calculations were derived from the 2011 Census. Averages and trends For this report, the CMWF average was calculated by adding the results from the 11 countries and dividing by the number of countries. The Canadian average represents the average experience of Canadians (as opposed to the mean of provincial results). Except where otherwise noted, results were compared over time using data from previous CMWF general population surveys for respondents age 55 and older. Significance testing CIHI developed statistical methods to determine whether • Canadian results were significantly different from the international average of 11 countries; • Provincial results were significantly different from the international average; and • Provincial results were significantly different from the Canadian average. An asterisk (*) indicates that results are significantly different on bar graphs, and colour codes are used elsewhere in the report. 13

Methodological notes (cont’d) Interpretation of significance testing The following colour codes are used throughout the report to indicate when results are statistically different from the average: Above average Same as average Below average Above-average results are more desirable, while below-average results often indicate areas in need of improvement. It must be cautioned, however, that sample sizes in some provinces are much smaller than in others and have wider margins of error. (The most robust samples are in Quebec, Ontario and Alberta because there was additional funding from those provinces. ) For this reason, 2 provinces may have the same numeric results in different colours (e. g. , 1 result might be blue, or same as average, while the other is orange, or below average). This may be due to a difference in margins of error rather than a difference in health system results. The wider the margin of error, the more difficult it is for a result to show up as significantly different from the average. 14

Access to care Timely access to care Cost as a barrier to health care 15

Most older Canadians have a regular doctor 96% of Canadians age 55 and older had 1 or more doctors they usually went to for their medical care. How does Canada compare (2014)? France Netherlands Germany • Older Canadians were more likely to have a regular doctor than younger Canadians. • 85% of Canadians older than Norway Switzerland Australia CANADA 96%* New Zealand CMWF AVERAGE United Kingdom United States Sweden 93% 12 had a regular doctor. Source Statistics Canada. Table 105 -0501—Health indicator profile, annual estimates, by age group and sex, Canada, provinces, territories, health regions (2013 boundaries) and peer groups, occasional. 16

Older Canadians wait longest for primary care 53% waited for at least 2 days to see a doctor or a nurse the last time they were sick or needed medical attention. How does Canada compare (2014)? CANADA No improvement since 2007 53%* Norway 2007 United States Sweden United Kingdom CMWF AVERAGE Australia 32% 53% Switzerland Netherlands Germany New Zealand France Source The Commonwealth Fund, 2007 International Health Policy Survey in Seven Countries. 30% of older Canadians waited at least 6 days or gave up (2014). 17

Canadians are least likely to get timely responses Proportion of older Canadians who always or often got an answer the same day when they called their regular doctor with a medical concern France Proportion of older Canadians who wished to or were able to email their doctors with a medical question, 2014 25% Switzerland United States New Zealand Netherlands 4% United Kingdom CMWF AVERAGE 72% Wished to Were able to Germany Sweden Norway Australia CANADA 63%* In 2012, 11% of family physicians offered patients the option to email them about a medical question or concern. Source The Commonwealth Fund, 2012 Commonwealth Fund International Survey of Primary Care Doctors. 18

Canadians have fewer after-hours options for primary care 51% thought it was very or somewhat difficult to get medical care in the evenings and on weekends or holidays without going to the emergency department (ED). How does Canada compare (2014)? CANADA 51%* United States Proportion of family physicians whose practice had an arrangement for after-hours care 2012 Sweden Australia CMWF AVERAGE Germany Norway United Kingdom 29% 45% New Zealand Switzerland France Netherlands Source The Commonwealth Fund, 2012 Commonwealth Fund International Survey of Primary Care Doctors. 19

Lack of access to timely care has an impact on ED use 37% of older Canadians went to an ED for a condition that could have been treated by their regular doctor. How does Canada compare (2014)? United States CANADA France New Zealand Switzerland Sweden CMWF AVERAGE Norway Australia United Kingdom Germany Netherlands 37%* 28% In 2013– 2014, 1 in 5 emergency visits in Canada was for a condition that could have been treated elsewhere, such as a doctor’s office. The most common conditions were upper respiratory infections (13%) and antibiotic therapy (13%). Source Canadian Institute for Health Information. Sources of Potentially Avoidable Emergency Department Visits. Ottawa, ON: CIHI; 2014. 20

Canadians wait longest for specialist care 25% of older Canadians waited for at least 2 months to see a specialist; these waits had not improved over time. How does Canada compare (2014)? CANADA Specialist wait times, by year 25%* Norway 60% New Zealand 50% Sweden 40% Germany 30% Australia 20% CMWF AVERAGE United Kingdom France 15% 10% 0% 2010 Netherlands <4 weeks Switzerland 2 months or longer 2013 2014 1 month to <2 months United States Sources The Commonwealth Fund, 2010 and 2013 Commonwealth Fund International Health Policy Survey. 21

How do the provinces compare? The timeliness of primary and specialist care was significantly below the international average for all Canadian provinces. Older Canadians (55+) who B. C. Alta. Sask. Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. CMWF Avg. Waited for at least 2 days to see a doctor 50% 55% 57% 54% 50% 58% 54% 55% 53% 53% 32% Said it was very or somewhat difficult to get medical care after hours 47% 45% 49% 55% 47% 60% 53% 59% 57% 65% 51% 29% Went to the ED for a condition that could have been treated by their regular doctor 30% 39% 33% 34% 39% 38% 42% 37% 40% 50% 37% 28% Waited for at least 2 months to see their specialist 24% 28% 32% 24% 25% 29% 27% 28% 34% 25% 15% Compared with the CMWF average Above average Same as average Below average 22

Is cost a barrier to accessing care? In Canada’s publicly funded health care system, most older Canadians accessed the medical care they needed without having to worry about costs. In the past year Canada CMWF average United States Did not see a doctor for a medical problem because of the cost 4% 5% 15% Skipped a medical test, treatment or follow-up recommended by a doctor because of the cost 5% 5% 15% Did not fill a prescription for medicine or skipped doses of medications because of the cost 7% 4% 15% N/A Did not see a dentist when needed to because of the cost Compared with the CMWF average Above average Same as average Below average Not applicable 23

Cost can be a barrier for prescription drugs Canada was second to only the United States in the proportion of older people who did not fill a prescription because of costs. How does Canada compare (2014)? Did not fill a prescription for medicine or skipped doses because of the cost United States CANADA Australia New Zealand CMWF AVERAGE Germany Netherlands Switzerland United Kingdom Sweden Norway France 7%* 4% Public share of total prescribed drug spending, 2012 or nearest year Germany United Kingdom* Switzerland France † New Zealand Netherlands Sweden CMWF AVERAGE † Australia Norway † CANADA United States Notes * 2008 data. † 2011 data. Source OECD Health Statistics 2014. 70% 43% 24

Drug costs affect a higher proportion of people age 55 to 65 1 in 10 Canadians age 55 to 64 did not fill their prescriptions or skipped their medications because of the cost. Proportion by age 10% 55– 64 5% 65+ Most Canadian provinces have public drug coverage programs for seniors age 65+. 25

Cost can be a barrier for dental care 15% of older Canadians did not receive the dental care they needed because of the cost. Proportion who did not receive dental care by age, 2014 19% 55– 64 12% 65+ Only 4 jurisdictions (Alberta, Yukon, the Northwest Territories and Nunavut) have public oral health care services for seniors. Source Canadian Academy of Health Sciences. Improving Access to Oral Health Care for Vulnerable People Living in Canada. Ottawa, ON: CAHS; 2014. 26

Public coverage of dental care is lower in Canada Probability of a dental visit, by income, 2009 Low income 47% Share of public spending on outpatient dental care, 2012 or nearest year High income 79% Source Organisation for Economic Co‑operation and Development. Health at a Glance 2013: OECD Indicators. 2013. Germany Sweden † New Zealand France † Australia Norway CMWF AVERAGE Netherlands United States Switzerland † Canada 25% 6% Notes † 2011 data. Source OECD Health Statistics 2014. 27

How do the provinces compare? Results were generally comparable to the international average. Differences in public coverage and program design for drug plans may partly explain variation in results between provinces. B. C. Alta. Sask. Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. CMWF Avg. Did not see a doctor for a medical problem because of doctor visit costs 4% 4% 3% 3% 4% 3% 5% 4% 4% 5% Skipped a medical test, treatment or follow-up recommended by a doctor because of diagnostic/ treatment costs 3% 4% 2% 4% 7% 4% 5% 5% 4% 6% 5% 5% Did not fill a prescription for medicine or skipped doses of medications because of prescription costs 8% 6% 2% 7% 8% 7% 12% 7% 8% 7% 7% 4% Compared with the CMWF average Above average Same as average Below average 28

Caregiving and planning for end-of-life care Informal caregiving Planning for end of life and advanced age 29

Informal caregiving is common across countries 19% of older Canadians provided care at least once a week to a person living with an age-related problem (CMWF average 20%). Relationship with care receiver Family member 76% Someone else (not family member) Both Proportion providing care for at least 10 hours a week (2014) 18% 5% United States Australia New Zealand CANADA Germany United Kingdom CMWF AVERAGE Netherlands Switzerland Norway France Sweden 47%* 40% 30

Informal caregivers in Canada don’t always get the support they need Proportion of caregivers who needed help to provide care in the past year but did not receive it Reasons for not receiving the help needed to provide care Services were not available in the area available in the 23% 28% Did where to go Didnot notknow where to go Cost was too expensive Wait times were too long Waiting times were too long 27% 16% 14% 31

Distress is common among Canadian caregivers 34% experienced distress, anger or depression while providing care or assistance for a family member or friend. Proportion of caregivers who experienced distress, anger or depression, by hours of care provision 43% 27% <10 hours or more Some factors most commonly associated with caregiver distress: • Caring for someone with aggressive behaviours • Caring for someone with cognition problems (e. g. , dementia) • Caring for someone for many hours a week Source Canadian Institute for Health Information. Supporting Informal Caregivers—The Heart of Home Care. Ottawa, ON: CIHI; 2010. 32

End-of-life care planning is common in Canada In 2014, older Canadians were more likely than older people in other countries to have planned for their end-of-life wishes. Proportion of older Canadians who Had discussions with someone Had a written document naming a substitute decision-maker Had a written plan about their end-of-life wishes 33

End-of-life care plans are more common with advanced age 39% of older Canadians had a written plan about their end-of-life wishes. How does Canada compare (2014)? Proportions by age Germany 49% United States CANADA Australia 32% Switzerland CMWF AVERAGE 43% 39%* 22% New Zealand United Kingdom Netherlands Sweden France Norway 55– 64 65– 74 75+ 34

How do the provinces compare? End-of-life care planning in most provinces exceeded the international average. B. C. Alta. Sask. Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. CMWF Avg. Had a discussion with someone 61% 62% 57% 60% 64% 57% 55% 56% 55% 47% 61% 44% Named a substitute decision-maker 46% 53% 44% 50% 60% 52% 47% 43% 42% 32% 53% 31% Had a written document about end-of-life wishes 36% 43% 29% 35% 44% 40% 24% 29% 26% 18% 39% 22% Compared with the CMWF average Above average Same as average Below average 35

About half of Canadians are planning for future care needs Proportion who considered supportive living, residential care or home care in future planning 47% 48% 46% 45% 48% 47% 42% Proportion who said they will likely require supportive living or long-term care in their lifetime 47% 45% 32% 36% 53% an. O nt. Q ue. N. B. N. S. P. E. I. N. L. C an. . M Sa sk ta. Al B. C . No significant variation by province Compared with the Canadian average Above average Same as average Below average 36

Advanced directives are common in long-term care Proportion of Canadian long-term care residents who had 66% Do not resuscitate order Do not hospitalize order 18% Living will 13% Other end-of-life care restrictions 5% Feeding restrictions 4% Medication restrictions 4% Source Continuing Care Reporting System, 2011, Canadian Institute for Health Information. 37

Quality of care Patient-centred primary and specialist care Medication reviews Chronic condition management and disease prevention 38

Most older Canadians have a positive experience with their regular doctor When older Canadians needed care or treatment, their regular doctor always or often Canada CMWF average Knew important information about their medical history 87% Spent enough time with them 82% 86% Encouraged them to ask questions 70% 66% Compared with the CMWF average Above average Same as average Below average 39

Patient-centred care from specialists is also relatively good in Canada When specialists provided care or treatment, they always or often Canada CMWF average Told patients about treatment choices 72% Involved patients as much as they wanted to be in decisions about treatment or care 79% 77% Compared with the CMWF average Above average Same as average Below average 40

However, continuity of care between regular doctors and specialists can be improved In the past 2 years, was there a time when Canada CMWF average A specialist did not have basic information or test results from the patient’s regular doctor about the reason for the visit 13% 9% A patient’s regular doctor did not seem informed and up to date about the specialist care received 25% 18% Compared with the CMWF average Above average Same as average Below average 41

How do the provinces compare? B. C. Alta. Sask. Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. CMWF Avg. Regular doctor always or often Knew important information about patients’ medical history 88% 86% 89% 84% 86% 89% 87% 85% 87% 84% 87% Spent enough time with patients 81% 80% 79% 81% 87% 80% 85% 80% 78% 82% 86% Encouraged patients to ask questions 72% 70% 64% 65% 68% 76% 68% 66% 72% 62% 70% 66% Told patients about treatment choices 74% 75% 78% 77% 58% 73% 76% 80% 77% 72% Involved patients as much as they wanted to be in decisions 81% 79% 83% 76% 80% 76% 81% 85% 88% 79% 77% Specialists always or often Compared with the CMWF average Above average Same as average Below average 42

How do the provinces compare? Continuity of care between primary doctors and specialists was comparable to the international average in most Canadian provinces. Specialist did not have basic medical information from primary doctor Primary doctor did not seem informed or up to date about care from specialist B. C. Alta. Sask. 8% 8% 8% Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. CMWF Avg. 11% 10% 26% 13% 6% 4% 9% 13% 9% 16% 18% 18% 46% 22% 10% 13% 10% 25% 18% Compared with the CMWF average Above average Same as average Below average 43

Medication reviews are common for older Canadians 80% said a health care professional reviewed their medications in the past 12 months. How does Canada compare (2014)? United States New Zealand CANADA 80%* Germany In Canada, seniors use an average of 7. 2 prescription drugs in a year. Australia United Kingdom Switzerland CMWF AVERAGE 70% Netherlands Norway France Sweden Source Canadian Institute for Health Information. Drug Use Among Seniors on Public Drug Programs in Canada, 2012: Revised October 2014. Ottawa, ON: CIHI; 2014. 44

Canadians are more likely to have discussions about medication use In the past 12 months, has a health care professional Explained potential side effects CANADA United Kingdom New Zealand United States Australia Germany CMWF. . . France Netherlands Switzerland Norway Sweden Provided a written list of all medications 74%* 59% Sweden United Kingdom CANADA New Zealand Netherlands United States Australia CMWF AVERAGE Germany Norway Switzerland France 67%* 57% 45

Patient safety incidents related to medication use are common in Canada Proportion of seniors on public drug programs taking a potentially inappropriate (Beers list) drug, 2012 Almost 140, 000 hospitalizations for adverse drug reactions among seniors between 2006– 2007 and 2010– 2011 Source Canadian Institute for Health Information. Adverse Drug Reaction– Related Hospitalizations Among Seniors, 2006 to 2011. Ottawa, ON: CIHI; 2013. 39% Source Canadian Institute for Health Information. Drug Use Among Seniors on Public Drug Programs in Canada, 2012: Revised October 2014. Ottawa, ON: CIHI; 2014. 46

How do the provinces compare? Across provinces, medication management among older patients was equal to or better than that in other countries, on average. In the past 12 months, has a health care professional B. C. Alta. Sask. Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. CMWF Avg. Reviewed all medications 77% 78% 75% 83% 75% 66% 77% 65% 80% 70% Explained potential side effects 72% 72% 67% 76% 67% 70% 68% 62% 74% 59% Given a written list of all medications 59% 58% 51% 67% 80% 66% 62% 57% 54% 67% 57% Compared with the CMWF average Above average Same as average Below average 47

Care to help manage chronic conditions is above average in Canada 78% of older Canadians had at least 1 chronic condition* (CMWF average 71%). Older people with chronic conditions who Canada CMWF average Had discussions about main goals or priorities with their health providers 60% 55% Received clear instructions about symptoms to watch for 60% 56% Compared with the CMWF average Above average Same as average Below average * Chronic conditions include hypertension or high blood pressure; heart disease, including heart attack; diabetes; asthma or chronic lung disease such as chronic bronchitis, emphysema or chronic obstructive pulmonary disease; depression, anxiety or other mental health problems; cancer; and joint pain or arthritis. 48

However, there is room to improve across countries People with chronic conditions who received a written plan for self-management from their health provider Canada CMWF average 37% 35% Compared with the CMWF average Above average Same as average 21% Routinely Occasionally 58% Below average 21% of family physicians routinely gave their patients with chronic conditions written instructions for self-management. Source The Commonwealth Fund, 2012 Commonwealth Fund International Survey of Primary Care Doctors. 49

Hospitalizations for chronic conditions are declining in Canada but vary widely across the country Ambulatory care sensitive conditions (ACSCs) are chronic conditions that—when treated effectively in community settings—should not, in most cases, lead to hospitalization. ACSC hospitalization rates (per 100, 000) Canadian rates 435 417 319 258 428 419 425 296 267 275 319 289 Sa sk. M an. O nt. Q ue. N. B. N. S. P. E. I. N. L. C an. ta. Al 2003200420052006200720082009201020112012 B. C . 289 Compared with the Canadian average Above average Same as average Below average Source Canadian Institute for Health Information. Your Health System. http: //yourhealthsystem. cihi. ca/. Accessed November 27, 2014. 50

How do the provinces compare? In most provinces, management of chronic conditions was similar to the international average experience. In the past 12 months, has a health professional B. C. Alta. Sask. Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. CMWF Avg. Discussed with patients their main goals or priorities in caring for this condition 59% 61% 57% 61% 56% 60% 61% 58% 60% 55% Given patients clear instructions about symptoms to watch for and when to seek further care or treatment 56% 57% 60% 58% 62% 58% 60% 56% Given patients a written plan to help them manage their own care 42% 36% 34% 35% 38% 35% 41% 42% 39% 37% 35% Compared with the CMWF average Above average Same as average Below average 51

Discussions about healthy life habits are more frequent in Canada But they happened less often in 2014 than they used to. During the past 2 years, has a health professional discussed 61% 57% 50% 54% 51%* 43% 55%* 48% 37% 35% 2010 2014 A healthy diet and healthy eating 2010 2014 Exercise or physical activity Canada 2010 23% 2014 Things in life that worry patients or cause stress CMWF Average Source The Commonwealth Fund, 2010 Commonwealth Fund International Health Policy Survey. 52

Canada leads in smoking cessation discussions 78% of older Canadians who smoked said a health professional talked to them about the health risks of smoking or using tobacco and ways to quit. How does Canada compare (2014)? CANADA United States New Zealand France United Kingdom CMWF. . . Sweden Switzerland Norway Germany Netherlands Australia 78%* 17% of older Canadians smoked, higher than the CMWF average. 63% Lung cancer mortality rates were among the highest in the world for Canadian women at 46 deaths per 100, 000 population. Source OECD Health Statistics 2014. 53

How do the provinces compare? During the past 2 years, has a health professional discussed B. C. Alta. Sask. Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. CMWF Avg. A healthy diet and healthy eating 54% 52% 49% 47% 52% 48% 52% 47% 51% 43% Exercise or physical activity 60% 55% 52% 51% 55% 49% 54% 55% 51% 55% 48% Things in life that worry patients or cause stress 27% 23% 25% 24% 26% 20% 22% 32% 24% 25% 23% Health risks of smoking or using tobacco and ways to quit 92% 75% 66% 84% 79% 71% 72% 60% 59% 78% 63% Compared with the CMWF average Above average Same as average Below average 54

Perception of health and health care 55

Older Canadians feel better about their health But they were not as optimistic about their health system. Proportion who rated their health as excellent or very good New Zealand CANADA Australia United Kingdom United States CMWF. . . Switzerland Sweden Norway Netherlands Germany France 52%* 38% Proportion who gave the highest rating to the health system Switzerland United Kingdom Norway Australia New Zealand CMWF. . . Germany Sweden Netherlands France CANADA United States 44% 34%* 56

Life expectancy for seniors in Canada is about the same as the international average Life expectancy is a different way of measuring the health of a population. Proportion who rated their health as very good or excellent Canada CMWF average 52% 38% Life expectancy at age 65, 2011 Canada CMWF average 18. 8 years 18. 6 years Canada CMWF average 21. 7 years 21. 6 years Compared with the CMWF average Above average Same as average Below average Source OECD Health Statistics 2014. 57

Perceptions of health systems are still low in Canada but have improved slightly Overall view of the health care system, 2007 and 2014 2007 2014 10% 16% 27% 54% 34% 53% On the whole, the system works well and only minor changes are necessary to make it work better. There are some good things in our health care system, but fundamental changes are needed to make it work better. Our health care system has so much wrong with it that we need to completely rebuild it. 58

How do the provinces compare? Self-reported health status by province B. C. Excellent or very good Alta. Sask. Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. 52% 56% 44% 48% 52% 53% 44% 42% 44% 56% 52% CMWF Avg. 38% Health system perceptions by province B. C. Alta. Sask. Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. CMWF Avg. Minor changes 40% 35% 33% 34% 39% 22% 36% 34% 33% 23% 34% 44% Fundamental changes 51% 52% 49% 48% 63% 51% 53% 52% 53% 42% 6% 10% Completely rebuilt 9% 10% 9% 12% 11% 9% 8% 21% 10% Compared with the CMWF average Above average Same as average Below average 59

Appendix Provincial results compared to the Canadian average Statistical testing indicates whether results are significantly different from the Canadian average. 60

Timely access to primary care Older Canadians (55+) who B. C. Alta. Sask. Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. Waited for at least 2 days to see a doctor 50% 55% 57% 54% 50% 58% 54% 55% 53% 53% Said it was very or somewhat difficult to get medical care after hours 47% 45% 49% 55% 47% 60% 53% 59% 57% 65% 51% Went to the ED for a condition that could have been treated by their regular doctor 30% 39% 33% 34% 39% 38% 42% 37% 40% 50% 37% Waited for at least 2 months to see their specialist 24% 28% 32% 24% 25% 29% 27% 28% 34% 25% Compared with the Canadian average Above average Same as average Below average 61

Cost as a barrier to health care B. C. Alta. Sask. Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. Did not see a doctor for a medical problem because of doctor visit costs 4% 4% 3% 3% 4% 3% 5% 4% 4% Skipped a medical test, treatment or follow-up recommended by a doctor because of diagnostic/treatment costs 3% 4% 2% 4% 7% 4% 5% 5% 4% 6% 5% Did not fill a prescription for medicine or skipped doses of medications because of prescription costs 8% 6% 2% 7% 8% 7% 12% 7% 8% 7% 7% 12% 9% 15% 16% 14% 19% 18% 11% 16% 15% Did not see a dentist when needed to because of the dental costs Compared with the Canadian average Above average Same as average Below average 62

Quality of care: patient-centred care B. C. Alta. Sask. Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. Regular doctor always or often Knew important information about patients’ medical history 88% 86% 89% 84% 86% 89% 87% 85% 87% 84% 87% Spent enough time with patients 81% 80% 79% 81% 87% 80% 85% 80% 78% 82% Encouraged patients to ask questions 72% 70% 64% 65% 68% 76% 68% 66% 72% 62% 70% Specialists always or often Told patients about treatment choices 74% 75% 78% 77% 58% 73% 76% 80% 77% 72% Involved patients as much as they wanted to be in decisions 81% 79% 83% 76% 80% 76% 81% 85% 88% 79% Compared with the Canadian average Above average Same as average Below average 63

Quality of care: continuity of primary and specialist care Specialist did not have basic medical information from primary doctor Primary doctor did not seem informed or up to date about care from specialist B. C. Alta. Sask. 8% 8% 8% Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. 11% 10% 26% 13% 6% 4% 9% 13% 16% 18% 18% 46% 22% 10% 13% 10% 25% Compared with the Canadian average Above average Same as average Below average 64

Quality of care: medication reviews In the past 12 months, has a health care professional B. C. Alta. Sask. Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. Reviewed all medications 77% 78% 75% 83% 75% 66% 77% 65% 80% Explained potential side effects 72% 72% 67% 76% 67% 70% 68% 62% 74% Given a written list of all medications 59% 58% 51% 67% 80% 66% 62% 57% 54% 67% Compared with the Canadian average Above average Same as average Below average 65

Quality of care: management of chronic conditions In the past 12 months, has a health professional B. C. Alta. Sask. Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. Discussed with patients their main goals or priorities in caring for this condition 59% 61% 57% 61% 56% 60% 61% 58% 60% Given patients clear instructions about symptoms to watch for and when to seek further care or treatment 56% 57% 60% 58% 62% 58% 60% Given patients a written plan to help them manage their own care 42% 36% 34% 35% 38% 35% 41% 42% 39% 37% Compared with the Canadian average Above average Same as average Below average 66

Quality of care: health promotion During the past 2 years, has a health professional discussed B. C. Alta. Sask. Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. A healthy diet and healthy eating 54% 52% 49% 47% 52% 48% 52% 47% 51% Exercise or physical activity 60% 55% 52% 51% 55% 49% 54% 55% 51% 55% Things in life that worry patients or cause stress 27% 23% 25% 24% 26% 20% 22% 32% 24% 25% Health risks of smoking or using tobacco and ways to quit 92% 75% 66% 84% 79% 71% 72% 60% 59% 78% Compared with the Canadian average Above average Same as average Below average 67

End-of-life care B. C. Alta. Sask. Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. Had a discussion with someone 61% 62% 57% 60% 64% 57% 55% 56% 55% 47% 61% Named a substitute decision-maker 46% 53% 44% 50% 60% 52% 47% 43% 42% 32% 53% Had a written document about end-of-life wishes 36% 43% 29% 35% 44% 40% 24% 29% 26% 18% 39% Compared with the Canadian average Above average Same as average Below average 68

Perception of health and health care Self-reported health status by province B. C. Excellent or very good Alta. Sask. Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. 52% 56% 44% 48% 52% 53% 44% 42% 44% 56% 52% Health system ratings by province B. C. Alta. Sask. Man. Ont. Que. N. B. N. S. P. E. I. N. L. Can. Minor changes 40% 35% 33% 34% 39% 22% 36% 34% 33% 23% 34% Fundamental changes 51% 52% 49% 48% 63% 51% 53% 52% 53% Completely rebuilt 6% 9% 10% 9% 12% 11% 9% 8% 21% 10% Compared with the Canadian average Above average Same as average Below average 69

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