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Forecasting acute-care hospital beds using intra-regional transfers Hastings, Gerald Leslie 1977

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FORECASTING ACUTE-CARE HOSPITAL BED DEMANDS USING INTRA-REGIONAL TRANSFERS by Gerald L e s l i e Hastings B. Comm., U n i v e r s i t y o f B r i t i s h Columbia, 1969  A Thesis Submitted I n P a r t i a l F u l f i l l m e n t Of The Requirements For The Degree Of MASTER OF SCIENCE in  The Faculty o f Graduate Studies Department Of Health Care And  Epidemiolgy  We acce.pt tku tkci>li> cu, ccrn&o fuming to the. KiiqvJjizd. i>ta.n.dcuid  U n i v e r s i t y o f B r i t i s h Columbia October, 1977 ©  Gerald L e s l i e Hastings, 1977  In p r e s e n t i n g t h i s  thesis  an advanced degree at  further  fulfilment  of  the  requirements  the U n i v e r s i t y of B r i t i s h Columbia, I agree  the L i b r a r y s h a l l make it I  in p a r t i a l  freely  available  for  this  thesis  f o r s c h o l a r l y purposes may be granted by the Head of my Department  of  this thesis for  It  financial  that  r e f e r e n c e and study.  agree t h a t p e r m i s s i o n for e x t e n s i v e copying o f  by h i s r e p r e s e n t a t i v e s .  for  or  i s understood that copying o r p u b l i c a t i o n gain s h a l l not be allowed without my  written permission.  Gerald L e s l i e Hastings  Department of  Health Care and Epidemiology  The U n i v e r s i t y o f B r i t i s h Columbia  2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5  Date  18 October, 1977  11  ABSTRACT  Governments i n t h i s country have a mandate from t h e i r e l e c t o r a t e t o obtain the best s o c i a l r e t u r n from p u b l i c investment i n h e a l t h Because o f e s c a l a t i n g c a p i t a l and operating c o s t s , the  care.  acute-care-hospital  component o f h e a l t h care has r e c e n t l y come under c l o s e s c r u t i n y . Accordingly, governments must forecast p u b l i c demands f o r h o s p i t a l services i n order t o plan the most e f f e c t i v e and e f f i c i e n t d e l i v e r y o f these expensive h o s p i t a l s e r v i c e s .  This t h e s i s examines the B r i t i s h  Columbia M i n i s t r y o f Health's current method o f f o r e c a s t i n g acute-carebed requirements which has been applied t o the Greater Vancouver Regional H o s p i t a l D i s t r i c t (G.V.R.H.D.) and then proposes an improved method which accounts f o r the movement of h o s p i t a l p a t i e n t s from t h e i r d i s t r i c t of residence t o a d i s t r i c t providing h o s p i t a l s e r v i c e s . A computer f o r e c a s t i n g program was designed using the P r o v i n c i a l f o r e c a s t i n g method as a base with the a d d i t i o n o f a Transfer Matrix  that  d i s t r i b u t e s the acute-care patient-days generated by each o f the G.V.R.H.D d i s t r i c t s t o those d i s t r i c t s that provide h o s p i t a l s e r v i c e s .  With t h i s  a d d i t i o n , the computer f o r e c a s t i n g program b e t t e r r e f l e c t s the G.V.R.H.D.' current source and d i s t r i b u t i o n o f the demand f o r h o s p i t a l s e r v i c e . computer f o r e c a s t i n g program was  verified  The  by comparing i t s Standard  Forecast t o a manually c a l c u l a t e d f o r e c a s t . The program was then used f i r s t l y t o analyse the s e n s i t i v i t y o f the forecast o f Hospital-Bed Requirements t o changes i n the values o f the Population and Incidence Rate v a r i a b l e s , and secondly, t o analyse the e f f e c t s o f a l t e r n a t e p o l i c i e s regarding the input values o f the program's variables.  iii. F i r s t l y , the s e n s i t i v i t y a n a l y s i s showed t h a t i f c e r t a i n equal changes are made t o the values o f input v a r i a b l e s , the s e n s i t i v i t y o f the output f o r e c a s t can vary among the d i s t r i c t s .  This aspect o f the  f o r e c a s t enhances the value o f the program as a method o f a n a l y s i n g unexpected r e l a t i o n s h i p s .  Secondly, the p o l i c y a n a l y s i s showed t h a t  the computerized f o r e c a s t i n g program can q u i c k l y produce a l t e r n a t e forecasts that correspond t o a l t e r n a t e p o l i c i e s regarding the values s e l e c t e d f o r the program's v a r i a b l e s .  The policy-maker can then analyse  the e f f e c t s o f these p o l i c i e s and thus be i n a b e t t e r p o s i t i o n t o weigh the costs and the b e n e f i t s involved. For these reasons, the computer f o r e c a s t i n g program developed f o r t h i s t h e s i s i s an improvement over the current method used i n B r i t i s h Columbia.  However, the t h e s i s does describe other current  techniques that can, and should, now be incorporated i n t o the computer f o r e c a s t i n g program t o o f f e r more f l e x i b i l i t y when analysing the e f f e c t s of p o s s i b l e future c o n d i t i o n s .  Supervisor  iv.  TABLE OF CONTENTS  ABSTRACT  i i  LIST OF TABLES LIST OF FIGURES  v v i i viii  ACKNOWLEDGEMENTS  CHAPTER I. II. III.  Introduction Problems o f Forecasting Acute-Care-Hospital Bed Requirements The Development o f Techniques f o r Forecasting the Demand f o r Acute-Care-Hospital Beds  IV. V. VI. VII. VIII. IX.  1 5 12  Current Forecasting Methods  23  Methodology  34  Experimental Procedures  43  Results  64  Discussion  81  Summary and Conclusions  93  GLOSSARY  97  BIBLIOGRAPHY  99  APPENDICES A. Computer Forecasting Program B.  Standard Forecast  102 103  V.  vi.  VII.  LIST OF FIGURES FIGURE 1.  Flow Diagram o f the Computer Forecasting Program  viii.  ACKNOWLEDGEMENTS  I wish t o take t h i s opportunity t o s i n c e r e l y  thank  Dr. John H. Milsum and Mr. Norman K. Barth f o r t h e i r advice and support during the development o f t h i s t h e s i s , and Mr. George Moore and Ms. Joan E.E. Wilson f o r the t y p i n g o f the manuscript.  CHAPTER I  INTRODUCTION  Hospitals are creatures o f t h e i r l o c a l community, and often o f only segments o f the community. I n general, they represent the f e e l i n g s , r a t h e r than the considered judgements o f t h e i r community. (Brown, 1967) This t h e s i s studies the planning o f future acute-care-hospital bed requirements which i s one aspect o f planning f o r h e a l t h s e r v i c e s .  Although  many techniques have been developed t o a s s i s t i n the h o s p i t a l - p l a n n i n g process, t h e i r e f f e c t i v e n e s s has been l i m i t e d by the f a c t t h a t frequently there have been no s p e c i f i c p o l i c i e s that f i r s t set the o b j e c t i v e s f o r the planning  process.  This study reviews the h i s t o r y o f planning f o r future hospital-bed requirements and the conceptual problems inherent i n techniques that forecast future requirements.  I t improves upon the f o r e c a s t i n g technique  used by the B r i t i s h Columbia M i n i s t r y o f Health which incorporates s e v e r a l generally recognized components but f a l l s short o f the s t a t e - o f - t h e - a r t methods o f analysing and f o r e c a s t i n g the i n t e r r e l a t i o n s h i p s among r e g i o n a l population groups and t h e i r h o s p i t a l s . S p e c i f i c a l l y , the f o l l o w i n g problems have been addressed i n t h i s thesis: 1.  To develop and v a l i d a t e a computerized method o f f o r e c a s t i n g future acute-care-hospital bed requirements based on the current B r i t i s h Columbia H o s p i t a l Programs' method, but w i t h the a d d i t i o n o f a matrix t o account f o r p a t i e n t t r a n s f e r s w i t h i n a region and,  2.  To exainine the s e n s i t i v i t y o f the developed method t o s e l e c t e d input v a r i a b l e s f o r which inaccuracies could occur i n t h e i r p r e d i c t e d values and,  2.  3.  To study the e f f e c t s o f a l t e r n a t e p o l i c y decisions i n the f o l l o w i n g areas: a. Population b. Incidence Rates o f H o s p i t a l i z a t i o n c. Inflow d. Infra-Regional P a t i e n t Transfers e. H o s p i t a l Occupancy Percentage.  The problems addressed are very narrow i n conceptual scope, but t h e i r r e s o l u t i o n depends on a l o g i c a l understanding o f t h e i r r e l a t i o n s h i p t o the broader concepts o f planning h e a l t h services now discussed. I f our community had unlimited resources t o meet i t s perceived health-care needs, there would be no requirement t o a l l o c a t e or r a t i o n resources - no requirement t o plan.  Because t h i s i s not so, systems  have evolved t o r a t i o n our l i m i t e d resources w i t h i n a spectrum ranging from p o l i t i c a l e d i c t t o open market w i t h a p r i c e system.  To the extent  that these systems prove e f f e c t i v e , they w i l l balance o v e r a l l community needs now and i n the f u t u r e .  Unfortunately, there i s no general agreement  that our resource a l l o c a t i o n systems are e f f e c t i v e . In the h e a l t h care sector, r a p i d l y r i s i n g c o s t s  are u s u a l l y viewed  as a s i g n a l t h a t the resource a l l o c a t i o n system i s out o f c o n t r o l .  The  p r e d i c t i o n o f the Economic C o u n c i l of Canada,that expenditures on h e a l t h care and education would t h e o r e t i c a l l y soon consume the e n t i r e Canadian Gross National Product unless changes are made,is constantly i n the background (Economic C o u n c i l o f Canada, 1970).  B e t t e r "planning" and thus  b e t t e r a l l o c a t i o n i s heralded as the answer. But what i s planning?  I t i s an a c t i v i t y t h a t has been described  as vaguely as the process o f t h i n k i n g before you a c t ( G o t t l i e b , 1974) and as s p e c i f i c a l l y as the development and implementation o f a course o f a c t i o n which i s expected t o lead t o desired r e s u l t s given the occurrence of expected events (Bergwall e t a l . , 1974).  Planning i s an a c t i v i t y that i s concerned w i t h the future having r e s u l t e d from an a l t e r a t i o n of the present o r , as i t i s defined f o r t h i s study, i t i s the management of the future. This d e f i n i t i o n o f planning implies the s e t t i n g o f goals and  the  o r g a n i z a t i o n o f e f f o r t t o a t t a i n them, and opens the question o f who plan f o r future h e a l t h s e r v i c e s .  should  C l e a r l y , the agency responsible f o r the  supply o f resources has a mandate t o ensure the most e f f e c t i v e use of those resources - a mandate t o plan. There i s much debate i n the United States over t h i s question as the h e a l t h sector and, s p e c i f i c a l l y , h o s p i t a l s struggle t o remain independent i n a market economy.  However, any agency that wishes t o plan the r e l a t i o n -  ship o f h o s p i t a l s t o other h e a l t h care and other community requirements must be able t o implement i t s s t r a t e g i e s . recognizes  The U.S.  P u b l i c Health  the need f o r planning due to cost e s c a l a t i o n s and  Service  population  changes, but maintains t h a t h o s p i t a l s should remain independent (U.S.P.H.S., 1961).  This independence i s c i t e d by May  (1976) as one reason f o r the  disappointing performance o f America's l a y e r s o f planning l e g i s l a t i o n . Because most American h o s p i t a l users s t i l l pay f o r s e r v i c e s d i r e c t l y t o the h o s p i t a l s or through t h i r d party i n s u r e r s , the State has been i n a weak p o s i t i o n i n proposing c e n t r a l c o n t r o l since i t has not been d i r e c t l y involved i n the t r a n s a c t i o n between the p a t i e n t and the h o s p i t a l . Recent U.S.  government p a r t i c i p a t i o n i n Medicare and Medicaid, however, has  a f i n a n c i a l l e v e r t h a t may be used to a t t a i n planning  created  goals.  In Canada, the health-care system i s d i f f e r e n t from t h a t i n the U.S.A., i n that the f e d e r a l and p r o v i n c i a l governments finance both h o s p i t a l care and the major p o r t i o n of h o s p i t a l c o n s t r u c t i o n , thus a c t i n g as t h i r d party agencies on behalf o f the consumer.  This c e n t r a l i z a t i o n o f funding has created a l e g i t i m a t e base f o r c e n t r a l planning, but i t has a l s o created a problem i n matching the demand and supply o f h o s p i t a l s e r v i c e s .  The consumer demands h e a l t h care as a  r i g h t , but i s not r e q u i r e d t o regulate h i s demands since the consumerprovider market system has beenreplaced by "insurance".  The State reacts  to these demands by r e g u l a t i n g the supply o f h o s p i t a l s e r v i c e s according to i t s f i s c a l resources.  To complete the c i r c l e , the consumer u s u a l l y  r e s i s t s the t a x increases t h a t the State r e q u i r e s t o meet the consumer's i n c r e a s i n g demands.  Thus, t h i s c e n t r a l i z a t i o n o f funding has removed the  consumer from the connection between s e r v i c e and i t s c o s t .  The problems  created by unregulated demands are discussed l a t e r i n t h i s study. In s p i t e o f these problems, the State attempts t o o b t a i n a balance i n the h o s p i t a l system by a l t e r i n g the supply o f h o s p i t a l s e r v i c e s t o meet the demand expressed by consumers.  Since there i s a lead-time o f s e v e r a l  years between the i n i t i a t i o n and the completion o f h o s p i t a l f a c i l i t i e s , current plans must be based on estimates o f f u t u r e demand i f a balance i s ever t o be reached between supply and demand. This t h e s i s studies the process o f e s t i m a t i n g , o r f o r e c a s t i n g , the future demand f o r h o s p i t a l f a c i l i t i e s and i t r e f i n e s one e s t a b l i s h e d f o r e c a s t i n g technique t o provide f o r r a p i d a n a l y s i s o f p o l i c y a l t e r n a t i v e s through use o f a f o r e c a s t i n g program on a computer.  F i n a l l y , the study  examines the s e n s i t i v i t y o f the technique t o changes i n the value o f input variables. I t must be c l e a r l y s t a t e d a t the onset t h a t systems-analysis techniques such as f o r e c a s t i n g cannot, and should not, be expected t o replace goal s e t t i n g and d e c i s i o n making; r a t h e r , they provide information t o a i d the p o l i c y makers.  To be e f f e c t i v e , these techniques must not only be t h e o r e t i c a l l y  sound, but must a l s o s u c c e s s f u l l y analyse r e a l problems.  ( B a i l e y , 1975).  5.  CHAPTER I I PROBLEMS OF FORECASTING ACUTE-CARE-HOSPITAL BED REQUIREMENTS H o s p i t a l planning i s u l t i m a t e l y s u b j e c t i v e . I f we t r y t o persuade ourselves t h a t i t i s o b j e c t i v e , we are deceiving ourselves. (Hudenburg, 1967) Canadian governments have removed most o f the h e a l t h care i n d u s t r y from the market economy.  This was not done as a contentious move t o c o n t r o l ,  but as an innocuous move t o "insure" i n d i v i d u a l s against the h i g h costs o f necessary h e a l t h s e r v i c e s . Government now "reimburses" h e a l t h care s u p p l i e r s by a c t i n g as the agent o f the consumer. Rapidly r i s i n g c a p i t a l and operating costs i n h o s p i t a l s have forced goverments t o determine whether the care consumed i s reasonable.  The  State i s expected t o provide h e a l t h care s e r v i c e s q u i c k l y i n response t o consumer demands and a l s o t o manage the taxpayers' funds prudently. two tasks o f t e n c o n f l i c t !  These  The State must r a t i o n i t s l i m i t e d resources t o  society's o v e r a l l demands and thus must compare the perceived health-care needs o f the consumer w i t h the demands expressed by o t h e r sectors o f society.  I n r e l a t i o n t o h o s p i t a l s e r v i c e s , the question the State must ask  i s , what IS the type and quantity o f a c u t e - h o s p i t a l care t h a t s o c i e t y should have? A spontaneous response might be "provide what the community needs". This i s an i d e a l i z e d approach but one that i s d i f f i c u l t t o implement. G r i f f i t h (1972) defines need as a "concept o f h e a l t h s e r v i c e r e q u i r e d by a population t o maintain i t a t a preconceived l e v e l o f h e a l t h " . laden concept i s a l l but impossible t o measure.  This value-  Unless d e t a i l e d and  expensive surveys o f the h e a l t h status o f the population are conducted,  the t r u e need f o r h o s p i t a l services cannot be known. The popular s u b s t i t u t e f o r need i s demand; "the sum o f e x p l i c i t requests f o r a given medical care service e i t h e r by the p a t i e n t . . . o r the doctor  " ( G r i f f i t h , 1972).  Newhouse (1971) suggests abandoning the  i n e f f e c t i v e concept o f "need" and using instead a p r e d i c t i o n o f future demand f o r s e r v i c e s and p r o v i s i o n o f the necessary corresponding resources. The disadvantage o f using t h i s s u b s t i t u t e i s t h a t such f a c t o r s as economic s t a t u s , s o c i a l pressures, and a v a i l a b i l i t y o f resources d i s t o r t true need i n t o demand f o r s e r v i c e s .  The advantage o f t h i s s u b s t i t u t e i s t h a t demand  i s expressed i n a c t i v i t y that can be e a s i l y as a s u b s t i t u t e f o r need, a judgement  measured.  By accepting demand  i s made t h a t m e a s u r a b i l i t y i s more  important t o planning than i s pertinence. Demand i s expressed i n the u t i l i z a t i o n o f acute-care f a c i l i t i e s ; p a r t i c u l a r l y by admissions t o h o s p i t a l s and the number o f days t h a t h o s p i t a l beds are occupied.  When u t i l i z a t i o n i s expressed as a r a t i o o f  h o s p i t a l bed days used (or p a t i e n t days) per 1000 persons, i t i s l a b e l l e d "THE INCIDENCE  RATE OF HOSPITALIZATION" ( G r i f f i t h , 1972).  such terms used i n t h i s study are contained i n the Glossary.  Definitions of This r a t e ,  when c a l c u l a t e d from current data, i s used as an i n d i c a t o r o f the current acute-care demand o f a population.  When projected t o a future p o i n t i n  time, the r a t e i s used t o estimate future demand f o r h o s p i t a l beds. The supply o f acute-care-hospital beds has a strong i n f l u e n c e on the u t i l i z a t i o n o f those f a c i l i t i e s by the community.  The concept t h a t supply  creates, w i t h i n some l i m i t s , i t s own demand (Abel-Smith,  1962) has  focused a t t e n t i o n on the number o f acute-care-hospital beds as a key t o a t t a i n i n g more "reasonable"  demands on the p u b l i c t r e a s u r y .  The study by  Roemer and Shain (1959) supports the argument t h a t empty h o s p i t a l beds are  7. soon f i l l e d and thus that the supply of beds i s d i r e c t l y l i n k e d t o c o s t s . This argument states that as beds are added i n response t o demand, they are soon occupied and t h i s u t i l i z a t i o n i s then used as a base f o r requesting more beds i n the f u t u r e . bed-count.  The s p i r a l must, i n p r a c t i c e , end a t a f i n i t e  This s t a b i l i z e d bed-count may not r e f l e c t the t r u e requirements  f o r acute-care f a c i l i t i e s as consumers may be i n a p p r o p r i a t e l y placed. These people may  s h i f t to less  c o s t l y a l t e r n a t i v e s , when provided,  leave the acute h o s p i t a l s w i t h i n e f f i c i e n t occupancy l e v e l s .  and  Ensminger (1975)  claims that t h i s i s the current s i t u a t i o n i n the United States w i t h higherthan-necessary costs f o r h o s p i t a l care due t o the o v e r - b u i l d i n g o f f a c i l i t i e s . Quality of care may  s u f f e r i n t h i s s i t u a t i o n as independent h o s p i t a l s and  t h e i r physicians compete f o r p a t i e n t s and a l s o d r a i n s t a f f and resources  from  public hospitals. The next major conceptual hurdle i n the planning process i s the projection or forecast of h o s p i t a l u t i l i z a t i o n .  The s o p h i s t i c a t e d s t a t i s t i c a l  t o o l s u s u a l l y used t o produce t h i s forecast do not create q u a n t i t a t i v e f o r e casts without the input o f q u a l i t a t i v e judgements.  Martin (1975) c o r r e c t l y  comments, "...no matter how complex the mathematics o f the p a r t i c u l a r technique appear, every f o r e c a s t i n g technique i s a mix o f two b a s i c elements, p r o j e c t i o n o f past trends and educated guesses."  The d i s t i n c t i o n between  these two elements i m p l i e s serious p o l i c y i m p l i c a t i o n s . For example, i f current u t i l i z a t i o n i s a p p l i e d t o a future time, o r i f past trends are extrapolated i n t o the f u t u r e , the i m p l i c i t assumption i s that no change from the status quo i s a n t i c i p a t e d . i s dynamic, t h i s i s a dubious assumption.  Since h o s p i t a l care  The second element, the educated  guess, i s i n t e r p r e t e d here t o mean e i t h e r the i d e n t i f i c a t i o n and examination o f f a c t o r s t h a t may a l t e r current demand o r the establishment  o f normative  8. demand l e v e l s .  The f i r s t element, the examination and p r o j e c t i o n o f past  trends, i s d e t e r m i n i s t i c ; the second, the educated guess, i s dynamic and implies conscious p o l i c y formation. Assuming that educated guessing i s necessary, how  does one e s t a b l i s h  normative u t i l i z a t i o n r a t e s ; how much h o s p i t a l care i s enough? Hoge (1958) notes that normative u t i l i z a t i o n r a t e s have been establ i s h e d , but t h a t they have been made equal to e x i s t i n g h o s p i t a l u t i l i z a t i o n . This acceptance of the status quo as a norm may be a mistake since there may be unexpressed demand due to a shortage of h o s p i t a l f a c i l i t i e s or overu t i l i z a t i o n o f h o s p i t a l f a c i l i t i e s due to a high ratio.  physician-per-population  For example, i f a population u n i t has i n s u f f i c i e n t h o s p i t a l s e r v i c e s  to meet i t s legitmate demands, u t i l i z a t i o n rates expressing the f u l l use of these f a c i l i t i e s w i l l only i n d i c a t e what h o s p i t a l use has occurred, not what use would have occurred i f more f a c i l i t i e s had been a v a i l a b l e . The f o r m a l i z i n g of the current u t i l i z a t i o n rate as a norm f o r future planning would perpetuate the inadequacy of the present s i t u a t i o n .  A l t e r n a t i v e l y , the current h o s p i t a l  u t i l i z a t i o n r a t e may r e f l e c t an o v e r - u t i l i z a t i o n of f a c i l i t i e s .  For example,  i f a population u n i t has more physicians than are r e q u i r e d t o meet i t s l e g i t i m a t e medical demands, h o s p i t a l s may be i n a p p r o p r i a t e l y over-used r a t h e r than physicians being appropriately under-used.  Again,  establishment  of t h i s i n f l a t e d h o s p i t a l incidence r a t e as a norm w i l l not a l t e r the future s i t u a t i o n as an improvement on the  present.  I t i s c l e a r l y d i f f i c u l t to judge the appropriateness hospital u t i l i z a t i o n rates.  o f current  A c t u a l h o s p i t a l occupancy r a t e s and p a t i e n t  w a i t i n g l i s t s can a s s i s t i n t h i s review, but they can be i n f l u e n c e d by such q u a l i t a t i v e f a c t o r s as the l o c a l patterns o f medical p r a c t i c e and e f f i c i e n c y o f the h o s p i t a l s ' management.  the  9. The appropriateness  o f l o c a l h o s p i t a l u t i l i z a t i o n r a t e s may be  assessed by comparing l o c a l rates w i t h the u t i l i z a t i o n experience o f other countries and d i f f e r e n t h e a l t h - c a r e - d e l i v e r y systems, b u t t h i s may y i e l d i n c o n c l u s i v e r e s u l t s as the f o l l o w i n g example shows. Anderson (1972) reported t h a t the 1968 average INCIDENCE RATE OF HOSPITALIZATION f o r the f r e e - e n t e r p r i s e U.S.A. was 1154/1000 while those o f S o c i a l i s t Sweden and England were 1569/1000 and 1132/1000 respectively.  No c l e a r pattern emerges from these few samples.  S i m i l a r l y , l o c a l INCIDENCE RATES may be compared w i t h i n a r e g i o n a l area i n an attempt t o s e t norms f o r future planning. Table One shows the a g e - s p e c i f i c a d u l t INCIDENCE RATES f o r d i s t r i c t s w i t h i n Greater Vancouver f o r the years 1971 and 1975. TABLE I ANNUAL INCIDENCE RATE OF HOSPITALIZATION PER 1000 PERSONS AGE GROUP 1 5 - 6 9 Districts  1971  1975  Surrey Delta Richmond Vancouver New Westminster Burnaby Coquitlam North Vancouver West Vancouver  1292 881 907 1374 1208 976 891 1247 1023  1141 828 867 1352 1275 941 912 1035 941  TOTAL POPULATION  1202  1136  Two o f the areas w i t h low u t i l i z a t i o n , D e l t a and Coquitlam, do not have l o c a l community h o s p i t a l s .  However, other i n d i c a t o r s would  need t o be studied t o deternrine whether these two areas were low because o f i n s u f f i c i e n t supply o f h o s p i t a l beds o r whether t h e other areas were high because o f an oversupply o f beds.  Such an a n a l y s i s  10. might lead t o reasonable norms f o r demand. Although the establishment o f norms i s d i f f i c u l t , f o r e c a s t i n g demand cannot be a u s e f u l technique i n the cost-reducing  planning  process unless e x i s t i n g patterns o f u t i l i z a t i o n are changed.  Paul  Ellwood i n a summary t o a work by Melum (1975) states t h a t sophist i c a t e d formulas, g i v i n g the appearance o f p r e c i s i o n , a c t as mathematical " s e c u r i t y blankest" and t h a t h e a l t h care costs w i l l not be contained unless "courageous c r i t e r i a " are used i n the f o r e c a s t i n g of future demands.  I n other words, Elwood b e l i e v e s t h a t the present  u t i l i z a t i o n o f h o s p i t a l f a c i l i t i e s i s not i d e a l and t h a t future u t i l i z a t i o n should be forced downward by r e s t r i c t i n g the supply o f acute care f a c i l i t i e s .  This statement implies t h a t , i n general,  acute-care-hospital f a c i l i t i e s are i n a p p r o p r i a t e l y used and t h a t lower-cost a l t e r n a t i v e s should be made a v a i l a b l e t o meet the consumer's perceived needs f o r h o s p i t a l care. As stated e a r l i e r , the two elements o f a f o r e c a s t i n g technique are, f i r s t l y , p r o j e c t i o n s o f past trends and,secondly, educated guesses.  Too o f t e n , a simple e x t r a p o l a t i o n o f a past trend i s used  to a r r i v e a t a f o r e c a s t without addressing the problems involved i n making educated guesses about value-laden  issues.  An e x t r a p o l a t i o n f o r e c a s t makes these guesses, o r p o l i c y decisions by d e f a u l t ; i t assumes a continuation o f the status quo.. These two elements must be combined and the i m p l i c i t p o l i c y decisions must be s t a t e d c l e a r l y i f the r e s u l t i n g forecast i s t o be e f f e c t i v e . This chapter has o u t l i n e d the f o l l o w i n g b a s i c  conceptual  problems involved i n planning acute-care-hospital requirements: the concept o f need vs. demand, the State as a t h i r d party i n the con-  11. sumer-provider r e l a t i o n s h i p , the appropriateness o f current h o s p i t a l u t i l i z a t i o n , and, the p r o j e c t i o n o f trends.  Since i t i s u n l i k e l y  that these problems w i l l be r e s o l v e d , the f o l l o w i n g comment by S i r George Godber ( T o t t i e , 1967) may be i r o n i c a l l y appropriate: "Although the number o f beds i s a poor measure o f h o s p i t a l need, i t does give a general guide and i t i s the only u n i t i n common use."  12. CHAPTER I I I THE DEVELOPMENT OF TECHNIQUES FOR FORECASTING THE DEMAND FOR ACUTE-CARE-HOSPITAL BEDS " r ^ t e r m i n i n g bed need, a t best, i s an educated guess; but, i n a l l p r o b a b i l i t y , i s b e t t e r than an uneducated one." (Hudenburg, 1967) Current techniques used t o f o r e c a s t the future demand f o r acutec a r e - h o s p i t a l beds have r e s u l t e d from past i n q u i r i e s i n t o the status of h o s p i t a l bed supply.  I t i s relevant t o t h i s t h e s i s t o t r a c e t h i s  development by l o o k i n g a t selected developments which can put the current s t a t e - o f - t h e - a r t i n t o perspective. One o f the e a r l i e s t formal recognitions o f the need t o p l a n the development o f h o s p i t a l s was made by the New York Academy o f Medicine i n 1920 (U.S.P.H.S., 1958).  This study used a U.S. P u b l i c  Health Service estimate t h a t two per cent o f the population would be i l l a t any p o i n t i n time.  Thus, by surveying 180 general h o s p i t a l s  i n New York C i t y , i t was determined that there were 5 beds per 1,000 people, o r one bed f o r every f o u r t h i l l person. f e l t that t h i s was s u f f i c i e n t .  The Academy  This uncomplicated approach has the  b a s i c elements o f a f o r e c a s t , namely, a q u a n t i t a t i v e measure o f current demands and a p r e d i c t i o n o f future demand.  Specifically,  the measure o f current demand was f i v e beds f o r every 1,000 persons and the p r e d i c t i o n o f future demand was t h e i r d e c i s i o n t h a t t h i s usage was acceptable and the assumption that t h i s bed per population r a t i o should be a p p l i e d t o future populations t o determine future h o s p i t a l bed requirements. The economic depression o f the 19 30's l i m i t e d the growth o f  13. h o s p i t a l s , although the U.S.  government began a g r a n t - i n - a i d program  i n 1933 to use h o s p i t a l s as p u b l i c works p r o j e c t s (Hodge, 1958). The manpower and m a t e r i a l shortages experienced during World War aggravated t h i s already slow growth i n the h o s p i t a l bed  II  supply.  During t h i s war, many countries recognized that changes i n the postwar h o s p i t a l sector would be necessary.  B r i t a i n planned t o reorganize  i t s e n t i r e h e a l t h s e r v i c e s while Canada and the U.S.  planned i n c e n t i v e s  f o r the c o n s t r u c t i o n o f new h o s p i t a l f a c i l i t i e s . The Commission on H o s p i t a l Care examined the status o f h o s p i t a l f a c i l i t i e s i n the United States i n the e a r l y 1940s (Commission on H o s p i t a l Care, 1947).  A f t e r e x p l o r i n g the d i f f i c u l t i e s of  determining  need, which are o u t l i n e d i n Chapter I I , the Commission used the death r a t e of the population as an i n d i c a t o r of the prevalence o f sickness i n the population.  They a l s o determined t h a t , on the average, 250  patient-days o f care are provided by h o s p i t a l s f o r every death occurring i n h o s p i t a l s ( t o t a l patient-days/deaths  i n hospitals); this  i s equivalent to approximately 0.7 h o s p i t a l beds f o r each death occurr i n g i n one year (250 days/365 days) at 100% occupancy.  Since the  gross death r a t e of the population was known, 10.1%/year., as w e l l as the proportion o f t o t a l deaths that occur i n h o s p i t a l s , 50%, i t was p o s s i b l e t o f o r e c a s t the future h o s p i t a l requirements as i n Table I I .  described  14.  TABLE I I FORECASTING TECHNIQUE USED BY THE COMMISSION ON HOSPITAL CARE U.S.A.  Forecast Annual Deaths per 1000 Persons  Forecast Proportion of T o t a l Deaths Occurring i n Hospitals  5.05/1000 - y r .  10.1/1000 - y r .  0.5  Forecast Annual Hospital-Bed Requirement a t 100% Occupancy Per 1000 Persons  Forecast Annual X Deaths i n H o s p i t a l s per 1000 Persons  0.7 Beds per H o s p i t a l Death  Forecast Annual Deaths i n H o s p i t a l s per 1000 Persons Example:  Example: X  0.7  3.54/1000 - y r .  5.05/1000 - y r .  Forecast Annual Hospital-BedRequirement a t Desired Occupancy Percentage  Forecast Annual Requirement a t 100% Occupancy  Desired Occupancy Percentage  3.54/1000 y r .  75^  Example: 4.71/1000 - y r .  15. This c a l c u l a t i o n used a 1944 U.S.  death r a t e and a p r o j e c t e d  1946 proportion of deaths i n h o s p i t a l s to f o r e c a s t a 1946  require-  ment o f approximately f i v e h o s p i t a l beds per 1000 persons.  The  Commission f o r e c a s t the requirement f o r maternity beds separately, i n p a r t i c u l a r the f o r e c a s t number of these beds were d i r e c t l y r e l a t e d to the number of b i r t h s o c c u r r i n g i n h o s p i t a l s . The p r a c t i c a l operation s i z e of h o s p i t a l s w i t h i n the  estab-  l i s h e d geographic areas was determined from the average d a i l y requirement f o r beds, the AVERAGE DAILY CENSUS.  Because h o s p i t a l s  with a low average d a i l y census were unable to maintain a high occupancy, the planned occupancy r a t e s f o r the h o s p i t a l s v a r i e d w i t h the expected average d a i l y census. These refinements enabled the study t o vary the supply o f h o s p i t a l beds to s u i t l o c a l c o n d i t i o n s , providing a b e t t e r approach than e a r l i e r f i x e d r a t i o s per population u n i t . This work of the Commission on H o s p i t a l Care i n the United States r e s u l t e d i n the H o s p i t a l Survey and Construction Act ( H i l l - B u r t o n ) of 1946  (Somers,  1969).  This Act was designed t o provide f e d e r a l funds  f o r l o c a l h o s p i t a l c o n s t r u c t i o n on a cost-sharing b a s i s , provided  that  each state conducted a survey o f current assets and projected demands. The s p e c i f i e d f o r e c a s t i n g formula a p p l i e d the current incidence r a t e f o r an area to an estimate o f the future population.  This projected  annual demand i n h o s p i t a l patient-days was converted t o h o s p i t a l bedequivalents and adjusted by the desired occupancy o f the h o s p i t a l s to y i e l d the projected demand f o r h o s p i t a l beds. summarized i n Table I I I .  These steps are  16. TABLE I I I FORECASTING TECHNIQUE USED BY THE HOSPITAL SURVEY AND CONSTRUCTION ACT U.S.A.  1.  2.  3.  Forecast Population  Forecast Annual Demand f o r Hospitalization  Current Incidence Rate of H o s p i t a l i z a t i o n  (Patient-Days/yr.)  (Patient-Days/yr.)  (Population i n 1000's)  Forecast Average D a i l y Census  Forecast T o t a l Annual Demand For H o s p i t a l i z a t i o n  365  (Patient-Days/yr)  (Patient-Days/yr.)  (days/yr.)  Forecast H o s p i t a l Bed Need  Forecast Average D a i l y Census  Desired Occupancy Percentage  Beds/day  (Patient-Days/day)  ( % )  (or Beds/Day)  X  +10 (Beds)  17. I n i t i a l l y , the Occupancy Percentage was  set a t 80% (or 0.8)  with  the a d d i t i o n a l 10 beds as an adjustment f o r small h o s p i t a l s t h a t are unable to maintain t h i s desired occupancy.  Note here t h a t , f o r s i m p l i c -  i t y , the method o f varying the desired Occupancy Percentage i n r e l a t i o n to the expected Average D a i l y Census of each h o s p i t a l used by the Commission on h o s p i t a l care, was not incorporated i n t o the H i l l - B u r t o n formula.  Subsequently, i n 1972, the occupancy r a t e was r a i s e d t o 85%  and i n 1973, the a d d i t i o n of 10 beds was deleted from the This Act required the establishment  formula.  of s t a t e planning agencies  as a c o n d i t i o n f o r f e d e r a l p a r t i c i p a t i o n i n h o s p i t a l c o n s t r u c t i o n programs and i t provided the agencies w i t h a uniform planning method. In recent years, however, the planning method has been c r i t i c i z e d 1971) because i t assumes that current usage as expressed as the  (Hill, Incidence  Rate i s l e g i t i m a t e and then a p p l i e s that Incidence Rate t o f u t u r e population estimates.  I f the current Incidence Rate i s inappropriate  f o r whatever reason, the discrepancy can be compounded i n the f u t u r e , as was explained i n Chapter I I . However, despite i t s t h e o r e t i c a l d e f i c i e n c i e s , the Act d i d stimulate h o s p i t a l c o n s t r u c t i o n i n a period of generally agreed shortage. Canada, l i k e the United States, experienced a post-World War shortage of h o s p i t a l f a c i l i t i e s .  II  The Canadian government implemented  a N a t i o n a l Health Program i n 1948 t o provide f e d e r a l funds on a cost-shared basis t o provinces f o r acute-care-hospital c o n s t r u c t i o n . L i k e the H i l l - B u r t o n program, f e d e r a l grants were c o n d i t i o n a l on p r o v i n c i a l surveys of h e a l t h s e r v i c e s . The hospital-insurance program of the Province o f  British  Columbia, t h e r e f o r e , required a comprehensive a n a l y s i s o f h o s p i t a l needs and such a study was commissioned (Hamilton, 1949).  The h o s p i t a l  18. plan subsequently recommended was based on forecasts o f "need" using the bed/death and bed/birth methods o f the Commission on H o s p i t a l Care discussed e a r l i e r .  The plan s p e c i f i e d h o s p i t a l regions created from  census t r a c t d i v i s i o n s w i t h a t h r e e - t i e r e d s t r u c t u r e o f community c l i n i c s , community h o s p i t a l s and r e g i o n a l h o s p i t a l s . r e g i o n a l h o s p i t a l s were teaching centres.  Some o f these  Some 15% o f demand a t the  community c l i n i c and h o s p i t a l l e v e l was t o be r e f e r r e d t o r e g i o n a l h o s p i t a l s and a f u r t h e r 5% t o the teaching h o s p i t a l s .  The Plan's  f o r e c a s t f o r 1971 was a bed/1000 population r a t i o o f 7.09.  Compared  w i t h recent standard o f 4.25* t h i s i s an i n c r e d i b l y high r a t i o , which may i n d i c a t e the p e r i l s o f f o r e c a s t i n g f o r a 20 year p e r i o d ! Further work was done i n B r i t i s h Columbia i n the e a r l y 1950s t o determine the number o f acute-care-hospital beds needed f o r the Lower Fraser V a l l e y H o s p i t a l Region.  The work was done by the former B.C.  Department o f Health and Welfare (Grigg and Whelen, 1954), based on 1952 data from the newly formed B.C. H o s p i t a l Insurance S e r v i c e .  Past  trends i n h o s p i t a l i z a t i o n , projected population growth, transport a t i o n f a c i l i t i e s and i n t e r - r e g i o n a l r e l a t i o n s h i p s were examined t o forecast the change i n the t o t a l number o f patient-days over a time period.  The reason f o r the use o f t o t a l patient-days as a base f o r  the f o r e c a s t r a t h e r than the more usual r a t e o f patient-days p e r 1,000  population i s c u r i o u s , and not explained.  This work, however,  d i d contribute a new feature t o the growing l i s t o f s o p h i s t i c a t e d f o r e c a s t i n g techniques.  S p e c i f i c a l l y , since accurate information on  * 1977 B.C. H o s p i t a l Programs P r o v i n c i a l Average-Care-Hospital Bed per 1000 Target R a t i o .  19. h o s p i t a l usage was a v a i l a b l e from the new u n i v e r s a l h o s p i t a l - i n s u r a n c e program, the source and d i s t r i b u t i o n o f p a t i e n t s was known and could, t h e r e f o r e , be used i n f o r e c a s t i n g the future demand a t Lower Fraser Valley hospitals. In the mid 1950s, the Swedish h o s p i t a l system was reorganized t o overcome the l i m i t a t i o n s experienced by the 25 independent county c o u n c i l s responsible f o r h o s p i t a l care due t o t h e i r o v e r a l l population bases.  A f t e r t r a n s p o r t a t i o n and geographic studies were conducted,  the country was d i v i d e d i n t o s e v e r a l s e l f - s u f f i c i e n t h o s p i t a l regions, each serving approximately one m i l l i o n persons.  Each region has a  r e g i o n a l h o s p i t a l o f f e r i n g s p e c i a l i z e d s e r v i c e s as w e l l as county and community h o s p i t a l s i n a t h r e e - t i e r e d system.  I n determining the  organization o f f a c i l i t i e s , the optimal s i z e o f departments f o r needed services was considered along w i t h the usual demographic characteri s t i c s o f the population.  Using f i f t e e n years o f experience,  standard  s i z e d u n i t s were determined f o r medical s p e c i a l i t i e s w i t h bed-topopulation r a t i o s .  T o t t i e and Janzon (1967) report t h a t the bed-to-  population r a t i o s were used as a guide i n the f o r e c a s t i n g o f demand but that s o c i a l f a c t o r s such as housing and family care o f the aged as w e l l as geographic f a c t o r s were important considerations i n the a l l o c a t i o n o f future f a c i l i t i e s .  This extensive n a t i o n a l p l a n was  mainly based on s u b j e c t i v e judgements o f l o c a l c o n d i t i o n s but i t d i d add t o the planning a r t the techniques o f developing and using r a t i o s o f specialty-beds-to-population and, a f t e r the t o t a l number o f s p e c i a l t y beds had been determined, e s t a b l i s h i n g r a t i o n a l l y s i z e d groups o f s p e c i a l t y beds. In Great B r i t a i n , f o l l o w i n g World War I I , the c r e a t i o n o f the National Health Service reorganized the d e l i v e r y o f medical and  20. h o s p i t a l care.  However, no e x p l i c i t f o r e c a s t was made o f t h e future  demand f o r h o s p i t a l f a c i l i t i e s .  By 1962, n a t i o n a l standards were  s e t f o r the demand expected i n 1975,  (National Health S e r v i c e , 1966).  A 3.3/1,000 hospital-bed-to-population r a t i o was s e t f o r acute care and a 0.58/1,000 r a t i o was s e t f o r maternity.  The combined 3.9 bed  to population r a t i o appears as a target t o be met r a t h e r than as an estimate o f consumer demand because the 1966 statement on the b u i l d ing program emphasizes t h a t acute care i s not the whole p i c t u r e and t h a t a l t e r n a t i v e s such as home care and day care can be improved. , This use o f targets i s an important change from the usual technique of e x t r a p o l a t i n g from past trends t o forecast the demand f o r h o s p i t a l services a t a future point i n time.  Despite the d i f f i c u l t i e s  inherent  with the s e t t i n g o f normative h o s p i t a l i z a t i o n r a t e s , noted i n Chapter I I , the N a t i o n a l Health Service e s t a b l i s h e d a p u b l i c - p o l i c y o b j e c t i v e t o change the system o f h o s p i t a l care and s e t h o s p i t a l b u i l d i n g targets a f t e r comparing estimates o f future need w i t h t h e policy objectives. In the e a r l y 1960s, t h e Canadian government commissioned a broad study on the s t a t e o f the nation's h e a l t h s e r v i c e s (Royal Commission on Health Services, 1964).  Part o f i t s mandate was t o  report on the future need f o r h e a l t h s e r v i c e s .  Although the Com-  mission c a r e f u l l y stated t h a t i t could not " p r e d i c t " the f u t u r e demand f o r beds, i t d i d extrapolate the 1958-61 h o s p i t a l i z a t i o n experience t o estimate t h a t the 1971 demand would be 1,995 p a t i e n t days per 1,000 population f o r acute h o s p i t a l care.  The Commission  exarnined occupancy r a t e s and a r b i t r a r i l y increased the average r a t e from 80.0% t o 81.6% when expressing the demand f o r e c a s t i n terms o f h o s p i t a l beds.  The Report o f the Commission s t a t e s t h a t  21. the f o r e c a s t was only intended t o i n d i c a t e a "general order o f magnitude of the need f o r p h y s i c a l f a c i l i t i e s . "  Because of i t s  g e n e r a l i t y , the f o r e c a s t could only be used t o show what might happen i f past trends were t o continue.  I n f a c t , the Greater Vancouver  Regional H o s p i t a l D i s t r i c t ' s incidence r a t e of h o s p i t a l i z a t i o n i n 1971 was 1,380  patient-days/1000  persons-year, 31% below the Royal  Commission's estimate of 1995/1000 f o r the 1971 n a t i o n a l average. The trend i n that era of i n c r e a s i n g usage of acute-care h o s p i t a l s d i d not i n f a c t continue. By the e a r l y 1960s, the United States had evaluated the p e r f o r mance of the H i l l - B u r t o n l e g i s l a t i o n of 1946 and found i t l e s s s a t i s f a c t o r y than expected.  Thus May  (1967) s t a t e s t h a t w h i l e the l e g i s l a t i o n  d i d expand the stock o f h o s p i t a l f a c i l i t i e s , unfortunately the f o r e c a s t i n g formula tended t o entrench l o c a l patterns.  Further, the area-wide  planning agencies created under H i l l - B u r t o n d i d not have a u t h o r i t y over a l l h o s p i t a l s which made coordination of development d i f f i c u l t . Funding f o r planning agencies was improved by f e d e r a l l e g i s l a t i o n i n 1961.  To provide guidance t o these agencies, the  U.S.  P u b l i c Health Service and the American H o s p i t a l A s s o c i a t i o n published a planning manual i n the same year.  This p u b l i c a t i o n i s comprehen-  sive i n i t s review o f f a c t o r s i n f l u e n c i n g planning d e c i s i o n s , but continues to apply current incidence rates t o f u t u r e populations i n order t o estimate f u t u r e demands, thus deserving the b a s i c c r i t i c i s m of the 1946 H i l l - B u r t o n method already noted. introduce  The manual does  one normative v a r i a b l e , however, because i t suggests t h a t  " d e s i r a b l e " m e d i c a l - s u r g i c a l occupancy r a t e s should be between 85-90%. In summary o f the period from the e a r l y 1900s t o the 1960s,  22. the techniques f o r f o r e c a s t i n g the future demand f o r acute care h o s p i t a l beds have evolved from simple s p e c i f i c a t i o n o f h o s p i t a l beds per population r a t i o s t o those o f complex use r a t e s , p o p u l a t i o n f o r e c a s t s , and occupancy equations.  The next chapter completes the  review by examining c u r r e n t f o r e c a s t i n g methods.  23.  CHAPTER IV CURRENT FORECASTING METHODS  Current methods used t o f o r e c a s t the future demand f o r acutec a r e - h o s p i t a l beds have evolved from e f f o r t s such as those described i n the previous chapter.  These techniques are now u s u a l l y used t o  j u s t i f y expansion of services t o meet the "needs" o f growing popu l a t i o n s and t o c o n t a i n the "unnecessary" growth o f expensive acute h o s p i t a l care - depending on the user's frame o f reference. Some techniques are more complicated than o t h e r s , but they a l l can be broken down i n t o some set of the stages l i s t e d i n Table IV. Many refinements can be made to these b a s i c r e l a t i o n s h i p s t o focus on s p e c i f i c diseases, populations, and age groups.  However,  no matter how s o p h i s t i c a t e d the technique may be, fundamental  dif-  f i c u l t i e s remain w i t h the use of incidence r a t e s , population f o r e casts and occupancy percentages. Before the f o r e c a s t process can begin, there must be agreement on the d e f i n i t i o n o f the population groups whose demands f o r h o s p i t a l care are t o be f o r e c a s t .  For convenience, these groups are u s u a l l y  organized communities w i t h p o l i t i c a l boundaries.  Hospital service  areas must a l s o be known i f reasonable forecasts o f demand are t o be made f o r i n d i v i d u a l h o s p i t a l s .  Since the geographic boundaries o f  these two area types do not u s u a l l y c o i n c i d e , adjustments must be made i n the f o r e c a s t t o r e f l e c t the flow o f p a t i e n t s among the areas. These adjustments are i n d i c a t e d by the reference t o RELEVANCE INDICES i n Equation 3, and are described l a t e r i n t h i s chapter. ing examples describe the c r e a t i o n o f population groups.  The f o l l o w -  24.  TABLE IV EQUATIONS OF THE STANDARD FORECASTING METHOD  1.  2.  FORECAST AVERAGE LENGTH OF STAY PER ADMISSION  FORECAST INCIDENCE RATE OF HOSPITALIZATION  FORECAST HOSPITAL ADMISSIONS RATE  Patient-Days/10 0 0-yr.  Admissions/1000/yr.  FORECAST GROSS TOTAL DEMAND FOR HOSPITALIZATION  FORECAST FORECAST INCIDENCE RATE x POPULATION OF HOSPITALIZATION  Patient-Days/yr.  Patient-Days /1000-yr.  FORECAST NET TOTAL DEMAND FOR HOSPITALIZATION  FORECAST GROSS TOTAL DEMAND  Patient-Days/yr.  Patient-Days /yr.  FORECAST AVERAGE DAILY CENSUS  FORECAST NET TOTAL DEMAND  Patient-Days/day (beds)  Patient-Days/yr.  Days/yr.  FORECAST HOSPITAL  FORECAST AVERAGE DAILY CENSUS beds  DESIRED OCCUPANCY PERCENTAGE  BED REQUIREMENTS  beds  x  Days per Admission  Population i n 1000's.  x  RELEVANCE INDICES  INFLOW +  Proportions  * 365  Patientdays/yr.  25. The province of Ontario uses a planning guide t h a t 80% o f a population group's need f o r h o s p i t a l care should be met by l o c a l hosp i t a l s , a f u r t h e r 10% by d i s t r i c t h o s p i t a l s , and the remaining 10% by r e g i o n a l or teaching h o s p i t a l s (Task Force on the Cost o f Health Services 1970).  These s e r v i c e areas must be defined before t h i s  hierachy of care l e v e l s can be e s t a b l i s h e d .  For example, the province  of A l b e r t a used 1971 h o s p i t a l insurance data on p a t i e n t - f l o w patterns to define the boundaries o f acute-care-hospital regions (Paine and Wilson, 1974).  The flow part ems were then incorporated i n t o f o r e -  casts of bed demand f o r each of the population groups organized as h o s p i t a l regions. I n B r i t i s h Columbia, r e g i o n a l h o s p i t a l d i s t r i c t s were arranged to coincide w i t h the p o l i t i c a l r e g i o n a l d i s t r i c t s i n order t o f a c i l i t a t e f i n a n c i a l c o s t sharing.  Unfortunately, these h o s p i t a l regions were  e s t a b l i s h e d f o r a d i n i n i s t r a t i v e convenience and do not n e c e s s a r i l y r e f l e c t the p a t t e r n of p a t i e n t flow from community t o r e g i o n a l h o s p i t a l s as do the h o s p i t a l regions of A l b e r t a .  The data on p a t i e n t flow pat-  terns i n B.C. are a v a i l a b l e , however, and were used by Anderson (1974) t o estimate the requirements f o r a proposed centre t o serve the r e f e r r a l needs i n o b s t e t r i c s and p a e d i a t r i c s f o r the whole province.  This  a n a l y s i s developed a working d e f i n i t i o n of t e r t i a r y care which was used t o f o r e c a s t the future i n f l o w to the proposed centre.  Unfortun-  a t e l y , the techniques he e s t a b l i s h e d have not been used to analyse broader i n t e r - r e g i o n a l p a t i e n t flow problems. Once the population groups have been defined by methods such as those j u s t described, the f o r e c a s t i n g process o u t l i n e d i n Table IV can be a p p l i e d . The f i r s t Equation i n the standard f o r e c a s t i n g method develops  26. a measure o f h o s p i t a l use by a s p e c i f i c population by m u l t i p l y i n g a f o r e c a s t o f the HOSPITAL ADMISSIONS RATE by a f o r e c a s t o f the AVERAGE LENGTH OF STAY.  This count of "patient-days" i s u s u a l l y expressed i n  terms o f u n i t s o f one thousand persons and time u n i t s o f one year t o form a use r a t e defined as the INCIDENCE RATE OF HOSPITALIZATION. The f o r e c a s t o f t h i s Incidence Rate at a f u t u r e p o i n t i n time i s a fundamental step and can be done i n two ways.  The conventional  method i s t o e x t r a p o l a t e the c u r r e n t r a t e a f t e r examining past trends and then to make adjustments f o r expected f u t u r e developments i n h e a l t h care.  A more r e f i n e d , but no l e s s s u b j e c t i v e method i s t o f i r s t f o r e -  c a s t the H o s p i t a l Admissions Rate f o r the population and then m u l t i p l y t h i s r a t e by the f o r e c a s t Average Length of Stay per admission t o y i e l d an Incidence Rate expressed as patient-days per thousand o f population. In e i t h e r method, the e s s e n t i a l question asked i s " W i l l past trends continue, and i f not, by how much should they be a l t e r e d ? " Here, a multitude o f i n f l u e n c i n g f a c t o r s can be considered, such as; the supply o f h e a l t h care personnel, the supply o f h o s p i t a l f a c i l i t i e s , advances i n medical technology, and patterns o f o r g a n i z a t i o n and t r e a t ment.  Nevertheless, i n the end, a s u b j e c t i v e judgement must be made  as to what numerical value i s to be given t o the Incidence Rate.  If  the softness o f t h i s estimate i s recognized i n i n t e r p r e t i n g the r e s u l t s , then the f i n a l f o r e c a s t can remain a u s e f u l planning t o o l .  I n many  cases, however, once the q u a n t i f i c a t i o n of s u b j e c t i v e judgement i s made, the chosen numerical value i s used t o produce r e s u l t s t h a t s u f f e r from spurious accuracy.  A reasonable way t o a l e r t the user t o t h i s  uncertainty i s t o s p e c i f y a range i n v o l v i n g both a minimum and a maximum r a t e , as i s done by the s t a t e planning agencies o f New York and  27. I l l i n o i s (Melum, 1975).  Although the range i s s t i l l based on s u b j e c t i v e  judgement, any u n j u s t i f i e d i m p l i c a t i o n o f p r e c i s i o n i s removed. The second Equation i n the standard f o r e c a s t method i s the a p p l i c a t i o n o f the FORECAST INCIDENCE RATE OF HOSPITALIZATION t o a f o r e c a s t o f the FUTURE POPULATION t o produce GROSS TOTAL DEMAND FOR HOSPITALIZATION.  The subject o f population f o r e c a s t i n g i s complex and  w i l l not be discussed i n t h i s examination beyond t h e comment t h a t i t can s u f f e r from the same problem o f spurious accuracy.  The steady  pattern o f population growth i n the years f o l l o w i n g World War I I i s no longer a r e l i a b l e trend because b i r t h r a t e s , immigration and migration p a t t e r n s , and economic conditions are a l l i n a s t a t e o f flux.  To r e f l e c t t h i s u n c e r t a i n t y , ranges should be again used.  For example, a study o f the h o s p i t a l bed needs o f Scarborough, Ontario, used three estimates o f the future population (most l i k e l y , next most l i k e l y , and l e a s t most l i k e l y ) as a base o f a l t e r n a t e forecasts (Thompson, 1971).  I n t h i s way, t h e f o r e c a s t can be a p p r o p r i a t e l y  used t o r e f l e c t d i f f e r e n t possible outcomes r a t h e r than s t a t i n g a s i n g l e f i g u r e and masking t h e inherent uncertainty i n the components. Taking t h i s approach one step f u r t h e r , p r o b a b i l i t i e s could be assigned to each a l t e r n a t e f o r e c a s t , which would give the p o l i c y maker an i n d i c a t i o n o f the degree o f r i s k t h a t the chosen f o r e c a s t w i l l not be accurate. The t h i r d Equation o f the 'standard f o r e c a s t i n g method converts the f o r e c a s t GROSS TOTAL DEMAND o f the subject population group t o a f o r e c a s t o f t h e NET TOTAL DEMAND through the use o f RELEVANCE INDICES that d i s t r i b u t e the Gross T o t a l Demands o f i n d i v i d u a l sub-regional d i s t r i c t s t o other d i s t r i c t s .  This r e a l l o c a t i o n accounts f o r t h e flow  of p a t i e n t s from t h e i r d i s t r i c t o f residence t o the d i s t r i c t where  28. t h e i r h o s p i t a l treatment i s provided.  Since the geographic boundaries  of the s p e c i f i e d sub-regional d i s t r i c t s do not u s u a l l y c o i n c i d e w i t h the s e r v i c e areas o f the i n d i v i d u a l h o s p i t a l s , t h i s flow o f p a t i e n t s across d i s t r i c t boundaries may s i g n i f i c a n t l y a f f e c t the Net T o t a l Demand o f i n d i v i d u a l d i s t r i c t s . For example, Table V shows a h y p o t h e t i c a l Region w i t h three d i s t r i c t s ; D i s t r i c t A, D i s t r i c t B, and D i s t r i c t C. Each d i s t r i c t has f o r e c a s t a GROSS TOTAL DEMAND f o r h o s p i t a l s e r v i c e s and a flow o f p a t i e n t demand, expressed i n patient-days, t o each other d i s t r i c t , and t o d i s t r i c t s outside the Region, l a b e l l e d OUTFLOW. The proportions that d i s t r i b u t e each d i s t r i c t ' s f o r e c a s t Gross T o t a l Demand have been named RELEVANCE INDICES (Johnstone, 1971).  INFLOW patient-days from  outside the Region are then added t o the d i s t r i c t s ' demand t o t a l s t o form the NET TOTAL DEMAND f o r e c a s t s . Table 5 shows t h a t , although D i s t r i c t A has a f o r e c a s t GROSS TOTAL DEMAND o f 20,000 patient-days o f h o s p i t a l care, the D i s t r i c t ' s h o s p i t a l s are f o r e c a s t t o r e c e i v e only 13,500 patient-days, the net r e s u l t o f the t r a n s f e r s i n and out.  On the other hand, D i s t r i c t B's  h o s p i t a l s are f o r e c a s t t o receive 115,000 patient-days although t h a t D i s t r i c t ' s Gross T o t a l Demand i s only 100,000 patient-days.  This flow  of p a t i e n t demand r e f l e c t s such f a c t o r s as the personal preference o f the p a t i e n t , geography, and the a v a i l a b i l i t y o f s e r v i c e s . Relevance Indices can d i s t r i b u t e a d i s t r i c t ' s f o r e c a s t Gross Total Demand e i t h e r among other d i s t r i c t s i n a r e g i o n , o r among i n d i v i d u a l h o s p i t a l s i n a region.  For convenience, the example i n Table V  has grouped the h o s p i t a l s w i t h i n the boundaries o f a d i s t r i c t i n t o one unit.  This grouping permits the use o f a s i n g l e RELEVANCE INDEX t o  t r a n s f e r patient-days from one d i s t r i c t t o a l l the h o s p i t a l s w i t h i n  29. another d i s t r i c t .  However, since the o b j e c t i v e o f f o r e c a s t i n g the demand  f o r h o s p i t a l f a c i l i t i e s i s t o determine the r e q u i r e d f u t u r e s i z e o f i n d i v i d u a l h o s p i t a l s , the forecast NET TOTAL DEMAND o f a d i s t r i c t must be a l l o c a t e d among the h o s p i t a l s w i t h i n that d i s t r i c t a t t h i s p o i n t i n the f o r e c a s t , o r a f t e r e i t h e r o f the next two equations. The i n d i v i d u a l Relevance Indices must be f o r e c a s t t o define a p a t i e n t flow p a t t e r n a t a future point i n time.  Although the current  flow p a t t e r n can be a p p l i e d to a forecast o f Gross T o t a l Demand, t h e " w i l l present trends continue?" question must be answered. The f o u r t h Equation reduces the forecast annual NET TOTAL DEMAND t o a d a i l y volume.  Because the smallest u n i t of h o s p i t a l care i s assumed  to be one bed used by one person f o r one day, the f o r e c a s t average d a i l y volume i n p a t i e n t days i s a l s o the forecast AVERAGE DAILY CENSUS o f the h o s p i t a l ( s ) l o c a t e d i n the f o r e c a s t area. The f i f t h Equation compensates f o r the f a c t t h a t there w i l l be f l u c t u a t i o n s i n the d a i l y h o s p i t a l census due t o the s t o c h a s t i c nature of demands f o r p a t i e n t admissions to h o s p i t a l s .  While many h o s p i t a l  procedures can be scheduled, maternity cases, accident cases, and urgent i l l n e s s e s occur randomly and cause f l u c t u a t i o n s i n the d a i l y census. Most planning studies have examined h o s p i t a l records and s t a t e t h a t e f f i c i e n t l y managed h o s p i t a l s operate i n the range o f 75-90% average occupancy with the balance t o 100% held as a reserve f o r peak demand occasions.  Since t h i s adjustment appears t o accommodate the f l u c -  t u a t i o n s , the standard f o r e c a s t i n g method s e l e c t s a DESIRED OCCUPANCY PERCENTAGE t o convert AVERAGE DAILY CENSUS i n t o a higher number o f acute-care-hospital-beds nearly a l l occasions. statistical  that w i l l e f f e c t i v e l y s a t i s f y the demands on The compensation f o r demand f l u c t u a t i o n i s a  problem t h a t does not have a u n i v e r s a l l y recognized  30.  TABLE V EXAMPLE OF RELEVANCE INDICES APPLIED TO A HYPOTHETICAL REGION  DISTRICT A FORECAST GROSS TOTAL DEMAND (PatientDays)^  20,000  DISTRICT B  100,000  DISTRICT C  50,000  RELEVANCE INDICES To A:  0.40  0.00  0.08  To B:  0.40  0.90  0.30  To C:  0.15  0.09  0.60  OUTFLOW  0.05  0.01  0.02  TOTAL  1.00  1.00  1.00  From A:  8,000  8,000  3,000  From B:  0  90,000  9,000  From C:  5,000  15,000  30,000  INFLOW:  500  2,000  1,000  13,500  115,000  43,000  TRANSFER: (PATIENTDAYS)  FORECAST NET TOTAL DEMAND (PATIENTDAYS)  31. solution.  The s e l e c t i o n o f a DESIRED OCCUPANCY PERCENTAGE i s conven-  i e n t because i t can be l i n k e d t o past experience b u t i t i s s t i l l based on value judgements which d i f f e r from one planner t o another.  Because  the d i s t i n c t i o n between operating e f f i c i e n c y and bed-capacity e f f i c i e n c y i s not c l e a r , the s i g n i f i c a n c e o f occupancy percentages can be deceptive. Low occupancy can r e s u l t from e i t h e r an i n e f f i c i e n t o p e r a t i o n o r from an oversupply o f beds; the reverse a p p l i e s t o h i g h occupancy.  Forecasts  t h a t use f i x e d occupancy r a t e s seldom discuss the b a s i s o f the choice other than t o s t a t e t h a t , "Informed and experienced judgement seems t o be the best o p t i o n p r e s e n t l y a v a i l a b l e f o r deciding upon d e s i r a b l e occupancy r a t e s " ( M a r t i n , 1975). The problem can be approached from another angle by changing the focus o f the f o r e c a s t from the population as a whole t o t h e i n d i v i d u a l hospital.  Using the f o r e c a s t average d a i l y census as the base s i z e o f  a h o s p i t a l , s t a t i s t i c a l theory can be used t o determine the operating s i z e t h a t w i l l accommodate most o f the demand f l u c t u a t i o n .  Blumberg  (1961) s t a t e s t h a t the Poisson d i s t r i b u t i o n may describe the f l u c t u ations i n the demand f o r h o s p i t a l f a c i l i t i e s i f there are no serious bed shortages.  Using t h i s d i s t r i b u t i o n , the standard d e v i a t i o n  is  t h e square r o o t o f the mean, which i s the average  precisely  d a i l y census i n t h i s case.  Since the p r o b a b i l i t y t h a t the demand  f l u c t u a t i o n s w i l l not exceed the mean plus three standard d e v i a t i o n s i s s u f f i c i e n t l y h i g h , i . e . , 0.997, the desired h o s p i t a l bed count can be determined by the f o l l o w i n g formula: FORECAST HOSPITAL BED REQUIREMENT  FORECAST AVERAGE DAILY CENSUS  j ^ \ /FORECAST \ / AVERAGE W DAILY CENSUS V  This method accommodates the r e a l i t y t h a t small h o s p i t a l s exper-  32. ience wider demand f l u c t u a t i o n s t h a t do large h o s p i t a l s .  Thus, i n  order t o accommodate the peak periods, small h o s p i t a l s must have a l a r g e r p r o p o r t i o n a l bed reserve, which i n t u r n w i l l lower t h e i r average occupancy percentage.  For example, an a r b i t r a r y average 90% occupancy  percentage may not then be r e a l i s t i c f o r a 75 bed h o s p i t a l . Table VI i l l u s t r a t e s the r e l a t i o n s h i p between the f o r e c a s t AVERAGE DAILY CENSUS and the DESIRED HOSPITAL BED COUNT using the Poisson method.  TABLE VI RELATIONSHIP OF AVERAGE DAILY CENSUS TO DESIRED HOSPITAL BED COUNT FORECAST AVERAGE DAILY CENSUS (A.D.C.)  SQUARE ROOT OF A.D.C.  FORECAST HOSPITAL BED REQUIREMENT _____  OCCUPANCY PERCENTAGE  1600  40  1720  93%  400  20  460  87%  100  10  130  77%  25  5  40  63%  Table VI c l e a r l y shows that smaller h o s p i t a l s r e q u i r e a l a r g e r bed margin above the f o r e c a s t Average D a i l y Census t o accommodate random f l u c t u a t i o n s i n demand.  These f l u c t u a t i o n s force smaller h o s p i t a l s  to operate a t occupancy percentages lower than those t h a t can be a t t a i n e d by l a r g e r h o s p i t a l s . When very small h o s p i t a l u n i t s are considered, the Poisson  method w i l l i n d i c a t e wide census swings and, thus, l a r g e r e q u i r e d bed reserves.  I n r e a l i t y , however, the h o s p i t a l admissions f o r scheduled  procedures dampen these swings, making the Poisson method i n a p p r o p r i a t e . To overcome t h i s problem, the s t a t e planning agency o f Alabama only uses the Poisson method f o r l a r g e r h o s p i t a l u n i t s , and uses the t r a d i t i o n a l occupancy guides f o r smaller u n i t s (Melum, 1975). These f i v e Equations, noted i n Table IV, summarize current methods used t o f o r e c a s t t h e GROSS TOTAL DEMAND f o r h o s p i t a l s e r v i c e s f o r a s p e c i f i c population group, and t o transform t h i s t o t a l i n t o a f o r e c a s t o f HOSPITAL BED REQUIREMENTS f o r groups o f h o s p i t a l s o r individual hospitals.  34.  CHAPTER V METHODOLOGY During the summer o f 1976, separate examinations o f the future acute-care-bed requirements o f the Greater Vancouver Regional H o s p i t a l D i s t r i c t (G.V.R.H.D.) were being conducted by both the Regional and P r o v i n c i a l h o s p i t a l - p l a n n i n g agencies.  The method used by B r i t i s h  Columbia H o s p i t a l Programs (B.C.H.P.) followed a t r a d i t i o n a l f o r e c a s t i n g pattern as described i n Chapter IV t o estimate the 1981 demand f o r each o f t h e nine sub-Regional d i s t r i c t s t h a t make up t h e G.V.R.H.D. However, t h i s method d i d not account f o r i n t r a - R e g i o n a l p a t i e n t flow and d i d not d i r e c t l y l i n k a f o r e c a s t o f t h e net demands o f the s i x sub-Regional d i s t r i c t s that have h o s p i t a l s t o the proposed bed c a p a c i t i e s o f those h o s p i t a l s .  For these reasons, t h e proposed bed  c a p a c i t i e s were not unanimously accpeted w i t h i n the Region. I n a d d i t i o n , there were d i f f e r e n c e s o f opinion on both the f u t u r e popu l a t i o n estimates and the forecast incidence r a t e s used by B.C.H.P. In order t o discuss these differences o f o p i n i o n , t h e G.V.R.H.D. a l t e r e d the values o f the input v a r i a b l e s used by B.C.H.P. and then manually c a l c u l a t e d a l t e r n a t e f o r e c a s t s .  The d i s c u s s i o n o f p o l i c y  issues was hampered by t h e slow response o f the manual f o r e c a s t i n g method. To overcome these d i f f i c u l t i e s , I developed f o r the G.V.R.H.D., a m o d i f i c a t i o n o f the B.C.H.P. forecast i n t h e form o f a computer program w i t h interchangeable  data f i l e s .  This enabled a quick response-  time t o questions about "what would happen i f ...?"  The B.C.H.P. f o r e -  c a s t was s t r a i g h t forward i n i t s method and i t d i d break down the sub-Regional population groups i n t o age c l a s s i f i c a t i o n s t h a t had d i s t i n c t  35. h o s p i t a l use patterns.  However, i t d i d not incorporate such current  techniques as the use o f high and low ranges f o r incidence r a t e and population f o r e c a s t s , the use o f occupancy f a c t o r s r e l a t e d t o the s i z e o f i n d i v i d u a l h o s p i t a l s , and, as mentioned e a r l i e r , the use o f a mechanism t o account f o r i n t r a - r e g i o n a l t r a n s f e r s and t o a l l o c a t e i n f l o w among the d i s t r i c t s . The computer f o r e c a s t i n g program that I developed could have incorporated a l l o f these techniques but would then have confused the Regional and P r o v i n c i a l p o l i c y makers by making them choose the "more correct" forecast.  To be u s e f u l , the f o r e c a s t i n g program had t o be  d i r e c t l y comparable t o the " o f f i c i a l " B.C.H.P. method and s t i l l  provide  a t o o l f o r the a n a l y s i s o f a l t e r n a t i v e values f o r the accepted v a r i a b l e s . The most important area o f concern was a method o f i n c o r p o r a t i n g the i n f r a - R e g i o n a l t r a n s f e r s . method.  The B.C.H.P. f o r e c a s t had no such  I decided t o d u p l i c a t e the B.C.H.P. method up t o the f o r e c a s t  of t h e GROSS TOTAL DEMAND f o r each d i s t r i c t .  At t h i s p o i n t , t h e GROSS  DEMAND and the INFLOW t o the G.V.R.H.D. were i n t e r n a l l y a l l o c a t e d t o the Region's d i s t r i c t s according t o the current p a t i e n t - f l o w patterns. By using t h i s approach, the two agencies could agree on the f o r e c a s t of the b a s i c GROSS TOTAL DEMAND but debate the a l l o c a t i o n o f r e q u i r e d facilities. The computer f o r e c a s t i n g program was organized so t h a t d i f f e r e n t values o f v a r i a b l e s could be incorporated and the r e s u l t i n g a l t e r n a t e forecasts q u i c k l y produced.  Examples o f such a l t e r n a t e forecasts are  described i n Chapter V I . The computer program was v a l i d a t e d by comparing the GROSS TOTAL DEMAND t o t a l s c a l c u l a t e d by t h e computer f o r e c a s t i n g method and t h e B. C.H.P. method.  A summary o f t h i s comparison i s discussed i n Chapter V I .  36. THE COMPUTER FORECAST COMPONENTS The f o l l o w i n g s e c t i o n describes the components ( v a r i a b l e s and processes) o f the computer f o r e c a s t i n g program and t h e i r i n t e r - r e l a t i o n ships.  These i n t e r - r e l a t i o n s h i p s are shown on the f o l d - o u t flow diagram,  Figure 1. DISTRICTS The twelve m u n i c i p a l i t i e s and three e l e c t o r a l areas o f the G.V.R.H.D. are organized i n t o nine school d i s t r i c t s .  Because hos-  p i t a l insurance records note the school d i s t r i c t as the p a t i e n t ' s place o f o r i g i n , these school d i s t r i c t s can be conveniently used as the b a s i c population groups f o r G.V.R.H.D. planning.  These d i s t r i c t s  are l i s t e d i n Table V I I .  TABLE VII SUB-REGIONAL DISTRICTS OF THE GREATER VANCOUVER REGIONAL HOSPITAL DISTRICT N6.  SCHOOL DISTRICT  SUB-REGIONAL DISTRICT  36  Surrey  Surrey  37  Delta  /-North D e l t a \. Ladner  38  Richmond  Richmond  39  Vancouver  Vancouver  40  New Westminster  New Westminster  41  Burnaby  Burnaby  43  Coquitlam  Coquitlam  44  North Vancouver  45  West Vancouver  }  North Shore  In most cases, the d i s t r i c t s are reasonable geographic e n t i t i e s  37. f o r h o s p i t a l planning purposes.  However, i n t h i s t h e s i s , two m o d i f i c -  ations were made t o b e t t e r s u i t the population concentrations.  District  No. 37, D e l t a , has two d i s t i n c t population centres, each having d i f ferent r e l a t i o n s h i p s w i t h neighbouring areas.  Hence, North D e l t a w i t h  48% o f the population and Ladner w i t h 52% were created.  They each were  assumed t o have the same per c a p i t a experience f o r h o s p i t a l use as f o r Delta as a whole.  The second m o d i f i c a t i o n concerned D i s t r i c t s 44 and  45, North and West Vancouver, which are separated from the r e s t o f the G.V.R.H.D. by water and can reasonably be considered as one e n t i t y f o r h o s p i t a l planning purposes.  The r e s u l t i n g combined u n i t , l a b e l l e d  "North Shore", assumed a population weighted average o f the per c a p i t a h o s p i t a l use experience o f North and West Vancouver. POPULATION The POPULATION o f each d i s t r i c t was grouped i n t o the c l a s s i f i c a t i o n s shown i n Table V I I I .  TABLE V I I I POPULATION AGE - SEX GROUPS AGE 0 - 1 4 yrs.  CLASSIFICATION Paediatric  15 - 44 y r s . female  Maternity  15 - 69 y r s .  Adult Medical £ S u r g i c a l  70 + y r s .  G e r i a t r i c Medical £ S u r g i c a l  ( l e s s maternity)  Each o f these groups was considered t o be a separate population having no i n t e r a c t i o n w i t h the others.  Separate r e g i o n a l f o r e c a s t s  were made f o r each population group and then these f o r e c a s t s were summed  38.  to produce the t o t a l Regional forecast. INCIDENCE RATES Separate INCIDENCE RATES OF HOSPITALIZATION f o r each population group In each d i s t r i c t were used.  I would have p r e f e r r e d t o use separate  forecasts o f HOSPITAL ADMISSION RATES per 1000 population and AVERAGE LENGTHS OF STAY t o determine t h e INCIDENCE RATES as shown by the dotted l i n e s i n Figure 1. However, t o ensure that the two forecasts would be as s i m i l a r as p o s s i b l e i n format, I used the B.C.H.P. INCIDENCE RATES. GROSS DEMAND The POPULATION o f each d i s t r i c t age group was m u l t i p l i e d by i t s corresponding f o r e c a s t  INCIDENCE PATE t o produce the GROSS DEMAND  f o r h o s p i t a l i z a t i o n expressed i n patient-days per year by d i s t r i c t . TRANSFER MATRIX The GROSS DEMAND f o r each d i s t r i c t was d i s t r i b u t e d among the other G.V.R.H.D. d i s t r i c t s and outside the Region by m u l t i p l y i n g the GROSS DEMANDS by the Relevance Indices o f the TRANSFER MATRIX defined below.  Relevance I n d i c e s , as discussed i n Chapter IV, u s u a l l y  r e f l e c t the proportion o f a population's t o t a l h o s p i t a l use t h a t i s serviced by each h o s p i t a l i n a region.  A t the time t h i s study was under-  taken, the future number and l o c a t i o n o f G.V.R.H.D. h o s p i t a l s was uncertain.  To avoid the problem r e s u l t i n g from t h i s u n c e r t a i n t y , the  intra-Regional r e f e r r a l s were transformed i n t o a d i s t r i c t - b y - d i s t r i c t matrix rather than a d i s t r i c t - b y - h o s p i t a l matrix; t h a t i s , the Relevance Indices were f o r p a t i e n t flows among d i s t r i c t s o f p a t i e n t o r i g i n and d i s t r i c t s o f p a t i e n t treatment r a t h e r than among d i s t r i c t s o f p a t i e n t o r i g i n and h o s p i t a l s o f p a t i e n t treatment. A TRANSFER MATRIX was computed from 1975 data f o r each o f the four age-sex groups. t h i s study.  Table IX shows a t y p i c a l TRANSFER MATRIX used i n  The numbers i n each row show, f o r the d i s t r i c t o f p a t i e n t  ***********************  TRANSFER MATRIX ASSUMED *********************** PATIENT ORIGIN *******  AREA OF HOSPITAL TREATMENT ************************** S  ND  L  SURREY  .550  .000  .000  NORTH DELTA  .350  .0 00  LADNER  .350  RICHMOND  R  V  NW  B  .000  , 250  .150  . 05u .000  .000  .100  ,400  . 100  .050  .00 0  .000  .100  ,400  .100  .000  .000  ,000  .400  ,550  VANCOUVER  .000  .000  ,000  .000  NEW WEST  .UOO  .000  ,0 00  BURNABY  .0U0  .0 00  COQUITLAM  .000  NORTH SHORE  .UOO  N3  OUT  .000  .000  1 . 000  . 000  .000  . 000  1.000  ,050  .000  . OuO  .000  1 . 000  .000  ,050  .000  ,000  .000  1. OuO  ,900  , ouu  ,100  .000  .000  .000  1. 000  .000  200  , /oo  ,050  .000  ,000  .050  1 .000  ,000  .000  450  ,200  ,3 50  .UOO  ,000  .000  1 .000  .000  .0 00  .000  300  ,600  050  ,uoo  ,000  .050  1 .OuO  .000  000  .000  350  000  000  ,000  650  .000  1.000  TABLE IX:  TYPICAL TRANSFER MATRIX (Paediatric  Age-Sex Group)  TOTAL CO CD  40. o r i g i n , the proportions o f the GROSS DEMAND t h a t are t r e a t e d i n the other G.V.R.H.D. d i s t r i c t s .  For example, the number .250 i n the  Surrey Row and "V" column, means t h a t 25% o f the d i s t r i c t o f Surrey's demand f o r h o s p i t a l care i s t r e a t e d i n Vancouver f o r t h i s p a r t i c u l a r age group f o r e c a s t .  C l e a r l y , the numbers i n each row must t o t a l 1.0.  The columns define the d i s t r i c t s where the p a t i e n t s are t r e a t e d , and c o n s i s t o f the same nine d i s t r i c t s o f o r i g i n plus the column "OUT", representing OUTFLOW f o r treatment outside the G.V.R.H.D. and thus beyond the scope o f t h i s study. With regard t o the patient-day a l l o c a t i o n s w i t h i n a d i s t r i c t , i t was assumed t h a t once the FORECAST HOSPITAL BED REQUIREMENTS o f a d i s t r i c t were determined, then the a l l o c a t i o n o f those requirements t o e x i s t i n g and new h o s p i t a l s w i t h i n that d i s t r i c t would need t o be the subject o f a more d e t a i l e d study. INFLOW The h o s p i t a l s i n the G.V.R.H.D. o f f e r Regional r e f e r r a l s e r v i c e s to adjacent communities and t e r t i a r y r e f e r r a l s e r v i c e s f o r the whole province o f B r i t i s h Columbia.  I n 1975, the patient-day volume from  outside the G.V.R.H.D. t h a t was serviced by Regional h o s p i t a l s was the equivalent o f approximately 720 acute-care-hospital beds * o r 16% o f the G.V.R.H.D's. own p a t i e n t care volume.  This i s a l a r g e volume and  i t s d i s t r i b u t i o n among G.V.R.H.D. h o s p i t a l s i s an important considera t i o n when determining  s p e c i f i c future requirements.  * The i n f l o w from outside the G.V.R.H.D. was 223,402 p a t i e n t days i n 1975. A t 85% occupancy, t h i s i s the equivalent o f 720 beds. Data sources: B.C.H.P. data on magnetic tape.  41  For the purpose o f t h e computer f o r e c a s t , t h e INFLOW was s t a t e d as a percentage o f the G.V.R.H.D. GROSS DEMAND i n p a t i e n t days; a separate percentage was used f o r each age-sex group. NET DEMAND A f t e r the INFLOW was determined, i t was a l l o c a t e d among the d i s t r i c t s according t o the s p e c i f i e d percentages. The d i s t r i b u t e d INFLOW was then added t o t h e DISTRIBUTED GROSS DEMAND t o form t h e NET DEMAND f o r e c a s t f o r each d i s t r i c t . AVERAGE DAILY CENSUS In order t o convert the f o r e c a s t NET DEMAND recorded i n p a t i e n t days t o h o s p i t a l bed equivalents, the t o t a l s were d i v i d e d by 365 t o produce t h e f o r e c a s t AVERAGE DAILY CENSUS. OCCUPANCY PERCENTAGE The B.C.H.P. t a r g e t OCCUPANCY PERCENTAGES were used i n t h e computer f o r e c a s t i n g programme.  I should have p r e f e r r e d t o use t h e  Poisson d i s t r i b u t i o n method, described i n Chapter IV, t h a t v a r i e s the planned occupancy w i t h t h e forecast AVERAGE DAILY CENSUS o f the i n d i v i d u a l h o s p i t a l . However, t o avoid confusing the more important i s s u e o f the r e c o g n i t i o n o f i n t r a - R e g i o n a l t r a n s f e r s , I adopted the B.C.H.P. p o l i c y o f s e t t i n g t a r g e t OCCUPANCY PERCENTAGES, no matter how inappropr i a t e they may be when a p p l i e d t o s p e c i f i c h o s p i t a l s . FORECAST HOSPITAL BED REQUIREMENTS The f o r e c a s t AVERAGE DAILY CENSUS was d i v i d e d by i t s corresponding OCCUPANCY PERCENTAGE t o produce t h e FORECAST HOSPITAL BED REQUIREMENTS f o r each age-sex group o f each d i s t r i c t . BALANCE OF BEDS REQUIRED The program was extended by a simple step t o compare t h e FORECAST HOSPITAL BED REQUIREMENTS w i t h the bed t o t a l s proposed by B.C.H.P. f o r  42.  the target date, i n this case, 1981.  This comparison produced the  BALANCE OF BEDS REQUIRED t o meet the forecast. I f the FORECAST HOSPITAL BED REQUIREMENTS are adopted as targets, this calculation provides the policy analysts with the incremental changes necessary to modify the proposed bed totals to match the forecast requirements of the d i s t r i c t s .  43.  CHAPTER VI EXPERIMENTAL PROCEDURES FORECAST PROCEDURE The structure o f the f o r e c a s t i n g process was t r a n s l a t e d i n t o a computer program using the BASIC language. attached as Appendix A.  A copy o f the program i s  I t was designed from the sequential steps  suggested i n the other current f o r e c a s t i n g methods noted i n Chapter IV, and the forecast produced by B.C.H.P. The f o r e c a s t i n g program was designed f o r use on a time-sharing computer f a c i l i t y w i t h i n p u t through cathode-ray-tube terminals and output from e i t h e r the t e r m i n a l s o r p r i n t e r s . In order t o o f f e r maximum f l e x i b i l i t y i n producing f o r e c a s t s f o r p o l i c y a n a l y s i s , the f i l e s containing the values o f the program v a r i a b l e s are e x t e r n a l t o the f o r e c a s t program.  This allows the user t o create a  s p e c i f i c f o r e c a s t from any selected data sets.  I n a d d i t i o n , the program  can be run f o r one o r more age-sex group forecasts w i t h the o p t i o n o f combining the separate runs i n t o a summary f o r e c a s t .  A series of instructions  appear on the terminal screen and lead the user through the process i n t e r actively.  Users can operate the program without having t o know t h e d e t a i l s  of e i t h e r i t s i n t e r n a l processes o r the l i n k s t o the data f i l e s , but the user must know the names o f the, data f i l e s because they are r e q u i r e d as inputs t o a l l o w the program t o function. The program output d i s p l a y s i n t a b u l a r form both the values i n i t i a l l y s p e c i f i e d by the user f o r the program v a r i a b l e s , and the comparison between the r e q u i r e d and planned h o s p i t a l beds f o r those d i s t r i c t s which contain h o s p i t a l s .  The d i s t r i c t s are then regrouped t o f o u r geographic  areas and the comparison i s repeated.  This information i s produced f o r  44. each run; a run c o n s i s t s o f a f o r e c a s t f o r one age-sex group o r a summary o f two o r more age-sex-group forecasts.  DATA The computer f o r e c a s t i n g program was created t o explore a l t e r n a t i v e s to the B.C.H.P. f o r e c a s t , and t o f a c i l i t a t e the r e s o l u t i o n o f d i f f e r e n c e s of opinion on p o l i c y i s s u e s .  Thus, i t was necessary t o avoid disagreements  about the method used i n the computer program since such disagreements would have pre-empted worthwhile d i s c u s s i o n about t h e G.V.R.H.D.'s contention that the B.C.H.P. planning proposal was not appropriate because i t didn't recognize i n t r a - R e g i o n a l p a t i e n t t r a n s f e r s .  I n order t o avoid  such disagreements, the s t r u c t u r e o f the computer program was based on t h e B.C.H.P. f o r e c a s t , as were the primary input data.  The computer program  could then be used t o provide a l t e r n a t e forecasts f o r the examination o f p o l i c y options by a l t e r i n g the input data.  POPULATION In the autumn o f 1976, there was considerable debate over the p r o j e c t i o n s o f the G.V.R.H.D. population. 1976  The p r e l i m i n a r y r e l e a s e o f the  S t a t i s t i c s Canada census showed that the p r e v i o u s l y r a p i d growth o f  the G.V.R.H.D. had severely slowed.  These r e s u l t s made e a r l i e r 1981  population p r o j e c t i o n s appear u n r e a l i s t i c .  Consequently, B.C.H.P.  adjusted t h e i r 1981 population p r o j e c t i o n s o f the nine G.V.R.H.D. school d i s t r i c t s and used past census data t o estimate the d i v i s i o n o f these t o t a l s i n t o the four age-sex groups.  The forecasts o f the d i s t r i c t s '  t o t a l population were rounded t o the nearest thousand, but, f o r some unexplained reason, t h e age-sex-group f o r e c a s t s appeared accurate t o one digit.  This was not reasonable i n l i g h t o f the t e n t a t i v e nature o f the  45. o r i g i n a l forecast.  To improve on t h i s , I rounded the data as c l o s e l y as  p o s s i b l e t o the nearest 50 persons without s u b s t a n t i a l l y s h i f t i n g the mix o f the age groups o r a l t e r i n g the t o t a l f o r e c a s t f o r each d i s t r i c t .  INCIDENCE RATES The Incidence Rates o f H o s p i t a l i z a t i o n were used d i r e c t l y from the B.C.H.P. f o r e c a s t .  The P r o v i n c i a l planners had examined the general d e c l i n e  i n h o s p i t a l i z a t i o n and judged that the trend would continue t o 1981.  Their  estimate was a l s o i n f l u e n c e d by the government's adopted p o l i c y o f strengthening the d e l i v e r y o f extended and intermediate care and reducing the inappropriate use o f acute-care-hospital f a c i l i t i e s .  This planned  reduction i n acute care h o s p i t a l i z a t i o n was not s p e c i f i c a l l y j u s t i f i e d by a q u a n t i t a t i v e r e l a t i o n , but i t was i m p l i c i t l y included i n the f o r e c a s t incidence r a t e s . These two data sets were the primary base used t o f o r e c a s t the Gross Demand f o r h o s p i t a l i z a t i o n f o r each o f the d i s t r i c t s by age-sex group. Up t o t h i s p o i n t , the two f o r e c a s t s produced e s s e n t i a l l y i d e n t i c a l r e s u l t s , w i t h any d i f f e r e n c e s being due t o the rounding o f the population t o t a l s f o r i n d i v i d u a l age-sex groups.  TRANSFER MATRIX The data used t o produce the t r a n s f e r matrix d i d not come d i r e c t l y from the B.C.H.P. f o r e c a s t because t h i s  component o f the computer program  was an a d d i t i o n t o the P r o v i n c i a l method.  B.C.H.P. has f o r s e v e r a l years  produced data on the source and d e s t i n a t i o n o f G.V.R.H.D. h o s p i t a l p a t i e n t s . This information i s compiled from hospital-insurance data and made a v a i l able t o the Region, but i s not published.  As o f December 1976, t h e l a t e s t  compiled information from B.C.H.P. was based on 1974 data.  The b a s i c 1975  46. data tapes were i n use a t the U n i v e r s i t y o f B r i t i s h Columbia and s p e c i a l arrangements were made through the D i v i s i o n o f Health S e r v i c e s , Research and Development* t o e x t r a c t the data on intra-G.V.R.H.D. p a t i e n t t r a n s f e r s i n a form c o n s i s t e n t w i t h the B.C.H.P. format.  The data was processed  using routines contained i n the S t a t i s t i c a l Package f o r the S o c i a l Sciences (S.P.S.S.) a v a i l a b l e a t the U.B.C. Computing Centre. The p a t i e n t t r a n s f e r data, i n p a t i e n t days, was organized t o show matrices o f d i s t r i c t o f p a t i e n t o r i g i n (9) by h o s p i t a l o f p a t i e n t treatment (17), f o r each age-sex group.  These matrices were converted manually i n t o  Transfer Matrices o f Relevance Indices showing d i s t r i c t o f p a t i e n t o r i g i n (9) by d i s t r i c t o f p a t i e n t treatment ( 9 + 1 f o r o u t f l o w ) . were i n i t i a l l y computed t o three places  These i n d i c e s  o f decimal f o r 1975 data.  To make the Relevance Indices consistent w i t h the u n c e r t a i n t y o f the data used i n the e a r l i e r p o r t i o n o f the f o r e c a s t , t h e use o f accuracy t o the t h i r d decimal-place precision.  had t o be changed because i t gave a f a l s e i m p l i c a t i o n o f  A Relevance Index w i t h an implied accuracy t o .001 cannot  l e g i t i m a t e l y be a p p l i e d t o a p a t i e n t day t o t a l format derived from a population estimate rounded t o the nearest 1000 persons.  To r e s o l v e t h i s  problem, the Relevance Indices were f i r s t rounded t o the nearest 1% and then t o the nearest 5% t o t e s t the s e n s i t i v i t y o f the computations t o such changes.  The rounding t o the nearest 5% produced r e s u l t s t h a t only  v a r i e d from the base r e s u l t s by approximately 1%; t h i s v a r i a t i o n was considered acceptable i n a t t a i n i n g an i n t e r n a l - d a t a consistency f o r the computer f o r e c a s t i n g program. The future a l l o c a t i o n o f p a t i e n t s t o Regional h o s p i t a l s was a h i g h l y c o n t r o v e r s i a l subject since i t could a f f e c t the operating s i z e o f each  * D i v i s i o n o f Health S e r v i c e s , Research and Development Co-ordinator's O f f i c e , Health Sciences Centre, U.B.C. Vancouver, B.C.  47. hospital.  I n order t o study the e f f e c t s o f a l t e r n a t e p o l i c i e s , I r a n the  computer f o r e c a s t i n g program w i t h an a l t e r n a t e Transfer M a t r i x t o r e f l e c t an a l t e r n a t e bed d i s t r i b u t i o n p o l i c y . t h i s chapter.  This a n a l y s i s i s described l a t e r i n  The 1975 p a t t e r n o f p a t i e n t r e f e r r a l s w i t h i n the G.V.R.H.D.  was used as the 1981 Transfer Matrix f o r the Standard Forecast produced by t h e computer program.  This was done t o introduce t h e concept o f the  Transfer M a t r i x w i t h ininimal controversy; the " i f present trends continue" approach.  INFLOW The B.C.H.P. f o r e c a s t accounted f o r the Inflow o f p a t i e n t s i n t o the G.V.R.H.D. by s u b t r a c t i n g the Outflow from the Inflow t o create a net Inflow expressed as a percentage o f the t o t a l G.V.R.H.D. h o s p i t a l usage.  B.C.H.P.  studied the h i s t o r i c a l p a t t e r n o f net Inflow t o t h e G.V.R.H.D. before the 1981 r a t e was f o r e c a s t .  Because the Transfer M a t r i x o f the computer program  incorporates the Outflow, i t was decided t o separate Inflow from Outflow r a t h e r t h a t use the B.C.H.P. composite Inflow r a t e . The data on the Inflow o f p a t i e n t s i n t o the G.V.R.H.D. and on t h e i r d i s t r i b u t i o n among the Region's h o s p i t a l s was obtained from the a n a l y s i s t h a t produced the Transfer Matrix.  For the purpose o f f o r e c a s t i n g  the Net Demand f o r h o s p i t a l s e r v i c e s i n the G.V.R.H.D., the Inflow t o the G.V.R.H.D. should be r e l a t e d t o the Gross Demand o f the B r i t i s h Columbia population outside the G.V.R.H.D., the source o f the Inflow t o the Region. However, since a population f o r e c a s t , c o n s i s t e n t w i t h the one used f o r the G.V.R.H.D., was not a v a i l a b l e f o r the r e s t . o f the province, I decided t o r e l a t e the Inflow t o the Gross Demand o f the G.V.R.H.D. as a secondbest method.  This convenience produces r e s u l t s j u s t as acceptable as the  more t h e o r e t i c a l l y c o r r e c t method since i t i s reasonable t o assume t h a t  48. the Gross Demand of the B.C. population outside of the G.V.R.H.D. w i l l be subject to the same influence as the Gross Demand of the G.V.R.H.D. and thus w i l l fluctuate similarly to the Gross Demand of the G.V.R.H.D. The actual 1975 Inflow i n patient-days for each age-sex group was expressed as a percentage of the t o t a l 1975 Gross Demand of that age-sex group. These percentages were then used i n the forecasting program to produce forecast Inflow.  The distribution of the t o t a l inflow among the  Region's d i s t r i c t s was expressed as proportions of the t o t a l Inflow i n the Inflow Transfer Vector.  For example, New Westminster received .05  of the t o t a l referrals i n the adult age-sex group (ages 15-69) i n 1975. In order to avoid spurious accuracy, and to be consistent with the previous use of 1975 data, the Inflow percentages and the Inflow Transfer Vector's percentages were rounded.  Since a 2 - 3% change i n  the Inflow percentages caused significant absolute changes i n the forecast Inflow patient-days, the Inflow percentages were rounded to the nearest 1%. Because such changes to the Inflow Transfer Vector's percentages did not produce significant absolute changes i n the d i s tribution of Inflow patient-days, the percentages were rounded to the nearest 5%, consistent with the Transfer Matrix Relevance Indices.  OCCUPANCY PERCENTAGES The Occupancy Percentages used to transform the Net Demand i n patient-days by d i s t r i c t to Forecast Hospital Bed Requirements were those used by B.C.H.P.: 80% f o r maternity, 85% for paediatrics, and 90% for adult.  The reason f o r t h i s choice has been discussed i n Chapter V.  PLANNED BEDS The f i n a l data set used i n the computerized forecasting program  49. i s the sum o f the h o s p i t a l beds serving each age group t h a t i s planned f o r each d i s t r i c t by 1981.  These t o t a l s were obtained from an unpublished  B.C.H.P. working paper e n t i t l e d "Review o f the 1981 Bed M a t r i x " . Any other proposal could have been incorporated since i t i s only used by the program as a benchmark f o r comparison w i t h the G.V.R.H.D. f o r e c a s t bed requirements.  However, since part o f the o b j e c t i v e o f t h i s t h e s i s was  to compare the r e s u l t s o f the two f o r e c a s t i n g techniques using t h e same b a s i c data and the same b a s i c method except f o r the a d d i t i o n o f t h e t r a n s f e r matrix i n the computer f o r e c a s t i n g program, the use o f the B.C.H.P. proposal was appropriate.  VERIFICATION The computer f o r e c a s t i n g program was v a l i d a t e d by producing a t e s t f o r e c a s t using a n e u t r a l * Transfer M a t r i x and then comparing the f o r e c a s t o f NET DEMAND patient-days f o r each age-sex group o f each d i s t r i c t w i t h the equivalent B.C.H.P. f o r e c a s t . A s e l e c t i o n o f t h e r e s u l t s i s l i s t e d i n Table X. Since both t h e f o r e c a s t s use the same data, t h e comparison should show a b s o l u t e l y no v a r i a t i o n .  There i s s l i g h t v a r i a t i o n i n the r e s u l t s  that i s caused by the rounding o f the B.C.H.P. population f o r e c a s t t o t a l s . The reasons f o r t h i s rounding have been noted i n Chapter V. The v a l i d a t i o n process confirmed t h a t the computer program contained t h e same i n i t i a l s t r u c t u r e as does the B.C.H.P. f o r e c a s t and t h a t the complexity o f t h e structure created i n t h e computer program t o accommodate i n t r a - R e g i o n a l p a t i e n t t r a n s f e r s had not contaminated the c a l c u l a t i o n sequence. *The Neutral Transfer M a t r i x had values o f 1.0 on the main diagonal t o correspond w i t h the f a c t t h a t the B.C.H.P. f o r e c a s t has no matrix.  50.  TABLE X COMPARISON OF GROSS DEMAND I N P A T I E N T DAYS OF P A E D I A T R I C AGE GROUP AND TOTAL POPULATIONS BY D I S T R I C T BETWEEN THE B.C.H.P. AND THE G.V.R.H.D. FORECASTS  P A E D I A T R I C AGE GROUP % GVRHD VARIATION  T O T A L POPULATION  GVRHD  15,345  15,342  0.02  185,879  185,882  0.00  DELTA  9,030  9,030  0.00  61,892  61,828  0.10  RICHMOND  8,293  8,296  0.04  88,145  88,084  0.07  VANCOUVER  27,000  27,000  0.00  649,520  649,515  0.00  NEW WEST.  3,093  3,088  0.16  57,430  57,488  0.10  BURNABY  11,025  11,025  0.00  153,293  153,290  0.00  COQUITLAM  10,605  10,609  0.04  92,853  92,845  0.01  9,608  9,595  0.14  158,012  158,103  0.01  93,999  93,986  0.01  SURREY  NORTH SHORE  TOTAL  BCHP  GVRHD  % GVRHD VARIATION  BCHP  1,447,024 1 , 4 4 7 , 0 3 6  0.00  51.  THE SENSITIVITY ANALYSIS The B.C.H.P. forecast was made from the interaction of many variables such as population, age group and incidence rate. I t i s true that any change i n input variables could be manually traced through the maze of calculations to explain the interactions, but, considering the number of changes possible, such a procedure would be impractical. The introduction of a Transfer Matrix would have made the interaction even more complex i f calculated manually. The computerization of the forecast made i t feasible to study the effect on the final FORECAST OF HOSPITAL BED REQUIREMENTS of a change in the value of any one of the variables. Since the computerized forecasting program incorporates non-linear relations, any given input change i n the value of a variable does not necessarily produce a proportional change i n a given output forecast. For example, since the age mix varies among the districts as do the incidence rates of hospitalization, an equal proportional change i n each district to the value of either, or both of these variables would produce disproportionate changes i n the net demand for hospital services i n each district because of the non-linear relations introduced by the Transfer Matrix. In order to examine this aspect of the forecast program, several controlled changes made to the input data were compared with the corresponding changes produced i n the output forecast. This experiment was called a SENSITIVITY ANALYSIS. The six primary variables (population, incidence rate, inflow, distribution of inflow, transfers, and occupancy percentage) could produce an unmanageable set of interactions i f a f u l l sensitivity study were undertaken. It was decided to restrict the analysis to the two most controversial variables: population and incidence  52. rate. The B.C.H.P. forecasts of the G.V.R.H.D. population's rate of growth, i t s age distribution, and i t s geographic distribution were based on both the preliminary federal census and on past distributions. However, without the benefit of a detailed census, the G.V.R.H.D. believed that there was l i t t l e likelihood that the forecasts would be accurate. The B.C.H.P. forecasts of Incidence Rates of Hospitalization were based partly on the assumption that alternate f a c i l i t i e s to acute care would be available to reduce the acute-care Incidence Rates.  There was  some doubt when the forecast was discussed i n 1976 whether these alternate f a c i l i t i e s really would be available and, therefore, some doubt whether the lower Incidence Rates could be achieved. Since there was no consensus on the values of these variables, the computer forecasting program was used to explore how sensitive the forecasting process was to changes in the values of the Population and Incidence Rate of Hospitalization variables. First, the possibility of the geriatric age group (70+ years) rising to 10% of the total population was considered.  Since the Incidence  Rate projected for that group i s almost four times the regular adult rate, such a change would be expected to reveal any unexpected results from obscure interactions.  Secondly, a change i n the Incidence Rate for  this age group also would be expected to reveal unexpected sensitivities. Table XI outlines the eight runs that were made to analyse the sensitivity of the computer forecasting technique. RUN ONE: This run was used as the standard for the analysis since i t contained the base data from the B.C.H.P. 1981 forecast with the addition of 1975 transfer and inflow data.  53.  TABLE XI INPUT CHANGES MADE FOR THE SENSITIVITY ANALYSIS  RUN  AGE GROUP  POPULATIONS  INCIDENCE RATES  ONE  GERIATRIC ADULT  STANDARD STANDARD  STANDARD STANDARD  TWO  GERIATRIC ADULT  PLUS 64% MINUS GERIATRIC INCREASE  STANDARD STANDARD  THREE  GERIATRIC ADULT  PLUS 64% -10% MINUS GERIATRIC INCREASE STANDARD  FOUR  GERIATRIC ADULT  PLUS 64% STANDARD MINUS GERIATRIC INCREASE -10%  FIVE  GERIATRIC ADULT  PLUS 64% -10% MINUS GERIATRIC INCREASE -10%  SIX  GERIATRIC ADULT  PLUS 64% MINUS GERIATRIC INCREASE  +10% STANDARD  SEVEN  GERIATRIC ADULT  PLUS 64% MINUS GERIATRIC INCREASE  STANDARD +10%  EIGHT  GERIATRIC ADULT  PLUS 64% MINUS GERIATRIC INCREASE  +10% +10%  54. RUN TWO:  I n t h i s r u n , the percentage o f the g e r i a t r i c age group was  increased from approximately  6% t o 10% o f the t o t a l G.V.R.H.D. population;  an increase o f approximately  64%.  This change brought the t o t a l G.V.R.H.D.  g e r i a t r i c population from 69,175 t o 113,500.  The e x i s t i n g age-group r a t i o s  vary among d i s t r i c t s and, ujifortunately, i t was not p o s s i b l e t o estimate how these r a t i o s would vary from each other i n the f u t u r e , t h e r e f o r e , p r o p o r t i o n a l changes, r a t h e r than absolute changes were made t o the g e r i a t r i c populations o f each d i s t r i c t , that i s , the g e r i a t r i c population o f each d i s t r i c t was increased by 64%.  I n t u r n , t h i s meant t h a t the a d u l t  population i n any given d i s t r i c t was decreased by an amount equal t o the g e r i a t r i c population increase so t h a t the combined a d u l t - g e r i a t r i c u l a t i o n group remained constant i n t o t a l .  pop-  This population s h i f t was  r e t a i n e d i n each o f the f o l l o w i n g s e n s i t i v i t y runs.  A l l other v a r i a b l e s  had standard values. RUN THREE:  The incidence r a t e s of the g e r i a t r i c population group i n each  d i s t r i c t were decreased by 10%, while the a d u l t incidence r a t e s remained a t standard RUN FOUR:  levels. The incidence r a t e s o f the adult population group i n each  d i s t r i c t was decreased by 10% w h i l e the g e r i a t r i c incidence r a t e s remained a t standard RUN FIVE:  levels. The incidence r a t e s o f both the g e r i a t r i c and the a d u l t pop-  u l a t i o n groups i n each d i s t r i c t were decreased by 10%. RUN SIX:  The incidence r a t e f o r the g e r i a t r i c population i n each d i s t r i c t  group was increased by 10%, w h i l e the a d u l t incidence r a t e s remained a t standard  levels.  RUN SEVEN;  The incidence r a t e s o f the a d u l t population group i n each  d i s t r i c t were increased by 10%, w h i l e the g e r i a t r i c incidence r a t e s remained a t standard l e v e l s .  55.  RUN EIGHT:  The incidence r a t e o f both the g e r i a t r i c and a d u l t population  groups i n each d i s t r i c t were increased by 10%.  THE POLICY ANALYSIS The P r o v i n c i a l M i n i s t r y o f Health and the Greater Vancouver Regional H o s p i t a l D i s t r i c t share i n the costs o f h o s p i t a l c o n s t r u c t i o n w i t h i n the G.V.R.H.D. The agencies, t h e r e f o r e , have assumed a mandate from t h e i r e l e c t o r a t e s t o ensure t h a t the most e f f e c t i v e changes i n h o s p i t a l s e r v i c e r e s u l t from the expenditure o f p u b l i c funds f o r h o s p i t a l c o n s t r u c t i o n . In order t o f o r e c a s t the expenditures required f o r h o s p i t a l c o n s t r u c t i o n , these two agencies must agree on the future values o f the v a r i a b l e s used i n the f o r e c a s t o f the demand f o r h o s p i t a l s e r v i c e s .  However, a l l o f  these v a r i a b l e s can be i n f l u e n c e d , t o some degree, by p o l i c y d e c i s i o n s . For example, future POPULATION t o t a l s can be i n f l u e n c e d by immigration p o l i c i e s , by economic p o l i c i e s and by urban-planning p o l i c i e s ; future RELEVANCE INDICES can be influenced by geographic s h i f t s i n population, by h o s p i t a l operating p o l i c i e s and by h o s p i t a l c o n s t r u c t i o n p o l i c i e s . To e f f e c t i v e l y discharge t h e i r mandate, the funding agencies must analyse the e f f e c t s o f a l t e r n a t e p o l i c y p o s i t i o n s .  The computer f o r e -  c a s t i n g program, described i n Chapter V, was designed t o r e a d i l y accept a l t e r n a t e input data so t h a t a l t e r n a t e FORECASTS o f HOSPITAL BED REQUIREMENTS can be used t o study the e f f e c t s o f the a l t e r n a t e p o l i c y p o s i t i o n s that the data r e f l e c t . The f o l l o w i n g sections describe the a l t e r n a t e p o l i c y p o s i t i o n s which were analysed by comparing the corresponding f o r e c a s t produced by the computer f o r e c a s t i n g program to the Standard Forecast.  56. A. POPULATION During the summer o f 1976, the G.V.R.H.D. was f o r e c a s t i n g a 1981 Population o f the Region o f 1,322,000 persons, a t o t a l which proved t o be 16% higher than the B.C.H.P. f o r e c a s t which was made l a t e r i n the year based upon the i n t e r i m r e s u l t s o f the 1976 f e d e r a l census.  Since the  G.V.R.H.D. questioned the accuracy o f the 1976 f e d e r a l census and, thus, the B.C.H.P. population forecast f o r 1981, the computer f o r e c a s t i n g program was used t o analyse the e f f e c t s o f a 10% increase i n t h e B.C.H.P. population f o r e c a s t f o r 1981. Table X I I shows the d e t a i l s o f t h i s i n crease .  B. INCIDENCE RATES OF HOSPITALIZATION The B.C.H.P. f o r e c a s t o f the 1981 G.V.R.H.D. Incidence Rates o f H o s p i t a l i z a t i o n was based on t h e assumption t h a t a l t e r n a t i v e l e v e l s o f care w i l l "soon" be a v a i l a b l e , and thus, t h e acute-care Incidence Rates should f a l l .  Since t h e G.V.R.H.D. questioned t h i s assumption, the com-  puter f o r e c a s t i n g program was used t o analyse t h e e f f e c t s o f a 10% increase i n t h e 1981 Incidence Rates o f H o s p i t a l i z a t i o n f o r each age-sex group i n each d i s t r i c t as f o r e c a s t by B.C.H.P. o v e r a l l increase by d i s t r i c t .  Table X I I I l i s t s the  The increased Incidence Rates l i s t e d were  c a l c u l a t e d by t h e program by d i v i d i n g the increased T o t a l Gross Demand, i n patient-days, o f each d i s t r i c t by that d i s t r i c t ' s population.  Because  of t h i s c a l c u l a t i o n , the increased Incidence Rates l i s t e d are not e x a c t l y 110% o f the Standard Rates^because o f rounding e r r o r s .  C. INFLOW The G.V.R.H.D's. Inflow (patient-days) expressed as a percentage o f the Gross Demand was assumed t o remain constant t o 1981; t h a t i s , remain equal t o t h e 1975 percentage. However, the G.V.R.H.D. was aware t h a t t h i s  57.  TABLE X I I  1981 FORECAST G.V.R.H.D. POPULATION TOTALS AT 110% OF 1981 STANDARD POPULATION FORECAST  DISTRICT  STANDARD FORECAST  110% STANDARD  SURREY  145,000  159,500  NORTH DELTA  36,000  39,600  LADNER  39,000  42,900  RICHMOND  90,000  99,000  VANCOUVER  400,000  440,000  37,000  40,700  BURNABY  140,000  154,000  COQUITLAM  103,000  113,300  NORTH SHORE  145,000  159,500  1,135,000  1,248,500  NEW WESTMINSTER  TOTAL  58.  TABLE X I I I  1981 FORECAST G.V.R.H.D. INCIDENCE RATES OF HOSPITALIZATION (PATIENT-DAYS/1000 POPULATION-YEAR) AT 110% o f 1981 STANDARD INCIDENCE RATES FORECAST STANDARD FORECAST  DISTRICT SURREY  110% STANDARD  1281  1410  NORTH DELTA  825  909  LADNER  823  907  RICHMOND  978  1076  VANCOUVER  1623  1786  NEW WESTMINSTER  1553  1709  BURNABY  1094  1204  901  991  1090  1199  1274  1402  COQUITLAM NORTH SHORE  TOTAL  59. Inflow percentage may f a l l as a r e s u l t o f the c o n s t r u c t i o n o f more s p e c i a l i z e d h o s p i t a l f a c i l i t i e s outside the Region. The e f f e c t s o f t h i s h o s p i t a l c o n s t r u c t i o n p o l i c y were analysed by reducing t h e G.V.R.H.D's. Inflow percentage by 10.0%.  For example, the  adult Inflow percentage o f 19.0% was reduced by 10.0% t o form an a l t e r n a t i v e Inflow percentage o f 17.1%*.  When t h i s percentage was  a p p l i e d t o the A d u l t Gross Demand i n the Standard Forecast o f 895,830 patient-days, the Inflow decreased from 170,208 t o 153,187 patient-days, a reduction o f 10%.  Table XIV l i s t s the standard and the a l t e r n a t i v e  Inflow percentages  TABLE XIV  1981 FORECAST INFLOW PERCENTAGES AT 0.9% OF 1981 STANDARD INFLOW PERCENTAGES AGE-SEX GROUP PAEDIATRIC MATERNITY ADULT GERIATRIC  * See the Standard Forecast i n Appendix B.  STANDARD INFLOW PERCENTAGE  ALTERNATE INFLOW PERCENTAGE  38.0  34.2  8.0  7.2  19.0  17.1  7.0  6.3  60. The Inflow Transfer Vector that d i s t r i b u t e s the annual Inflow patient-days among the d i s t r i c t s o f the G.V.R.H.D. was not a l t e r e d t o analyse the e f f e c t s o f an a l t e r n a t e Inflow d i s t r i b u t i o n p o l i c y because the Inflow i s c u r r e n t l y d i s t r i b u t e d t o s p e c i a l i z e d f a c i l i t i e s and no change i n these f a c i l i t i e s i s contemplated.  D. TRANSFER MATRIX The Transfer M a t r i x used by the computer f o r e c a s t i n g program t o produce the Standard Forecast, r e f l e c t s the 1975 p a t t e r n o f i n t r a G.V.R.H.D. p a t i e n t t r a n s f e r s .  The use o f t h i s p a t t e r n i n the f o r e c a s t  process means t h a t the p a t t e r n i s not expected t o change. However, as the G.V.R.H.D's population s h i f t s towards the suburban d i s t r i c t s , i t i s reasonable t o assume t h a t a greater proportion o f these d i s t r i c t s ' annual Gross Demands f o r h o s p i t a l s e r v i c e s should be accommodated by h o s p i t a l s w i t h i n these d i s t r i c t s .  The computer f o r e c a s t -  ing program was used t o analyse the e f f e c t o f the a l t e r n a t e p o l i c y that 80% o f a d i s t r i c t ' s annual Gross Demands f o r acute-care h o s p i t a l s e r v i c e s i s t o be accommodated by the d i s t r i c t ' s own h o s p i t a l s , w i t h a f u r t h e r 10% t o be t r a n s f e r r e d t o more s p e c i a l i z e d r e g i o n a l r e f e r r a l h o s p i t a l s , and with the remaining 10% t o be t r a n s f e r r e d t o t h e t e r t i a r y - c a r e s e r v i c e s provided by designated'.hospitals  i n Vancouver.  Table XV d i s p l a y s the Transfer Matrix which was used t o r e f l e c t this alternate policy.  The 80-10-10 p o l i c y was adapted t o f i t the f o l -  lowing c h a r a c t e r i s t i c s o f the G.V.R.H.D.: 1.  SURREY  80% o f Gross Demand r e t a i n e d i n Surrey w i t h 10%  to the nearest r e g i o n a l r e f e r r a l h o s p i t a l , i n New Westminster, and 10% t o the t e r t i a r y care h o s p i t a l s i n  *********************** T R A N S F E R M A T R I X ASSUMED *********************** AREA  PATIENT ORIGIN *******  OF  HOSPITAL  TREATMENT  ************************** B  C  NS  OUT  TOTAL  V  NW  .000  100  .100  .000  .000  .000  .000  1.000  .000  .000  100  .100  .000  .000  .000  .000  1.000  .000  .800  .000  200  .000  .000  .000  .000  .000  1.000  .000  .000  .000  .800  200  .000  .000  .000  .000  .000  1.000  VANCOUVER  .000  .000  .000  .000  950  .000  .050  .000  .000  .000  1.000  NEW  .000  .000  .000  .000  ,100  .900  .000  .000  .000  .000  1.000  BURNABY  .00 0  .000  .000  .000  ,150  .150  .700  .000  .000  .000  1.000  COQUITLAM  .000  .000  .000  .000  ,100  .100  .000  .800  .000  .000  1.000  NORTH  .000  .000  .000  .000  200  .000  .000  .000  .800  .000  1.000  S  ND  .800  .000  .000  .800  .000  LADNER  .000  RICHMOND  SURREY NORTH  DELTA  WEST  SHORE  L  TABLE XV:  R  THE ALTERNATE TRANSFER MATRIX  62. Vancouver. 2.  NORTH DELTA North D e l t a i s adjacent t o Surrey's h o s p i t a l and thus, was given the same p a t t e r n as Surrey.  3.  LADNER  80% r e t a i n e d i n Ladner w i t h both t h e 10% r e g i o n a l  and 10% t e r t i a r y t r a n s f e r s t o Vancouver. 4. RICHMOND 80% r e t a i n e d i n Richmond w i t h both the 10% r e g i o n a l and 10% t e r t i a r y t r a n s f e r s t o Vancouver. 5.  VANCOUVER  5% o f Vancouver's Gross Demand t o Burnaby because  Burnaby's h o s p i t a l i s on the boundary between these two districts. 6.  The remaining 95% t o remain i n Vancouver.  NEW WESTMINSTER  90% r e t a i n e d in New Westininster because  of the l o c a t i o n there o f a r e g i o n a l r e f e r r a l h o s p i t a l . 10% t o Vancouver. 7. BURNABY  70% r e t a i n e d i n Burnaby and 5% each t o Vancouver  and New Weslaninster because o f Burnaby's adjacency t o nearby h o s p i t a l s .  A f u r t h e r 10% t o the r e g i o n a l r e f e r r a l  h o s p i t a l i n New Westminster. A f u r t h e r 10% t o t e r t i a r y care h o s p i t a l s i n Vancouver. 8. COQUITLAM  80% r e t a i n e d i n Coquitlam w i t h 10% t o New Westnrinster  and 10% t o Vancouver. 9. NORTH SHORE  80% r e t a i n e d i n the North Shore w i t h 10% each t o  the r e g i o n a l and t e r t i a r y h o s p i t a l s i n Vancouver.  E.  OCCUPANCY PERCENTAGE The B.C.H.P. f o r e c a s t used "target" percentages f o r each age-sex  group t o compensate f o r f l u c t u a t i o n s i n the demand f o r h o s p i t a l admissions. As described i n Chapter IV, a method using the Poisson d i s t r i b u t i o n can be used t o account f o r the r e l a t i o n s h i p between t h e s i z e o f the i n d i v i d u a l  63. h o s p i t a l ' s f o r e c a s t Average D a i l y Census and t h e expected range o f demand fluctuations. To analyse the e f f e c t s o f using t h i s approach, r a t h e r than the "target" occupancy percentage approach, t h e f o r e c a s t Average D a i l y Census f o r each d i s t r i c t was pro-rated t o each o f the d i s t r i c t ' s h o s p i t a l s on the basis o f e x i s t i n g h o s p i t a l bed c a p a c i t i e s .  From t h i s base, t h e f o r e c a s t  Hospital-Bed Requirement f o r each h o s p i t a l was c a l c u l a t e d using the f o l lowing formula:  FORECAST HOSPITALBED REQUIREMENT  FORECAST AVERAGE DAILY CENSUS  These Forecast Hospital-Bed Requirements were grouped by d i s t r i c t and then compared t o t h e corresponding t o t a l s i n t h e Standard Forecast.  The f o l l o w i n g Chapter gives the r e s u l t s o f THE STANDARD FORECAST, THE SENSITIVITY ANALYSIS and THE POLICY ANALYSIS discussed i n t h i s Chapter.  64.  CHAPTER VII  RESULTS  THE STANDARD FORECAST The computer f o r e c a s t i n g program was loaded w i t h data described i n Chapter VI and produced the STANDARD FORECAST; a copy o f t h i s output forecast i s attached as Appendix B. Tables XVI t o XIX show the compari s o n between B.C.H.P's. planning proposal ( l a b e l l e d PLANNED BEDS) and the Standard Forecast produced by the computer f o r e c a s t i n g program ( l a b e l l e d G.V.R.H.D's. NEEDED BEDS) w i t h the Standard Forecast as the base.  This comparison i s made f o r each o f the f o l l o w i n g age-sex groups:  P a e d i a t r i c , Maternity, A l l A d u l t , and T o t a l . The A d u l t (ages 15-69) and G e r i a t r i c (age 70 +) groups were combined f o r t h i s comparison because the B.C.H.P. method does not d i f f e r e n t i a t e G e r i a t r i c acute-care h o s p i t a l beds from other  Adult beds i n the f i n a l proposal.  Note,  however, t h a t t h e i r requirements are t r e a t e d separately during the f o r e cast.  65.  TABLE XVI  COMPARISON BETWEEN B.C.H.P. AND G.V.R.H.D. FORECASTS OF 1981 G.V.R.H.D. REQUIREMENTS FOR PAEDIATRIC ACUTE-CARE BEDS  AREA (DISTRICT)  B.C.H.P's. PLANNED BEDS  G.V.R.H.D's. NEEDED BEDS  BALANCE  SURREY  44  43  1  LADNER  0  0  0  RICHMOND  26  14  12  VANCOUVER  200  254  -54  NEW WESTMINSTER  55  51  4  BURNABY  37  29  8  0  0  0  24  26  -2  386  417  -31  COQUITLAM NORTH SHORE  TOTAL  66.  TABLE XVII  COMPARISON BETWEEN B.C.H.P. AND G.V.R.H.D. FORECASTS OF 1981 G.V.R.H.D. REQUIREMENTS FOR MATERNITY ACUTE-CARE BEDS  AREA (DISTRICT)  B.C.H.P's. PLANNED BEDS  G.V.R.H.D's. NEEDED BEDS  BALANCE  SURREY  50  41  9  LADNER  0  0  0  30  25  5  120  140  -20  NEW WESTMINSTER  40  46  -6  BURNABY  25  26  1  0  0  0  32  34  -2  297  312  -15  RICHMOND VANCOUVER  COQUITLAM NORTH SHORE  TOTAL  67.  TABLE XVIII  COMPARISON BETWEEN B.C.H.P. AND G.V.R.H.D. FORECASTS OF 1981 G.V.R.H.D. REQUIREMENTS FOR ALL ADULT ACUTE-CARE BEDS  AREA (DISTRICT)  B.C.H.P's. PLANNED BEDS  G.V.R.H.D's. NEEDED BEDS  BALANCE  SURREY  322  391  -69  LADNER  75  0  75  173  133  40  2,616  2,705  -89  NEW WESTMINSTER  573  566  7  BURNABY  360  251  109  75  0  75  400  408  - 8  4,594  4,454  140  RICHMOND VANCOUVER  COQUITLAM NORTH SHORE  TOTAL  68.  TABLE XIX  COMPARISON BETWEEN B.C.H.P. AND G.V.R.H.D. FORECASTS OF 1981 G.V.R.H.D. REQUIREMENTS FOR TOTAL ACUTE-CARE BEDS  AREA (DISTRICT)  B.C.H.P's PLANNED BEDS  G.V.R.H.D's. NEEDED BEDS  BALANCE  SURREY  416  475  -59  LADNER  75  0  75  RICHMOND  229  172  57  VANCOUVER  2,936  3,099  -163  NEW WESTMINSTER  668  663  5  BURNABY  422  306  116  75  0  75  456  468  -12  5,277  5,183  94  COQUITLAM NORTH SHORE  TOTAL  69.  THE SENSITIVITY ANALYSIS The e i g h t computer runs described i n ChapterVI provided a data base on changes i n the f o r e c a s t NET DEMAND which the computer program produced i n response t o changes made from the standard population mixes and incidence r a t e s .  adult-geriatric  Since the separate p a e d i a t r i c  and maternity f o r e c a s t s were not a f f e c t e d by these data  alterations,  they were excluded from the s e n s i t i v i t y a n a l y s i s . A.  SENSITIVITY TO POPULATION CHANGES Runs 1 and 2 were compared t o determine the " s e n s i t i v i t y " i n the  NET DEMAND ( i n patient-days) o f the combined d i s t r i c t  adult-geriatric  age groups, t o increases i n the percentages o f e l d e r l y people r e l a t e d t o the t o t a l adult p o p u l a t i o n groups i n each d i s t r i c t .  Table XX summarizes  t h i s comparison and l i s t s the " s e n s i t i v i t y " defined as the percentage change i n NET DEMAND f o r each 1% increase i n the g e r i a t r i c p o p u l a t i o n percentage o f the t o t a l adult group.  Note t h a t t h i s d e f i n i t i o n i s used  f o r convenience i n understanding the s i g n i f i c a n c e f o r the NET DEMAND o f an increase i n the percentage o f t o t a l population t h a t i s g e r i a t r i c ; f o r example, from 6 t o 7%. This " s e n s i t i v i t y " i s not the same as the formal S e n s i t i v i t y which i s defined as the percentage change i n OUTPUT ( i n t h i s case, NET DEMAND) r e s u l t i n g from a one percent change i n INPUT ( i n t h i s case, absolute POPULATION t o t a l s ) .  B.  SENSITIVITY TO INCIDENCE RATE CHANGES  1.  Runs 2 and 3 were compared t o determine the percentage change i n the  NET DEMAND ( i n p a t i e n t days) o f the combined a d u l t - g e r i a t r i c  age groups  by d i s t r i c t t h a t r e s u l t e d from a 10% decrease i n the g e r i a t r i c incidence rates w h i l e the a d u l t incidence r a t e s were h e l d constant. Table XXI summarizes t h i s comparison and includes a l i s t i n g o f the s e n s i t i v i t y o f  70. NET DEMAND by d i s t r i c t t o a 1% decrease i n the g e r i a t r i c incidence r a t e s . 2.  Runs 2 and 5 were compared t o determine the percentage change i n t h e  NET DEMAND t h a t r e s u l t e d from a 10% increase i n the g e r i a t r i c r a t e s while the a d u l t r a t e s were h e l d constant.  incidence  The c a l c u l a t e d s e n s i -  t i v i t i e s were i d e n t i c a l t o those i n the previous a n a l y s i s , B - l , and t h e r e f o r e , were not t a b u l a t e d . 3.  Runs 2 and 4 were compared t o determine the percentage change i n NET  DEMAND that r e s u l t e d from a 10% decrease i n the a d u l t incidence r a t e s while the g e r i a t r i c incidence r a t e s were h e l d constant.  Table XXII  summarizes t h i s comparison and includes a l i s t i n g o f the s e n s i t i v i t y o f NET DEMAND t o a 1% decrease i n the a d u l t incidence r a t e s . 4.  Runs 2 and 7 were compared t o determine the percentage change i n  NET DEMAND t h a t r e s u l t e d from a 10% increase i n the a d u l t incidence r a t e s while the g e r i a t r i c incidence r a t e s were h e l d constant.  The c a l c u l a t e d  s e n s i t i v i t i e s were i d e n t i c a l t o those i n the previous a n a l y s i s , B-3, and t h e r e f o r e , were not tabulated. 5.  Runs 2 and 5 were compared t o determine the percentage change i n  NET DEMAND t h a t r e s u l t e d from a 10% decrease i n both the g e r i a t r i c and the adult incidence r a t e s .  Table XXIII summarizes t h i s comparison and  includes a l i s t i n g o f the s e n s i t i v i t y o f NET DEMAND t o a 1% decrease i n both the g e r i a t r i c and the a d u l t incidence r a t e s . 6. Runs 2 and 8 were compared t o determine the change i n NET DEMAND t h a t r e s u l t e d from a 10% increase i n both the g e r i a t r i c and t h e a d u l t incidence r a t e s .  The c a l c u l a t e d s e n s i t i v i t i e s were i d e n t i c a l t o those  i n the previous a n a l y s i s , B-5, and t h e r e f o r e , were not tabulated.  71.  TABLE XX  "SENSITIVITY" OF TOTAL ADULT NET DEMAND (IN PATIENT DAYS)  TO A 1% INCREASE IN THE PERCENTAGE OF GERIATRIC POPULATION TO THE TOTAL ADULT POPULATION 1.  District Surrey  2.  3.  Net Demand Change T o t a l A d u l t I n Net (Standard) Demand  4. Geriatric  %  5. Geriatric  Percent Percent (Standard) Increase  "Sensitivity" (Col. 3 * C o l . 5)  128,364  21,792  16.98  7.99  5.12  3.32  Richmond  43,573  5,351  12.28  5.18  3.33  3.69  Vancouver  888,610  109,621  12.34  10.49  6.72  1.84  New West.  185,981  23,196  12.47  11.80  7.57  1.65  82,346  16,195  19.67  6.33  4.06  4.84  134,302  17,790  13.25  6.10  3.92  3.38  1,463,176  193,945  13.26  7.90  5.07  2.62  Burnaby North Shore  TOTAL  72.  TABLE XXI  SENSITIVITY OF TOTAL ADULT NET DEMAND (IN PATIENT DAYS) TO A 1% DECREASE IN THE GERIATRIC INCIDENCE RATES 1.  3.  District  Net Demand Total Adult (Run 2)  Change % Change I n Net Net Demand Demand  Geriatric Incidence Rate Change  Surrey  150,156  - 6,728  - 4.48  - 10.0  0.45  Richmond  49,924  - 1,652  - 3.38  - 10.0  0.34  Vancouver  998,231  -38,791  - 3.89  - 10.0  0.39  New West.  209,177  - 7,755 - 3.71  - 10.0  0.37  - 4,898  - 4.97  - 10.0  0.50  - 5,702 - 3.75  - 10.0  0.37  -65,526  - 10.0  0.40  Burnaby North Shore  TOTAL  98,541 151,092  1,657,121  - 3.95  Sensitivity (Col. 3 * Col.4)  73.  TABLE XXII  SENSITIVITY OF TOTAL ADULT NET DEMAND (IN PATIENT-DAYS) TO A 1 % DECREASE IN THE ADULT INCIDENCE RATES  District Surrey  Net Demand Total Adult (Run 2)  Change I n Net Demand  % Change Net Demand  Adult Incidence Rate % Change  Sensitivity (Col. 3 * C o l . 4)  150 ,156  - 8 ,317  - 5.53  - 10 .0  0 .55  49 ,924  - 3,,257  - 6.65  - 10,.0  0 .67  Vancouver  998 ,231  -61.,022  - 6.11  - 10..0  0,.61  New West.  209 ,177  -13.,170  - 6.30  - 10..0  0,.63  98 ,541  - 4.,956  - 5.03  - 10.,0  0.,50  151 ,092  - 9.,383  - 6.17  - 10.0  0.,62  1,657,121  - 100,105  - 6.04  - 10.0  0.60  Richmond  Burnaby North Shore  TOTAL  74.  TABLE XXIII  SENSITIVITY OF TOTAL ADULT NET DEMAND (IN PATIENT-DAYS) TO A 1% DECREASE IN BOTH THE GERIATRIC AND THE ADULT INCIDENCE RATES  District  Net Demand Change % T o t a l A d u l t I n Net Change (Run 2) Demand Net Demand  Change Incidence Rates  Surrey  150 ,156  Richmond  48 ,924  Sensitivity (Col. 3 + C o l . 4)  - 15.,045  - 10 .02  - 10 .0  1 .00  4,,909  - 10,.03  - 10 .0  1..00  -  Vancouver  998 ,231  - 99,,813  - 10..00  - 10,.0  1,.00  New West.  209,,177  - 20.,925  - 10..00  - 10..0  1..00  -  - 10.,00  - 10.,0  1.,00  9.92  - 10.,0  0.99  - 10.00  - 10.0  1.00  Burnaby North Shore  TOTAL  98.,541  9.,854  151.,092  - 15,,086  1,657,121  165,632  -  75.  THE POLICY ANALYSIS  A. POPULATION The population o f the G.V.R.H.D's age-sex groups by d i s t r i c t were increased by 10%, as explained i n Chapter V I , and the r e s u l t s were compared to the Standard Forecast.  Table XXIV shows t h i s comparison w i t h the  Standard Forecast as the base.  B.  INCIDENCE RATES The incidence r a t e s o f the G.V.R.H.D's. age-sex groups by d i s t r i c t  were increased by 10%, as explained i n Chapter VI and the r e s u l t s were compared t o the Standard Forecast.  The c a l c u l a t e d r e s u l t s were i d e n t i c a l  to the previous p o l i c y a n a l y s i s , Population,and t h e r e f o r e , were not tabulated.  C.  INFLOW The i n f l o w o f patient-days t o the G.V.R.H.D. was reduced by 10%  as explained i n Chapter VI and the r e s u l t s were compared t o the Standard Forecast.  Table XXV shows t h i s comparison w i t h the Standard Forecast as  the base.  D.  TRANSFER MATRIX The Transfer M a t r i x , designed t o r e f l e c t the u l t i m a t e p a t i e n t -  t r a n s f e r p o l i c y described i n Chapter V I , was used i n t h e computer f o r e c a s t i n g program t o produce P o l i c y Forecast D.  Table XXVI compares t h i s  forecast t o the Standard Forecast, which i s used as the base.  76. E.  OCCUPANCY PERCENTAGE The Poisson method o f estimating the forecast Requirement f o r H o s p i t a l  Beds above the f o r e c a s t Average D a i l y Census t o accommodate f l u c t u a t i o n s i n the demand f o r h o s p i t a l admissions, described i n Chapter V I , was t o the forecast Average D a i l y Census o f i n d i v i d u a l h o s p i t a l s .  applied The h o s p i t a l s '  forecast bed-compliments were summed by d i s t r i c t t o form P o l i c y Forecast E.  Table XXVII compares P o l i c y Forecast E t o the Standard Forecast, which  i s used as the base.  77.  TABLE XXIV COMPARISON BETWEEN THE STANDARD FORECAST AND POLICY FORECAST A (POPULATION)  Forecast Hospital Bed Requirements (Standard)  Forecast Hospital Bed Requirements ( P o l i c y A)  Surrey  475  522  Ladner  0  0  172  Vancouver  Districts  Increase  Increase  47  10.0  188  16  9.3  3,099  3,407  308  9.9  New West.  663  729  66  10.0  Burnaby  306  336  30  9.8  0  0  468  516  48  10.3  5,183  5,698  515  9.9  Richmond  Coquitlam North Shore TOTAL  78.  TABLE XXV  COMPARISON BETWEEN THE STANDARD FORECAST AND POLICY FORECAST C (INFLOW)  Districts  Forecast Hospital Bed Requirements (Standard)  Forecast Hospital Bed Requirements ( P o l i c y C)  Decrease  Surrey  475  471  Ladner  0  0  172  172  0  3,099  3,043  56  New Westminster  663  656  7  Burnaby  306  306  0  0  0  468  461  5,183  5,109  Richmond Vancouver  Coquitlam North Shore TOTAL  74  79.  TABLE XXVI COMPARISON BETWEEN THE STANDARD FORECAST AND POLICY FORECAST D (TRANSFER MATRIX)  Districts  Forecast Hospital Bed Requirements (Standard)  Forecast Hospital Bed Requirements ( P o l i c y D)  %  Difference  Difference + 20.2  Surrey  475  571  +  96  Ladner  0  80  +  80  172  217  +  45  +  26.2  Vancouver  3,099  2,798  -  301  -  9.7  New West.  663  400  -  263  -  40.0  Burnaby  306  435  +  129  + 42.2  0  230  +  230  468  458  -  10  5,183  5,189  +  Richmond  Coquitlam North Shore TOTAL  6 *  00  CO  -  2.1  +  0.6  *This s l i g h t d i f f e r e n c e from Standard r e s u l t s from the e x c l u s i o n of OUTFLOW from the P o l i c y Forecast f o r convenience i n programming the Transfer Matrix.  80.  TABLE XXVII COMPARISON BETWEEN THE STANDARD FORECAST AND POLICY FORECAST E (OCCUPANCY PERCENTAGE)  Districts  Forecast Hospital Bed Requirements (Standard)  Forecast Hospital Bed Requirements ( P o l i c y E)  Surrey  475  504  Ladner  0  0  172  188  Vancouver  3,099  3,203  New West.  663  Burnaby  Richmond  Coquitlam North Shore TOTAL  %  Difference +  29  Differei +  -  0 +  6.1  16  +  9.3  + 104  +  3.4  689  +  26  +  3.9  306  320  +  14  +  4.6  0  0  468  479  5,183  5,383  -  0 +  11  +  2.4  + 200  +  3.9  81.  CHAPTER  VIII  DISCUSSION  THE STANDARD FORECAST The B.C.H.P. planning proposal was based on t h e i r f o r e c a s t o f t h e Gross Demand ( i n p a t i e n t days) expected by the G.V.R.H.D.'s d i s t r i c t s . The connection between t h a t forecast and the B.C.H.P. hospital-bed was never e s t a b l i s h e d .  proposal  However, I suspect t h a t a r b i t r a r y d e c i s i o n s were  made when the f o r e c a s t Gross Demands o f an i n d i v i d u a l d i s t r i c t were compared t o the number o f h o s p i t a l beds c u r r e n t l y i n operation i n t h a t district.  The B.C.H.P. proposal, then, i s not s t r i c t l y a f o r e c a s t ,  whereas the computer f o r e c a s t i n g program's r e b u t t a l t o i t i s a f o r e c a s t , based on s p e c i f i e d assumptions.  Nevertheless, the two " f o r e c a s t s " were  compared here t o r e v e a l the d i f f e r e n c e s created by t h e use o f d i f f e r e n t approaches t o t r a n s l a t e Gross t o Net Demand f o r h o s p i t a l s e r v i c e s i n each district.  Table XXVIII transforms the balance ( d i f f e r e n c e ) data i n  Tables XVI t o XIX i n t o percentages o f the computer program's Standard Forecast o f Hospital-Bed Requirements. Before analysing t h i s data, a complicating f a c t o r must be explained. Since p a t i e n t s can only t r a n s f e r t o d i s t r i c t s t h a t have h o s p i t a l s , t h e d i s t r i c t s o f Coquitlam, Ladner and North D e l t a , w i t h no h o s p i t a l s o f t h e i r own,  export 100% o f t h e i r p a t i e n t s and are shown on the G.V.R.H.D. f o r e c a s t  with no f o r e c a s t Net Demand, and thus, no requirement f o r h o s p i t a l beds. Obviously, t h i s i s not s t r i c t l y t r u e . There was considerable debate i n 1976 as t o whether Coquitlam and Ladner had s u f f i c i e n t Gross Demand and access t o i n f l o w patient-days  from  82.  TABLE XXVIII VARIATION BETWEEN B.C.H.P. AND G.V.R.H.D. HOSPITAL BED FORECASTS EXPRESSED AS % G.V.R.H.D. FORECAST  AREA  PAEDIATRIC  SURREY  2.3  LADNER  -  MATERNITY 22.0 -  ADULT  TOTAL  17.6  12.4  co  oo  RICHMOND  85.7  20.0  30.1  33.1  VANCOUVER  21.3  14.3  3.4  5.3  NEW WEST.  7.8  13.0  1.2  0.8  27.6  3.8  43.4  38.0  BURNABY COQUITLAM  -  _  oo  co  NORTH SHORE  7.7  5.9  0.2  2.6  TOTAL  7.4  4.8  3.1  1.8  83. neighbouring d i s t r i c t s , t o j u s t i f y the establishment o f t h e i r own h o s p i t a l s . B.C.H.P. s a i d "yes" and proposed a new h o s p i t a l i n each o f the two d i s t r i c t s ; the G.V.R.H.D. s a i d "no" and d i d not so propose.  For t h i s  reason, an i n f i n i t e percentage d i f f e r e n c e e x i s t s between the B.C.H.P. and the Standard f o r e c a s t s o f the Hospital-Bed Requirements o f Coquitlam and Ladner. Table XXVIII shows t h a t there i s considerable v a r i a t i o n between the two f o r e c a s t s . Although the o v e r a l l B.C.H.P. t o t a l d i f f e r s by o n l y 1.8% from the G.V.R.H.D. f o r e c a s t , i n d i v i d u a l age-sex group f o r e c a s t s f o r i n d i v i d u a l d i s t r i c t s have some s u b s t a n t i a l v a r i a t i o n s .  For example, the  85.7% v a r i a t i o n i n Richmond's p a e d i a t r i c f o r e c a s t r e f l e c t s an absolute v a r i a t i o n o f 12 beds.  While t h i s i s not a l a r g e v a r i a t i o n , i t could  considerably a f f e c t the planning o f a p a e d i a t r i c u n i t w i t h i n an i n d i v i d u a l hospital.  The 43.4% v a r i a t i o n i n Burnaby's a d u l t bed f o r e c a s t i s a lower  percent than t h a t o f the previous example, but the absolute v a r i a t i o n i s 109 beds - a l a r g e and c r i t i c a l v a r i a t i o n . In summary, t h i s a n a l y s i s reveals t h a t , although the B.C.H.P. and G.V.R.H.D. f o r e c a s t i n g p o l i c i e s and methods are not s t r i c t l y comparable, the two f o r e c a s t s do not vary s i g n i f i c a n t l y o v e r a l l , as i s t o be expected considering t h e i r common data.  However, the a l l o c a t i o n s o f the o v e r a l l  Net Demand t o age-sex groups by d i s t r i c t do vary s i g n i f i c a n t l y .  This i s  a l s o expected c o n s i d e r i n g the two d i f f e r e n t a l l o c a t i o n methods:  B.C.H.P.'s  i n t u i t i o n and the computer f o r e c a s t i n g program's 1975 Transfer M a t r i x .  THE SENSITIVITY ANALYSIS A.  SENSITIVITY TO POPULATION CHANGES Without an opportunity t o study the data, an outside observer might  propose t h a t f o r the d i s t r i c t s w i t h high proportions o f e l d e r l y people i n  84. t h e i r t o t a l a d u l t populations, the s e n s i t i v i t i e s o f t h e i r Net Demands f o r h o s p i t a l s e r v i c e s t o changes i n the g e r i a t r i c population would be high. Since the g e r i a t r i c incidence r a t e i s approximately f o u r times t h a t o f other a d u l t s , t h i s proposal i s reasonable. Table XX i n Chapter VII shows that t h i s i s not n e c e s s a r i l y the case. As described i n Chapter VI, the g e r i a t r i c populations o f the G.V.R.H.D. d i s t r i c t s were increased by approximately 64% above the standard g e r i a t r i c / t o t a l adult r a t i o s .  The r e s u l t i n g percentages o f g e r i a t r i c population i n  1981 vary from 5.18%  i n Richmond t o 11.80% i n New Westminster.  The i n t r a -  Regional p a t i e n t t r a n s f e r r e d i s t r i b u t e d the increase i n p a t i e n t days w i t h the r e s u l t that some areas, notably Burnaby, received "more than t h e i r share" when t h e i r percent increase i n net demand i s compared w i t h t h e i r percent increase i n g e r i a t r i c population. For example, the general 64% increase i n absolute numbers o f e l d e r l y people r a i s e d Burnaby's percentage o f g e r i a t r i c population t o t o t a l a d u l t population from 6.33% t o 10.40% - an increase o f 4.07%.  However,  Table XX shows t h a t the same general increase r a i s e d the f o r e c a s t o f the t o t a l - a d u l t - N e t Demand f o r h o s p i t a l services by 19.67%.  Thus, f o r every  1% increase i n the g e r i a t r i c population, the net demand was increased by 4.84%; a s e n s i t i v i t y o f 4.84.  By comparison, New Westminster's s e n s i t i v i t y  to a 1% increase i n the g e r i a t r i c population was 1.65 even though t h e i r g e r i a t r i c population i s 11.80% o f t h e i r t o t a l a d u l t population while t h a t o f Burnaby i s only 6.33%.  This can be explained by the f a c t t h a t Burnaby  has the highest g e r i a t r i c i n f l o w proportion o f t o t a l a d u l t Inflow o f the G.V.R.H.D.'s d i s t r i c t s as shown i n Table XXIX. This t a b l e shows t h a t Burnaby i s f o r e c a s t t o import 36,787 a d u l t patient-days o r 45% o f the 82,346 adult patient-days t h a t i t i s f o r e c a s t to accommodate, and o f those imported patient-days, 33% are g e r i a t r i c .  85.  TABLE XXIX PROPORTION OF GERIATRIC INFLOW TRANSFERS TO TOTAL ADULT INFLOW TRANSFERS*  ADULT NET DEMAND  ADULT INFLOW  GERIATRIC INFLOW  GERIATRIC PROPORTION  128,364  26,612  3,406  .138  RICHMOND  43,573  9,062  2,109  .233  VANCOUVER  888,610  322,524  46,768  .145  NEW WEST.  185,981  143,457  31,641  .221  82,346  36,787  12,199  .332  134,302  19,581  2,611  .133  AREA SURREY  BURNABY NORTH SHORE  '•Calculated from the Standard Forecast using the Transfer M a t r i x .  86. Thus, Burnaby's a d u l t Net Demand i s h i g h l y s u s c e p t i b l e t o changes i n the g e r i a t r i c population o f the G.V.R.H.D. Without the p a t i e n t t r a n s f e r s among the d i s t r i c t s , t h e c a l c u l a t i o n  o f the Net Demand would be a l i n e a r  process and thus, the s e n s i t i v i t y o f the output t o changes i n the i n p u t would be equal f o r a l l d i s t r i c t s . B.  SENSITIVITY TO INCIDENCE RATE CHANGES  1. S 2.  I n t h i s a n a l y s i s o f s e n s i t i v i t y , the g e r i a t r i c Incidence  Rates were lowered by 10% and then were r a i s e d by 10% w h i l e the a d u l t Rates were h e l d constant a t standard values.  The summary o f the s e n s i t i v i t y  by d i s t r i c t t o the 10% decrease i n the g e r i a t r i c Incidence Rates, Table XXI i n Chapter V I I , again shows t h a t t h e s e n s i t i v i t i e s o f t h e d i s t r i c t s ' Net Demand vary among the d i s t r i c t s .  Somewhat as before,  Burnaby's Net Demand decreased by 4.97% f o l l o w i n g the 10% drop i n the g e r i a t r i c Incidence Rates, a s e n s i t i v i t y o f 0.50, w h i l e t h a t o f New Westmins t e r , w i t h a much h i g h e r percentage o f e l d e r l y persons, decreased by only 3.71%, a s e n s i t i v i t y o f 0.37. Burnaby's higher s e n s i t i v i t y can be explained by t h a t d i s t r i c t ' s high percentage o f g e r i a t r i c Inflow, as noted i n the previous s e c t i o n . Because the i n t r a - R e g i o n a l t r a n s f e r patterns a r e constant f o r a l l the s e n s i t i v i t y analyses, the Net Demand o f each d i s t r i c t i s e q u a l l y s e n s i t i v e t o an i d e n t i c a l increase o r decrease i n the standard Incidence Rates. 3. S 4.  I n t h i s a n a l y s i s o f s e n s i t i v i t y , the a d u l t Incidence Rates  were lowered by 10% and then were r a i s e d by 10% w h i l e t h e g e r i a t r i c Rates were h e l d constant.  The summary o f the s e n s i t i v i t y by d i s t r i c t t o the 10%  decrease i n the a d u l t Incidence Rates, Table XXII i n Chapter V I I , shows t h a t , as expected, t h e s e n s i t i v i t i e s o f t h e Net Demand by d i s t r i c t vary  87. among the d i s t r i c t s . In a d d i t i o n , these s e n s i t i v i t i e s have a r e l a t i o n s h i p t o the s e n s i t i v i t i e s shown on Table XXI.  Burnaby, f o r example, has the lowest  s e n s i t i v i t y t o a 10% decrease i n the a d u l t Incidence Rates, whereas i t has the highest s e n s i t i v i t y t o a 10% decrease i n the g e r i a t r i c Incidence Rates.  This opposite order o f d i s t r i c t s e n s i t i v i t i e s was expected because  a d i s t r i c t w i t h a high g e r i a t r i c i n f l o w p r o p o r t i o n has a correspondingly low adult i n f l o w proportion.  Thus, t h i s d i s t r i c t ' s Net Demand i s more  s e n s i t i v e t o changes i n the g e r i a t r i c Incidence Rates than are the Net Demands o f other d i s t r i c t s , and correspondingly t h i s d i s t r i c t ' s Net Demand i s l e s s s e n s i t i v e t o changes i n the a d u l t Incidence Rates than are the Net Demands o f other d i s t r i c t s . 5. S 6.  I n t h i s a n a l y s i s o f s e n s i t i v i t y , both the g e r i a t r i c and the  a d u l t Incidence Rates were f i r s t decreased by 10% and then were increased by 10%. . With the values o f the other f o r e c a s t v a r i a b l e s h e l d a t Standard values, the Net Demand by d i s t r i c t was expected t o have a s e n s i t i v i t y o f 1.0 t o an equal percentage Incidence Rates.  change i n both the g e r i a t r i c and the a d u l t  This i s because the v a r i a t i o n by d i s t r i c t i n the g e r i a t r i c -  a d u l t i n f l o w proportions w i l l not a f f e c t the conversion o f Gross t o Net Demand. Table X X I I I , Chapter V I I , shows t h a t the s e n s i t i v i t i e s are 1.0 which i n d i c a t e s t h a t the computer f o r e c a s t i n g program produces r e s u l t s c o n s i s t e n t w i t h those expected.  I n summary, these exaircLnations o f the s e n s i t i v i t y o f the computer f o r e c a s t i n g program's output f o r e c a s t t o changes made t o the values o f the input v a r i a b l e s have shown t h a t the user o f the program cannot assume a common output-response t o changes i n Populations and Incidence Rates.  88. An exanuination o f the p a t i e n t t r a n s f e r patterns w i l l r e v e a l p e c u l i a r i t i e s o f a p a r t i c u l a r d i s t r i c t ' s h o s p i t a l s e r v i c e patterns.  If  the combined p a t t e r n o f a l l the d i s t r i c t s i s judged t o be undesirable by the policy-makers, then the e f f e c t s of r e v i s e d patterns (TRANSFER MATRICES) can be analysed through the use o f the computer f o r e c a s t i n g program.  THE POLICY ANALYSIS A.  POPULATION I f an equal percentage increase i s a p p l i e d t o a l l the population  groups of the d i s t r i c t s , the computer f o r e c a s t i n g program should produce a f o r e c a s t o f Hospital-Bed Requirements t h a t w i l l be increased by the same percentage.  This should occur because the equal percentage change i n a l l  the values o f the population v a r i a b l e w i l l be transmitted through the f o r e c a s t process t o the f o r e c a s t o f Hospital-Bed Requirements. Table XXIV i n Chapter VII shows t h a t a 10.0% increase i n a l l population groups o f a l l d i s t r i c t s produced an average increase o f i n the Forecast Hospital-Bed Requirements.  9.9%  This s l i g h t d i f f e r e n c e i s  a t t r i b u t a b l e to"rounding"in the conversion o f Net Demand i n patient-days to equivalent hospital-beds. The computer f o r e c a s t i n g program does not g r e a t l y a s s i s t i n t h i s a n a l y s i s as the e f f e c t s o f a general population increase can be c a l c u l a t e d manually w i t h l e s s complication. B.  INCIDENCE RATES An equal percentage increase i n a l l Incidence Rates o f H o s p i t a l i z -  a t i o n should produce an equivalent increase i n the f o r e c a s t o f H o s p i t a l Bed Requirements f o r the same reason s t a t e d i n the previous s e c t i o n .  The  a n a l y s i s , described i n Chapter V I I , of the e f f e c t s o f a 10% increase i n  89, the Incidence Rates revealed t h a t these e f f e c t s were i d e n t i c a l t o the e f f e c t s o f the 10% population increase. As i n the population a n a l y s i s , the computer f o r e c a s t i n g program does not g r e a t l y a s s i s t i n the a n a l y s i s o f the e f f e c t s o f general Incidence Rate changes.  However, the program can a s s i s t i n t h e a n a l y s i s o f d i f f e r -  e n t i a l changes i n Population and Incidence Rates as discussed under the Sensitivity Analysis. C.  INFLOW Table XXV i n Chapter V I I shows the e f f e c t s o f a 10% decrease i n  the Inflow patient-days t o the G.V.R.H.D.  Since the Inflow Transfer Vector  (Standard) d i s t r i b u t e s 75% o f the G.V.R.H.D.'s Inflow t o Vancouver's s p e c i a l i z e d h o s p i t a l s e r v i c e s , i t was expected t h a t 75% o f the r e d u c t i o n i n Inflow would occur i n Vancouver.  I n f a c t , Vancouver's Forecast H o s p i t a l -  Bed Requirements were reduced by 56 beds o r 75% o f the t o t a l 74 bed reduction that r e s u l t e d from the 10% decrease i n Inflow. Although the e f f e c t s o f changes i n Inflow are completely p r e d i c t able i n t h i s f o r e c a s t i n g method, the computer f o r e c a s t i n g program does produce an a l t e r n a t e f o r e c a s t q u i c k l y and, "thus, can a s s i s t t h e p o l i c y analyst. D.  TRANSFER MATRIX I f the G.V.R.H.D. were t o e s t a b l i s h a p o l i c y t h a t 80% o f a  d i s t r i c t ' s Gross Demand should be s e r v i c e d i n l o c a l community h o s p i t a l s (see Chapter I I I f o r Ontario's p o l i c y ) , then a t h e o r e t i c a l Transfer M a t r i x could be used t o f o r e c a s t the e f f e c t s o f t h i s p o l i c y .  The Transfer M a t r i x  described i n Chapter VII was developed t o r e f l e c t such a p o l i c y and was used t o produce the p o l i c y f o r e c a s t l i s t e d i n Table XXVI i n Chapter V I I .  90.  This p o l i c y would d r a m a t i c a l l y s h i f t the d i s t r i b u t i o n o f h o s p i t a l f a c i l i t i e s from Vancouver and New Westminster t o the surrounding d i s t r i c t s . Once provided w i t h t h i s information, the p o l i c y maker must then weigh the s o c i a l b e n e f i t s o f the p o l i c y against the c o s t s .  For example,  New Westminster's r e v i s e d Forecast Hospital-Bed Requirement i s 40% below the Standard Forecast and a l s o 40% below B.C.H.P.'s proposal f o r t h i s district.  The s o c i a l b e n e f i t s would have t o be high to balance the high  c o s t o f the abandoned o r u n d e r u t i l i z e d c a p i t a l f a c i l i t i e s t h a t would f o l l o w the implementation o f t h i s p o l i c y . The computer f o r e c a s t i n g program could be a valuable t o o l i n t h i s type o f a n a l y s i s because i t q u i c k l y completes the necessary c a l c u l a t i o n s t o produce f o r e c a s t s t h a t can be used t o analyse the e f f e c t s o f a l t e r n a t e patient d i s t r i b u t i o n s . E.  OCCUPANCY PERCENTAGE As an a l t e r n a t i v e t o the B.C.H.P. "desired" occupancy percentages,  the Poisson method o f accommodating demand f l u c t u a t i o n s was a p p l i e d t o the Forecast Average D a i l y Census o f each G.V.R.H.D. h o s p i t a l .  The r e s u l t s ,  shown i n Table XXVII i n Chapter V I I , i n d i c a t e t h a t such a p o l i c y would increase the Forecast Hospital-Bed Requirements by an average o f 3.9%,  or  200 h o s p i t a l beds. The Poisson method, described i n Chapter V I , accounts f o r  99.7%  o f the demand f l u c t u a t i o n . The c o s t of providing such a h i g h l e v e l o f s e r v i c e a v a i l a b l i t y must be weighed against the h e a l t h costs t o the p a t i e n t o f not having s u f f i c i e n t bed-capacity a v a i l a b l e a t some peak demand occasions.  A l s o , such an a n a l y s i s could i n i t i a t e the i n v e s t i g a t i o n  o f a l t e r n a t e s e r v i c e s t o accommodate peak demand.  91.  I n summary, Table XXX d i s p l a y s the f o r e c a s t s o f H o s p i t a l Bed Requirements that r e s u l t e d from the a l t e r n a t e p o l i c i e s discussed i n Chapter V I . These p o l i c i e s were selected as examples o f p o s s i b l e a p p l i c a t i o n s o f the computer f o r e c a s t i n g program.  The program i s best  s u i t e d t o the a n a l y s i s o f p o l i c i e s which incorporate d i f f e r e n t i a l changes i n the values o f input v a r i a b l e s by age-sex group and by d i s t r i c t .  The  program can q u i c k l y provide the p o l i c y analyst w i t h a f o r e c a s t o f the net e f f e c t o f these p o l i c i e s .  TABLE XXX COMPARISON AMONG THE B.C.H.P. PROPOSAL, THE STANDARD FORECAST, AND THE POLICY FORECASTS OF HOSPITAL-BED REQUIREMENTS  POLICY B INCIDENCE RATES  POLICY D TRANSFER MATRIX  POLICY E OCCUPANCY PERCENTAGE  B.C.H.P. PROPOSAL  STANDARD FORECAST  POLICY A POPULATION  SURREY  416  475  522  522  471  571  504  LADNER  75  0  0  0  0  80  0  RICHMOND  229  172  188  188  172  217  188  VANCOUVER  2,936  3,099  3,407  3,407  3,043  2,798  3,203  NEW WEST.  668  663  729  729  656  400  689  BURNABY  422  306  336  336  306  435  320  75  0  0  0  0  230  0  456  468  516  516  461  458  479  5,277  5,183  5,698  5,698  5,109  5,189  5,383  DISTRICT  COQUITLAM NORTH SHORE  TOTAL  POLICY C INFLOW  93.  CHAPTER IX SUMMARY AND CONCLUSIONS  This t h e s i s has s t u d i e d the h i s t o r y and present a v a i l a b i l i t y o f techniques f o r f o r e c a s t i n g the demand f o r acute-care-hospital beds.  A  computerized f o r e c a s t i n g program was developed, based on the current h o s p i t a l planning method used i n B r i t i s h Columbia, but w i t h some improvements. 1.  The current method o f f o r e c a s t i n g acute-care-bed demand  i n B r i t i s h Columbia does not use many o f the refinements t h a t have been developed and published.  These refinements include the f o l l o w i n g :  a) The separation o f incidence r a t e i n t o both the admission r a t e per 1,000  persons and the length o f h o s p i t a l s t a y f o r d i f f e r e n t ?  diagnostic categories. b) The d i v i s i o n of d i s t r i c t s i n t o homogeneous population groups where p o s s i b l e . c) The r e c o g n i t i o n o f intra-Regional p a t i e n t t r a n s f e r s . d) The r e c o g n i t i o n o f the d i s t r i b u t i o n o f i n f l o w among d i s t r i c t h o s p i t a l s w i t h i n the region. e) The use o f occupancy c r i t e r i a t h a t take account o f the s i z e o f the i n d i v i d u a l h o s p i t a l r a t h e r than applying a set occupancy r a t e t o a l l h o s p i t a l s . f ) The use o f a l t e r n a t e forecasts t o r e f l e c t most l i k e l y and l e a s t l i k e l y estimates o f the p r i n c i p a l v a r i a b l e s . 2.  The current B r i t i s h Columbia technique has been r e f i n e d by  i n c l u d i n g three o f the above aspects:  ( b ) , ( c ) , and ( d ) .  The other improvements noted i n #1 were not incorporated i n t o the f o r e c a s t i n g program, i n order t o conform w i t h my e x p l i c i t d e c i s i o n  94. to match the B.C.H.P. method as much as p o s s i b l e t o focus d i s c u s s i o n on the more important i s s u e o f a Transfer Matrix to accommodate i n t r a - R e g i o n a l patient transfers. 3.  The computerization o f the f o r e c a s t i n g process was e f f e c t i v e  i n that the B.C.H.P. r e s u l t s were reproduced when a n e u t r a l Transfer Matrix was used.  This v a l i d a t i o n confirmed t h a t the Transfer M a t r i x  component was s u c c e s s f u l l y i n t e g r a t e d i n t o the c a l c u l a t i o n sequence without d i s t o r t i n g the f o r e c a s t t o t a l Net Demand f o r h o s p i t a l s e r v i c e s . 4.  The standard f o r e c a s t produced by the computer program was  compared w i t h the B.C.H.P. f o r e c a s t r e v e a l i n g t h a t B.C.H.P.'s best estimated h o s p i t a l bed a l l o c a t i o n v a r i e d considerably from f o r e c a s t requirements based on current p a t i e n t flow patterns.  My use o f  1975  p a t i e n t t r a n s f e r data i s subject to the c r i t i c i s m t h a t i t provides entrenchment o f the status quo, but, since the Standard Forecast  an was  produced t o show what might happen i f present trends continue, and s i n c e the computer program was s p e c i f i c a l l y designed t o use a l t e r n a t e data, I do not b e l i e v e t h a t such c r i t i c i s m i s v a l i d . 5.  The s e n s i t i v i t y o f the technique to changes i n the values o f  input v a r i a b l e s was analysed by comparing the canges i n output (Net Demand f o r h o s p i t a l s e r v i c e s ) to the changes made t o Population Incidence Rates.  and  This a n a l y s i s revealed t h a t the i n d i v i d u a l d i s t r i c t s  have d i f f e r e n t s e n s i t i v i t i e s t o input data changes and t h a t the output o f each d i s t r i c t does not vary i n proportion to the v a r i a t i o n made t o the input data.  This f a c t makes the computer f o r e c a s t i n g program a  valuable t o o l f o r the a n a l y s i s o f the p o s s i b l e e f f e c t s caused by inaccurate population o r incidence r a t e f o r e c a s t s . 6.  Once the computer f o r e c a s t i n g program was t e s t e d and v a l i d a t e d ,  95. i t was a v a i l a b l e t o serve i n the r o l e f o r which i t was policy-analysis tool.  designed:  as a  Since h o s p i t a l planning has been plagued by  the  questionable usefulness of input data, the process o f f o r e c a s t i n g the future demand f o r f a c i l i t i e s has been f r u s t r a t i n g f o r both researchers and p o l i c y analysts.  The computer f o r e c a s t i n g program cannot be used  t o improve the data f e d i n t o i t , but i t can be used t o explore the range of data options, from most l i k e l y to l e a s t l i k e l y , t o give the p o l i c y analyst a range of the p o s s i b l e r e s u l t s to be expected i f an estimate, or p o l i c y d e c i s i o n , proves t o be i n c o r r e c t .  Several a l t e r n a t e p o l i c y  p o s i t i o n s regarding the values of the program's v a r i a b l e s were analysed, w i t h the conclusion t h a t the program i s w e l l s u i t e d f o r the a n a l y s i s o f differential  changes made t o the values of input v a r i a b l e s by age-sex  group and by d i s t r i c t . 7.  I n conclusion, the computer f o r e c a s t i n g program should  now  be improved by i n c o r p o r a t i n g the remainder of the items p r e v i o u s l y noted under  #1.  96.  TRANSFER MATRIX  POPULATION By Age-Sex £ District  FIGURE 1.  OCCUPANCY PERCENTAGE By Age-Sex  FLOW DIAGRAM OF THE COMPUTER FORECASTING PROGRAM  2. Multiply A  DISTRIBUTED GROSS DEMAND ! ! ^ I n Patient-Days Multiply '' Annual by AgeSex £ D i s t r i c t  GROSS DEMAND i n Patient-Days Annual by AgeSex £ D i s t r i c t  ±-  Sum INCIDENCE RATES OF HOSPITALIZATION Annual by Age-Sex £ District HOSPITAL ADMISSION RATES Annual by Age-Sex £ District  >  AVERAGE I LENGTH _1_ _0F STAY M u l t i p l y fc- - In Days per Admission  \ Multiply •  / INFLOW As % o f T o t a l Gross Demand f o r Age-Sex  INFLOW In P a t i e n t ^ D a y s by ' Age-Sex £ Year  T~  Multiply  TRANSFER VECTOR  DISTRIBUTED INFLOW By Age-Sex £ District  NET DEMAND I n Patient-Days by Age-Sex £ District .  4  -aDivide 365 Days  AVERAGE DAILY CENSUS In P a t i e n t - _ ^ Days by AgeSex £ D i s t r i c t  FORECAST HOSPITAL BED REQUIREMENTS-, Divide L>, By AgeSex £ District  B.C.H.P.' Proposal  Compare  BALANCE OF BEDS REQUIRED  97. GLOSSARY Average D a i l y Census  :  The average d a i l y number o f beds t h a t are expected t o be used i n a h o s p i t a l o r group of h o s p i t a l s .  Average Length o f Stay  :  The average l e n g t h o f time i n days t h a t p a t i e n t s r e s i d e i n a h o s p i t a l per admission.  Gross T o t a l Demand f o r Hospital!zation  :  The t o t a l number o f p a t i e n t days consumed by a population group o r s e r v i c e d by a geographical area e x c l u s i v e o f i n f l o w and outflow.  H o s p i t a l Admissions Rate  :  The number o f persons from a population group who a r e admitted t o a h o s p i t a l expressed as the number o f admissions per 1000 persons per year.  Incidence Rate o f Hospitalization  :  The number o f patient-days consumed by a population group, u s u a l l y 1000 persons, per year. The number o f patient-days provided by h o s p i t a l s i n a d i s t r i c t f o r p a t i e n t s whose residence i s not i n t h a t d i s t r i c t .  Inflow  Net T o t a l Demand f o r Hospitali zation  :  The t o t a l number o f p a t i e n t days s e r v i c e d by a geographic area i n c l u s i v e o f i n f l o w and outflow.  Occupancy Percentage  :  The percentage o f a h o s p i t a l ' s t o t a l beds t h a t are being used by p a t i e n t s a t a p o i n t i n time.  Outflow  :  The number o f patient-days provided f o r t h e r e s i d e n t s o f a d i s t r i c t by h o s p i t a l s not i n that d i s t r i c t .  P a t i e n t Day  :  The use o f one h o s p i t a l bed by one p a t i e n t f o r one day.  Relevance Index  :  The p r o p o r t i o n o f a population group's t o t a l number o f p a t i e n t days t h a t are s e r v i c e d a t a specific hospital or i n a specific geographic area.  A district-of-patient-residence by dis1n?ict-of-patient-treatment matrix composed o f Relevance Indices.  99. BIBLIOGRAPHY Literature Cited Abel-Smith, B r i a n .  H o s p i t a l s (May, 1962)  Anderson, D.O. " P a e d i a t r i c Bed Requirements" An unpublished paper produced f o r t h e B r i t i s h Columbia Medical Centre, A p r i l 1974. Anderson, O.W. Health Care: and Sons, 1972.  Can There Be Equity?  New York: John Wiley  B a i l e y , Norman T.J. and Mark Thompson, eds. Systems Aspects o f Health Planning. Oxford: North Holland P u b l i s h i n g Company Amsterdam, 1975. Bergwall, D.F., P.N. Reeves and N.B. Woodside. I n t r o d u c t i o n t o Health Planning. Washington: Information Resources P r e s s , 1974. Blumberg, M.S. "'DPF Concept' Helps P r e d i c t Bed Needs." 97 (6) December 1961. Brown, R.E. i n Medicare and the H o s p i t a l s , H.M. The Brookings I n s t i t u t e , 1967.  Modern H o s p i t a l  and A.R. Somers.  Washington:  Commission on H o s p i t a l Care. H o s p i t a l Care i n the United States. New York: Commonwealth Fund, 1947. Economic C o u n c i l o f Canada. Seventh Annual Review Patterns o f Growth. Ottawa: Queen's P r i n t e r f o r Canada, 1970. Ensminger, Barry. The E i g h t B i l l i o n D o l l a r H o s p i t a l Bed Overrun. Washington! P u b l i c C i t i z e n s ' Health Research Group, 1975. Godber, S i r George. "Health Planning i n Great B r i t a i n . " i n Regional H o s p i t a l Planning, Malcolm T o t t i e and Bengt Janzen, eds. Stockholm: N a t i o n a l Board o f Health, 1967, G o t t l i e b , S.R. "A B r i e f H i s t o r y o f Health Planning i n the United States." i n Regulating Health F a c i l i t i e s Construction, C C . Havighurst, ed. Washington: American E n t e r p r i s e I n s t i t u t e f o r P u b l i c P o l i c y Research, 1974. G r i f f i t h , John R. Q u a n t i t a t i v e Techniques f o r H o s p i t a l Planning and C o n t r o l . Lexington, Mass.: Lexington Books, 1972. Grigg, Naomi I . and G l o r i a E. Whelen. A Study o f the Bed Requirements f o r Acute Care i n Lower Fraser V a l l e y H o s p i t a l Region. V i c t o r i a : B.C. Dept. o f Health and Welfare, 1954. Hamilton, James A. and Assoc. A H o s p i t a l Plan and a P r o f e s s i o n a l Educational Programme f o r the Province o f B r i t i s h Columbia, Canada. Minneapolis, 1949. H i l l , D.R.  "Planning Model Found F a u l t y . " H o s p i t a l s (December 16, 1971)  100. Hoge, V.M. " H o s p i t a l Bed Needs." Canadian J o u r n a l o f P u b l i c Health 49 (1) 1-8. (January, 1958T! Hudenburg, Roy. 1967.  Planning the Community H o s p i t a l .  New York:  McGraw-Hill,  Johnstone, D.K. "The Concept and D e f i n i t i o n of An I n d i v i d u a l H o s p i t a l Geographic Service Area." Major Report Submitted t o F a c u l t y o f Department o f Health Care A d m i n i s t r a t i o n o f the School o f Government and Business Administration. George Washington U n i v e r s i t y , 1971. M a r t i n , Joseph R. Comprehensive Health Planning: A n a l y t i c Concepts. Blue Cross A s s o c i a t i o n , 1975. May, J . J o e l . Health Planning: I t s Past and P o t e n t i a l . U n i v e r s i t y o f Chicago, 1967. " W i l l T h i r d Generation Planning Succeed?" March 1976, p. 60. Melum, Mara M. Assessing the Need f o r H o s p i t a l Beds. InterStudy, 1975.  Chicago: H o s p i t a l Progress  Minneapolis:  N a t i o n a l Health S e r v i c e . The H o s p i t a l B u i l d i n g Program. Majesty's S t a t i o n e r y O f f i c e , 1966.  London:  Her  Newhouse, J.P. 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APPENDIX A COMPUTER FORECASTING PROGRAM  10 ! 20 ! 30 ! 40 ! 50 ! 60 70 ! 80 90 1 100 110 120 130 140 150 160 170 i 180 i 190 i 200  T I ( 9)  210 220 230 240 250 260 270 280 290 300 310 320 330 340 350 360 370 380 390 400 410 420 430 440 450 460 470 480 490 500 510 520 530 540 550 560 570 580 590 600 610 620 630  i  ********************************************************************  *** A PROGRAM TO FORECAST ACUTE CARE HOSPITAL BEDS I N THE GVRHD *** *************************************** KILL  'BEDS'  K I L L 'SUM'  ! CLEAR PREVIOUS RUN'S PRINT OUTPUT F I L E ! CLEAR PREVIOUS RUN'S SUMMARY F I L E .  C1% = 0  ! I N I T I A L I Z E THE RUN COUNTER.  OPEN  'BEDS' AS F I L E 1%  ! OPEN OUTPUT F I L E  OPEN  'SUM' FOR OUTPUT AS F I L E 9%  L SUM INDIVIDUAL RUNS ON DISK F I L E .  MAT READ  A$,B$,Al$  (DISK) FOR PRINTING.  ! READ AREA T I T L E S .  *** DIMENSION THE VIRTUAL ARRAYS ON DISK *** DIM # 9 , U 0 ( 9 ) , U 3 % ( 9 ) , U 4 % ( 9 ) , U 5 % ( 9 ) , V 0 ( 9 ) , V 1 ( 9 ) , V 1 % ( 9 ) , V 2 % ( 9 ) , V 3 % ( 9 ) , ,T2(9) ,T5%(9) ,T7(9) ,T9(9) ,X(9,9) ,Y(9 ,9) I F K%=5 GO TO 600 * * * I N I T I A L I Z E THE VIRTUAL ARRAYS *** MAT MAT MAT MAT MAT  T1=ZER T2=ZER T5%=ZER T7=ZER T9=ZER  ! i ! ! !  SUM SUM SUM SUM SUM  OF OF OF OF OF  POPULATION BY AREA. PATIENT DAYS BY AREA. INCIDENCE RATE BY AREA. NET PATIENT DAYS BY AREA. INFLOW PATIENT DAYS BY AREA.  MAT MAT MAT MAT  U0=ZER U3%=ZER U4%=ZER U5%=ZER  I I ! i  SUM SUM SUM SUM  OF OF OF OF  INFLOW RATE BED NEED BY BEDS.NEEDED BED BALANCE  MAT MAT MAT MAT MAT  V0=ZER V1=ZER V1%=ZER V2%=ZER V3%=ZER  . . . . .  SUM SUM SUM SUM SUM  OF OF OF OF OF  OUTFLOW DAYS BY AREA. OUTFLOW AS A % BY AREA. PLANNED BEDS BY REGROUPED AREA. NEEDED BEDS BY REGROUPED AREA. BED BALANCE BY REGROUPED AREA.  MAT X=ZER MAT Y=ZER  AS A % BY AREA. AREA. BY AREA. BY AREA.  . SUM OF PATIENT DAYS IN AREA TO AREA MATRI SUM OF PATIENT DAY % DISTRIBUTION MATRIX.  I F K%=5 GO TO 600 PRINT ! MESSAGE FOR USER ON TERMINAL, PRINT 'ANOTHER FORECAST SEQUENCE HAS STARTED. PRINT ' ': PRINT ' ' 1  ***  INSTRUCTIONS FROM TERMINAL  ** *  INPUT ' I F THIS I S A MATERNITY FORECAST, TYPE I N THE WORD YES',M$ I F M$='YES' GO TO 600 : PRINT ' ' INPUT ' I F THIS I S AN ADULT FORECAST, TYPE I N THE WORD YES',A$ PRINT ' 1  INPUT 'WHAT I S THE T I T L E OF THIS FORECAST INPUT 'DATE PREPARED  ' ,C$ ,L$ 1  \J  -> v/  m  r  u  i  * v n x * ~ u  r  u  r  u  u  f  i  n  u  i  i  r w i M j ^ n o j .  u o & L J  '  660 INPUT WHICH TRANSFER MATRIX USED ,F$ 670 INPUT 'WHICH PLANNED BED TOTALS USED ',G$ 680 INPUT ANY COMMENTS TO ADD ',H$ 690 INPUT ANY MORE COMMENTS TO ADD ' K$ 700 INPUT 'LAST CHANCE FOR COMMENTS ',J$ •710! 715 I F K%=5 GO TO 5360 720 PRINT ' 730 ! 740 , INPUT NAME OF INCIDENCE RATE DATA F I L E TO BE USED ';R$ 750 INPUT NAME OF POPULATION DATA F I L E TO BE USED ';P$ 760 INPUT NAME OF PLANNED BEDS DATA F I L E TO BE USED ';B1$ 770 INPUT NAME OF OUTFLOW RATE DATA F I L E TO BE USED * ;0$ 780 INPUT NAME OF TRANSFER MATRIX DATA F I L E TO BE USED ' ;T$ 790 INPUT NAME OF INFLOW DISTRIBUTION F I L E TO BE USED ' ;I$ 800 INPUT 'INFLOW RATE AS A % GVRHD RESIDENT VOLUME ' ,L 810 PRINT ' ' 820 PRINT 'STANDARD OCCUPANCY RATES: PAEDS = .85 MAT = .80 ADULT = .90' 830 PRINT ' ' 840 INPUT 'WHICH OCCUPANCY RATE TO BE USED ',01 850 PRINT ' ' 860 ! 870 OPEN R$ FOR INPUT AS F I L E 2% ! DESIGNATE DISK DATA F I L E FOR INPUT. 880 OPEN P$ FOR INPUT A3 F I L E 3% 890 OPEN B l $ FOR INPUT AS F I L E 4% 900 OPEN 0$ FOR INPUT AS F I L E 5% 910 OPEN T$ FOR INPUT AS F I L E 6% 920 OPEN 1$ FOR INPUT AS F I L E 8% 930 ! 9401 950! *** DIMENSION THE ARRAYS *** 960! 970 ! 980 DIM #2%, R ( 9 ) ! INCIDENCE RATES PER 1000 POPULATION. 990 DIM #3%, P ( 9 ) ! POPULATION IN THOUSANDS. 1000 DIM #4%, B ( 9 ) ! PLANNED BEDS BY AREA. 1010 DIM #5%, C ( 9 ) ! OUTFLOW BY AREA AS % AREA TOTAL VOLUME. 1020 DIM #6%, T ( 9 , 9 ) ! INTERNAL GVRHD TRANSFERS AS % AREA VOLUME. 1030 DIM #8%, F ( 9 ) ! INFLOW DISTRIBUTION AS % TOTAL INFLOW. 1040 ! 1050 DIM D ( 9 ) ! PATIENT DAYS. 1060 DIM D l ( 9 ) ! NET PATIENT DAYS. 1070 DIM G l % ( 4 ) ! REGROUPING OF PLANNED BEDS. 1080 DIM G2%(4) ! REGROUPING OF NEEDED BEDS. 1090 DIM B % ( 9 ) ! NET BED REQUIREMENT. 1100 DIM X % ( 9 ) ! NEEDED BEDS BY AREA. 1110 DIM B$(4) ! NAMES OF AREA GROUPS. 1120 DIM A l $ ( 9 ) ! ABBREVIATION OF AREA NAMES. 1130 DIM A $ ( 9 ) ! NAMES OF AREAS. 1140 DIM P 9 ( 9 ) ! CORRECTION FOR MATERNITY POPULATION COUNT. 1150 DIM X 9 ( 9 ) ! SUM OF MATRIX PERCENTAGES BY AREA. 1160 DIM X 8 ( 9 ) ! SUM OF ACCUMULATED MATRIX PERCENTAGES BY AREA. 1170 ! 1190 ! 1200 ! 1210! 1220! *** CALCULATION OF PATIENT DAYS *** 1230! 1240 ! 1250 RESTORE ! RECYCLE DATA FOR THE NEXT READ STATEMENT. 1260 ! 1270 FOR 1=1 TO 9 1280 D(I)=R(I)*P(I) ! PATIENT DAYS=INCIDENCE RATE X POPULATION. 1290 31=S1+D(I) ! TOTAL OF PATIENT DAYS. 1  1  1 1  f  1  1  1  1  1 1  1  1310 1320 1330 1340 1350 1360 1370 1380 1390 1400 1410 1420 1430 1440 1450 1460 1470 1480 1490 1500 1510 1520 1530 1540 1550 1560 1570 1580 1590 1600 1610 1620 1630 1640 1650 1660 1670 1680 1690 1700 1710 1720 1730 1740 1750 1760 1770 1780 1790 1800 1810 1820 1830 1840 1850 1860 1870 1880 1890 1900 1910 1920 1930 1940 1950  !  SUM FOR TOTAL POPULATION BY AREA. SUM FOR TOTAL PATIENT DAYS BY AREA. SUM FOR TOTAL PATIENT DAYS GVRHD. SUM FOR TOTAL GVRHD POPULATION. CUMULATIVE INCIDENCE RATE BY AREA.  TI(I)=T1 (I)+P(I) T2 ( I ) = T 2 ( I ) + D ( I ) T3 =T3+D(I) T4 =T4+P(I) T5%(I)=T2(I)/T1(I) NEXT I ! ! !  ! !  ! ! ! ! ! !  1 i !  ! ! ! ! ! ! ! ! !  !  ! AVERAGE INCIDENCE RATE FOR THIS AGE GROUP,  R%=R%+S1/P2 I F M$ <>  1  YES  1  ! AVOID DOUBLE MATERNITY COUNT I N SUMMARY.  GO TO 1480  FOR J = l TO 9 P9 ( J ) = P ( J ) P9=P9+P(J) NEXT J IF P 9 O 0  AND A$='YES' GO TO 1510  GO TO 1560 FOR 1=1 TO 9 Tl(I)=T1(I)-P9(I) NEXT I  ! SUBTRACT MATERNITY DOUBLE COUNT.  T4=T4-P9 T6%=T3/T4  ! SUMMARY INCIDENCE RATE  * * * INTERNAL GVRHD TRANSFERS * * *  FOR 1=1 TO 9 : FOR J = l TO 9 DI(J)=D1 (J)+T(I,J)*D(I) X(I,J)=X(I,J) + (T(I,J)*D(I) ) Y(I,J)=X(I,J)/T2(I)  ! AN AREA'S PATIENT DAYS = TRANSFERS TO I T . ! CUMULATIVE PATIENT DAYS IN TRANSFER MATRIX, ! CUMULATIVE TRANSFER MATRIX IN PERCENTAGES.  X9(I)=X9(I)+T(I,J) X8(I)=X8(I)+Y(I,J)  ! SUM OF MATRIX PERCENTAGES. f SUM OF ACCUMULATED MATRIX PERCENTAGES.  NEXT J ACCUMULATED OUTFLOW DAYS BY AREA. ACCUMULATED OUTFLOW AS A % BY AREA. SUM OF OUTFLOW PATIENT DAYS. SUM OF MATRIX PERCENTAGES + OUTFLOW. SUM OF ACCUMULATED MATRIX PERCENTAGES + OUTFLOW,  V0(I)=V0(I) + (C(I)*D(I) ) V I ( I ) =V0 ( I ) /T2 ( I ) X7=X7+(C(I)*D(I)) X9(I)=X9(I)+C(I) X8(I)=X8(I)+V1(I) NEXT I  ACCUMULATED  TOTAL OUTFLOW PATIENT DAYS,  X6=X6+X7  i  DI(3)=D1(3)+D1(2) DI (2)=0 .  ! DELTA ADJUSTMENT WHEN NEUTRAL MATRIX USED, ! NORTH DELTA CAN'T RECEIVE PATIENTS.  ***  CALCULATION FOR INFLOW  ***  T2=S1*L T=T+T2  ! INFLOW PATIENT DAYS FROM THIS AGE GROUP, I CUMULATIVE SUM OF INFLOW PATIENT DAYS.  FOR 1=1 TO 9 D1(I)=D1(I)+T2*F(I) D2=D2+D1(I)  1 ADD INFLOW FROM OUTSIDE THE GVRHD. ! SUM OF TOTAL PATIENT DAYS.  ±  V  I  u  1980 1990 2000 ! 2010 2020 ! 2030 2040 2050 2060 ! 2070 ! 2080 ! 2090 ! 3000 ! 3020 ! 3030 3040 3050 3060 3070 3080 3090 ! 3450 ! 4000 4010 4020 4030 4040 4050 4060 ! 4070 4075 ! 4080 4090 ! 5000 ! 5010 ! 5020 ! 5030 5040 5050 5060 5070 ! 5080 5090 5100 5110 5120 ! 5130 5140 5150 5160 ! 5170 5180 5190 5200 5210 5220 5230 5240 5250 ! 5260 5270 ! 5280 5290 5300  autn u r i u x a b f f l i x c N i u f t i a U N i n n U CUMULATIVE INFLOW BY AREA. PERCENT TOTAL INFLOW TO EACH AREA.  I O - I O t U l \ 1 J  T9 ( I ) = T 9 (I) + ( T 2 * F ( I ) ) U0(I)=T9(I)/T  V M U ,  NEXT I B%=T2/ (365*01) U1=U1+B% U2=T/T3  INFLOW AS BEDS. TOTAL INFLOW AS BEDS. OVERALL INFLOW RATE AS  GVRHD DAYS.  *** BED NEED CALCULATIONS ***  FOR J = l TO 9 X%(J)=D1(J)/(365*01)+0 , B%(J)=B(J)-X%(J) A%=A%+B(J) C%=C%+X%(J) D%=D%+B%(J)  BED NEED = DAYS/OCCUPANCY RATE. BALANCE = PLANNED BEDS - NEEDED BEDS SUM OF PLANNED BEDS. SUM OF NEEDED BEDS. ! NET BED BALANCE,  U3% (J)=U3 % ( J ) + X % ( J ) U4%(J)=U4%(J)+B(J) U5% (J) =U5% (J) +B% (J) U6%=U6%+B(J) U7%=U7%+X%(J) U3%=U3%+8%(J)  ! ! ! ! ! !  ACCUMULATION ACCUMULATION ACCUMULATION ACCUMULATION ACCUMULATION ACCUMULATION  ! ! ! !  NORTH = CENTRAL SOUTH = EAST =  OF OF OF OF OF OF  BED NEED BY AREA. PLANNED BEDS BY AREA. BED BALANCES BY AREA. TOTAL BEDS. NEEDED BEDS. BED BALANCE.  NEXT J GO TO 5360 ***  REGROUP THE GEOGRAPHIC AREAS  Gl% Gl% Gl% Gl%  (1) =3(9) (2) = B ( 5 ) + B ( 7 ) (3) =B(3)+B(4) (4) = B(1)+B(2)+B(6)+B(8) G2% (1) G2% (2) = X%(9) G 2 % ( 3 ) =X% (5)+X% (7) G 2 % ( 4 ) = X% (3) +X% (4) = X% (1) +X% (2) +X% (6) +X% (8) A% = 0. C% = 0 . D% = 0 . FOR J = l TO 4 B% ( J ) = G 1 % ( J ) - G 2 % ( J ) A%=A%+G1%(J) C%=C%+G2%(J) D%=D%+B%(J) V l % (J) =V1% (J) +G1% ( J ) V2%(J)=V2%(J)+G2%(J) V3%(J)=V3 %(J)+B%(J)  *** NORTH SHORE. - VANCOUVER + BURNABY LADNER + RICHMOND. SURREY + WHITE ROCK + N DELTA + NEW WEST + COQUITLAM,  ! REGROUP NEEDED BEDS.  ! RESET TOTALS TO ZERO.  ! ! ! ! ! ! !  BED BALANCE. TOTAL PLANNED BEDS. TOTAL NEEDED BEDS. NET BED BALANCE. ACCUMULATE PLANNED BEDS, ACCUMULATE NEEDED BEDS. ACCUMULATE BED BALANCE.  NEXT J V4%=V4%+A% V5%=V5%+C% V6%=V6%+D%  ! ACCUMULATE TOTAL PLANNED BEDS, ! ACCUMULATE TOTAL NEEDED 3EDS. ! ACCUMULATE TOTAL BED BALANCE.  - ) -> J .  J  5320 ! 5330 ! 5340 ! 5350 ! 5360 5370 5380 5390 ! 5400 5410 5420 5430 5440 5450 5460 5470 5480 5490 5500 5510 5520 5530 5540 5550 5560 5570 5580 5590 5600 5610 5620 5630 5640 5650 5660 5670 5680 ! 5690 5700 5710 5720 ! 5730 5740 5750 ! 5760 5770! 5790 ! 5800 5810 5820 5830 5840 5850 5860 5865 ! 5866 5870 5880 5890 5900 5910 5920 5930 5940  Vj'vJ  l'U  ***  / ± u  u  PRINT SEQUENCE  ***  FOR 1 = 1 TO 14 PRINT #1, NEXT I PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT  #1, ' #1, #1, ' #1, ' #1, #1, ' #1, ' #1, #1, ' #1, #1, ' #1, #1, ' #1, #1, ' #1, #1,' #1, #1, ' #1, #1, #1/ #1, #1, ' #1, #1, ' #1, #1, '  ************************i  FORECAST OF GVRHD' ACUTE CARE HOSPITAL BEDS' •  ,c$ ************************i  DATA USED:' INCIDENCE RATE :',D$ POPULATION  :',E$  TRANSFER MATRIX:',F$ PLANNED BEDS  :',G$  **************************  REMARKS :' i ,H$ i ,K$ i ,J$  FOR 1 =1 TO 13 PRINT #1, NEXT I PRINT #1, ' PRINT #1, '  DATE PREPARED :',L$ *************'  PRINT #1, CHR$(12%) PRINT PRINT PRINT PRINT PRINT PRINT PRINT  #1,  ! S K I P TO A NEW  | ]_, * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * #1,' * * * ASSUMPTIONS USED I N THE FORECAST OF AC #1, * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 1  1  #1, : PRINT #1,: PRINT #1, #1,' AREA , * INCIDENCE*, ' POPULATION' , OWN DAYS' , ' #1,' * ** * i * * * * * * * * * i 1 * * * * * * * * * * 1 1 * * * * * * * * 1 i  I F K%=5 GO TO 7960 PRINT #1, FOR 1 = 1 TO 9 PRINT #1 ,USING * \ PRINT #1 ,USING #### PRINT #1 ,USING ' ####### PRINT #1,USING '######£ PRINT #1,USING '######* PRINT #1,  1  V  ,A$ ( I ) ; ',R(I) ; ' ,P(I)*1000 . ; ' ,D(I) ; ' ,D1 ( I )  5970 5980 5990 6000 6010 6020 6030 6040 ! 6050 6060 6070 6080 6090 6100 6110 6120 6130 6140 6150 6160 6170 6180 6190 ! 6200 6210 6220 6230 6240 6250 6260 6270 6280 6290 ! 6300 6310 6320 6330 ! 6340 6350 6360 63 70 6380 6390 6400 6410 6420 6430 I 6435 6440! 6450 6460 6470 6480 ! 6490 6500 6510 6520 6530! 6540 6550 6560 6570 6580 6590  PRINT PRINT PRINT PRINT PRINT PRINT PRINT  # 1 , : PRINT #1, #l,'TOTALS #1 ,USING ' #### ' ,R%; #1,USING ' ###&### ',P2*1000.; #1,USING '######* ' ,S1; #1,USING '####### ' ,D2 #1,: PRINT #1,: PRINT #1,  PRINT #1, *********************** PRINT #1,'TRANSFER MATRIX ASSUMED' PRINT #1 '***********************' PRINT #1,' PRINT #1,'PATIENT PRINT #1,"ORIGIN' PRINT #1, ******* PRINT #1, PRINT #1,* ' ; FOR K = l TO 9 PRINT #1,USING ' \\ ',A1$(K); NEXT K PRINT #1,' OUT TOTAL' PRINT #1, 1  1  1  FOR 1=1 TO 9 PRINT #1,USING FOR J = l TO 9 PRINT #1,USING NEXT J PRINT #1,USING PRINT #1,USING PRINT #1, NEXT I  '\ '.###  AREA OF HOSPITAL TREATMENT **************************'  \',A$(I); ',T(I,J);  '.###', C ( I ) ; ' #.###',X9(I)  FOR K = l TO 8 PRINT #1, NEXT K PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT  #1,'INFLOW ASSUMED #1, USING ' ##.#',L*100 . ; #1,' % OR AS BEDS: B% #1,' **************' #1, #1,'OUTFLOW ASSUMED '; #1, USING ' ## .#' ,X7/S1*100.; #1,' % OR AS BEDS: #1, USING ' ### ' , X 7 / ( 3 6 5 . * 0 1 )  PRINT #1  •***************'  FOR K = l TO 5 PRINT #1, NEXT K PRINT # 1 D I S T R I B U T I O N OF INFLOW PRINT #1,'BY AREA (PERCENTAGE) PRINT ft\ ***********************' PRINT #1, 1  1  r  I F K%=5 GO TO 8550 FOR 1=1 TO 9 F1%=F1%+(F(I)*1000.) PRINT #1, USING '\ \',A$(I); PRINT #1, USING ###.#',F(I)*100 NEXT I 1  1  O U i U  6620 6630 6640 ! 6650 6680 ! 6690 6700 6710 6720 6730 ! 6740 6750 ! 6760 67 70 6780 6790 ! 6800 6810! 6820 6825 6828 6830 6840 6850 6855! 68 56 6857 ! 6860 6870 6380 6890 6900 6910 6920 6930 ! 6940 6950 6960 6970 ! 6980 6990 ! 7000 7010 7020 7030 7040 7050 70 60 7070 ! 7080 7090 7095! 7100 7200 7210 7220 7230 ! 7240 7250 7260 7270 7280 7290 7300  f K 1 N X ff X ,  PRINT #1,'TOTAL '; PRINT #1, USING '###.#',F1%/10 FOR J = l TO 6 : PRINT #1, : NEXT J PRINT #1, OCCUPANCY RATE ASSUMED PRINT #1, '**********************' PRINT #1, 1  1  PRINT #1, PAEDIATRICS - 85% :  MATERNITY - 80% :  1  ADULT - 9 0 % '  I F K%=5 GO TO 3660 PRINT #1, PRINT #1,'THE OCCUPANCY RATE FOR THIS FORECAST I S ' ; PRINT #1,01*100;'%' PRINT #1, CHR$(12%) PRINT PRINT PRINT PRINT PRINT PRINT  #1 , ***************************************** ' #1,'***** GVRHD BED NEED FORECAST BY AREA *****' #1 , *********************************************' #1, #1,'AREA','PLANNED BEDS','NEEDED BEDS','BALANCE' #1, '****' '*************' <***********• >*******< 1  1  f  I F K%=5 GO TO 8860 PRINT #1, PRINT #1, A $ ( 1 ) , B ( 1 ) , X % ( 1 ) , B % ( 1 ) PRINT #1, FOR 1=3 TO 9 PRINT #1, A$ (I) , B ( I ) , X % ( I ) , B % ( I ) PRINT #1, NEXT I  ! PRINT SURREY'S NEEDS. ! PRINT OTHER AREAS' NEEDS  PRINT t l , '************' •*****' •*******' <*******• PRINT #1, PRINT #1,'TOTALS',A%,C%,D% FOR J = l TO 6 : PRINT #1, : NEXT J PRINT PRINT PRINT PRINT PRINT PRINT PRINT  #1, ' ********************************************************' #1,'***** GVRHD BED NEED FORECAST BY REGROUPED AREAS *****' #1 , ' ********************************************************' #1, #1,'AREA','PLANNED BEDS','NEEDED BEDS','BALANCE' #1, '****' , '*************' ^'***********• <*******> #1, f  I F K%=5 GO TO 8990 GO TO 5030 FOR K = l TO 4 PRINT #1, B $ ( K ) ,G1%(K) ,G2%(K) ,B% (K) PRINT #1, NEXT K PRINT PRINT PRINT PRINT PRINT PRINT PRINT  #1 , ' * * * * * * * * * * * * ' * * * * * ' #1, #1, TOTALS ,A%,C%,D% #1, : PRINT #1, #1,'EXPLANATION OF AREAS' #1 '********************' #l) 1  /  1  1  r  1  * * * * * * * <  i * * * * * * *  1  7330 7340 7350 7360 7370 7380 7390 ! 7400 7410 ! 7420 ! 7430 ! 7440 7450 7460 7470 7480 7490 7500 7510 ! 7520 7530 7540 7550 7560 7570 7580 7590 7600 7610 7620 7630 ! 7640 7650 ! 7660! 7670 ! 7680 7690 7710 7720 7730 7740 7750 ! 7760 7770 ! 7780 7790 7800! 7810 7820 7830 7840 ! 7850 7860 ! 7870 7880 ! 7890 7900 7910 ! 7920 ! 7930 ! 7940 ! 7950 ! 7960 7970  P R I N T ffi,  PRINT PRINT PRINT PRINT PRINT PRINT  #1,'2. CENTRAL = VANCOUVER AND BURNABY. #1, #1,'3. SOUTH = RICHMOND AND LADNER.' #1, #1,'4. EAST = COQUITLAM, NEW WESTMINSTER, NORTH DELTA,' #1,' SURREY AND WHITE ROCK.' 1  I F K%=5 GO TO 9410 *****  RESET TOTALS FOR ANOTHER FORECAST RUN  MAT MAT MAT MAT MAT MAT MAT  D Dl = Gl % = G2 % = B% = X9 = X% =  A% C% D% R% S SI Fl% T2 P2 D2 X7  = = = =  Cl%  = Cl%+1  0 0 0 0 0 0 0 0 0 0 0  = = = =  =  =  *****  *****  Z ER ZER ZER ZER ZER ZER ZER  . . . . . . ! INCREMENT THE COUNTER.  INSTRUCTIONS TO THE USER  *****  PRINT ' ' PRINT RUN #';C1%; I S COMPLETE.' I F K%=6 GO TO 9410 PRINT '' INPUT ' I F YOU WANT TO SUMMARIZE THESE FORECASTS, TYPE I N THE # 5 ',K% PRINT '' 1  ,  I F K%<>5 GO TO 7850 CLOSE 9% OPEN 'SUM' FOR INPUT AS F I L E 9% PRINT 'GIVE THE FOLLOWING PRINT ' ' GO TO 200  ! CLOSE THE SUMMARY F I L E FOR OUTPUT. ! OPEN THE SUMMARY F I L E FOR INPUT.  INFORMATION FOR THE SUMMARY RUN:'  INPUT ' I F YOU WANT TO STOP NOW, TYPE I N THE # 6 MAT X8 = ZER  ',K1%  ! I F ANOTHER RUN HAS STARTED, RESET ACCUMULATED P%,  I F K l % = 6 GO TO 9410 GO TO 49 0 ******************************************************  ***** PRINT SEQUENCE FOR THE SUMMARY FORECAST ***** ****************************************************** FOR K = l TO 9 PRINT #1, USING  V  ,A$ (K) ?  IWK)  fK1WT  8000 8010 8020 8030 8040! 8050 80 60 8070 8080 8090 8100 8110 8120 8130 8140 8150 8160 8170 8180 8190 ! 8200 8210 8220 82 30 8240 ! 82 50 8260 8270 ! 8280 8290 8300 8310 8320 8330 8340 8350 8360 8370 ! 8380 8390 8400 8410 ! 84 20 8430 8440 8450 8460 8470 8480 8490 8500 8 510 8520! 8530 8540! 8550 8560 8570 8580 8590 8600 ! 8610 8620 8630  PRINT #1, USING PRINT #1, USING PRINT #1, NEXT K  ffi,  UOllNSj  •  fffffffff-ffff  •, T 1 ( K )  '####### '#######  "1UUU. ;  ',T2(K); ' ,T7(K)  PRINT #1, : PRINT #1, : PRINT #1, PRINT #1, 'TOTALS '; PRINT #1, USING ' #### ',T6%; PRINT #1, USING ' ####### ',T4*1Q00.; PRINT #1, USING '####### ,T3; PRINT #1, USING '####### ' ,T8 FOR K = l TO 3 : PRINT #1, : NEXT K PRINT #1, 'TRANSFER MATRIX ASSUMED PRINT #1 '***********************' PRINT # l ' PRINT #1, 'PATIENT AREA OF HOSPITAL TREATMENT PRINT #1, 'ORIGIN' PRINT #1 '******* **************************i PRINT %l\ 1  1  1  PRINT #1, ' FOR 1=1 TO 9 PRINT #1, USING NEXT I  ' \\  PRINT #1, ' OUT PRINT #1, FOR 1=1 TO 9 PRINT #1, USING FOR J = l TO 9 PRINT #1, USING NEXT J PRINT #1, USING PRINT #1, USING PRINT #1, NEXT I  *,Al$(I);  TOTAL'  '\  \',A$(I);  '.###  ' ,Y(I,J);  '.###',VI(I); * #.###',X8(I)  FOR K = l TO 8 PRINT #1, NEXT K PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT  #1, 'INFLOW ASSUMED '; #1, USING '##.#',U2*100 . ; #1, ' % OR AS BEDS: ';U1 #1, '**************' #1, #1, 'OUTFLOW ASSUMED '; #1, USING ' ## . # ' ,X6/T3*100.; #1, ' % OR AS BEDS: '; #1, USING ' ### ,X6/(T3/U7%) #1 "***************' 1  GO TO 6450 FOR K = l TO 9 F2%=F2%+(U0 (K)*10000 . + .5) ! SUM INFLOW PERCENTAGES. PRINT #1, USING '\ \',A$(K); PRINT #1, USING '###.#' , U 0 ( K ) * 1 0 0 . + .0005 NEXT K PRINT #1, PRINT #1,'TOTAL '; PRINT #1, USING '###.#',F2%/l00  tfb^U I  8660 8670 8680 8690 8700 1 8710 8720 ! 8730 87 40 8750 8760 8765 8770 8775 8780 8790 8800 8810 8820 8830 i 8840 8850 ! 8860 8870 8880 ! 8890 8900 8910 8920 8930! 8940 8950 8960 8970 8980 ! 8990 9000 9010 9020 9030 9040 9050 9060 ,9070 ! 9080 ! 9090 !  PRINT PRINT PRINT PRINT  #1, #1, 'THE AVERAGE OCCUPANCY RATE FOR THIS FORECAST I S : #1, USING ' # # . # ' , ( T 8 / ( U 7 % * 3 6 5 . ) ) * 1 0 0 . ; #1, '%'  FOR K = l TO 8 : PRINT #1, : NEXT K PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT PRINT  #1, #1, #1, #1, #1, #1, #1, #1, #1, #1, #1,  'PATIENT DAY FLOW S T A T I S T I C S ' '***************************' 'RESIDENT ACUTE PATIENT DAYS: LESS OUTFLOW:  PRINT  #l,USING'######r,T3  PRINT #1,USING'#####«' ,X6  PLUS INFLOW : PRINT #1, 'NET GVRHD PATIENT DAYS :  PRINT #1, 'ACUTE CARE BED REQUIREMENTS:  PRINT  #1,USING'#######',T  PRINT #1,USING'HJI#####' ,T3-X6+T PRINT #1,USING'#######',(T3-X6+T)/(T8/U7%)+.5  GO TO 6800 PRINT #1, A§(1) ,U4% (1) ,U3% (1) ,U5%(1) PRINT #1, FOR J=3 TO 9 PRINT #1, A$ (J) ,U4% (J) , U 3 % ( J ) ,U5%(J) PRINT #1, NEXT J PRINT #1, '************' '***•*" PRINT #1, PRINT #1, 'TOTALS' ,U6%,U7%,U8% GO TO 6980  !*****•*>  FOR K = l TO 4 PRINT # 1 , B $ ( K ) , V 1 % ( K ) , V 2 % ( K ) , V 3 % ( K ) PRINT #1, NEXT K PRINT #1, '************' >*****' <*******< PRINT #1, PRINT #1, 'TOTALS',V4%,V5%,V6% GO TO 9410  * * * * * * * i  •*******>  *** HEADINGS ***  9100 DATA 'SURREY','NORTH DELTA','LADNER','RICHMOND','VANCOUVER', NEW WEST', 'BURNABY' ,'COQUITLAM' ,'NORTH SHORE' 9 2 00 DATA 'NORTH','CENTRAL','SOUTH','EAST' 93 00 DATA ' S','ND',' L',' R',' V'^NW',' B',' C','NS' 9400 ! 9410 PRINT 'THIS FORECAST I S COMPLETE.' : PRINT ' ' 9420 PRINT 'TO PRINT THE RESULTS, RUN $QUE , QLP0:=BED3 9430 PRINT #1, : PRINT #1, 9440 ! 9450 CLOSE 1% 9460 CLOSE 6% 9470 CLOSE 5% 9480 CLOSE 4% 9490 CLOSE 3% 9500 CLOSE 2% 9510 CLOSE 8% 9520 CLOSE 9% 9530 ! 1  103.  APPENDIX B STANDARD FORECAST  *******************  GVRHD FORECAST ACUTE HOSPITAL BEDS TITLE  :  PAEDIATRIC  (0-14) 1981  *********************************************  DATA USED: INCIDENCE RATES:  R001  POPULATION  P001  TRANSFERS  MO 21  PLANNED BEDS  B001  *********************************************  REMARKS:  THIS I S THE STANDARD FORECAST.  DATE P R E P A R E D : *************  1 OCTOBER  *************************************  *** ASSUMPTIONS USED IN FORECAST OF 1981 HOSPITAL BEDS *** **********************************************************  AREA ****  INCIDENCE *********  POPULATION **********  OWN DAYS ********  SURREY  425  36100  15343  13385  NORTH DELTA  350  12400  4340  0  LADNER  350  13400  4690  0  RICHMOND  340  24400  8296  4221  VANCOUVER  375  72000  27000  78788  NEW WEST  475  6500  3088  15722  BURNABY  375  29400  11025  8877  COQUITLAM  330  32150  10610  0  NORTH SHORE  286  33550  9595  8023  TOTALS  361  259900  93986  129016  TOTAL DAYS **********  ***********************  TRANSFER MATRIX ASSUMED *********************** PATIENT ORIGIN *******  AREA OF HOSPITAL  TREATMENT  **************************  S  ND  L  R  V  NW  B  C  NS  OUT  TOTAL  000  1.000  SURREY  .550 .000  .000  ,000  ,250  .150  ,050  , 000 .000  NORTH DELTA  .350 .000  .000  ,100  400  .100  , 050  ,000  . 000  000  1.000  LADNER  .350 .000  .000  ,100  400  .100  ,050  ,000  .000  000  1.000  RICHMOND  .000 .000  .000  ,400  ,550  .000  ,050  .000  .000  000  1.000  VANCOUVER  .000  .0 00  .000  000  900  .000  ,100  000  .000  000  1.000  NEW WEST  .000 .000  .000  000  200  .700  ,050  000  . 000  050  1.000  BURNABY  .000 .000  .000  000  450  ,200  ,350  ,000  .000  000  1.000  COQUITLAM  .000 .000  .000  000  300  ,600  050  ,000  .000  050  1.000  NORTH SHORE  .000 .000  .000  000  350  , 000  000  000  .650  000  1.0.00  INFLOW ASSUMED ************** OUTFLOW ASSUMED ***************  38.0 %  OR AS BEDS:  115  0.7 %  OR AS BEDS:  2  DISTRIBUTION OF INFLOW BY AREA (PERCENTAGE) ********************** SURREY NORTH DELTA LADNER RICHMOND VANCOUVER NEW WEST BURNABY COQUITLAM NORTH SHORE TOTAL  5.0 0.0 0.0 0.0 8 5.0 5.0 0.0 0.0 5.0 10 0.0  OCCUPANCY RATE ASSUMED ********************** PAEDIATRICS - 8 5 % THE OCCUPANCY  :  MATERNITY - 8 0 %  RATE FOR THIS FORECAST IS  :  ADULT - 90% 85 %  ****************************************  ***** GVRHD BED NEED FORECAST FOR 1981 ***** ************************************************* AREA ****  PLANNED  BEDS NEEDED BEDS  *************  ***********  BALANCE *******  SURREY  44  43  1  LADNER  0  0  0  RICHMOND  26  14  12  VANCOUVER  200  254  NEW WEST  55  51  4  BURNABY  37  29  8  COQUITLAM  0  0  0  NORTH SHORE  24  26  -2  ************  TOTALS  *****  *******  386  417  -54  *******  -31  *************************************************  *** GVRHD BED NEED FORECAST FOR 1981 BY AREA '*** **************************************** *'* ******* AREA ****  PLANNED  BEDS NEEDED BEDS  *************  ***********  BALANCE *******  NORTH  24  26  -2  CENTRAL  237  283  -46  SOUTH  26  14  12  EAST  99  94  5  ************ TOTALS  ***** 386  ******* 417  ******* -31  EXPLANATION OF AREAS ******************** 1. NORTH INCLUDES THE NORTH SHORE 2. CENTRAL INCLUDES VANCOUVER AND BURNABY 3. SOUTH INCLUDES RICHMOND AND SOUTH DELTA 4. EAST INCLUDES COQUITLAM, NEW WESTMINSTER, NORTH DELTA, SURREY, AND WHITE ROCK  *******************  GVRHD FORECAST ACUTE HOSPITAL BEDS TITLE  :  MATERNITY  (15-45 FEMALE) 1981  ********************************************* DATA USED: INCIDENCE RATES:  R002  POPULATION  POO2  TRANSFERS  M022  PLANNED BEDS  B002  ********************************************* REMARKS:  THIS I S THE STANDARD FORECAST.  DATE PREPARED: *************  1 OCTOBER  ************************************  *** ASSUMPTIONS USED IN FORECAST OF 1981 HOSPITAL BEDS *** **********************************************************  AREA ** **  INCIDENCE *********  POPULATION **********  OWN DAYS ********  TOTAL DAYS **********  SURREY  400  33350  13340  11923  NORTH DELTA  400  8450  3380  0  LADNER  400  9100  3640  0  RICHMOND  350  21250  7438  7 2 36  VANCOUVER  300  88800  26640  40740  NEW WEST  300  8050  2415  .13378  BURNABY  300  32750  9825  7651  COQUITLAM  325  24400  7930  0  NORTH SHORE  296  32500  9620  10039  TOTALS  325  258650  84228  90966  ***********************  TRANSFER MATRIX ASSUMED *********************** PATIENT ORIGIN *******  AREA OF HOSPITAL  TREATMENT  ************************** S  ND  L  R  V  NW  B  C  NS  OUT  TOTAL  SURREY  .650 .000  000  .050  100  .150  050  ,000  . 000  000  1.000  NORTH DELTA  .350 .000  .000  .300  ,200  .100  ,050  ,000  .000  000  1.000  LADNER  .350 .000  000  .300  ,200  .100  ,050  ,000  .000  000  1.000  RICHMOND  .000 .000  000  .600  ,400  .000  ,000  000  .000  000  1.000  VANCOUVER  .000 .000  000  .000  900  .000  050  000  .050  000  1.000  NEW WEST  .050 .000  000  .000  100  .750  100  000  .000  000  1.000  BURNABY  .000 .000  000  .000  400  .200  400  000  .000  000  1.000  COQUITLAM  .000 .000  000  .000  200  .700  100  000  .000  000  1.000  NORTH SHORE  .000 .000  000  .000  200  ,000  000  000  .800  000  1.000  INFLOW ASSUMED  8.0 %  OR AS BEDS:  23  OUTFLOW ASSUMED  0.0 %  OR AS BEDS:  0  **************  ***************  DISTRIBUTION OF INFLOW BY AREA (PERCENTAGE) ********************** SURREY NORTH DELTA LADNER RICHMOND VANCOUVER NEW WEST BURNABY COQUITLAM NORTH SHORE TOTAL  10 .0 0 .0 0 .0 0 .0 50 0 20 .0 5 0 0 0 15 0 100. 0  OCCUPANCY RATE ASSUMED ********************** PAEDIATRICS - 8 5 % THE OCCUPANCY  :  MATERNITY - 8 0 %  RATE FOR THIS FORECAST I S  :  ADULT - 9 0 % 80 %  ****************************************  ***** GVRHD BED NEED FORECAST FOR 1981 ***** ************************************************* AREA ****  PLANNED BEDS NEEDED BEDS ************* ***********  BALANCE *******  SURREY  50  41  9  LADNER  0  0  0  RICHMOND  30  25  5  VANCOUVER  120  140  -20  NEW WEST  40  46  -6  BURNABY  25  26  -1  COQUITLAM  0  0  NORTH SHORE  32  34  ************  TOTALS  *******  *****  297  312  0 -2 *******  -15  *************************************************  *** GVRHD BED NEED FORECAST FOR 1981 BY AREA *** ************************************************* AREA ****  PLANNED  BEDS NEEDED BEDS  *************  ***********  BALANCE *******  NORTH  32  34  -2  CENTRAL  145  166  -21  SOUTH  30  25  5  EAST  90  87  3  ************  TOTALS  *****  297  *******  312  *******  -15  EXPLANATION OF AREAS ******************** 1. NORTH INCLUDES THE NORTH SHORE 2. CENTRAL INCLUDES VANCOUVER AND BURNABY 3. SOUTH INCLUDES RICHMOND AND SOUTH DELTA 4. EAST INCLUDES COQUITLAM, NEW WESTMINSTER, NORTH DELTA, SURREY, AND WHITE ROCK  *******************  GVRHD FORECAST ACUTE HOSPITAL BEDS TITLE  :  ADULT  (15-69) 1981  *********************************************  DATA USED: INCIDENCE RATES:  R003  POPULATION  POO3  TRANSFERS  M023  PLANNED BEDS  B003  ********************************************* REMARKS:  THIS I S THE STANDARD  DATE PREPARED: *************  FORECAST.  1 OCTOBER  **********************************  *** ASSUMPTIONS USED IN FORECAST OF 1981 HOSPITAL BEDS *** **********************************************************  AREA ** **  POPULATION **********  OWN DAYS ********  1100  100200  110220  87375  NORTH DELTA  830  22700  18841  0  LADNER  830  24650  20460  0  RICHMOND  950  62200  59090  33509  VANCOUVER  1350  293600  396360  652297  NEW WEST  1250  26900  33625  138734  BURNABY  900  103600  93240  52507  COQUITLAM  900  67450  60705  0  NORTH SHORE  987  104650  103290  99652  1111  805950  895830  1064073  SURREY  TOTALS  INCIDENCE *********  TOTAL DAYS **********  ***********************  TRANSFER MATRIX ASSUMED *********************** PATIENT ORIGIN *******  AREA OF HOSPITAL  ************************** S  SURREY  TREATMENT  ND  L  R  V  NW  B  C  NS  OUT  TOTAL  ,.600 .000  000  .000  200  .200  000  000  .000  000  1.000  NORTH DELTA  .350 .000  ,000  .150  350  .100  000  000  .000  050  1.000  LADNER  .300 .000  000  .200  350  .100  000  000  .000  050  1.000  RICHMOND  .000 .000  000  .450  550  .000  000  000  .000  000  1.000  VANCOUVER  .000 .000  000  .000  950  .000  050  000  .000  000  1.000  NEW WEST  .000 .000  000  .000  150  . 800  050  000  .000  000  1.000  BURNABY  .000 .000  000  .000  450  .250  300  000  .000  000  1.000  COQUITLAM  .000 .000  000  .000  200  .750  050  000  .000  000  1.000  NORTH SHORE  .000 .000  000  .000  200  .000  000  000  .800  000  1.000  INFLOW ASSUMED **************  OUTFLOW ASSUMED ***************  19.0 %  OR AS BEDS:  518  0.2 %  OR AS BEDS:  6  DISTRIBUTION OF INFLOW BY AREA (PERCENTAGE) ********************** SURREY NORTH DELTA LADNER RICHMOND VANCOUVER NEW WEST BURNABY COQUITLAM NORTH SHORE TOTAL  5 .0 0 .0 0 .0 0 0 75 0 10 0 0 0 0 0 10 0 100. 0  OCCUPANCY RATE ASSUMED ********************** PAEDIATRICS - 8 5 % THE OCCUPANCY  :  MATERNITY - 80%  RATE FOR THIS FORECAST I S  :  ADULT - 9 0 % 90 %  ********************************************  ***** GVRHD BED NEED FORECAST FOR 1981 ***** ************************************************* AREA ** **  PLANNED BEDS NEEDED BEDS ************* ***********  BALANCE *******  SURREY  322  266  56  LADNER  75  0  75  RICHMOND  173  102  71  VANCOUVER  2616  1986  630  NEW WEST  573  422  151  BURNABY  360  160  200  COQUITLAM  75  0  75  NORTH SHORE  40 0  303  97  ************  TOTALS  *****  4 59 4  *******  *******  3239  1355  *************************************************  *** GVRHD BED NEED FORECAST FOR 1981 BY AREA *** ************************************************* AREA ** **  PLANNED BEDS NEEDED BEDS ************* ***********  BALANCE *******  NORTH  400  303  97  CENTRAL  2976  2146  830  SOUTH  248  102  146  EAST  970  688  282  ************  TOTALS  *****  4594  *******  *******  3239  1355  EXPLANATION OF AREAS ******************** 1. NORTH INCLUDES THE NORTH SHORE 2. CENTRAL INCLUDES VANCOUVER AND BURNABY 3. SOUTH INCLUDES RICHMOND AND SOUTH DELTA 4. EAST INCLUDES COQUITLAM, NEW WESTMINSTER, NORTH DELTA, SURREY, AND WHITE ROCK  *******************  GVRHD FORECAST ACUTE HOSPITAL BEDS TITLE  :  GERIATRIC  (70+) 1981  *********************************************  DATA USED: INCIDENCE RATES:  R004  POPULATION  POO4  TRANSFERS  M024  PLANNED BEDS  B004  *********************************************  REMARKS:  THIS I S THE STANDARD FORECAST.  DATE PREPARED: *************  1 OCTOBER  ********************************************  *** ASSUMPTIONS USED IN FORECAST OF 1981 HOSPITAL BEDS *** **********************************************************  AREA ****  INCIDENCE *********  POPULATION **********  OWN DAYS ********  TOTAL DAYS **********  SURREY  5400  8700  46980  40990  NORTH DELTA  3500  900  3150  0  LADNER  3500  950  3325  0  RICHMOND  3900  3400  13260  10065  VANCOUVER  5800  34400  199520  236312  NEW WEST  5100  3600  18360  47247  BURNABY  5600  7000  39200  29839  COQUITLAM  4000  3400  13600  0  NORTH SHORE  5235  6800  35598  34649  TOTALS  5393  69150  372993  399103  ***********************  TRANSFER MATRIX ASSUMED *********************** PATIENT ORIGIN *******  AREA OF HOSPITAL TREATMENT **************************  S  ND  L  R  V  NW  B  NS  OUT  TOTAL  SURREY  .800 .000  ,000  ,000  .100  .100  . 000  ,000  .000  000  1.000  NORTH DELTA  .350 .000  ,000  ,300  .300  ,050  .000  ,000  .000  000  1.000  LADNER  .300 .000  ,000  ,350  .300  ,050  .000  000  .000  000  1.000  RICHMOND  .000 .000  ,000  ,600  .350  ,050  .000  ,000  .000  000  1.000  VANCOUVER  .000 .000  ,000  000  ,950  ,000  .050  000  .000  000  1.000  NEW WEST  .00 0 .000  000  000  ,100  ,850  .0 50  000  .000  000  1.000  BURNABY  .000 .000  000  000  , 300  ,250  .450  000  .000  000  1.000  COQUITLAM  .000 .000  000  000  ,100  ,900  .000  000  .000  000  1.000  NORTH SHORE  .000 .000  000  000  ,10 0  000  .000  000  .900  000  1.000  INFLOW ASSUMED  7.0 %  OR AS BEDS:  79  OUTFLOW ASSUMED  0.0 %  OR AS BEDS:  0  **************  ***************  DISTRIBUTION OF INFLOW BY AREA (PERCENTAGE) ********************** SURREY NORTH DELTA LADNER RICHMOND VANCOUVER NEW WEST BURNABY COQUITLAM NORTH SHORE TOTAL  5 .0 0 .0 0 .0 0 .0 65 .0 15 0 5 0 0 0 10 0 100. 0  OCCUPANCY RATE ASSUMED ********************** PAEDIATRICS - 8 5 % THE OCCUPANCY  :  MATERNITY - 8 0 %  RATE FOR THIS FORECAST IS  :  ADULT - 9 0 % 90 %  ********************************************  ***** GVRHD BED NEED FORECAST FOR 1981 ***** ************************************************* AREA ****  PLANNED  BEDS NEEDED BEDS  *************  ***********  BALANCE *******  SURREY  0  125  LADNER  0  0  RICHMOND  0  31  -31  VANCOUVER  0  719  -719  NEW WEST  0  144  -144  BURNABY  0  91  -91  COQUITLAM  0  0  0  NORTH SHORE  0  10 5  ************  TOTALS  *****  *******  0  1215  -125 0  -10 5 *******  -1215  *************************************************  *** GVRHD BED NEED FORECAST FOR 1981 BY AREA *** ************************************************* AREA ****  PLANNED  BEDS NEEDED BEDS  *************  ***********  BALANCE *******  NORTH  0  105  -105  CENTRAL  0  810  -810  SOUTH  0  31  -31  EAST  0  269  -269  ************  TOTALS  *****  0  *******  1215  *******  -1215  EXPLANATION OF AREAS ******************** 1. NORTH INCLUDES THE NORTH SHORE 2. CENTRAL INCLUDES VANCOUVER AND BURNABY 3. SOUTH INCLUDES RICHMOND AND SOUTH DELTA 4. EAST INCLUDES COQUITLAM, NEW WESTMINSTER, NORTH DELTA, SURREY, AND WHITE ROCK  *******************  GVRHD FORECAST ACUTE HOSPITAL BEDS TITLE  :  SUMMARY OF A L L AGE-SEX GROUPS,  *********************************************  DATA USED: INCIDENCE RATES:  ROOX  POPULATION  POOX  TRANSFERS  M02X  PLANNED BEDS  BOOX  ********************************************* REMARKS:  THIS I S THE STANDARD FORECAST.  DATE PREPARED: *************  1 OCTOBER  ********************************************  *** ASSUMPTIONS USED IN FORECAST OF 1981 HOSPITAL BEDS *** **********************************************************  AREA ** **  POPULATION **********  OWN DAYS ********  TOTAL DAYS **********  1281  145000  185883  153671  NORTH DELTA  825  36000  29711  0  LADNER  823  39000  32115  0  RICHMOND  978  90000  88084  55030  VANCOUVER  1623  400000  649520  1008137  NEW WEST  1553  37000  57488  215081  BURNABY  1094  140000  153290  98874  901  103000  92845  0  NORTH SHORE  1090  145000  158103  152363  TOTALS  1274  1135000  1447036  1683158  SURREY  COQUITLAM  INCIDENCE *********  TRANSFER MATRIX ASSUMED *********************** PATIENT ORIGIN *******  AREA OF HOSPITAL  TREATMENT  ************************** 3  ND  L  R  V  NW  B  C  NS  OUT  TOTAL  SURREY  .650 .000  ,000  ,004  ,172  ,167  ,008  ,000  .00 0  000  1.000  NORTH DELTA  .350 .000  ,000  ,176  ,335  ,095  ,013  ,000  .000  032  1.000  LADNER  .313 .000  ,000  ,212  ,335  ,095  ,013  ,000  .000  032  1.000  RICHMOND  .000 .000  ,000  ,481  , 507  ,008  ,005  ,000  .000  000  1.000  VANCOUVER  .000 .000  000  000  ,946  000  052  ,000  .002  000  1.000  NEW WEST  .00 2  .0 00  000  000  135  808  052  000  .000  003  1.000  BURNABY  .000 .000  000  000  ,408  243  348  000  .000  000  1.000  COQUITLAM  .00 0 .000  000  000  197  751  047  000  .000  006  1.000  NORTH SHORE  .000 .000  000  000  187  000  000  000  .813  000  1.000  INFLOW ASSUMED  16.5 %  **************  OUTFLOW ASSUMED  OR AS BEDS:  0.2 %  ***************  735  OR AS BEDS:  8  DISTRIBUTION OF INFLOW BY AREA (PERCENTAGE) ********************** SURREY NORTH DELTA LADNER RICHMOND VANCOUVER NEW WEST BURNABY COQUITLAM NORTH SHORE TOTAL  5 .1 0 0 0 .0 0 0 74 .7 10 1 0 7 0 0 9 4 100. 0  OCCUPANCY RATE ASSUMED ********************** PAEDIATRICS - 8 5 %  :  THE AVERAGE OCCUPANCY  MATERNITY - 8 0 %  ADULT  RATE FOR THIS FORECAST I S  PATIENT DAY FLOW S T A T I S T I C S *************************** RESIDENT ACUTE PATIENT DAYS: 1447036 LESS OUTFLOW: PLUS INFLOW  :  :  NET GVRHD PATIENT DAYS : ACUTE CARE BED REQUIREMENTS:  2650 238770 1683156 5183  89 .  ********************************************  ***** GVRHD BED NEED FORECAST FOR 1981 ***** ************************************************* AREA ****  PLANNED BEDS NEEDED BEDS ************* ***********  BALANCE ******* -59  SURREY  416  475  LADNER  75  0  75  RICHMOND  229  172  57  VANCOUVER  2936  3099  -163  NEW WEST  668  663  5  BURNABY  422  306  116  COQUITLAM  75  0  75  NORTH SHORE  456  468  ************  TOTALS  *****  5277  ******* 5183  -12 *******  94  *************************************************  *** GVRHD BED NEED FORECAST FOR 1981 BY AREA *** ************************************************* AREA ** **  PLANNED BEDS NEEDED BEDS ************* ***********  BALANCE *******  NORTH  456  468  -12  CENTRAL  3358  3405  -47  SOUTH  304  172  132  EAST  1159  1138  21  ************  TOTALS  *****  5277  ******* 5183  ******* 94  

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