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Prediction of acute care bed requirements for scattered area populations O’Brien, Eoin 1980

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PREDICTION OF ACUTE CARE BED REQUIREMENTS FOR SCATTERED AREA POPULATIONS by EOIN O'BRIEN B.B.A., U n i v e r s i t y of P r i n c e Edward I s l a n d , 1971 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE (Health S e r v i c e s Planning) i n ' . . THE FACULTY OF GRADUATE- STUDIES ... ' , (Department of Health Care and Epidemiology) We accept t h i s t h e s i s as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1980 c ) EOIN O'BRIEN, 1980 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r a n a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e Head o f my D e p a r t m e n t o r by h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t nf //Wfc Qtfe AvJi ^ t k i o W y The U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 W e s b r o o k P l a c e V a n c o u v e r , C a n a d a V6T 1W5 ABSTRACT In supporting the p r o j e c t i o n of bed requirements f o r Newfoundland to 1986, an extensive l i t e r a t u r e review was conducted to i d e n t i f y s m a l l area p o p u l a t i o n p r o j e c t i o n methods and bed p r e d i c t i o n models. A bed p r e d i c t i o n model was developed f o r t h i s study. For each h e a l t h r e g i o n ^ . p r o j e c t e d m o r b i d i t y f o r d i a g n o s t i c (bed) c l u s t e r s was c a l c u l a t e d by: p r o j e c t i n g the age-sex p o p u l a t i o n ; h o l d i n g 1976 age-sex c l u s t e r m orbidity patterns and l e n g t h of stay constant; p r o j e c t i n g the base and flow r e f e r r a l m o rbidity patterns of four h e a l t h regions and f i n a l l y the p r o j e c t e d m o r b i d i t y p a t t e r n s were combined and t r a n s l a t e d i n t o beds and adjusted f o r occupancy. The p o p u l a t i o n p r o j e c t i o n method was the Short R a t i o . The d i a g n o s t i c c l u s t e r s were m e d i c a l - s u r g i c a l , o b s t e t r i c a l , p e d i a t r i c s and p s y c h i a t r y . The p r e d i c t i o n of beds u t i l i z i n g t h i s model was com-pared w i t h a bed to po p u l a t i o n r a t e method. I t was demonstrated that bed requirements do change i n respect of age-sex pop u l a t i o n changes. The requirements are s t a t e d f o r each region. This study suggests t h a t the model used f o r bed and po p u l a t i o n p r o j e c t i o n s are u s e f u l planning t o o l s i n Newfoundland because of ease i n use. The elemental problem of supplying a po p u l a t i o n data base f o r each h o s p i t a l d i s t r i c t by age and sex was solved and i s expected to be extremely u s e f u l i n years to come. The usefulness w i l l come from an e v a l u a t i o n of these methods and t h e i r acceptance as f i r s t steps i n the planning process. i i DEDICATION I f e e l t h a t to pursue the w r i t i n g of a t h e s i s i n the manner i n which I have r e q u i r e s a complete d e d i c a t i o n of time, thought and e f f o r t . T his I have been able to do. I have a l s o had the time to meet w i t h and attend to the accompanying f r u s t r a t i o n s and pressures The completion of t h i s t h e s i s i s important to me because there i s a very personal s a t i s f a c t i o n which i t has given and there i s a keener sense of d i r e c t i o n to my l i f e . I t i s from my w i f e , Connie, t h a t t h i s s a t i s f a c t i o n and d i r e c t i o n was given. I t was given by ac c e p t i n g my c o n t i n u a l absence from hone, by. accepting f r u s t r a t i o n s which s u r f a c e d at home and by c o n t i n u a l l y s h a r i n g w i t h and supp o r t i n g me through the highs and lows. A thank-you,as appreciation,does not s u f f i c e because the m a j o r i t y of t h i s t h e s i s , the freedom to t h i n k and organ i z e i d e a s , was encouraged and given to me. To s t a t e i t more a p p r o p r i a t e l y , I f e e l i t was f a r e a s i e r f o r me to be w r i t i n g than to be contending w i t h f a m i l y , home and t h e s i s . i i i ACKNOWLEDGEMENTS There were many who had an instrumental part i n the comple-t i o n of t h i s t h e s i s . I am sure they knew that the assistance which they had given to me was both important and appreciated. The value which I impart to each and every contribution goes f a r beyond the expression of a word. I s h a l l remember each and every contribution warmly; i t i s the sincerest thanks that I can give. To Mort M. Warner, Ph.D., University of B r i t i s h Columbia, I would l i k e to give a very s p e c i a l thanks for both h i s "investment" i n an unforgettable entre l a s t year and the ensuing energy which he i n s t i l l e d to me. To Dave Bryant, Ph.D., Memorial U n i v e r s i t y , I would l i k e to give a personal thanks for h i s keen c r i t i c i s m s , under-standing and sense of d i r e c t i o n as I sought the completion of my thesi s . I give thanks to both the Deputy Min i s t e r , Dr. Lome K l i p p e r t and Assistant Deputy M i n i s t e r , Mr. Ambrose. Hea-rn,. executives of the Newfoundland Department of Health who have continually expressed t h e i r i n t e r e s t f o r and support i n my endeavors. I am c e r t a i n that Mr. and Mrs. Arthur Rodd, Charlottetown, Prince Edward Island do not expect thanks. However, I would l i k e to take this opportunity to thank them because they were important to the completion of th i s thesis. I would also l i k e to thank S t a t i s t i c s Canada o f f i c i a l s , p a r t i c u l a r l y Mr. L. Lefebre for h i s help. I would l i k e to acknowl-i v edge w i t h a p p r e c i a t i o n the e f f o r t s of the Canadian H o s p i t a l Asso-c i a t i o n ' s l i b r a r y s t a f f who provided me w i t h a t i m e l y and t a i l o r e d reading package. Mr. George Courage, D i r e c t o r , and Mr. Hugh R i d d l e r , demographer, w i t h the C e n t r a l S t a t i s t i c s D i v i s i o n , Newfoundland Government, provided me w i t h census data and a great deal of advice. I would l i k e to thank both. F i n a l l y , I must thank my own s t a f f who co n t r i b u t e d whatever resource they could to a s s i s t me i n t h i s study. v TABLE OF CONTENTS Page ABSTRACT i i DEDICATION . . . . . . . . i i i ACKNOWLEDGEMENTS . . i v TABLE OF CONTENTS . . v i LIST OF TABLES . . . . . . . . . . . . . . . . . . . . . . . . x LIST OF FIGURES . . . . . . . . . . x i CURRICULUM VITAE x i i CHAPTER I. INTRODUCTION . • . . . . . . . . . 1 The Purpose and Nature, of the Study 1 Health Planning and Health S t a t i s t i c a l Systems. . . 1 S i g n i f i c a n c e of the Study 7 The Study Problem . . . 10 L i m i t a t i o n s 11 Footnotes . . . . . . . . . . . . . . . . . . . . . 13 I I . THE BROAD SPECTRUM OF FACTORS ASSOCIATED WITH HEALTH RESOURCE UTILIZATION. 15 I n t r o d u c t i o n : The Broad Spectrum of Factors . . . . 15 Demand and U t i l i z a t i o n : Factors and Examples. . . . 15 Selected Factors Associated w i t h Health Resource U t i l i z a t i o n : M o r b i d i t y , Age and Sex, and Geographical D i s t r i b u t i o n 17 M o r b i d i t y , Age-Sex . . . 17 M o r b i d i t y , Age-Sex and Geographical D i s t r i b u t i o n . . . . . 18 Fo r e c a s t i n g : P r e d i c t i o n , P r o j e c t i o n and Esti m a t i o n 21 Methods of Subnational P o p u l a t i o n P r o j e c t i o n s . . . 23 Mathematical . . . . . . . . . . . . . 24 v i CHAPTER Page Ra t i o . 25 Component. . . . . . . . . . . 26 Econometric 27 Other Methods •. . . . . . . . . . . . 28 Accuracy of Subnational P o p u l a t i o n P r o j e c t i o n . . . 29 The Temporal R e l i a b i l i t y and R e l a t i o n s h i p Between F o r e c a s t i n g and Health Planning . . . . . . 31 Summary . . . . . . 34 Footnotes 35 I I I . RESOURCE (BED) DISTRIBUTION MODELS 38 Bed Planning Models . . . . . . . . . . . . . . . • 38 U t i l i z a t i o n . . . . 39 M u l t i p l e Factor A n a l y s i s . . . . 42 D i s t r i b u t i o n A n a l y s i s . . . . . . 43 Non-Formal and Consensus . . . . . . . 44 Standards 45 M u l t i p l e Methodology 46 Summary of Methods 47 D e s c r i p t i o n of Three Bed Planning Models at Higher P o l i c y Making Levels . . . . . . 49 New Brunswick Regional Bed D i s t r i b u t i o n a l Model. . . . . . . . . . •• . • . . . • . . . • • 50 Short-term Model . . . . . . . . . . . . . . . . 50 D i v i s i o n of H o s p i t a l and Medical F a c i l i t i e s P u b l i c Health Services Model . . 51 H o s p i t a l Bed Requirements: An Occupancy Factor Determination Approach 1979 52 Summary • • 54 Planning Studies i n Newfoundland Related to Resource D i s t r i b u t i o n 55 Problems As s o c i a t e d w i t h the D i s t r i b u t i o n of Health Care Resources to Rural Areas i n Newfoundland . 59 Footnotes . . . . . . . . . . . . . . . • • . • • • 61 IV. METHODOLOGY . . . . . . . . . . . . . . . . 65 Research Strategy 65 v i i CHAPTER Page Research S e t t i n g . . . . . . . . . . . 67 Data Sources. . . . . . . . . . . . . . . . . . 67 Methods of C o l l e c t i n g Data . . . . . . . 68 S o r t i n g of Codes. . . . . . . . . . . . . . . . 68 Popu l a t i o n P r o j e c t i o n Method. . . . . . . . . . 69 H o s p i t a l I n p a t i e n t M o r b i d i t y Computer Program 73 Manual Tabulation of Bed Categories . . . . . . 75 Method of A n a l y s i s . . . . . . . . 75 Bed P r e d i c t i o n Formula. 75 Est i m a t i o n of E r r o r Associated w i t h the Ratio P o p u l a t i o n P r o j e c t i o n Technique 78 Footnotes. . . . . . . . . . . . . . . . . . . . . 80 V. ESTIMATION OF ERROR ASSOCIATED WITH THE USE OF THE RATIO METHOD . . 81 In t r o d u c t i o n . . . . . . . . . . . . . . . . . . . 81 Assumptions 82 Method 84 Res u l t s . . . . . . . . . . . . . . . . . . . . . . 86 Footnotes. . . . . . . . . . . . . . . . . . . . . 94 VI. CHANGES IN BED REQUIREMENTS IN RESPECT OF POPULATION CHANGES 95 In t r o d u c t i o n • 95 Methods 96 Pop u l a t i o n Results 98 Bed P r e d i c t i o n Results . . . . . 103 V I I . SUMMARY AND DISCUSSION . 116 In t r o d u c t i o n . . . . . . . • • • . 1 1 6 Sum of E r r o r E s t i m a t i o n Associated With The Ratio Method . . . . . . . . . . . . . . . . . . . . 116 Summary of Popu l a t i o n P r o j e c t i o n s . . 119 Summary of Bed P r e d i c t i o n s . . . . . . . . . . . . 120 Advantages and Disadvantages of the Ratio P r o j e c t i o n Method. . . . . . . . . . . . . . . . • 122 The Advantages and Disadvantages o f the Bed P r e d i c t i o n Model . . . . . . . . . . . . . . . . . 124 v i i i CHAPTER Page Key Observations Regarding the Po p u l a t i o n P r o j e c t i o n s . . . . . 126 Key Observations Regarding the Bed P r e d i c t i o n Model . . . . 128 Future D i r e c t i o n s from t h i s Study. . . . . . . . . 132 APPENDICES A. PROBLEMS ASSOCIATED WITH THE DISTRIBUTION OF HEALTH.CARE RESOURCES TO RURAL AREAS IN NEWFOUNDLAND. 136 B. DETERMINATION OF SAMPLE SIZE. . . . . . . . . . . . . 147 C. TEST FOR BIAS. IN THE RANDOM ROUNDING PROCESS EMPLOYED BY.STATISTICS CANADA . . . . . . . . . . . . 1 5 2 D. ESTIMATES OF ERROR IN THE <. 2999 POPULATION STRATUM: TO EXCLUDE.UNSTABLE CENSUS DIVISIONS AND ERRORS >. 20% 154 E. THE ARRAY OF ESTIMATES OF ERROR PLOTTED AGAINST POPULATION SIZE . . 156 F. POPULATION PROJECTIONS FOR THE HEALTH REGIONS . . . . 158 BIBLIOGRAPHY 160 i x LIST OF TABLES TABLE Page V - l . E s t i m a t i o n of E r r o r s Associated w i t h the Ratio Method. . . 87 V-2. A r c s i n Percent Transformation of E r r o r Estimates A s s o c i a t e d w i t h the Ratio Method (Based on Sample) . . . . . . . . . . . . 90 V-3. Test f o r the R e l a t i o n s h i p Between the P r o p o r t i o n of E r r o r s <. 20% and Po p u l a t i o n S i z e . . . 92 VI-1. Summary A n a l y s i s of Po p u l a t i o n P r o j e c t i o n s . . . . . 99 VI-2. Newfoundland and Regional Bed Service Requirements: 1976, 1981, 1986 104 VI-3. Newfoundland and Regional Bed Ser v i c e Requirements Adjusted f o r R e f e r r a l P a t t e r n s : 1976, 1981, 1986 104 VI-4. Newfoundland and Regional Age-Sex Bed Requirements: 1976, 1981, and 1986 108 VI-5. P o p u l a t i o n Change Compared w i t h Bed Services Changes, Newfoundland and Regions 1976-86 109 VI-6. Sex Po p u l a t i o n Changes Compared w i t h Bed Service Changes, 1976-1986. 109 VI-7. Newfoundland and Regional Age S p e c i f i c P o p u l a t i o n and Bed Ser v i c e Changes, 1976 to 1986 110 VI-8. Comparison of the Bed to Po p u l a t i o n R a t i o , Bed Service to Po p u l a t i o n and Bed Service Requirement w i t h Adjustment f o r R e f e r r a l . Techniques: Newfoundland and Regions 1976, 1981 and 1986. 112 VII-1. Summary of the 1986 T o t a l Bed Requirements f o r the Four Health Regions i n Newfoundland . . . . . . 121 x LIST OF FIGURES FIGURE p a g e I I I - l . Bed Requirement Models: O u t l i n e of Key Factors 48 x i CURRICULUM VITAE Eoin O'Brien graduated from the U n i v e r s i t y of P r i n c e Edward I s l a n d i n 1971 w i t h a Bachelor of Business A d m i n i s t r a t i o n degree. Between 1971 and 1973, Mr. O'Brien was employed as a teacher at St. Joseph's Elementary School i n Windsor, Newfoundland. Between J u l y 1973 and September 1974, a f t e r being accepted i n t o the Govern-ment of Newfoundland H o s p i t a l A d m i n i s t r a t i v e Program, he completed a year's residency at the C e n t r a l Newfoundland H o s p i t a l , Grand F a l l s , Newfoundland. In September 1974, Mr. O'Brien entered the Health Care and Epidemiology's program of Masters of Science (Health Services Planning) at the U n i v e r s i t y of B r i t i s h Columbia. Following a two year program he was employed i n the p o s i t i o n of H o s p i t a l Consultant w i t h the Newfoundland Department of Health. In January 1977, Mr. O'Brien assumed new r e s p o n s i b i l i t i e s w i t h h i s appointment as D i r e c t o r of Research and S t a t i s t i c s w i t h the Newfoundland Depart-ment of Health. x i i CHAPTER I INTRODUCTION The Purpose and Nature of the Study Between 1966 and the present, numerous l a r g e s c a l e s t u d i e s , r e l a t e d to Newfoundland's Health Care System^have had d i f f i c u l t i e s i n d e f i n i n g populations by h e a l t h s t a t i s t i c a l d i s t r i c t and by age and sex. This i n f o r m a t i o n i s c u r r e n t l y not a v a i l a b l e to e i t h e r the Department of Health or to researchers. This data i s a n e c e s s i t y f o r h e a l t h planning and research, and t h e r e f o r e , i t s i n e f f i c i e n t o r g a n i z a t i o n i n or absence from a h e a l t h data system i s a c r i t i c a l problem. Over the years no f o r m a l i z e d mechanism has been adopted to c a l c u l a t e the need f o r acute care h o s p i t a l beds for. the Province of Newfoundland. Instead, the Department of Health has r e l i e d upon i n t i m a t e knowledge of the system, i m p l i c i t methods and recommenda-t i o n s of bed needs contained i n various independent s t u d i e s . Thus, the Department has been hindered i n i t s a n a l y s i s of area-wide patterns and i n i t s planning of resources f o r age and/or s e x - s p e c i f i c groups i n the province. During 1979, the Department of Health's r e s p o n s i b i l i t i e s were expanded to in c l u d e the op e r a t i o n of Nursing Homes. Future planning f o r the e l d e r l y age groups or chronic care p a t i e n t s w i l l , of n e c e s s i t y , r e q u i r e an age and sex a r e a - s p e c i f i c data f i l e . 1 2 I t i s the design of t h i s study to propose u s e f u l and p r a c t i c a l methods to solve t h i s problem and to provide a b a s i s f o r f u t u r e development. Therefore, i t i s the study's s p e c i f i c i n t e n t that an age-sex d i s t r i b u t i o n by h e a l t h s t a t i s t i c a l d i s t r i c t and r e g i o n be e s t a b l i s h e d and proj e c t e d i n t o the f u t u r e ; that a statement of acute care beds w i l l be e s t a b l i s h e d by area and by c l i n i c a l (bed) s e r v i c e ; and that the changes i n the age-sex s t r u c t u r e of the province and h e a l t h regions w i l l be observed i n respect of the p r e d i c t i o n of acute care h o s p i t a l beds. Health Planning and Health S t a t i s t i c a l Systems A very simple d e f i n i t i o n of planning i s : "The i n t e l l i g e n t process that precedes d e c i s i o n making."^ This i s a t e r s e statement c a r r y i n g many i m p l i c i t meanings. Four p e r t i n e n t and d i s t i n c t themes found i n a l i t e r a t u r e review r e l a t e to t h i s process: r a t i o n a l i t y , u n c e r t a i n t y , p r e c i s i o n and confusion. R a t i o n a l i t y . R a t i o n a l i t y can be viewed from two perspec-2 t i v e s . I t i s a c h a r a c t e r i s t i c of a planner who combines i n t e l l i -gence and data i n s e l e c t i n g the proper a l l o c a t i o n of resources. From the second p e r s p e c t i v e , i t describes the same process i n which the planner must choose according to predetermined c o n s t r a i n t s . The a b i l i t y to reason i s r e l a t i v e to the s i t u a t i o n at hand, to the l i m i t a t i o n s imposed on choice, and to the s t a t e of knowledge which i s to be reasoned. U n c e r t a i n t y . As planning i n v o l v e s f o r e c a s t i n g and the d e c i s i o n to increase or decrease present a c t i v i t i e s , or to a l t e r more appropriate a c t i v i t i e s , the highest degree of c e r t a i n t y must be 3 3 c a r r i e d from the present to the f u t u r e . Therefore, a thorough a n a l y s i s of the present s i t u a t i o n must r e s t upon the a v a i l a b i l i t y , t i m e l i n e s s , v a l i d i t y and r e l i a b i l i t y of the data which c h a r a c t e r i z e s the s i t u a t i o n at hand or the d e c i s i o n that must be taken. P r e c i s i o n . Throughout the course of the review i t was evident that there were a multitude of f a c t o r s which determine h e a l t h r e l a t e d u t i l i z a t i o n l e v e l s . To understand t h e i r i n t r i c a t e r e l a t i o n -s h i p s , a l t e r n a t i v e techniques such as m u l t i v a r i a t e analyses have been a p p l i e d . On-the d i s t r i b u t i o n s i d e , planners are now d e s i r i n g to be more observant of the various and d i f f e r i n g h e a l t h care needs of s p e c i f i c groups i n the p o p u l a t i o n . The emphasis at a government p o l i c y l e v e l i s changing from a resource d i s t r i b u t i o n which i s focused upon the concept of bed to the r e a l i z a t i o n that the char-a c t e r of the h o s p i t a l i s undergoing changes. The h o s p i t a l i s assuming more r e s p o n s i b i l i t y f o r a l t e r n a t i v e forms of care. At the planning l e v e l of government, the d e l i v e r y system i s not only g e t t i n g 4 5 6 more remote, i t i s g e t t i n g more complex. ' ' To attend to these views, the q u a n t i t y of data w i l l increase but the need f o r p r e c i s i o n w i l l be of greater concern i n the conduct of t e c h n i c a l r a t i o n a l i t y . 1 7 Confusion. J e f f e r s et a l . have drawn a t t e n t i o n to the d i f f i c u l t y of d e f i n i n g and v a l i d a t i n g what u t i l i z a t i o n r e a l l y means. Many w r i t e r s use the terms need and demand interchangeably. Need i s an "ought to be" or "medical" statement that i s not r e s t r a i n e d by economics. M e d i c a l l y defined need does not have to agree w i t h consumer defined need. Nei t h e r n e c e s s a r i l y equate w i t h demand. Demand represents the a c t u a l usage of h e a l t h resources which may f a l l short of or exceed the l e v e l of need. The d i f f e r e n c e between 4 demand and need defined by the consumer may be i n f l u e n c e d i n some degree by supply which r e l a t e s to m e d i c a l l y defined need. Often c i t e d i n the l i t e r a t u r e as a c r i t i c i s m of demand d i s t r i b u t i o n models. i s the expression: "need minus demand produces an unseen p a r t of the 8 "iceberg. Being s p e c i f i c i n view reduces the confusion of the observer; t h e r e f o r e , r a t i o n a l i t y i s enhanced. Data Requirements f o r Various Examples of Planning Approaches. 9 Four approaches to h e a l t h planning described by Newhouse a r e * the production f u n c t i o n approach; i t s v a r i a n t , the needs approach; the market s i g n a l approach; and a modified v e r s i o n of the market s i g n a l approach which i s supported by a smaller a c c e s s i b l e data base. Data f o r the production f u n c t i o n and needs approaches focus upon the h e a l t h s t a t u s of the pop u l a t i o n . Data f o r the market and modified market approaches r e l y upon h e a l t h s t a t u s , p o p u l a t i o n growth and insurance coverage. The modified market approach uses a higher c o n c e n t r a t i o n of demographic data which i s a v a i l a b l e . The modified market approach i s proposed as an a l t e r n a t i v e to more c o s t l y surveys and as a means to reduce the planner's dilemma i n d e c i d i n g what f a c t o r s , and t h e r e f o r e , what data should be c o l l e c t e d when data bases are becoming i n c r e a s i n g l y complex. The choice of any of these models i s not only dependent upon the nature of the problem but a l s o upon the ex i s t e n c e of an adequate data base. The common data bases r e q u i r e d f o r each of the f o u r approaches are h e a l t h s t a t u s (and u t i l i z a t i o n ) and demographic. The h e a l t h s t a t u s data base describes both morbidity and m o r t a l i t y i n the population. A l t e r n a t i v e l y , s t a t u s i s i n f e r r e d from the u t i l i z a -t i o n l e v e l s of h e a l t h resources. The demographic data base provides i n f o r m a t i o n on "the s i z e , t e r r i t o r i a l d i s t r i b u t i o n and composition 5 of the p o p u l a t i o n ; the components of p o p u l a t i o n c h a n g e - f e r t i l i t y , m o r t a l i t y and m i g r a t i o n ; and w i t h the c h a r a c t e r i s t i c s of the popu-l a t i o n . " ^ MacStavic s t a t e s that these two data bases form the "heart" of a h e a l t h care s t a t i s t i c a l system and must be separate but interdependent data b a s e s . ^ Any system d e l i v e r i n g a h e a l t h care resource, must by purpose, i n f l u e n c e d i r e c t l y or i n d i r e c t l y the h e a l t h status (and u t i l i z a t i o n ) of i t s s e r v i c e p o p u l a t i o n . The "heart" of the system must be able to d e l i v e r appropriate data to the task of determining the e f f e c t i v e n e s s or e f f i c i e n c y o f resource d i s t r i b u t i o n on h e a l t h s t a t u s (and u t i l i z a t i o n ) . By s u b j e c t i n g t h i s data to s t a t i s t i c a l analyses, mathematical p r o j e c t i o n and e s t i m a t i o n , analyses such as b a s i c u t i l i z a t i o n , community h e a l t h s t a t i s t i c s , 12 f u t u r e f a c i l i t y needs and b a s i c resource can be conducted. Demographic i n f o r m a t i o n as one of the data bases deserves a d d i t i o n a l a t t e n t i o n because i t i m p l i e s much more than a c o l l e c t i o n of data and c h a r a c t e r i s t i c s . I t was observed i n the review that planners are concerning themselves, more and more, w i t h the s p e c i f i c d i s t r i b u t i o n of resources to defined p o p u l a t i o n groups. Planners o f t e n compare data between region or province ( f o r example, the S t a t i s t i c s Canada data on I n t e r p r o v i n c i a l H o s p i t a l U t i l i z a t i o n and M o r b i d i t y ) . When comparing or i n f a c t using or d e r i v i n g data by p o p u l a t i o n s , age and/or sex, i t i s e s s e n t i a l that planners know the "source of demography and the accompanying methods of handling 13 s t a t i s t i c s d erived from them." This a l s o i m p l i e s that planners must be f a m i l i a r w i t h the methods of d e r i v i n g p o p u l a t i o n data. This d i s c u s s i o n i s l e a d i n g to the c o n c l u s i o n that as a mentor f o r h e a l t h planning, a very important construct i s the c o n t i n u i n g •development of a data base which i s as c l e a r , p r e c i s e and c e r t a i n as 6 the planner or d e c i s i o n maker r e q u i r e s f o r an informed and i n t e l l i -gent d e c i s i o n . This c o n c l u s i o n i s a l s o presented i n the Report of  the Ontario C o u n c i l of Health on Health S t a t i s t i c s which describes 14 the needs and purposes to be served by a h e a l t h s t a t i s t i c a l system. 1. The system should enable the i d e n t i f i c a t i o n of h e a l t h problems, needs and wants of the p o p u l a t i o n and should provide f o r the population's major h e a l t h problems. 2. The system should provide the data needed f o r the sound planning of h e a l t h s e r v i c e s and programmes. 3. The system should provide the data needed f o r e f f e c t i v e and e f f i c i e n t operations and a d m i n i s t r a t i o n of h e a l t h s e r v i c e s and programmes. 4. The system should provide the data f o r e v a l u a t i o n of h e a l t h s e r v i c e s and programmes. 5. The system should f a c i l i t a t e the conduct of e p i d e m i o l o g i c a l research p a r t i c u l a r l y f o r the major l e t h a l , d i s a b l i n g and p r o d u c t i v i t y reducing diseases which a f f l i c t the p o p u l a t i o n . The q u a l i t y of a h e a l t h p l a n n i n g d e c i s i o n i s dependent upon i t s preceding i n t e l l i g e n t process. P r e d i c t i n g the future or a l t e r i n g present systems to present or f u t u r e o b j e c t i v e s t h e r e f o r e c a s t s considerable importance on the processes of a n a l y s i s and c o l l e c t i o n of data. The concept of a h e a l t h s t a t i s t i c a l system, as presented i n t h i s d i s c u s s i o n , i s intended as a comparative base f o r the various p o i n t s r a i s e d to support the s i g n i f i c a n c e of t h i s study. Of equal importance i n the d i s c u s s i o n i s thecchoice of the term " h e a l t h s t a t i s t i c a l system." P r i o r to 1978, the S t a t i s t i c s D i v i s i o n had been the respon-s i b i l i t y of the H o s p i t a l Services D i v i s i o n of the Department. The f u n c t i o n of the S t a t i s t i c s D i v i s i o n had been to capture and analyze h o s p i t a l u t i l i z a t i o n and i n p a t i e n t morbidity data. Recently there was an expansion of r e s p o n s i b i l i t i e s which e n t a i l e d : c l e a n i n g up data f i l e s ; c o o r d i n a t i o n , c o l l e c t i o n and dissemination of any type 7 of information requested by Department of Health o f f i c i a l s or researchers i n the f i e l d ; and a planning function i n research when data f i l e s and c o l l e c t i o n methods (under reorganization) are at the stage of producing timely and accurate data. In other words, the r o l e which the D i v i s i o n i s developing i s being influenced by a more encompassing view of the delivery of health care. Therefore, the points raised to support the s i g n i f i c a n c e of the studynare not only statements of f a c t , they are p h i l o s o p h i c a l statements of what ought to be, and as presented, would mean that the study i s contributing a great deal to planning and research both inside and outside the Department of Health. Significance of the Study Together, the Hospital Services and the Cottage Hospital Divisions of the Department of Health are held accountable for 39 health s t a t i s t i c a l d i s t r i c t s . Each health s t a t i s t i c a l d i s t r i c t can be subdivided to h o s p i t a l community or i t can form part of a health region (4 i n t o t a l ) . Each health s t a t i s t i c a l d i s t r i c t has a h o s p i t a l or an a l t e r n a t i v e f a c i l i t y which i s funded or operated d i r e c t l y by the Department. Two major types of data are c o l l e c t e d f o r the health s t a t i s t i c a l d i s t r i c t s . For each h o s p i t a l , u t i l i z a t i o n , personnel, and cost figures are c o l l e c t e d from the Annual Eeturn of Hospitals, and from a more general accounting from the monthly f i n a n c i a l s t a t e -ments submitted by the h o s p i t a l s . The second type of data i s the Inpatient Hospital Morbidity F i l e which can i d e n t i f y community, d i s t r i c t h o s p i t a l and region of patients, including t r a n s f e r s . Presently, these age-sex s p e c i f i c f i l e s are r e l a t e d to population by t o t a l populations at the d i s t r i c t and regional l e v e l s (no age and 8 sex), and to an age and sex po p u l a t i o n at the p r o v i n c i a l l e v e l . There have been and continues to be too many instances i n which Department of Health o f f i c i a l s and researchers and/or epide-m i o l o g i s t s , or other researchers outside the department have not been able to o b t a i n the b a s i c demographic data of age and sex f o r h e a l t h s t a t i s t i c a l d i s t r i c t s . The B r a i n Commission i n 1966 described the demographic data i n Newfoundland as " l i m i t e d i n scope and d e t a i l . " ^ In 1973 and 1974 the Health Planning and Development Committee published four reports covering 21 h e a l t h s t a t i s t i c a l d i s t r i c t s . I t had t h i s to say: "Because the census t r a c t s do not coi n c i d e to t h i s s t a t i s t i c a l d i s t r i c t [ r e f e r r i n g to h e a l t h s t a t i s -t i c a l d i s t r i c t ] i t i s not p o s s i b l e to obt a i n a p o p u l a t i o n breakdown 16 by age, sex, m a r i t a l s t a t u s or f a m i l y s i z e . " U n f o r t u n a t e l y , t h i s study group made no attempt at s o l v i n g t h i s problem. McKinsey and Company i n 1978 were greeted w i t h t h i s problem i n a commissioned study f o r the St. John's H o s p i t a l Advisory Council.''''' This group d i d s o l v e t h e i r problem and d i d provide an age-sex pop u l a t i o n and p r o j e c t i o n s but t h i s was done f o r three l e v e l s of care r e g i o n s : primary, secondary and t e r t i a r y . There are 4 h e a l t h regions and 39 h e a l t h s t a t i s t i c a l d i s t r i c t s which under normal c o n d i t i o n s are not defined by l e v e l s of care f o r planning. Boundaries of these v a r i o u s planning d i v i s i o n s do not conform to present age-sex d i s t r i b u t i o n s of the p o p u l a t i o n by census d i v i s i o n s . The Department of Health has been supportive of o b t a i n i n g an age-sex d e s c r i p t i o n of the po p u l a t i o n i n each h e a l t h s t a t i s t i c a l d i s t r i c t . Resources are d i s t r i b u t e d to these d i s t r i c t s e i t h e r d i r e c t l y through programs w i t h i n the various d i v i s i o n s of the Department or through the h o s p i t a l , which i s the f o c a l p o i n t of the 9 d i s t r i c t . To accommodate the measure of e f f e c t i v e n e s s and to d e f i n e f u r t h e r d i s t r i b u t i o n of resources to s p e c i f i c needs, aggregate po p u l a t i o n f i g u r e s alone are not s u f f i c i e n t . A very r e a l concern at the present time i s the Department's d e s i r e to estimate the e l d e r l y p o p u l a t i o n f o r each h e a l t h d i s t r i c t and r e g i o n . This a r i s e s because of the new r e s p o n s i b i l i t y which has been assumed by the Department of Health f o r the operation of Nursing Homes. Four s t u d i e s by the Planning D i v i s i o n of the Department of Health p o i n t to the need f o r new estimates of d i s t r i c t and/or r e g i o n age-sex populations and bed requirements. Three of the s t u d i e s 18 r e l a t e to p o p u l a t i o n p r o j e c t i o n s . In only one does the p r o j e c t i o n go beyond 1976. "In P o p u l a t i o n 1971 and 1976, Newfoundland by Health Region and Health D i s t r i c t " the t o t a l p o p u l a t i o n was to have been 19 pr o j e c t e d to 1991. The p r o j e c t i o n s are incomplete i n that few d i s t r i c t s are p r o j e c t e d to 1991 or even beyond 1981. These Reports do not s t a t e t h e i r methodological approach. However, i t i s known that a v a r i e t y of methods were used, one of which was the average y e a r l y growth r a t e . The r e p l i c a t i o n of these s t u d i e s would be d i f f i -c u l t because there i s a l a r g e component of experience and judgement i n v o l v e d . F i n a l l y , a study e n t i t l e d " H o s p i t a l Beds i n Newfoundland Per 1000 P o p u l a t i o n as Compared to P r o j e c t e d H o s p i t a l Beds i n Newfoundland 20 Per 1000 P r o j e c t e d P o p u l a t i o n " d i s t r i b u t e d beds to regions on the b a s i s of current and t o t a l p o p u l a t i o n . This study s u f f e r s the same problems as c i t e d p r e v i o u s l y . The methodology, as confirmed by the Planning D i v i s i o n i n v o l v e d the use of p o p u l a t i o n estimates from va r i o u s s t u d i e s and the i n t u i t i o n and experience of the w r i t e r of that r e p o r t . The method of e s t i m a t i n g beds was i n c o n s i s t e n t ; i n e s t a b l i s h i n g bed r a t e s , p r o j e c t e d bed r a t e s were modified according to future plans f o r expanding or c o n s t r u c t i n g f a c i l i t i e s , to the 21 a s s i m i l a t i o n of areas and to " r u l e s of thumb," a l l of which were not s t a t e d i n the Report. In the review of a h e a l t h s t a t i s t i c a l system and i n the l i g h t of the preceding d i s c u s s i o n , the s i g n i f i c a n c e of having a more, p r e c i s e demographic base f o r the S t a t i s t i c s D i v i s i o n i s l i n k e d w i t h i t s f u t u r e e f f o r t s and r e s p o n s i b i l i t i e s i n research. By f o c u s i n g upon bed p r e d i c t i o n s and the concommittant changes i n the age-sex po p u l a t i o n , i t i s a n t i c i p a t e d that more a t t e n t i o n w i l l be given to f u t u r e data requirements i n the province. L i t t l e has been s a i d w i t h regard to the bed p r e d i c t i o n i t s e l f . The p r e d i c t i o n s w i l l be t i m e l y and w i l l provide a b a s i s f o r d i s c u s s i o n i n determining bed r e q u i r e -ments. The methods which are to be designed f o r t h i s study bear weight because they w i l l a l low i n s p e c t i o n , c r i t i c i s m and improve-ment. In other words, the q u a l i t y of data should be enhanced, and therefore the character of a h e a l t h planning d e c i s i o n should be improved under the assumption of i n t e l l i g e n c e or r a t i o n a l i t y . The Study Problem This study's purpose i s to e s t a b l i s h standards f o r c a l c u -l a t i n g and p r e d i c t i n g the acute care bed requirements, t a k i n g i n t o account the changes i n the age-sex d i s t r i b u t i o n of the p o p u l a t i o n . For Newfoundland, the requirements which have been i d e n t i f i e d are as f o l l o w s : 1. Determine the bed s e r v i c e categories by: (1) current and p r o j e c t e d years,. (2) morbidity d i a g n o s t i c codes. 11 2. Determine a v a l i d and r e l i a b l e p r o j e c t i o n p e r i o d f o r popu-l a t i o n p r o j e c t i o n s and bed e s t i m a t i o n s . 3. Determine the age-sex pop u l a t i o n f o r the current year (reference year) f o r each h e a l t h s t a t i s t i c a l d i s t r i c t and h e a l t h region. 4. P r o j e c t the age-sex p o p u l a t i o n f o r each h e a l t h s t a t i s t i c a l d i s t r i c t and h e a l t h region f o r the p r o j e c t i o n p e r i o d . 5. Determine by bed s e r v i c e , the morbidity use by age, sex and region f o r the reference year. 6. P r o j e c t bed s e r v i c e requirements by age and sex f o r each region. 7. Determine the changes i n the age-sex d i s t r i b u t i o n of the p o p u l a t i o n i n respect of the acute care bed requirements f o r Newfoundland. L i m i t a t i o n s The l i m i t a t i o n s l i s t e d below have been e s t a b l i s h e d f o r the present study. Limitations }number<. (1) and (6) should be noted as they are important to the a n a l y s i s of r e s u l t s . 1. The p o p u l a t i o n s o r t i n g and assignment of an age-sex p o p u l a t i o n are to be c a r r i e d out at the h e a l t h s t a t i s t i c a l d i s t r i c t l e v e l s . P o p u l a t i o n p r o j e c t i o n s : w i l l i n v o l v e aggregation of data to r e g i o n a l l e v e l s so that the accuracy of i t s input to morbidity pro-j e c t i o n s f o r regions w i l l be enhanced. Therefore p o p u l a t i o n a n a l y s i s w i l l be confined to r e g i o n a l and p r o v i n c i a l l e v e l s . 2. M o r b i d i t y incidence i s r e s t r i c t e d to 1976 H o s p i t a l I n p a t i e n t morbidity f o r 44 acute care h o s p i t a l s i n Newfoundland. 3. Newborns are being omitted from the study. 4. Beds are r e s t r i c t e d to acute care beds: m e d i c a l - s u r g i c a l ; o b s t e t r i c a l ; p s y c h i a t r i c (acute care h o s p i t a l ) and p e d i a t r i c c l a s s i -f i c a t i o n s . 5. Four h o s p i t a l s are being omitted from the study. The beds i n these f a c i l i t i e s are considered long-term. The h o s p i t a l s are: Waterford (Mental H e a l t h ) , Children's R e h a b i l i t a t i o n , St. P a t r i c k ' s and St. Luke's Nursing Homes. 6. Diagnostic bed s e r v i c e i s a h o s p i t a l i n p a t i e n t m orbidity c l a s s i f i c a t i o n which re q u i r e s a s p e c i f i c type of bed to s e r v i c e or care f o r the c l u s t e r of diagnoses. In other words, a g y n e c o l o g i c a l p a t i e n t cannot as sometimes occurs, occupy an o b s t e t r i c a l bed by t h i s study's d e f i n i t i o n . 7. The h e a l t h s t a t i s t i c a l d i s t r i c t i s being used by t h i s study because i t i s the current geographical area that i s employed by the Department of Health. I t i s not w i t h i n the scope of t h i s study to discuss a l t e r n a t i v e d i v i s i o n s f o r use by the Department of Health. 13 Chapter I Footnotes ^Stephen Sieverts, "Influences of Area-wide Planning," Hospitals 44 (January 1970): 63-65. 2 Gerry Bernard H i l l , "The Use of V i t a l S t a t i s t i c s and Demographic Information i n the Measurement of Health and Health Care Needs," i n Methods of Health Care Evaluation, 3rd ed., edited by David L. Sackett and Marjorie S. Baskin (Hamilton, Ontario: McMaster University, 1974), ch. 2, pp. 1-49. 3 Robin E. MacStravic, "How Many Hospital Beds Does V i r g i n i a Need?" V i r g i n i a Medical (January 1978): 73-75. 4 Avery C o l t , "Element of Comprehensive Health Planning," American Journal of' Public Health 60 (July 1970) : 1194-1204. ^Stephen Sieverts, pp. 63-65. Werner F. 0. Daechsel, "Regional Health Care Planning," Hospital Administration i n Canada (December 1972) : 25-28. ^James R. J e f f e r s , Mario F. Bognano and John C. B a r t l e t t , "On the Demand Versus Need for Medical Services and the Concept of Shortage," American Journal of P u b l i c Health 61 (January 1971): 46-63. g Vincente Navarro, "Planning for the D i s t r i b u t i o n of Personal Health Services," Public Health Reports 84 (July 1969): 573-581. 9 J. P. Newhouse, "Forecasting Demand and- the Planning of ' Health Services," i n Systems Aspects of Health Planning, ed. Norman T. J . Bailey and Mark Thompson (Amsterdam, Oxford: North-Holland Publishing Company, 1975), pp. 45-55. ^Margaret Bright, "The Demographic Base for Health Planning," i n Health Planning: Q u a l i t a t i v e Aspects and Quantitative  Techniques, ed. by William A. Reinke (Baltimore: John Hopkins Uni v e r s i t y , 1972), pp. 138-157. ^Robin E. MacStravic, Determining Health Needs (Ann Arbor, Michigan: Health Administration Press, 1978), pp. 73-135. 12 Jerome Chubin, et a l . , eds., S t a t i s t i c s f o r Comprehensive  Planning, Report No. H.S.M. 73-1217 (Washington, D.C: U.S. Govern-ment P r i n t i n g O f f i c e ) , pp. 62-64. 13 Gerry Bernard H i l l , pp. 1-49. 14 14 Ontario Council of Health, Report of the Ontario Council  of Health on Health S t a t i s t i c s , Part I, Annex G (Ontario Department of Health, January 1969), pp. 17-23. ^D. V. Glass, "Structure of the Newfoundland Population," c i t e d by Right Honourable Lord Brain, Royal Commission on Health, V. 3 (Government of Newfoundland, 1966), 2:34. 16 Health Planning and Development Committee, Health Care  Delivery, Reports 1-4, St. John's: Newfoundland Department of Health, May-March, 1975. ^McKinsey and Company, Provisions of C l i n i c a l Services and  Programs i n St. John's: A Study to Determine Future Requirements, St. John's: St. John's Advisory Council, 1979. 18 A. B. Murphy, "Newfoundland Population: Census Years 1961, 1966, 1971, 1976," St. John's: 1975 (working copy); Idem, "Population 1971 and 1976, Newfoundland by Health Regions, by Health S t a t i s t i c a l D i s t r i c t s , " St. John's: 1975; Idem, "Newfoundland and Labrador Population 1966-1971, Part I I , Health S t a t i s t i c a l D i s t r i c t s , " St. John's: September 1976. 1 9Idem, "Population 1971 and 1976." 20 Health Planning D i v i s i o n , "A Study of Current H o s p i t a l Beds i n Newfoundland Per 1000 Population as Compared to Projected Hospital Beds i n Newfoundland Per 1000 Projected Population 1980-81," St. John's: Newfoundland Department of Health, September 1975. 21 Personal communication with G. Gover, Acting Director of Planning, Department of Health, Newfoundland, August, 1979. CHAPTER I I THE BROAD SPECTRUM OF FACTORS ASSOCIATED WITH HEALTH RESOURCE UTILIZATION I n t r o d u c t i o n : The Broad Spectrum of Factors In the context of t h i s l i t e r a t u r e review, there were numerous s t u d i e s which examined the c o n t r i b u t o r y f a c t o r s which l e d to the expression of a demand f o r or the u t i l i z a t i o n of a h e a l t h care resource. W h i l s t a r e p r e s e n t a t i v e catalogue of a l l these v a r i a b l e s has the appearance of a shopping l i s t , i t i s evident that a p r e c i s e statement of determinants and r e l a t i o n s h i p s has not yet been found. Even though some of the s t u d i e s have examined r e l a t i v e l y few v a r i -a b l e s , t h e i r reviewers are very quick to p o i n t out that such an i s o l a t e d view forms but one band of the spectrum. A synoptic p i c t u r e of these v a r i a b l e s can be obtained by 1 2 combining the s t u d i e s of P i e r c e and MacStravic . Given below are headings and examples. The order i n which these appear does not i n d i c a t e t h e i r r e l a t i v e importance. Demand and U t i l i z a t i o n : Factors and Examples Economic: The i n d i v i d u a l ' s cost of time, distance and t r a n s -p o r t a t i o n ; the h e a l t h system's cost of resources and p r i o r -i t i e s ; the l e v e l of resources a v a i l a b l e . S o c i o - p s y e t i o l o g i c a l : The i n d i v i d u a l ' s behaviour i n c o n f r o n t i n g the acuteness, delay, f e a r or p r e v e n t a b i l i t y present i n a s i t u a t i o n . 15 16 Demographic: The population's growth, education l e v e l , income, c u l t u r a l o r i g i n s and age-sex structure. P h y s i c a l : A population's l e v e l of morbidity or mortality. Organizational: The i n d i v i d u a l ' s or professional's a c c e s s i -b i l i t y to services under the consideration of a v a i l a b i l i t y and u n i v e r s a l i t y of resources and f a c i l i t i e s , or degree of c e n t r a l i z a t i o n or d e c e n t r a l i z a t i o n of the system. Environmental: The absence of an adequate water and sewage disposal system or the pollutant e f f e c t s of an i n d u s t r i a l complex. P o l i t i c a l : The lobbying of a community for a h o s p i t a l when the primary reason, although stated as health, i s economic (jobs). Technological: The l e v e l of medical expertise for the services required. The previous l i s t i n g was presented to emphasize that demand or u t i l i z a t i o n can be considered by a statement c o n s i s t i n g of many var i a b l e s . MacStravick suggests that i n the future techniques such as multivariate analyses w i l l become more commonplace. As an example of numbers and r e l a t i o n s h i p s , the studies by Harris and Brooks and 3 4 Beenhaker provide a good s t a r t i n g point. ' Not only do these studies point to a growing l i s t of v a r i a b l e s , they also point to the s e l e c t i o n of what variables through a n a l y s i s , are considered to be the most important for a.given s i t u a t i o n . In t h i s context, a study which s e l e c t s but a few factors should be cognizant of possible r e l a t i o n s h i p s with other v a r i a b l e s , and that the same i s true of many fa c t o r s ; that i s , the importance of variables i n one s i t u a t i o n i s not n e c e s s a r i l y the same i n another s i t u a t i o n . The s e l e c t i o n of variabl e s for study can cover a broad spectrum by l o g i c alone, but the f i n a l s e l e c t i o n of variables to be analyzed i s dependent upon the s i t u a t i o n , p r a c t i c a l i t i e s of time and e f f o r t , the techniques of a n a l y s i s , and the appropriateness to the problem at hand. Selected Factors A s s o c i a t e d w i t h Health Resource  U t i l i z a t i o n : M o r b i d i t y , Age and Sex, and  Geographical D i s t r i b u t i o n M o r b i d i t y , Age-Sex Although the l e v e l and s t r u c t u r e of morbidity are  be l i e v e d to be important determinants of h e a l t h resources u t i l i z a t i o n , m o rbidity data have o f t e n been overlooked i n the planning of h e a l t h resources.^ [ u n d e r l i n i n g by the present w r i t e r ] . This quotation from Navarro has a number of key concepts which r e q u i r e f u r t h e r explanation. The l e v e l and s t r u c t u r e of morbidity are grounded i n age, sex and h e a l t h c o n d i t i o n . M o r b i d i t y a p p l i e s i n two d i s t i n c t s e t t i n g s . F i r s t , m o rbidity i s an aggregate term which describes the h e a l t h s t a t u s of the pop u l a t i o n . Second, mor b i d i t y i s a modified term which defines the numbers and types of co n d i t i o n s which are admitted t o , or separated from, h e a l t h care i n s t i t u t i o n s . The quotation a l s o i m p l i e s that there are va r i o u s l e v e l s or pers p e c t i v e s to morbidity. Some of these l e v e l s are: expressed a c t u a l or demand mor b i d i t y (prevalence, i n c i d e n c e ) ; p r i -mary, secondary or t e r t i a r y m o rbidity (resource d i s t r i b u t i o n and degree of s i c k n e s s ) ; and consumer or expert defined morbidity ( f a c -t u a l or perceived l e v e l s that ought to e x i s t ) . Although authors recognize morbidity and age-sex f a c t o r s , f r e q u e n t l y these f a c t o r s take a back seat to other s e t s of v a r i a b l e s . Donabedian made r e f e r ence to t h i s i n a review of 225 st u d i e s by a number of researchers. In only one case was morbidity data used to derive a statement of resource requirement. According to Doyle e t a l . ^ "the most s t a t i s t i c a l l y s i g n i f i -cant v a r i a b l e a f f e c t i n g h o s p i t a l bed days were age and sex." "Age was f i v e times a b e t t e r p r e d i c t o r than any other s i n g l e v a r i a b l e . " [Previous h o s p i t a l i z a t i o n , income, income groups, r u r a l - u r b a n d i f f e r e n c e s ( a c c e s s i b i l i t y as one), residence, sex d i f f e r e n c e s , race and age were other v a r i a b l e s considered.] One would a n t i c i p a t e a r e s u l t such as t h i s because resources are, i n a l a r g e measure, being s u p p l i e d to deal w i t h morbidity which i s a f u n c t i o n of age and sex. Examples of t h e . r e l a t i o n s h i p between age-sex and mo r b i d i t y are drawn from B r i g h t , ^ Das and Das, 9 and Umenyi."'^ As age or s u r v i v a l i n c r e a s e s , the i n d i v i d u a l ' s s u s c e p t i b i l i t y to mor b i d i t y and to the chronic degenerative or d e b i l i t a t i n g c o n d i t i o n s a l s o i n c r e a s e s . This r e q u i r e s a s p e c i a l type of care. Changes i n b i r t h , death and s u r v i v a l rates may w i t h i n a generation cause s i g n i f i c a n t s h i f t s i n the age-sex groups. Younger, and e s p e c i a l l y e l d e r l y groups, consume more resources i n the acute care s e t t i n g , ceretus paribus. Depending upon the age d i s t r i b u t i o n and number of women i n the c h i l d - b e a r i n g years, the need f o r o b s t e t r i c a l s e r v i c e s may vary. However, women at r i s k f o r complicated pregnancies may d i f f e r i n age p a t t e r n s , and re q u i r e a d i f f e r i n g set of resources. Sex-age r e l a t e d c o n d i t i o n s such as cancers of the p r o s t r a t e or reproductive organs r e q u i r e separate types of beds. Car d i o v a s c u l a r disease and cancers of the stomach or upper r e s p i r a t o r y organs are age-related. To c i t e more examples would be redundant f o r l o g i c alone t e l l s that changes i n the age-sex d i s t r i b u t i o n of the po p u l a t i o n w i l l have a consequent e f f e c t upon u t i l i z a t i o n , at l e a s t i n the volume of s e r v i c e s , i f a l l other f a c t o r s are hel d constant. Therefore, one of the b a s i c steps f o r the planning of h e a l t h resources to morbidity l e v e l s i s to know the age-sex d i s t r i b u t i o n of the popul a t i o n . M o r b i d i t y , Age-Sex and Geographical D i s t r i b u t i o n A d i f f e r e n c e i n morbidity p a t t e r n s by age groups between r u r a l and urban areas was demonstrated by P f e i f f e r et a l . who p l o t t e d stomach cancer cases on a map of Newfoundland. The observed pattern which followed the coastline was also concentrated i n a pocket on the east c o a s t . ^ Fodor's preliminary observations, on cardiovas-cular disease rates between two areas of Newfoundland i n d i c a t e that one area has twice the rate of the other, and t h i s f i n d i n g i s true 12 fo r a l l age s p e c i f i c rates. A number of consultant reports on the more northern and les s densely populated regions of the province record a greater proportion of morbidity conditions which are asso-ciated with environment, s a n i t a t i o n , n u t r i t i o n and s o c i a l d i s i n t e -gration when compared with the re s t of the province. Whilst these studies support generalizations to geographical differences the authors also point to the important intervening variables such as c u l t u r a l and eating habits. The remoteness experienced by some communities often accom-pany such problems as weather, distance, a c c e s s i b i l i t y and delay. These contribute to longer stays, higher costing services and more consumption of resources. The remoteness of phys i c a l separation from larger centers can sometimes lead to a lower p r o f i l e when demands are expressed. Planners are often forced p o l i t i c a l l y to recognize high v i s i b i l i t y areas such as c i t i e s or larger communi-t i e s . This i s also a bias because these communities have more resources, higher l e v e l s of s k i l l s and education and more organiza-t i o n a l a b i l i t y . In t h i s context the development and organization of resources i s far easier. The natural outcome i s that u t i l i z a t i o n rates are higher. This does not ne c e s s a r i l y mean that there i s a s i g n i f i c a n t q u a l i t a t i v e difference i n the services provided to e i t h e r the urban or r u r a l patient. Many small area v a r i a t i o n s i n h e a l t h resource u t i l i z a t i o n 13 were described by Wennberg and Gottelsohn. Some examples were: h o s p i t a l bed r a t e s , discharge r a t e s , occupancy, length of s t a y , d i a g n o s t i c r a t e s and p r o p o r t i o n of e l d e r l y (over 65 y e a r s ) . An i n t e r e s t i n g comment which they make i s that the p h y s i c i a n s , which they observed, tend to concentrate i n urban areas f o r more than economic reasons. P h y s i c i a n s are al s o cognizant of the age s t r u c t u r e of a community and the type of medical p r a c t i c e which they d e s i r e . They suggest (as one reason) that p h y s i c i a n s , i n general, do not move to r u r a l s e t t i n g s because there i s a higher concentration of unproductive age groups. Many p h y s i c i a n s do not l i k e to care f o r the e l d e r l y because case v a r i e t y and cure i s l i m i t e d . The outcome of t h i s g e n e r a l i z a t i o n i s that supply of p h y s i c i a n s i s reduced; t h e r e f o r e , a corresponding r e d u c t i o n i n u t i l i z a t i o n i s experienced. When MacStravic. discussed the f a c t o r of distance he c i t e d J a r v i s ' 14 Law: The u t i l i z a t i o n r a t i o i s i n v e r s e l y r e l a t e d to dist a n c e . This law i n conjunction w i t h the previous d i s c u s s i o n contends t h a t d i f f e r e n t populations by area and s t r u c t u r e r e q u i r e v a r i e d sets of h e a l t h resources, a t l e a s t to s a t i s f y current u t i l i z a t i o n p a t t e r n s . To summarize both d i s c u s s i o n s of morbidity by age and sex and by geographic d i s t r i b u t i o n , two p o i n t s are presented as being appropriate to h e a l t h planning i n the Newfoundland s e t t i n g . S i b o l e suggests that the growth of the p o p u l a t i o n has created a very d i f f e r e n t type of e f f e c t . Growth i n the p o p u l a t i o n has f a r out-s t r i p p e d the growth of h e a l t h care r e s o u r c e s . ^ Present resource l e v e l s o f t e n do not r e l a t e to newer populations and th e r e f o r e may  represent substandards, i f and when resource u t i l i z a t i o n i s intended f o r planning. The c r i t i c a l element of t h i s view i s the r e l a t i o n s h i p between present consumption and the present population which i s consuming resources. Small area population information i s considered by Wennberg and Gottlesohn as v i t a l to sound health planning. In the quotation that follows note the implication that there i s an absence of current population analysis r e l a t i v e to the resources d i s t r i b u t e d . Health information about t o t a l population i s a prere-q u i s i t e for sound planning, decision making and plan-ning i n the health care f i e l d . Experience with a population based health data system i n Vermont reveals that there are wide v a r i a t i o n s i n resource input u t i l -i z a t i o n of services and expenditures among neighbouring communities. . Variations i n u t i l i z a t i o n indicate that there i s considerable uncertainty about the e f f e c -tiveness of d i f f e r e n t l e v e l s of aggregate as w e l l as s p e c i f i c kinds of s e r v i c e s . ^ The Newfoundland geography i s comprised of many small area populations: and as previously stated there are elements of data c o l l e c t i o n that require improving i n the Newfoundland s i t u a t i o n . Consequently a discussion of Newfoundland and i t s r u r a l problems of health resource delivery and in t e g r a t i o n with l a r g e r systems w i l l be presented under a separate heading i n Chapter I I I and i n Appendix A. Forecasting: P r e d i c t i o n , P r o j e c t i o n and Estimation The term health planning, by d e f i n i t i o n , must include some element of forecasting, p r e d i c t i o n , p r o j e c t i o n or estimation. To many planners these terms are used interchangeably to describe one phenomena, a quantitative state i n the future. To the ardent demo-grapher each of these terms i s d i s t i n c t and has i t s own s p e c i a l i z e d body of knowledge. K e y f i t z uses p r e d i c t i o n and forecast as equiva-lents which mean a future statement'of what i s to occur with a p r o b a b i l i t y of i t s o c c u r r e n c e . ^ Projection does not have a proba-b i l i t y attached. Instead i t i s c o n d i t i o n a l : " I f the b i r t h rate declines, what w i l l happen?" If a p r o b a b i l i t y i s attached to a 18 "what i f " statement, the r e s u l t i s a r e s t r i c t e d forecast. To carry the "what i f " b i r t h rate statement to a r e a l s i t u a t i o n , the p r o b a b i l i t y of the decline would have to be stated. In the case of t h i s thesis there i s a population projection, a morbidity assumption and a p r e d i c t i o n of bed requirements. The p r e d i c t i o n arises because a r e a l s i t u a t i o n (current pattern) i s expected at the future date. Determining the future i s d i s t i n c t from forecasting the future. Determining the future involves i d e n t i f y i n g the factors which r e l a t e to health care u t i l i z a t i o n , and intervening by a l t e r i n g those factors which are amenable to adjustment. In other words, the r e a l or current s i t u a t i o n i s being modified for the future u t i l i z a -t i o n l e v e l s . Forecasting does not a l t e r current factors. Instead, observed changes of factors are used to predict the impact that these changes w i l l have on future u t i l i z a t i o n . S p e c i f i c a l l y , the content of a forecast must cover a l l aspects of the s i t u a t i o n which i s to be planned. 19 As Bergwall et a l . describe content, the forecast must contain projections for the planning period and a thorough analysis of facts r e l a t i n g to the current s i t u a t i o n . The forecast should appear as i f i n a table comparing 1979 on one side and 1989 on the other side. An encompassing forecast should consider the following components: p o l i t i c a l ; s o c i a l (demographic); economic; technological and health: resources, status s e r v i c e s ; and health (environment). A . 20 short l i s t of forecasting techniques i s derived from MacStravic r, 21 22 Bergwall et a l . and Navarro. 1. Present Centered (present w i l l repeat) 2. Trend Extrapolation (past w i l l repeat) 23 3. Trend C o r r e l a t i o n (past l i n k between two f a c t o r s w i l l repeat) 4. M u l t i v a r i a t e F o r e c a s t i n g (past l i n k i n complex ways to one f a c t o r w i l l repeat) 5. Consensus ( f u t u r e defined by experts) 6. I n t u i t i o n ( s u b j e c t i v e judgement) 7. S t a t i s t i c a l Models (numerous e s t i m a t i n g equations p r e d i c t future) 8. Analogy ( p l a u s i b l e p a r a l l e l s drawn between f u t u r e and p r i o r event) Fo r e c a s t i n g methods can a l s o be defined by t h e i r a s s o c i a t i o n w i t h p a r t i c u l a r branches of knowledge. Of concern to t h i s t h e s i s are two methods, s o c i a l f o r e c a s t i n g (demographic and populations) and h e a l t h planning. Each of these i n t u r n w i l l be discussed: s o c i a l f o r e c a s t i n g i n terms of methods of p r o j e c t i n g s u b n a t i o n a l p o p u l a t i o n s ; and h e a l t h planning i n terms of bed (resource) d e t e r -mination or p r e d i c t i o n methods. Regardless of method, o f t e n the 23 very b a s i c step i s a p o p u l a t i o n p r o j e c t i o n . This i s so because planners o f t e n must focus t h e i r a t t e n t i o n upon a c t i v i t i e s which are r e l a t e d to the i n d i v i d u a l or groups w i t h i n the p o p u l a t i o n . The a c t i v i t y r a t e , such as morbidity by age, i s dependent upon popula-t i o n . To determine future l e v e l s of morbidity by age, the growth of 24 the p o p u l a t i o n by age i s taken i n t o account. Bergwall et a l . describe s o c i a l f o r e c a s t i n g - p o p u l a t i o n p r o j e c t i o n , as the key inde-pendent v a r i a b l e of h e a l t h planning. Methods of Subnational P o p u l a t i o n P r o j e c t i o n s There are various methods of p r o j e c t i n g populations and these can be d i v i d e d i n t o two broad c a t e g o r i e s : n a t i o n a l ; and sub-n a t i o n a l ( l o c a l , r e g i o n a l , area). The methods which are l i s t e d below can be a p p l i e d to e i t h e r category. However, the methodologies 25 a v a i l a b l e f o r l o c a l p r o j e c t i o n s are more numerous and are more germane to the t h e s i s : 1. A r i t h m e t i c or Geometric E x t r a p o l a t i o n Methods 2. Ratio Method 3. C o r r e l a t i o n Method (Econometric) 4. Component Method 5. Cohort S u r v i v a l Method _. ™ ^ J _ , ^ „ ._vr.uuj ~ Component Methods Cohort-Component Method 6. Other Methods Many of the a r t i c l e s d e a l i n g w i t h p o p u l a t i o n methods review very b r i e f l y those which apply to the determination of l o c a l area 2 6 populations. The d i s c u s s i o n which f o l l o w s was drawn from W o l f f , 27 28 29 30 S i e g e l , Schmitt and C r o s e t t i , ' Z i t t e r and Shryock J r . j 31 32 33 Spiegelman, Grauman, Bergwall e t a l . , U.S. Bureau of the Census,"^^ and Gnanasekaran. Mathematical P r o j e c t i o n Models i n v o l v e an assumption of past trends and a c o n t i n u a t i o n of these trends as a constant i n t o the fu t u r e by a s p e c i f i c annual or average amount. S p e c i f i c a l l y , the a r i t h m e t i c method p r o j e c t s an increase or decrease i n annual or average amount whereas the geometric p r o j e c t s an average annual ra t e or percentage increase or decrease. A l t e r n a t i v e l y , these methods are known as trend curves. These methods are used l e s s f r e q u e n t l y because t h e i r a b i l i t y to handle numerous assumptions i s very l i m i t e d . Yet they are o f t e n u s e f u l f o r short term p r o j e c t i o n s or quick s t u d i e s where time and cost are at a premium and rough estimations w i l l s u f f i c e . Of the va r i o u s types of trend curves to which data are f i t t e d only the l o g i s t i c curve i s suggested as s u i t a b l e f o r long term p r o j e c t i o n s . 25 The Ratio Methods f i n d t h e i r main a p p l i c a t i o n i n p r o j e c t i o n problems which deal with geographical subdivisions. This method i s employed i n s i t u a t i o n s where areas are not defined by boundaries for which data i s r e a d i l y a v a i l a b l e and where independent projections of a larger reference area are a v a i l a b l e . The method involves calcu-l a t i n g , from census data, the r a t i o of a smaller population area to i t s reference population area. The r a t i o s may be applied to t o t a l population or to the age-sex s p e c i f i c population of both areas. The r a t i o which i s calculated can be based upon a constant (one obser-vation) or a trend period (multiple observations). This r a t i o i s then applied to an independent population p r o j e c t i o n for the l a r g e r area. Four d i s t i n c t Ratio Methods are observed i n the l i t e r a t u r e : Short, Long, Ratio C o r r e l a t i o n and Ratio Cohort. The short calcu-l a t i o n involves the bypass of h i e r a r c h i c a l d i v i s i o n s i n the popula-t i o n ; that i s , the community may be calculated against the larger reference area. In the long method the steps would follow a sequence, for example, community, d i s t r i c t , region and county or province. The r a t i o c o r r e l a t i o n involves the c o r r e l a t i o n of the r a t i o s of percent change or observed change between one area and i t s larger reference area between observation points. The r a t i o method has also been used to work backwards from a population p r o j e c t i o n towards i t s constituent parts. The disadvantage of t h i s method i s that i t r e l i e s on past data as with mathematical methods. However, i t can provide a p r o j e c t i o n , when trends are examined, that i s not overtly o p t i m i s t i c . A d i s t i n c t advantage i s the method's f l e x i b i l i t y i n a given s i t u a t i o n i n that i t can be modified without producing wide variance i n the end product. This does not imply that the f l e x i b i l i t y extends to a l l s i t u a t i o n s . The Component Methods are o f t e n used to p r o j e c t populations because they demonstrate a b e t t e r understanding of the f a c t o r s which comprise po p u l a t i o n growth and because they can present a f i n e r p i c t u r e . Methods can be combined so that a component-cohort design can be u t i l i z e d to provide age p r o j e c t i o n s which the sim p l e r compo-nent methods cannot provide. From numerous observations over time, t o t a l b i r t h s , t o t a l deaths and net m i g r a t i o n are p r o j e c t e d and t h e i r values are s u b s t i -tuted i n an equation, such that the observed p o p u l a t i o n plus projects b i r t h s minus p r o j e c t e d deaths, and plus o r minus net m i g r a t i o n y i e l d the p r o j e c t e d p o p u l a t i o n f o r the time p e r i o d d e s i r e d . The component- cohort method i n v o l v e s the a p p l i c a t i o n of a g e - s p e c i f i c v i t a l r a t e s p r o j e c t i o n s to the age-sex popu l a t i o n which i s to be pr o j e c t e d . Researchers suggest t h i s method even when the component method i s the method of choice. The cohort method u t i l i z e s a g e - s p e c i f i c f e r t i l i t y and v i t a l rates and c a r r i e s forward the l a t e s t p o p u l a t i o n by age to a s p e c i f i e d date. Some of the component methods assume zero m i g r a t i o n whereas other r e l a t e d methods t r e a t m i g r a t i o n as a d i s t i n c t component. The advantage of the component methods i s that they are more a n a l y t i c a l i n t h e i r treatment of p o p u l a t i o n change because they are p r o j e c t i n g the major components of p o p u l a t i o n change. The method als o has greater f l e x i b i l i t y i n assumptions of future growth. Compo' nent methods are not suggested where there are a great many areas to p r o j e c t and when mi g r a t i o n v a r i e s f r e q u e n t l y between regions and/or over time. The accuracy of t h i s method al s o depends upon the a v a i l -a b i l i t y and p r e c i s i o n of v i t a l s t a t i s t i c r ates f o r the sm a l l e r areas I f t h i s i n f o r m a t i o n i s not a v a i l a b l e then assumptions of n a t i o n a l or p r o v i n c i a l r a t e s may have to be a p p l i e d . S i g n i f i c a n t s h i f t s i n these v i t a l r ates may a l s o a f f e c t the p r o j e c t i o n r e s u l t s . However, these c r i t i c i s m s are a l s o r e l e v a n t to other types of p r o j e c t i o n methods i n degrees. W r i t e r s a l s o suggest the use of simpler a l t e r -n a t i v e methods where there are a l a r g e number of s m a l l area p r o j e c -t i o n s . I f the a n t i c i p a t e d r e s u l t s of a l t e r n a t i v e s are approximately the same, time, cost and d e t a i l m i t i g a t e choice. Econometric Models i n v o l v e the p r o j e c t i o n of a p o p u l a t i o n by comparing e i t h e r the p o p u l a t i o n to i t s components w i t h other economic v a r i a b l e s or i n d i c a t o r s which are f e l t to be associated w i t h popu-l a t i o n growth or change. For example, a c o r r e l a t i o n may be a p p l i e d between m i g r a t i o n and such economic v a r i a b l e s as employment, unem-ployment, income or wage l e v e l , l o c a t i o n of i n d u s t r y and economic prospects of areas. The assumption i s that past r e l a t i o n s h i p s between v a r i a b l e s w i l l continue i n t o the f u t u r e . An example of t h i s type of model i s h o l d i n g c a p a c i t y which r e l a t e s p o p u l a t i o n change w i t h the number of d w e l l i n g u n i t s , vacant d w e l l i n g u n i t s , vacant or excess l a n d , household s i z e and topography of the land. Econometric methods have the advantage of understanding the components of popu-l a t i o n w i t h a higher degree of s e n s i t i v i t y . I t i s suggested that t h i s method l i e s more a p p r o p r i a t e l y , at the present time, i n the domain of the true demographer. The s e n s i t i v i t y a p p l i e d i n t h i s type of model could be demonstrated through c o n s i d e r a t i o n of the f o l l o w i n g example: When an i n d u s t r y i n a l o c a l community closes down normally there i s a temporary o r permanent out migration of the productive p o p u l a t i o n f o r work only or for« work and permanent r e s i -dence. The age s t r u c t u r e of the community may a l s o be s e r i o u s l y 2 8 a f f e c t e d i n the sense of",having a higher percentage of young (unpro-ductive) and e l d e r l y p o p u l a t i o n (unproductive) r e l a t i v e to newly defined p o p u l a t i o n . Other Methods are a l s o i d e n t i f i e d i n the l i t e r a t u r e from time to time. The analogy method examines the experience of an area which i s deemed to be s i m i l a r to the area under c o n s i d e r a t i o n . The past trends of the "other" determines average growth patterns which i n t u r n are a p p l i e d to the area under c o n s i d e r a t i o n . The apportion- ment method, although c i t e d i n many instances as d i s t i n c t from the r a t i o method, appears i n p r i n c i p l e to be a v a r i a n t of t h i s method. The p r o j e c t e d growth of a p o p u l a t i o n ( u s u a l l y an independent c a l c u -l a t i o n ) i s prorated among i t s c o n s t i t u e n t parts according to t h e i r r e l a t i v e growth. I f a p o p u l a t i o n decreases or remains s t a b l e i n an area, the p o p u l a t i o n i n an area remains as a constant. Even very crude methods such as adding the n a t u r a l increase of the p o p u l a t i o n to the census has been used. A number of researchers have mentioned t a k i n g the average of s e v e r a l methods i n producing p r o j e c t i o n s . Although t h i s might provide a more r e l i a b l e p r o j e c t i o n , the averaging tends to minimize highs and lows which might be worthy of a n a l y s i s . F i n a l l y , there i s a method c a l l e d the v i t a l rates method which compares trends i n b i r t h r a t e s , death rates f o r l o c a l areas and compares these w i t h n a t i o n a l or r e g i o n a l r a t e s . C i t a t i o n s from the 1950's, 1960's and 1970's confirm that there i s as yet no s i n g l e method which can be a p p l i e d i n a l l s i t u a -36 t i o n s . The v a r i e t y of methods has a r i s e n because p o p u l a t i o n para-meters are o f t e n i l l - d e f i n e d , s i t u a t i o n s r e q u i r e a t a i l o r e d method, and there are d i f f e r e n c e s i n the a v a i l a b i l i t y and q u a l i t y of l o c a l area data. S i e g e l s t a t e d i n the 1950's that " i t i s not p o s s i b l e to 29 37 f o r e c a s t the p o p u l a t i o n of small geographic areas a c c u r a t e l y . " Grauman, i n the 1960's, addressed the search f o r a r o u t i n e and f l e x i b l e method of a l l s i t u a t i o n s as being " l i k e the attempt to 38 c i r c l e the square." Gnanasekaran, i n the 1970's, suggested that the "need f o r research can h a r d l y be over-emphasized" i n the attempt 39 at f i n d i n g a s u p e r i o r method f o r p r o j e c t i n g l o c a l area p r o j e c t i o n s . What these authors conclude i s that the contention that one method i s s u p e r i o r to others does not hold water because each method, r e l -a t i v e to givens of s i t u a t i o n , time p e r i o d or p o p u l a t i o n s i z e , can be considered as accurate as any other method. When e s t a b l i s h i n g the appropriateness of method, accuracy, time, and cost c o n s i d e r a t i o n s balance between the statements of choice and the marginal r e t u r n of increased accuracy. I n other words, the ease i n method of simpler p r o j e c t i o n s may f a r outweigh the more complicated measures when r e s -u l t s approximate each other. Accuracy of Subnational P o p u l a t i o n P r o j e c t i o n There are a number of w r i t e r s who s t a t e without t e s t i n g that the v a r i o u s p r o j e c t i o n methods are s i m i l a r i n t h e i r accuracy. There are a l s o w r i t e r s who suggest the use of one method over another. Two of the more encompassing t e s t s and r e p o r t s on accuracy are provided 40 41 42 by White and S e i g e l both of which are c i t e d by Gnanasekaran who s t a t e s that more t e s t i n g i s r e q u i r e d . White concludes that no one method provides a c l e a r l y super-i o r edge on accuracy. In v a r i o u s t e s t s of the wide range of methods against v a r i o u s c o n t r o l s , the c o h o r t - s u r v i v a l w i t h m i g r a t i o n , appor- tionment and the r a t i o I I methods make c o n s i s t e n t l y b e t t e r p r o j e c t -ions c o n s i d e r i n g average percentage of e r r o r and percentage 30 e r r o r s exceeding 10% f o r both the 10-year and 20-year p r o j e c t i o n s . The r a t i o I I method assumes that the percentage increase i n popu-l a t i o n i n an area i s the same as that experienced by the n a t i o n a l p o p u l a t i o n . In 20-year p r o j e c t i o n s , e r r o r s on the average, are twice that of 10-year p r o j e c t i o n s . On average percent e r r o r i n 10-year p r o j e c t i o n s , these methods scored i n the 5 to 6% range whereas the o v e r a l l average was 7% i n a l l 10-year p r o j e c t i o n s . S e i g e l concludes i n h i s study that f o r e c a s t s beyond 15 years are u s e l e s s . With a f o r e c a s t p e r i o d of 10 years, the average e r r o r was 8.4% w i t h more than 25% of these i n v o l v i n g e r r o r s of 10% or more. The r a t i o method was scored at 5.7%, the c o h o r t - s u r v i v a l was scored 5.9% and the simpler component method was scored at 10.3%. The average e r r o r f o r estimates of 5 years or l e s s was 7.5% and f o r estimates between 5 and 10 years 9.5%. The f i n d i n g s of t h i s study correspond w i t h the f i n d i n g s presented by White. I n terms of acc-uracy S e i g e l has t h i s to say: In view of the negative evidence so f a r regarding the s u p e r i o r i t y of the more elaborate over the more simpler methods of making s m a l l area f o r e c a s t s , i t should be recognized that no c o n s i s t e n t demand can be p r o p e r l y made at t h i s time f o r the use of more elaborate methods on the grounds of accuracy of r e s u l t s . A b a s i c set of p r i n c i p l e s which promote the accuracy of pop-43 44 u l a t i o n p r o j e c t i o n s or f o r e c a s t s are drawn from S e i g e l , White, Gnanasekaran,^ and Grauman.^ The p r i n c i p l e s are as f o l l o w s : (a) ^Errors increase d i r e c t l y w i t h the l e n g t h of p r o j e c t i o n . Twenty-year p r o j e c t i o n s on the average have twice as many e r r o r s as 10-year p r o j e c t i o n s . (b) Rate of e r r o r s decreases as p o p u l a t i o n s i z e i n c r e a s e s . (c) Rate of e r r o r s decreases as observed economic bases become more d i v e r s i f i e d . 31 (d) There i s inherent danger i n u t i l i z i n g a constant rate of growth over co n s i s t e n t l y long periods because unique s h i f t s i n rates may be missed. (e) Accuracy i s dependent upon the q u a l i t y of data: that i s , the accuracy of census data, v i t a l s t a t i s t i c s data or rates of projections which are r e l i e d upon. (f) Rate of errors tends to be larger i n areas that experience wide fluctuations i n migration. (g) Where the population i s considered to be stable i n both past and present, l e s s a n a l y t i c a l models may be more appro-p r i a t e . (h) No one method of population p r o j e c t i o n i s c l e a r l y superior. Therefore, the choice of method must rest with appropriate-ness of s i t u a t i o n and of time and cost. (i ) The average forecast range i s generally between 10 and 20 years. (j) In evaluating accuracy,Seigel (1953),noted the following two p r a c t i c a l d i f f i c u l t i e s which he stated appeared quite frequently. i . "the inadequacy of the methodological statement given i n a report or the numerous v a r i a t i o n s of a p a r t i c u l a r method which may be employed rendering d i f f i c u l t or impossible the important c l a s s i f i c a t i o n i n terms of type of method." i i . "the f a i l u r e of the author to specify the actual base date of forecasts rendering d i f f i c u l t or impossible the important allowance for the length of the forecast period." Note. Errors are defined as the quantity of errors and as a per-centage difference between projected and a c t u a l population fig u r e s . The Temporal R e l i a b i l i t y and Relationship Between  Forecasting and Health Planning As stated previously, both a p r o j e c t i o n and p r e d i c t i o n are involved i n a r r i v i n g at a statement of required beds. Previously i t was noted that population was the key independent v a r i a b l e i n health planning. I t follows that the p r e d i c t i o n period f o r health planning must ne c e s s a r i l y follow the guidelines established which enhance the r e l i a b i l i t y of po p u l a t i o n p r o j e c t i o n s . Most w r i t e r s agree that f o r e c a s t s and p r o j e c t i o n s should f a l l between f i v e and f i f t e e n years. P r o j e c t i o n s beyond t h i s p o i n t reduce accuracy considerably. However, planners and f o r e c a s t e r s are sometimes asked to make p r o j e c -t i o n s of twenty years or more. In these cases there has to be an e x p l i c i t assumption that the future s t a t e i s l i m i t e d . P a r t i c u l a r l y i n these cases, a range of hi g h , medium and low are given. Based upon the assumptions of r e l i a b i l i t y , the d e c i s i o n maker chooses h i s p r o j e c t i o n . From the review of bed f o r e c a s t i n g formulas most h e a l t h planners d i d not commit themselves to a p e r i o d greater than f i f t e e n years. I n v a r i a b l y , the p e r i o d of choice i s between f i v e and ten years. Although reasons are not o f t e n given f o r f o r e c a s t l e n g t h , there are i m p l i e d assumptions which conform to theory and p r a c t i c e . In the e x p l i c i t s t a t e , a number of p l a u s i b l e arguments can be o f f e r e d f o r a f i v e to ten-year p r o j e c t i o n o r f o r e c a s t (short term), which i n the opinion of the w r i t e r , i s a more appropriate planning c y c l e than a p e r i o d over f i f t e e n years (long term). In t h i s context, a medium expe c t a t i o n of r e l i a b i l i t y would be a n t i c i p a t e d f o r the ten to f i f t e e n - y e a r c y c l e s . A long term p l a n can mean the d e d i c a t i o n of current resources to a future course of a c t i o n which i s h i g h l y u n c e r t a i n . A l t e r n a -t i v e l y , i t may als o c a l l f o r a f u t u r e l e v e l and a v a i l a b i l i t y of resources which may als o be u n c e r t a i n ; A long term plan allows enough time f o r unexpected s h i f t s i n the f a c t o r s which determine demand i n the f u t u r e . Examples might i n c l u d e the age-sex d i s t r i b u -t i o n , economic s t a b i l i t y , m i g r a t i o n , l e v e l of education or income. How does one p r e d i c t t e c h n o l o g i c a l advances p a r t i c u l a r l y i n a f i e l d where advances are very rapid? There i s a heavy cost i m p l i c a t i o n a t two p o i n t s f o r long range plans i f there i s a major d e v i a t i o n from the plan. There i s the cost of a l t e r a t i o n and new plans (and resources which might not be used f u r t h e r ) , and there i s the cost of modifying systems or resources introduced i n phases of the o r i g i n a l p l a n so that they conform to the new p l a n . Long range planning a l s o presupposes a p o l i t i c a l s t a b i l i t y and the n o n - a r b i t r a r y i n t e r v e n t i o n of p r i o r i t i e s and p h i l o s o p h i c a l underpinnings. A very decided advantage to long range planning i s that there i s a s p e c i f i c goal on the h o r i z o n . The path i n t o the future w i t h short term plans may be very haphazard or incremental i n nature. In other words, the p a r t may not r e l a t e to the whole. Long range planning, t h e r e f o r e , o f f e r s a higher p r o b a b i l i t y of a f u n c t i o n i n g and coordinated system. With the propensity of h e a l t h care systems to maintain what they have i n resources and programs, there i s an ever i n c r e a s i n g focus upon cost and a c c o u n t a b i l i t y , f o r example, zero base budgeting i s being promoted f o r a l l areas of government. The i n t e n t of zero base budgeting i s that programs must have t h e i r purpose and operating l e v e l j u s t i f i e d each year. In the same v e i n , a s h o r t term p r o j e c t i o n forces a more frequent a p p r a i s a l . The path may be t e n t a t i v e or incremental i n nature, but r e l a t i v e to the d i s t r i b u t i o n of very c o s t l y resources t h i s approach would tend to minimize e r r o r . A ten-year p r o j e c t i o n (and to f i f t e e n years) allows age cohorts to move to d i f f e r e n t u t i l i z a t i o n and morbidity l e v e l s . F i v e years may be enough time to experience dramatic changes i n medical and r e l a t e d technologies. To t h i s extent short term plans would be more respon-s i v e . 34 To summarize, the main reason that a short forecasting term should be used i s that accuracy i s s u b s t a n t i a l l y increased, ceretus  parabus i n comparison to long range forecasting. Inaccuracies may produce services and resources which are both c o s t l y and unsatis-factory to the public and government. Summary I n i t i a l l y i t had been stated that the factors associated with u t i l i z a t i o n formed a broad spectrum. These can be derived s c i e n t i f i c a l l y or l o g i c a l l y but s e l e c t i o n of factors f or analysis i s unique to a s i t u a t i o n , even though there may be general a p p l i c a -b i l i t y . This i s so because need or demand are " s o f t ; " that i s , there i s a heavy re l i a n c e upon standards many of which have a q u a l i -t a t i v e base. For any health s t a t i s t i c a l system to function properly i n r e l a t i o n with a health planning function, demographic, morbidity and u t i l i z a t i o n data must be a v a i l a b l e and interdependent. One v i t a l element of forecasting future l e v e l s of resources i s the necessity for a thorough analysis of the present s i t u a t i o n . Current resources must, therefore, be re l a t e d to the current population consuming these resources. The technique of forecasting whether i t i s population, u t i l i z a t i o n rates or l e v e l of resources to be consumed takes i t s design and method from the problem of focus. Of importance i s that the choice of approach has to be c r e d i b l e ; i t has to l a y i t s assump-tions before the decision maker for examination, v a l i d a t i o n and a p p l i c a t i o n . It i s through.this process that research and p r a c t i c e are blended. 35 Chapter I I Footnotes *"G. A. H. P i e r c e , "Bed Need Determination i n Canada" (Diploma Thesis, U n i v e r s i t y of Toronto, 1967), pp. 1-62. 2 Robin E. MacStravick, Determining Health Needs (Ann Arbor, Michigan: Health A d m i n i s t r a t i o n P r e s s , 1978), pp. 73-135. 3 D a n i e l M. H a r r i s , " E f f e c t of Po p u l a t i o n and Health Care Environment on H o s p i t a l U t i l i z a t i o n , " Health Services Research ( F a l l 1975) : 229-242. 4 George H. Brooks and H e n r i L. Beenhakker, "A New Technique f o r P r e d i c t i o n of Future H o s p i t a l Bed Needs," H o s p i t a l Management (June 1964): 47-50. ^Vincente Navarro, "Planning f o r the D i s t r i b u t i o n of Personal Health S e r v i c e s , " P u b l i c Health Reports 84 ( J u l y 1969): 573-581. Avedis Donabedian, Aspects of Medical Care A d m i n i s t r a t i o n : S p e c i f y i n g Requirements f o r Health Care (Cambridge, Mass.: Harvard U n i v e r s i t y P ress, 1973), pp. 532-639. ^B. C. Das and Rhea S. Das, "Some I m p l i c a t i o n s of Age-S p e c i f i c M o r t a l i t y , H o s p i t a l i z a t i o n and M o r b i d i t y f o r the Planning of H o s p i t a l S e r v i c e s , " i n Studies i n Demography, eds. Ashish Base, P. B. Desai and S. P. J a i n (Chapel H i l l , N.C: U n i v e r s i t y of North C a r o l i n a P r e s s , 1970), pp. 262-281. Rachel Doyle, Joseph A. Z i e g l e r , Mary Jo Grinstead and Bernard L. Green, "Estimating H o s p i t a l Use i n Arkansas," P u b l i c  Health Reports 92 (May/June 1977): 211-216. 9 Margaret B r i g h t , "The Demographic Base f o r Health P l a n n i n g , " i n Health Pl a n n i n g : Q u a l i t a t i v e Aspects and Q u a n t i t a t i v e Techniques, ed. by W i l l i a m A. Reinke (Baltimore: John Hopkins U n i v e r s i t y , 1972), pp. 138-157. 1 0Das and Das, pp. 262-281. * '''Francis M. 0. Umenyi, Trends i n U t i l i z a t i o n of Newborn and  O b s t e t r i c S e r v i c e s : I m p l i c a t i o n s f o r Future Demand (Ottawa: S t a t i s t i c s Canada, A p r i l 1978), pp. 1-74. 12 C. J . P f e i f f e r , J . C. Fador and E. J . Canning, "An Epide-m i o l o g i c a l Study of Hypertension i n Newfoundland," Canadian Medical  A s s o c i a t i o n _ J o u r n a l 108 (1974): 1374-1380." 13 Personal communication w i t h Dr. J . C. Fador, E p i d e m i o l o g i s t , Community Medicine, Memorial U n i v e r s i t y , St. John's, Newfoundland, 15 August 1979. 36 14 John Wennberg and Alan G i t t e l s o h n , "Small Area V a r i a t i o n s i n Health Care D e l i v e r y , Science 182 (December 1973): 1102-1108. 1 5 R o b i n E. MacStravick, pp. 73-135. 16 Wayne R. S i b o l e , "The Impact of Bed Planning Standards," H o s p i t a l A d m i n i s t r a t i o n i n Canada (May 1976) : 34-37. 1 7Wennberg and G i t t e l s o h n , pp. 1102-1108. 18 David F. Bergwall, P h i l l i p N. Reeves and Nina B. Woodside, I n t r o d u c t i o n to Health Planning (Washington, D.C.: Information Resources Press, 1974), pp. 61-76. 19 Nathan K e y f i t z , A p p l i e d Mathematical Demography (New York: John Wiley and Sons, 1976), pp. 210-236. 20 Roland P r e s s a t , Demographic A n a l y s i s (Chicago: A l d i n e -A l b e r t o n , 1972), pp. 363-370. 21 Robin E. MacStravick, pp. 73-135. 22 Bergwall, Reeves and Woodside, pp. 61-76. 23 Navarro, pp. 573-581. 24 Bergwall, Reeves and Woodside, pp. 61-76. I b i d . 26 Meyer Z i t t e r and Henry S. Shryock, J r . , "Accuracy of Methods of Preparing Postcensal P o p u l a t i o n Estimates f o r States and L o c a l Areas," Demography 1:1, 1964, pp. 227-241. 27 Reinhold Wolff, "The F o r e c a s t i n g of Pop u l a t i o n by Census Tracts i n an Urban Area," Land Economics 27 (November 1951): 379-383. 28 Jacob S. S i e g e l , " F o r e c a s t i n g the P o p u l a t i o n of Small Areas," Land Economics 29 (February 1953): 72-87. 29 Robert C. Schmitt and A l b e r t H. C r o s e t t i , "Short Cut Methods of F o r e c a s t i n g C i t y P o p u l a t i o n , " J o u r n a l of Marketing 17, 1953, pp. 417-424. 30 Robert C. Schmitt and A l b e r t H. C r o s e t t i , "Accuracy of the Ratio Method: Rejoinder," Land Economics 28 (May 1952) : 183-184. 31 Z i t t e r and Shryock, J r . , pp. 227-241. 32 Mortimer Spiegelman, I n t r o d u c t i o n to Demography, rev. ed. (Cambridge, Mass.: Harvard U n i v e r s i t y Press, 1968), pp. 410-415. 33 John V. Grauman, "Po p u l a t i o n Estimates and P r o j e c t i o n s , " i n The Study of P o p u l a t i o n : An Inventory and A p p r a i s a l , eds., P h i l l i p M. Hauser and O t i s Dudley Duncan (Chicago: U n i v e r s i t y of Chicago Press, 1969), pp. 554-565. 37 34 Ber g w a l l , Reeves and Woodside, pp. 61-76. 35 Bureau of the Census, The Methods and M a t e r i a l s of Demo-graphy, V. 2 (Washington, D.C: U.S. Department of Commerce, 1966), pp. 793-806. 36 K. S. Gnanasekaran, "Data Base and Methodological Problems i n Preparing Small Area P o p u l a t i o n P r o j e c t i o n s , " Ottawa: S t a t i s t i c s Canada, 1975, pp. 1-8. (Paper.) Ibid. 38 S i e q u e l , pp. 72-87. 39 V. Grauman, pp. 554-565. ^Gnanasekaran, pp. 1-8. ^ H e l e n R. White, " E m p i r i c a l Study of the Accuracy of Selected Methods of P r o j e c t i n g State Populations," J o u r n a l of the  American S t a t i s t i c a l A s s o c i a t i o n 49: 207 (September 1954), pp. 480-498. 42 S i e g e l , pp. 72-87. 43 Gnanasekaran, pp. 108. 44 S i e g e l , pp. 72-87. 4 5 W h i t e , pp. 480-498. 46 Gnanasekaran, pp. 1-8. ^Grauman, pp. 554-565. CHAPTER I I I RESOURCE (BED) DISTRIBUTION MODELS Bed Planning Models P r i o r to d i s c u s s i n g the various categories of bed planning models a number of comments are i n order. In the l i t e r a t u r e many of the bed planning, p r e d i c t i o n or determination models are not e x c l u -s i v e to t h e i r own branch of planning. The word 'bed' can be replaced by the generic term, "resource." The type of bed planning model, t h e r e f o r e , describes a general approach to the d i s t r i b u t i o n of resources e i t h e r i n the present or i n the f u t u r e . J u s t as there i s no one rou t i n e or s u p e r i o r method f o r p r o j e c t i n g s m a l l area popula-t i o n s , there i s yet no one r o u t i n e or s u p e r i o r model f o r determining or planning beds i n the f u t u r e . * The choice of a bed planning model belongs to both the s i t u a t i o n and to the d e c i s i o n maker. The model i s as accurate as i t s assumptions and use by a d e c i s i o n maker who understands i t s l i m i t a t i o n s and who has the necessary s k i l l s and 2 data to apply the model. There have been many methods developed to determine current and future bed requirements. These vary from the very simple bed to popu l a t i o n r a t i o method to the more complex methods, which attempt to acknowledge and inco r p o r a t e the many f a c t o r s which may be asso-c i a t e d w i t h the u t i l i z a t i o n of a bed. S i m i l a r l y , planning perspec-t i v e s have undergone a gradual s h i f t from the aggregate po p u l a t i o n 38 39 base to the more s p e c i f i c and l o c a l i z e d needs expressed i n the population. Regardless of the perspective and model, four c r i t i c i s m s are common to both. F i r s t , most models deal only with demand, and therefore, overlook the influence of supply. Second, demand i s often treated as representative of the population's morbidity. Third, demand frequently i s comprised of few components. Fourth, d i r e c t morbidity data i s seldom u t i l i z e d for c a l c u l a t i o n s . These c r i t i c i s m s could be handled i n one formula but i t would be a monu-mental task i n time, energy and money. More important, planners and decision makers operate under constraints. The s t r a t e g i c constraint i n a modelling design and a p p l i c a t i o n i s that what i s relevant i n one s i t u a t i o n at one point i n time may not be relevant i n another s i t u a t i o n or time. What i s appropriate for the researcher may not be p r a c t i c a l f o r the administrator. To continue the present discussion of bed planning models a si x - p a r t c l a s s i f i c a t i o n schema was developed from the observations 3 4 5 of Donabedian, Navarro and MacStravick. The types of bed planning models are: I) U t i l i z a t i o n II) M u l t i p l e Factor III) D i s t r i b u t i o n a l Analysis IV) Non-Formal or Consensus V) Standards VI) Mu l t i p l e Methodology U t i l i z a t i o n s This method e n t a i l s the use of a bed related u t i l i z a t i o n rate such as admissions, separations or patient days expressed as a use rate per thousand population. The resultant rate i s then mani-pulated by standards through the use of simple mathematics. The use ra t e may be past , current or p r e d i c t e d . The e n t i r e formula's c a l c u -l a t i o n can be used to analyze the d e f i c i e n c i e s of the current s i t u a t i o n or to provide a statement of expected resources. Below are t y p i c a l formulas: Rate x Standard m , „ . , „ , 1) -rrs 7TZ 3 1— = T o t a l Required Beds 365 x Standard Admissions per Thousand Current P o p u l a t i o n (projected) x 2% P o p u l a t i o n x Average Length of Stay  365 days x Occupancy Rate = T o t a l Required Beds ^ Beds per Thousand Current P o p u l a t i o n x P r o j e c t e d P o p u l a t i o n = T o t a l Required Beds The rates method i s the most fr e q u e n t l y encountered. I t e x i s t s i n various forms such as: the bed to death or b i r t h r a t i o which assumes a constant r e l a t i o n s h i p between the event and bed;^ and the c r i t i c a l number of beds ( i n two forms) which i s computed by m u l t i p l y i n g average d a i l y census by average lengths of stay and d i v i d i n g by 365 days. A l t e r n a t i v e l y , average d a i l y census j u s t equals the req u i r e d beds. To these c a l c u l a t i o n s an a r b i t r a r y adjustment i s made to inc o r p o r a t e peak periods or to in c l u d e the 7 8 w a i t i n g l i s t . ' The same type of a r b i t r a r y adjustment i s made i n the H i l l - B u r t o n Formula of the United States. The average d a i l y census, however, i s f i r s t adjusted by an occupancy standard. The c r i t i c i s m s of t h i s model are numerous and are worth d i s c u s s i n g because they are a l s o germane to the other models. A bed rate formula assumes that i t i s the s i z e of the popu l a t i o n which determines the beds and i s , t h e r e f o r e , a trend c o r r e l a t i o n s i m i l a r 9 to the bed death r a t i o formulas. Bed rat e s imply that a l l the beds are a v a i l a b l e to the p o p u l a t i o n ^ and that the beds and r e l a t e d s e r v i c e s are the same and can meet a l l the population's d i f f e r i n g 1 1 1 2 m o r b i d i t y p a t t e r n s . ' The c r i t i c a l number has f a c t o r s which are 1 3 not independent and demand c o n s t i t u t e s a greater number of f a c t o r s . Using current u t i l i z a t i o n p r o t e c t s the status quo and a m p l i f i e s any defects which are i n the system. Of the standards used i n the formula, Shonick's r e a c t i o n i s tempered w i t h qu e s t i o n s : What i s the 1 4 proper occupancy rate? average length of stay? or bed rate? Roemer suggests that supply i n f l u e n c e s demand.*"' Beside these c r i t i c i s m s are advantages of speed, of ease, and of f l e x i b i l i t y i n a d j u s t i n g 1 6 standards to produce a range of values.. Donabedian s t a t e s that these methods can be used a c c u r a t e l y i n the hands of a s k i l l f u l a d m i n i s t r a t o r o r d e c i s i o n maker.^ The changing p e r s p e c t i v e of many planners from the aggregate to the s p e c i f i c needs of populations has l e d many to r e f i n e methods. These refinements are being added to simple formulas which continue 1 8 to s u r v i v e because no s u p e r i o r method as yet has been found. The refinements discussed below are i n t e r e s t i n g because they demonstrate t a i l o r i n g to a s i t u a t i o n . Umenyi ( 1 9 7 7 ) d i s p l a y s a number of refinements: a d j u s t i n g the length of stay to provide a range of bed requirements; and using a simple formula i n conjunction w i t h a thorough a n a l y s i s of nine 1 9 v a r i a b l e s i n es t i m a t i n g maternal and newborn bed requirements. MacStravic employs a simple model w i t h f o u r c r i t e r i a of a v a i l a b i l i t y 2 0 2 1 and choice of h o s p i t a l , u n i t , and bed. Laine and Wilson and 2 2 Caldwell c a l c u l a t e beds by region using r a t e s per catchment popu-l a t i o n and p a t i e n t flow. Laine and.Wilson f u r t h e r r e f i n e by u t i l i z i n g group standards and c a l c u l a t i n g , beds by s e r v i c e . Dufour combines average d a i l y census, p o p u l a t i o n p r o j e c t i o n s and u t i l i z a t i o n p atterns 23'; by c l i n i c a l s e r v i c e and by age-sex c a t e g o r i e s . " Karniewicz a p p l i e s a normal d i s t r i b u t i o n to coronary incidence by h o s p i t a l to check the reasonableness of the incidence which i s then i n s e r t e d i n t o a simple formula. M u l t i p l e Factor A n a l y s i s This method, as described by F e l d s t e i n , i s a " r e l a t i o n between current demand and p o p u l a t i o n and economic c h a r a c t e r i s t i c s . Beds are then b u i l t to s a t i s f y f u t u r e demand p r e d i c t e d by the f o r e -cast equation of values of p o p u l a t i o n c h a r a c t e r i s t i c s , again, to 25 a l l o w the c a p a c i t y f o r random f l u c t u a t i o n . " The use of m u l t i p l e 26 r e g r e s s i o n i s c h a r a c t e r i s t i c of t h i s method. Brooks and Beenhaker give a very good idea of the complexity of r e l a t i o n s h i p s and f a c t o r s i n a h o s p i t a l s e t t i n g . They p r e d i c t demand f o r 17 s e r v i c e s using 3-4 v a r i a b l e s f o r each s e r v i c e . They had i n i t i a l l y s e l e c t e d 117 27 v a r i a b l e s f o r examination. Doyle et a l . use r e g r e s s i o n to estimate the p r o b a b i l i t y of h o s p i t a l i z a t i o n which i s then a p p l i e d to the p o p u l a t i o n and average le n g t h of stay by age to y i e l d h o s p i t a l bed days, a f a c t o r f o r the convention formula. Simulation has a l s o been experimented w i t h and queuing theory has been adapted f o r s o l u -28 t i o n s to both c r i t i c a l number of beds and w a i t i n g l i s t . Regression, s i m u l a t i o n , and queuing theory seem to be l a r g e l y confined to l o c a l s e t t i n g s such as h o s p i t a l s or c l i n i c a l s e t t i n g s . Two requirements of t h i s model are that the user must have a l a r g e a v a i l a b l e and s p e c i f i c data set and must have an i n t i m a t e knowledge of systems s t r u c t u r e s and r e l a t i o n s h i p s of the h o s p i t a l or s e r v i c e which he i s observing. These requirements make the task of a p p l i -c a t i o n to a number of regions or l a r g e areas more d i f f i c u l t . The advantage of the r e g r e s s i o n i s a greater d e a l of understanding and accuracy to the p r e d i c t i o n of demand but as mentioned p r e v i o u s l y i t i s r e l a t i v e to the s i t u a t i o n at hand. However, r e g r e s s i o n techniques deal only w i t h demand and the p o s s i b i l i t y of o m i t t i n g a key v a r i a b l e 29 increases the s i g n i f i c a n c e of e r r o r s . D i s t r i b u t i o n A n a l y s i s This model assumes that there i s a p a t t e r n to the presenta-t i o n of p a t i e n t s f o r admission and that the p a t t e r n can be described by a d i s t r i b u t i o n curve. In simple terms, the c r i t i c a l number of beds i s adjusted which insures that the beds w i l l be o v e r - f i l l e d on one to f i v e days out of a hundred. The adjustment i s a m u l t i p l e of the standard d e v i a t i o n and the insurance i s a p r o b a b i l i t y that the beds determined w i l l not be exceeded ( p a t i e n t s turned away) given the p a t t e r n of admissions each day. The method normally used i s the poisson d i s t r i b u t i o n , a skewed form of the binomia l d i s t r i b u t i o n which r e q u i r e s c o n s i s t e n t observations that are random and indepen-30 31 dent i n nature. ' The key advantage of t h i s method i s that the number of beds can be c a l c u l a t e d from one type of i n f o r m a t i o n : the mean average d a i l y census. T y p i c a l l y , the poisson technique i s a p p l i e d to s e r v i c e beds which do not have e l e c t i v e s or co n t a i n a lower percentage of e l e c t i v e s , steady or long term care, m e d i c a l / s u r g i c a l care and o b s t e t r i c a l care. However, Lichterman and Gulinson have a p p l i e d the technique to each of the bed s e r v i c e s i n a h o s p i t a l on the assumption that the e r r o r s 32 are not s i g n i f i c a n t . ::>;> As the average d a i l y census increases the d i f f e r e n c e between t o t a l beds and mean number of beds i s sm a l l e r than i t would be f o r 33 34 a sm a l l e r h o s p i t a l or s e r v i c e . Normile and Z i e l propose s e r v i c e s which are f l e x i b l e ; that i s , the beds can be increased or decreased to s u i t the average d a i l y censusi This has an e f f e c t on occupancy 35 while maintaining a high service or protection l e v e l . Shonick suggests the increasing of d a i l y census by aggregating service catchment area. However, t h i s not only produces e f f i c i e n c y but i t 36 37 reduces a c c e s s i b i l i t y . Two a r t i c l e s , by Weckworth and Blumberg, provide very p r a c t i c a l applications of the poisson formula. Refinements to this method include: a p p l i c a t i o n with c r i t e r i a 38 of distance, occupancy and service l e v e l ; incorporation with the concept of d i s t i n c t patient f a c i l i t y (patient and f a c i l i t y are 39 exclusive to each other under normal conditions); and a p p l i c a t i o n to the c r i t i c a l number of beds so that an allowance i s made f o r bed turnover i n t e r v a l which r e s u l t s from i n e f f i c i e n c i e s or maintenance a c t i v i t i e s . Shonick u t i l i z e s a refined d i s t r i b u t i o n c a l l e d CENSA which he believes i s more representative than poisson. C l e a r l y , writers f e e l that the poisson technique should not be used unless i t s s t a t i s t i c a l assumptions f i t the s i t u a t i o n . The more important refinement of this model i s that i t forces a perspective to a l e v e l of service f o r the population with e f f i c i e n c y as a function of service. Simpler methods use occupancy adjustment which assumes e f f i c i e n c y and an a b i l i t y to meet service l e v e l s . However, the a r t i c l e s c i t e d demonstrate that t h i s i s not ne c e s s a r i l y so and that service l e v e l s are very often exceeded. Non-Formal and Consensus Non-formal methods are those which do not apply conventional or mathematical models. In many cases they w i l l also lack formality. 40 Donabedian describes a consensus model c a l l e d the delphi technique. This technique i s a formal process which involves an o r i g i n a l l i s t i n g of variables which i s passed to a group f o r consensus. Through a process of r e p e t i t i o n and refinement, a f i n a l l i s t of v a r i a b l e s i s prepared which has the consensus of a l l members. Some st u d i e s have s t a t e d that i n the development of t h e i r model, standards such as bed r a t e s and occupancy from other study areas were examined. Presum-ab l y , t h i s e s t a b l i s h e d a consensus f o r the parameters of the model or f o r the standards which were to be employed. S i m i l a r l y , a meeting of planners or a d m i n i s t r a t o r s i n which a bed r a t e i s decided through observation and argument c o n s t i t u t e s a non-formal mechanism. The c h i e f disadvantage of t h i s d i s t r i b u t i v e method i s that i t i s h i g h l y s u b j e c t i v e even though experts are used. However, the r e s u l t s which are a p p l i e d may be v a l i d as has been s t a t e d p r e v i o u s l y . Standards This method n e c e s s a r i l y overlaps w i t h previous models because the b a s i c formulae i n v o l v e the choice of an occupancy, a l e n g t h of stay or a bed r e l a t e d use r a t e standard. This standard can be derived by analogy, from past u t i l i z a t i o n or current u t i l i z a t i o n and by assumption based on experience. The standards model i s s e t apart from others by the o v e r a l l f o r c e which a standard impacts on the model. In Nova S c o t i a a bed r a t i o of 4.5 acute care beds per thou-sand p o p u l a t i o n i s used. The method to d i s t r i b u t e beds i s a c a l c u -l a t i o n i n v o l v i n g l o c a l i t y , number of separations, percent of t o t a l m u n i c i p a l s e p a r a t i o n s , current year p o p u l a t i o n served and p o p u l a t i o n estimates. The model assumes d i s t r i b u t i o n to r e g i o n a l or area needs yet the d i s t r i b u t i o n i s confined by the standard of 4.5 beds which 41 i m p l i e s that area needs do not d i f f e r from the standard. 42 The model used by Laine and Wilson not only p o i n t s to a r e f i n e d use of standards but a l s o to the problems inherent i n any standard. In t h i s model a bed r a t i o standard i s chosen f o r each region (defined by a catchment p o p u l a t i o n ) . Each h o s p i t a l i n a region i s grouped by rated bed s i z e . An acceptable occupancy standard i s e s t a b l i s h e d by group performance. W i t h i n h o s p i t a l , by d i a g n o s t i c category, a standard l e n g t h of stay i s e s t a b l i s h e d . As i s p o i nted out i n the study, c a l c u l a t i o n would have been f a r e a s i e r and more p r e c i s e i f p r o f e s s i o n a l s could decide on acceptable standards of length of stay. Shonick has already been c i t e d f o r the comment, 'What i s proper? or appropriate?' S p e c i f i c reference i s made to p r o d u c t i v i t y and performance 43 44 models and to an i d e a l resource model. P r o d u c t i v i t y i s expressed as t o t a l u t i l i z a t i o n (current or expected) over the t o t a l c a p a c i t y , per resource u n i t . I f the standard i s not r e l a t e d to l o c a l produc-t i o n u n i t s , resource d i s t r i b u t i o n may be very u n s a t i s f a c t o r y . Performance can be subdivided i n t o : the d i s t r i b u t i o n of exact quan-t i t i e s of resources to meet the d e s i r e d standardjor the best p o s s i b l e mix of resources i s determined by a value w i t h i n the range of values e s t a b l i s h e d f o r a standard. The i d e a l resource u n i t such as a r e n a l d i a l y s i s u n i t determines i t s own u t i l i z a t i o n and popula-t i o n i d e n t i f i c a t i o n i s the l a s t step. S e r v i c e p o t e n t i a l i s prede-termined. This model can a l s o work i n reverse order. M u l t i p l e Methodology In the course of the present d i s c u s s i o n a number of w r i t e r s r e s o r t e d to d i f f e r e n t means i n s o l v i n g t h e i r problem. For example, given a p e d i a t r i c and o b s t e t r i c u n i t , p e d i a t r i c beds could be c a l c u -l a t e d by a conventional method and o b s t e t r i c beds could be c a l c u l a t e d through the poisson technique. The r e s u l t s would then be combined f o r t o t a l bed needs. Umenyi H J used both convention and c o r r e l a t i o n , 46 S l u t s k y used r e g r e s s i o n , poisson and queing theory. Brooks and 47 Beenhaker used m u l t i p l e r e g r e s s i o n w i t h a conventional model. The key advantage of these types of studies i s t i e d more to the f l e x i -b i l i t y i n approaching bed d i s t r i b u t i o n problems, not to mention the p o s s i b i l i t y of comparing various methods w i t h i n the study. Summary of Methods Figure 3-1 presents i n o u t l i n e form many of the key compo-nents which c h a r a c t e r i z e the models p r e v i o u s l y discussed. As presented, the components f o l l o w a predetermined order. However, t h i s does not n e c e s s a r i l y imply that each i s i n the c o r r e c t order nor that a l l the f a c t o r s have been considered. Instead, i t i s presented f o r the purpose of i l l u s t r a t i n g the various methods which could be u t i l i z e d i n determining beds. With d i s c r e t i o n , and as i l l u s t r a t e d on the o u t l i n e , a l i n e can be drawn between components to d e scribe a p a r t i c u l a r model. The p r e s e n t a t i o n o f the various types of bed planning models brings together a number of observations r e l e v a n t to both the design and a p p l i c a t i o n of these models. In the more l o c a l i z e d s e t t i n g , the v a r i e t y was greater and these t e s t i f y to the v e r s a t i l i t y of tech-niques to problem s o l v i n g . Some models i n v o l v e d m u l t i p l e techniques w h i l e others sought p r e d i c t i o n through the a n a l y s i s of a l a r g e number of v a r i a b l e s . Even w i t h the simpler methods more refinements were being added to compliment the s h i f t i n g emphasis from planning f o r an aggregate p o p u l a t i o n to planning f o r a l o c a l p o p u l a t i o n . Yet the focus of these models i s a formula common to a l l (average d a i l y .. census equals r e q u i r e d beds). The d i f f e r e n c e s i n approaches a r i s e 1 P r o b l e m f o c u s O CO c ro rt- Qt (—' H- » 3 n> c O F-M» It • (0 * 3 M ro ro H 3 M rt 1 *1 M JU S O O rt a o ro I-l I-* ca ca G e n e r a l O r i e n t a t i o n D a t a B a s e O e m a n d o r M e e d F a c t o r s A n a l / s i s o f D a t a B a s e B e d R e o u i r e m e n t M o d e l R e s u l t s A n a l y s i s O e s i r e d A d j u s t m e n t s A n d / O r R e l e v a n t I s s u e s D i s t r i b u t i o n o f 8eds F o c u s . 8*7 49 from the many i n t r i c a t e r e l a t i o n s h i p s between variables associated with u t i l i z a t i o n , the designer and the many q u a l i t a t i v e judgements often required i n health planning. , Each type of model, therefore, has i t s own assumptions and each i n i t s own way contributes to a better understanding of what i s or i s not relevant to d i s t r i b u t i n g resources. As variables are acknowledged and selected, the l i m i t a t i o n s of a bed planning model become known. The model's a p p l i c a t i o n i s therefore enhanced. As has been stated on numerous occasions, there i s as yet no one model which i s superior to another. The p r a c t i c a l i t y and r e s u l t s of a bed planning model are dependent upon assumptions, s i t u a t i o n , data a v a i l a b i l i t y q u a l i t y , etc., which are the very reasons c i t e d i n population models. Therefore, the design of a bed planning model i s l e f t to the ingenuity and reason of the planner, under assumptions that can be val i d a t e d by decision makers who are associated with or know the problem. Description of Three Bed Planning Models  at Higher P o l i c y Making Levels The following three examples of bed planning models are presented i n d e t a i l to i l l u s t r a t e both the approach and methods which are being used at the government or regional l e v e l . These models also demonstrate current thinking and the s h i f t i n g of emphasis to deal with l o c a l i z e d needs, from a higher p o l i c y l e v e l than the h o s p i t a l . These approaches would be appropriate i n the Newfoundland s e t t i n g i n the sense that the data i s a v a i l a b l e or could be made ava i l a b l e f o r use i n these approaches. New Brunswick Regional Bed D i s t r i b u t i o n a l Model"'" V a r i a t i o n i n bed d i s t r i b u t i o n was noted among areas i n the province. These v a r i a t i o n s were compared w i t h bed d i s t r i b u t i o n p o l i c i e s i n other provinces. On the b a s i s of observed d e f i c i e n c i e s i n the prov i n c e , the Department of Health decided to implement a method of e q u i t a b l e d i s t r i b u t i o n ; t h e r e f o r e , planning g u i d e l i n e s were e s t a b l i s h e d f o r both the i n t e r i m o r short run and f o r the long range periods. The b a s i c d i s t r i b u t i o n v a r i a b l e was bed a l l o c a t i o n per c a p i t a . Refinements of d i s t r i b u t i o n i n c l u d e d : age d i s t r i b u t i o n , i n f l o w of out-of-province r e s i d e n t s and i n t e r - r e g i o n a l i n f l o w and outflow of New Brunswick r e s i d e n t s . At the heart of the model i s the c a l c u l a t i o n of the net p o p u l a t i o n which i s adjusted f o r i t s age s t r u c t u r e r e l a t i v e to the p r o v i n c i a l age s t r u c t u r e . In both the short term and long term model, the r a t i o of 5.5 beds per 1000 i s he l d as a p o l i c y o b j e c t i v e . Short-term Model By r e g i o n , the f o l l o w i n g bed c a l c u l a t i o n s are incorporated to step 5. 1. Beds f o r a c t u a l census pop u l a t i o n . 2. Beds due to i n f l o w from out of province. 3. Beds due to i n f l o w from other regions. 4. Beds due to outflow to other regions 5. T o t a l beds to serve net p o p u l a t i o n ( 1 + 2 + 3 ) - 4 These beds are then d i s t r i b u t e d : acute, 75%; extended care, 15%; r e h a b i l i t a t i o n , 5%; and p s y c h i a t r y , 5%. These f i g u r e s a l s o represent p o l i c y statements as to what s e r v i c e s should be a v a i l a b l e i n a region. The model excludes t e r t i a r y s e r v i c e , daycare, r e n a l 51 d i a l y s i s , hemodialysis, labour, h o l d i n g , h o s t e l , d e t o x i f i c a t i o n , recovery room, D.V.A. and D.N.D. beds which are considered s e p a r a t e l y . The t o t a l beds c a l c u l a t e d are compared w i t h what a c t u a l l y e x i s t s and the d i f f e r e n c e becomes a target f o r a c t i o n . The long range model i s a m o d i f i c a t i o n of the short-term. Both i n f l o w and outflow between regions i s e l i m i n a t e d from the c a l c u l a t i o n . The i m p l i e d assumption i s that the r e g i o n w i l l have the s e r v i c e or a l t e r n a t i v e f o r which the migrant was seeking. D i v i s i o n of H o s p i t a l and Medical F a c i l i t i e s P u b l i c Health Services Mode Donabedian drew a t t e n t i o n to the P u b l i c Health Services model because of i t s various refinements, even though conventional methods were used. His i n t e r e s t r e s t e d upon i t s s p e c i f i c data requirements: age-sex composition of the p o p u l a t i o n ; u t i l i z a t i o n by age and sex; a p r o j e c t e d use r a t e by age and sex; and a demand estimate, comprised of the preceding v a r i a b l e s , which i s c a l c u l a t e d by s e r v i c e category. The bed requirements are adjusted by a d e s i r e d occupancy l e v e l which i s p a r t i c u l a r to the c h a r a c t e r i s t i c s of the s e r v i c e . Bed requirements f o r a l l h o s p i t a l s are the summation of aggregate s e r v i c e requirements. The s e r v i c e s considered i n s h o r t -term h o s p i t a l s are O b s t e t r i c s , P e d i a t r i c s , Medical and S u r g i c a l . Long-term f a c i l i t y beds are c a l c u l a t e d using the same methodology. To summarize the methodology f o r a given number of h o s p i t a l s , the procedure i s : by s e r v i c e , the p a t i e n t day r a t i o by age and sex i s p r o j e c t e d on a future age-sex p o p u l a t i o n ; a l l age groups w i t h i n the s e r v i c e are summed to get a grand t o t a l p a t i e n t day f i g u r e , and these t o t a l days are then d i v i d e d by 365 and m u l t i p l i e d by a d e s i r e d occupancy f a c t o r . A p r i o r i , there are chronic or extended care 52 (long stay p a t i e n t s ) who occupy short-term beds. These have not been addressed i n the model even though there i s a separate c a l c u -l a t i o n f o r long-term p a t i e n t s (over 65 y e a r s ) . The medical s u r g i c a l days are c a l c u l a t e d on the e n t i r e age s t r u c t u r e and o b s t e t r i c s and p e d i a t r i c s are subtracted out. The f o l l o w i n g e x t r a c t i s taken from the t e x t of Donabedian. O b s t e t r i c a l bed use, short-term h o s p i t a l Average d a i l y census by type of s e r v i c e , short-term h o s p i t a l s Beds by type of s e r v i c e ; at s p e c i f i e d occupancy r a t i o s , short-term h o s p i t a l s D. P r o j e c t e d number of females aged 15-44 i n thousands (from a previous p r o j e c t i o n ) E. D e l i v e r i e s per 1000 i n females aged 15-44 per year (current or p r o j e c t e d rates) FV. Length of s t a y , i n days, per d e l i v e r y (current or p r o j e c t e d values) G. P r o j e c t e d p a t i e n t days of o b s t e t r i c a l care per year (D x E x F) H. P r o j e c t e d average d a i l y census f o r o b s t e t r i c a l care (D x E x F) v 365 Pr o j e c t e d beds f o r o b s t e t r i c a l care at 75% occupancy L v .75 H o s p i t a l Bed Requirements: An Occupancy Factor  Determination Approach 197<PU The • Occupancy Factor Determination model proposed by the authors was a p p l i e d to the C i t y of Chicago Health Service Area and Suburban Health Service Area. The key concepts employed are poisson d i s t r i b u t i o n , d i s t i n c t p a t i e n t f a c i l i t y (D.P.F.), p r o t e c t i o n l e v e l , out of s e r v i c e beds (due to maintenance, remodelling, e t c . ) , pro-tected occupancy (the average d a i l y census d i v i d e d by the number of beds r e q u i r e d f o r a D.P.F.,- which represents maximum occupancy). A d i s t i n c t p a t i e n t f a c i l i t y represents a s e r v i c e which, under normal c o n d i t i o n s , cannot be occupied by other than the type of p a t i e n t f o r which i t was designed to serve. The model which i s used to determine bed requirements i s given below (from t e x t pp. 6-8). 1. Determine the average d a i l y census by D.P.F. Current u t i l i z a t i o n (or d e s i r e d or p r o j e c t e d ? ) . 2. Set a p r o t e c t i o n l e v e l f o r each D.P.F. ( A r b i t r a r y c h o i c e ) . 3. S e l e c t t h e o r e t i c a l p r o b a b i l i t y d i s t r i b u t i o n f o r each type of D.P.F. (This study used poisson f o r a l l D.P.F.'s). 4. C a l c u l a t e the net req u i r e d beds f o r each D.P.F. 5. Add average out of s e r v i c e beds to net req u i r e d beds f o r each D.P.F. and sum these to get gross r e q u i r e d beds f o r each set of D.P.F.'s. 6. Divide the sum of the average d a i l y census f o r a l l D.P.F.'s i n the set by the sum of the gross r e q u i r e d beds to determine the appropriate average occupancy f o r each set of D.P.F.'s. Returning to o r i g i n a l formula i n Step #1, Beds required i n year X are c a l c u l a t e d f o r each D.P.F. ca t e -gory i n each h o s p i t a l and f o r a l l h o s p i t a l s s t u d i e d . The D.P.F. (bed) categories are: m e d i c a l / s u r g i c a l , o b s t e t r i c s , p e d i a t r i c s , p s y c h i a t r i c and other. The re q u i r e d beds which are determined may be analyzed w i t h i n county boundaries by the s i z e of h o s p i t a l or D.P.F. S i m i l a r l y , the components of the c a l c u l a t i o n of beds (average d a i l y census and occupancy f a c t o r ) can be given i n these types of analyses.. Average d a i l y census = re q u i r e d beds, and Occupancy f a c t o r (Step #6) P r o j e c t e d p a t i e n t days i n year X ^ Occupancy f a c t o r (Step #6) 365 = beds r e q u i r e d i n year X Summary The h o s p i t a l bed continues to occupy a s t r a t e g i c p o s i t i o n i n h e a l t h care planning. I t i s to the h o s p i t a l that a great p o r t i o n of our h e a l t h costs are d i r e c t e d because of the c u r a t i v e r o l e which they play. T h e o r e t i c a l l y , the h o s p i t a l i s the most e f f i c i e n t p l a c e where a "package" of s e r v i c e s and resources can be d i s t r i b u t e d to the p o p u l a t i o n . This "package" i s given i n e r t i a when a p a t i e n t occupies a bed or when the bed i s expected to be f i l l e d . Goldman and Knappenberger"^ respond to t h e i r own question of a l l o c a t i n g beds: "The p r i n c i p l e advantage of bed a l l o c a t i o n i s the p o t e n t i a l e f f i c i e n c y to be derived by grouping p a t i e n t s w i t h s i m i l a r h e a l t h problems i n the same p h y s i c a l area convenient to f a c i l i t i e s and the s e r v i c e s they r e q u i r e . P a t i e n t grouping allows s p e c i a l i z a t i o n which i s p a r t i c u l a r l y good f o r the s p e c i a l i s t . " In u t i l i z i n g one concept f o r resource d i s t r i b u t i o n such as beds, r i g h t l y or wrongly, the task of comprehending the multitude of various i n t e r a c t i n g p a r t s and resource requirements i s reduced to manageable pr o p o r t i o n s . However, F e r r e r suggests that l e s s time be devoted to focusing upon determination of f u t u r e l e v e l s of resources. Perhaps we should, i n s t e a d , concentrate on using the a v a i l a b l e resources i n the most e f f e c t i v e manner or mix to deal w i t h the problems presented 52 by p a t i e n t s . I t i s evident from the review that various methods and m o d i f i c a t i o n s to bed planning formulae have been developed as f l e x i b l e t o o l s f o r problem s o l v i n g . No one method i s demonstrably s u p e r i o r based on r e s u l t s ; however, models which show refinements such as age-sex u t i l i z a t i o n rates and c l i n i c a l s e r v i c e rates are models which d i s p l a y more a p p r e c i a t i o n f o r the f a c t o r s which impact upon demand: a p r i o r i , these models are su p e r i o r . I t i s a l s o obvious that some methods are experimental and s t i l l must be proven. Regardless of the method used, i t i s at best a g u i d e l i n e f o r the 53 planner or d e c i s i o n maker. Walsh and B i c k n e l l a p p r o p r i a t e l y conclude i n t h e i r model: " f o l l o w i n g the determination of beds other r e l e v a n t issues are considered and f u r t h e r adjustments are made." A l t r u i s t i c a l l y , the h e a l t h planner i s faced w i t h the task of de c i d i n g what l e v e l of resources w i l l produce an acceptable standard f o r both the l o c a l and e n t i r e p o p u l a t i o n , given t h a t some of h i s d e c i s i o n f a c t o r s are s u b j e c t i v e i n nature. P a r t of t h i s d e l i c a t e task r e l i e s upon the c a p a b i l i t i e s of both the model and i t s user. Planning Studies i n Newfoundland Related to  Resource D i s t r i b u t i o n P i e r c e , i n 1967, had t h i s to say about the province's method of c a l c u l a t i n g bed requirements: In planning f o r new f a c i l i t i e s the Department con-s i d e r s each s i t u a t i o n on an i n d i v i d u a l b a s i s . Although there i s no formula or standard such as age-sex breakdowns, occupancy l e v e l s , t r a v e l d i s t a n c e , past patterns of h o s p i t a l i z a t i o n and other f a c t o r s are taken i n t o c o n s i d e r a t i o n . P i e r c e ' s comment r e l a t e s to the Department of Health as a planning e n t i t y w i t h methods developed w i t h i n a planning f u n c t i o n . Methods can be found i n numerous s t u d i e s commissioned by the Department. Further, an examination of s t a t i s t i c s and events leads to a con c l u -s i o n that there i s an i m p l i c i t model f o r c a l c u l a t i n g beds i n Newfoundland. Beds set up per thousand p o p u l a t i o n i n the province f o r the years 1960, 1970 and 1976 were 7.9, 7.9 and 7.6, respec-t i v e l y . From 1976 to the present the budget f o r the Department has undergone t i g h t e n i n g . In t h i s same p e r i o d , other provinces exper-ienced t h i s c o n s t r a i n t and a l s o questioned the appropriateness of e x i s t i n g bed l e v e l s . The outcome was a general r e d u c t i o n of beds per thousand pop u l a t i o n . Newfoundland and other provinces have reduced t h e i r bed l e v e l s . By March 31, 1978, a r a t e of 6.4 approved and s t a f f e d was the experience f o r both short term and long term beds. Yet, P i e r c e ' s o r i g i n a l observation remains, i n p a r t , to be true. There i s no f o r m a l i z e d model w i t h i n the department. P i e r c e made reference to the B r a i n Commission Report of 1969. The B r a i n Commission used an analogy method w i t h other provinces and the Canadian average to e s t a b l i s h a bed r a t e of 8.0 beds per thousand population. At that time money was p l e n t i f u l ; t h e r e f o r e , expert opinion and statements of what ought to be could be entertained."'"' A s i m i l a r analogy method' was adopted i n O u t l i n e of Mental 5 6 Health S e r v i c e s , 1973. The p s y c h i a t r i c bed r a t e i n Nova S c o t i a of .4 short term and .6 long term was m u l t i p l i e d by a p r o j e c t e d popu-l a t i o n f o r each region i n the province. In t h i s determination of r a t e , both the census and occupancy of each region was surveyed. Dr. Rowe, i n a p r e s e n t a t i o n to a G e r i a t r i c Symposium i n 1975, used both ratioaand analogy to show the g e r i a t r i c needs of the Newfound-land p o p u l a t i o n . ^ 7 The p r o p o r t i o n of types of g e r i a t r i c beds expressed as a percentage of t o t a l beds i n an E n g l i s h County was a p p l i e d to the estimated beds i n Newfoundland. Between 1973 and 1974 the Health Planning and Development Committee published a general overview and three reports which d e a l t 58 w i t h 21 h e a l t h s t a t i s t i c a l d i s t r i c t s i n Newfoundland. A great deal of d i s c u s s i o n i n these reports f e l l upon the determination of bed requirements. L i b e r t i e s had to be taken i n i n t e r p r e t i n g the methodology as there was no statement of procedure. Numerous sub-methodologies were employed. Extended care and p s y c h i a t r i c care beds were p r o j e c t e d as a s t a n d a r d ^ r a t i o to the p o p u l a t i o n . Aggregate beds were p r o j e c t e d i n the same fa s h i o n but there were assumptions of both time and distance. Beds i n use were surveyed to determine the number of beds which could be assigned to a l e v e l of care (e.g., acute, convalescent). These bed c a l c u l a t i o n s ( f a c t o r s ) were combined w i t h a c e n t r a l methodology to provide a f i n a l estimate of beds. At the core of the c a l c u l a t i o n are two bed e s t i m a t i o n s : s u r g i c a l and n o n - s u r g i c a l . In very simple terms, the c a l c u l a t i o n i n v o l v e s the m u l t i p l i c a t i o n of cases, l e n g t h of stay and occupancy f a c t o r . A study, developed by the Department of Health Planning D i v i s i o n , deals e x c l u s i v e l y w i t h the current bed to p o p u l a t i o n t e c h -59 nique of d i s t r i b u t i o n . The bed r a t i o i s a p p l i e d to p r o j e c t e d p o p u l a t i o n (aggregate) by h e a l t h s t a t i s t i c a l d i s t r i c t . In a number of cases the bed determination i s adjusted i n the f u t u r e according to f u t u re expectations of h e a l t h d e l i v e r y and according to rates e s t a b l i s h e d i n previous s t u d i e s . Beds are estimated f o r 1981, and on paper i t i s the f u r t h e s t p r o j e c t i o n a v a i l a b l e . As 1981 i s c l o s e at hand, a new set of p r o j e c t i o n s i s i n order. This study i s more important f o r i t s underlying work on p o p u l a t i o n p r o j e c t i o n s , the methodology of which has been v a l i d a t e d by the Government's S t a t i s -t i c a l D i v i s i o n . As there was no p o p u l a t i o n f i g u r e f o r the h e a l t h s t a t i s t i c a l d i s t r i c t or f o r h o s p i t a l s e r v i c e s area, communities and h e a l t h s t a t i s t i c a l d i s t r i c t s had to be cross-referenced to census d i v i s i o n data. This task was done manually. Consequently, a p a r t i a l s o l u t i o n to the problem of d e f i n i n g the age-sex d i s t r i b u t i o n of these h e a l t h s t a t i s t i c a l d i s t r i c t s had been accomplished. During 1978, McKinsey and Company conducted a study f o r the 60 St. John's H o s p i t a l s C o u n c i l . As of J u l y 31, 1979, the f i n a l r e port had not yet been released. The f o l l o w i n g comments are from working papers. In the "Determining Need/Resource Balances" of Phase I of the p r o j e c t , the key elements f o r determining h e a l t h needs were: po p u l a t i o n p r o j e c t i o n s ; m o r b i d i t y and u t i l i z a t i o n p a t t e r n s ; the a n t i c i p a t i o n of changes i n methods of care; the measure of needs met by f a c i l i t i e s outside St. John's; and f o r e -c a s t i n g the net demand on St. John's, This p r o j e c t went beyond previous h e a l t h care r e l a t e d s t u d i e s i n Newfoundland i n i t s attempt to define and p r o j e c t the age-sex population of three areas. These areas were defined by l e v e l s of care (primary, secondary and t e r t i a r y ) and t h e r e f o r e d i d not c o i n c i d e w i t h census d i v i s i o n s . To circumvent t h i s problem, the age-sex composition of the subregions was c a l c u l a t e d through the use of a r a t i o method on census p r o j e c t i o n s . The c r o s s - r e f e r e n c i n g and p o p u l a t i o n f i g u r e s f o r h e a l t h s t a t i s t i c a l d i s t r i c t s was obtained from the study "Newfoundland and Labrador P o p u l a t i o n , P a r t I I , 1966/1971." The age-sex p r o j e c t i o n s were at the care l e v e l boun-darie s only. A l s o i n t e r e s t i n g was the method of d e r i v i n g and f o r e c a s t i n g bed requirements. For the St. John's area a u t i l i z a t i o n r a t e ( p a t i e n t days per 1000) was c a l c u l a t e d f o r each age and sex through a process of grouping p a t i e n t days i n t o four s e r v i c e s (the computer program was developed by the Newfoundland Department of H e a l t h ) . The grouping was performed on the Canadian 188 Diagnostic L i s t i n g . The age-sex morbidity s e r v i c e rates were m u l t i p l i e d by the age-sex p o p u l a t i o n f i g u r e s to produce a s e r v i c e need. The average d a i l y census of the h o s p i t a l was taken i n t o account and subjected to the r a t i o n a l e of the Poisson d i s t r i b u t i o n to determine maximum r e a l i s t i c occupancy r a t e s . The f i n a l e s t i m a t i o n of bed requirements was c a l c u l a t e d by d i v i d i n g the s e r v i c e s p e c i f i c p a t i e n t days by 365 and by the maximum occupancy r a t e . A c l e a r l y defined methodology f o r e s t i m a t i n g bed requirements does not appear to e x i s t at the government l e v e l . However, there i s an i m p l i c i t model which u t i l i z e s a standard r a t e . This standard r a t e appears to be a product of a d m i n i s t r a t i v e judgement, comparison w i t h r a t e s e s t a b l i s h e d by other governments, recommendations from previous s t u d i e s , d o l l a r c o n s t r a i n t s , the summation of i n d i v i d u a l -i z e d ( h o s p i t a l ) bed requirements and an e x p e r i e n t i a l f e e l i n g f o r the needs of areas. In the o p i n i o n of the w r i t e r the c o n t i n u a t i o n of t h i s method i s f o s t e r e d by the r e l a t i v e smallness of the system. This smallness has t r a d i t i o n a l l y l e d to c l o s e r contact between a d m i n i s t r a t o r s and department of h e a l t h o f f i c i a l s . As a r e s u l t , o f f i c i a l s have a p r a c t i c a l f e e l f o r the needs i n areas. Yet there i s the question of a s t a b l e bed r a t e over the past two decades. P l a u s i b l e explanations do e x i s t and these are attended to i n the d i s c u s s i o n to f o l l o w . Problems Associated w i t h the D i s t r i b u t i o n of Health  Care Resources to R u r a l Areas i n Newfoundland At l e a s t 60% of the Newfoundland popu l a t i o n r e s i d e s i n communities c l a s s i f i e d as r u r a l by s i z e , t r a v e l time or dist a n c e . The 340,000 r u r a l r e s i d e n t s do have problems i n a t t a i n i n g a l e v e l of h e a l t h care which has the q u a l i t y , a c c e s s i b i l i t y and a v a i l a b i l i t y of 60 resources found i n the urban d e l i v e r y system. In many r e s p e c t s , the problems which are experienced i n r u r a l areas are the same as those experienced by t h e i r l a r g e r more organized counterparts. Their d i f f e r e n c e which i s f e l t i s one i n degrees. The problems which a r i s e i n t r y i n g to deal w i t h r u r a l h e a l t h 61—6 8 care d e l i v e r y are w e l l attended to i n the l i t e r a t u r e . The p h i l o s o p h i c a l approach which surfaces i s that the r u r a l system must be thought of as unique; yet i t must be i n t e g r a t e d w i t h a much l a r g e r urban system which i s w i l l i n g to deploy resources to so l v e r u r a l system problems without j e o p a r d i z i n g the r i g h t s and needs of the r u r a l p o p u l a t i o n . This type of approach r e q u i r e s a c o n t i n u i n g f l e x i b l e and innova t i v e management and planning s t y l e . The problems a s s o c i a t e d w i t h r u r a l h e a l t h care d e l i v e r y are given below i n a combined and g e n e r a l i z e d form. These are not meant to be i n c l u s i v e ; i n s t e a d they form the bases of d i s c u s s i o n i n Appendix A. Appendix A presents a more d e t a i l e d d i s c u s s i o n of these l i s t e d t r a i t s and a l s o describes r e l e v a n t examples a p p l i c a b l e to the r u r a l s e t t i n g i n Newfoundland. 1. Recruitment 2. Educational maintenance 3. Environment ( p u b l i c h e a l t h , s o c i a l , geography, etc.) 4.' Po p u l a t i o n s t r u c t u r e 5. Leadership and o r g a n i z a t i o n a l a c t i v i t i e s 6. Imposition of other system standards 7. Economic base of community 8. A t t i t u d e s towards cooperation 9. Economic dependence on delivery•system 10. Methods of f i n a n c i n g 11. Misuse of p r o f e s s i o n a l time 61 Chapter III Footnotes Avedis Donabedian, Aspects of Medical Care Administration: Specifying Requirements f o r Health Care (Cambridge, Mass.: Harvard University Press, 1973), pp. 532-639. 2 Rosson L. Cardwell, "How to Measure Metropolitan Bed Needs," The Modern Hospital 103 (August 1964): 107-111, 181. 3 Donabedian, pp. 532-639. 4 Vincente Navarro, "Planning f o r the D i s t r i b u t i o n of Personal Health Services," P u b l i c Health Reports 84 (July 1969): 573-581. "*Robin E. MacStravic, Determining Health Needs (Ann Arbor, Mich.: Health Administration Press, 1978), pp. 73-135. 56 'Robin E. MacStravic, "How Many Hospital Beds Does V i r g i n i a Need?" V i r g i n i a Medical (January 1978): 73-75. 77 'Navarro, pp. 573-581. 8 •Ibid. 9 H, P. Ferrer, ed., The Health Services - Administration, Research and Management (London: Butterworth, 1972), pp. 186-197. 10 "MacStravic, Determining Health Needs, pp. 73-135. 1 1 >Mark S. Blumberg, "DPF Concept Helps Predict Bed Needs," The Modern Hospital 97 (December 1971): 75-8}. 12 "•Cardwell, pp. 107-111, 181. 13 ""William Shonick, "Understanding the Nature of the Random Fluctuations of the Hospital Daily Census: An Important Planning Tool," Medical Care 10 (March/April, 1972): 118-137. 14 ""Ferrer, pp. 186-197. 15 "Shonick, pp. 118-137. 16 . "Milton L. Roemer, Bed Supply and Hospital U t i l i z a t i o n : A Natural Experiment," Hospitals 35 (November 1961): 36-42. 17 B. M. Kleczkowski and R. Pibouileau, eds., Approaches to  Planning and Design of Health Care F a c i l i t i e s i n Developing Areas, WHO Offset Pub. No. 37 (Geneva: World Health Organization), pp. 44-47. 18 Donabedian, pp. 532-639. 19 . Cardwell, pp. 107-111, 181. 62 20 Franc i s M. 0. Umenyi, Trends i n U t i l i z a t i o n of Newborn and  O b s t e t r i c S e r v i c e s : I m p l i c a t i o n s f o r Future Demand ( S t a t i s t i c s Canada: Ottawa, A p r i l 1978), pp. 1-74. 21 MacStravic, Determining Health Needs, pp. 73-75. 22 ,, Douglas W. Paine and Lawrence L. Wilson, The Determination of Acute Care Bed Requirements f o r P r o v i n c i a l Acute Care H o s p i t a l s , " i n Systems Aspects of Health P l a n n i n g , eds., Norman T. J . B a i l e y and Mark Thompson (Amsterdam, Oxford: North-Holland P u b l i s h i n g Company, 1975), pp-. 63-76. 23 Cardwell, pp. 107-111, 181. 24 ' "Richard G. DuFour, " P r e d i c t i n g H o s p i t a l Bed Needs," H o s p i t a l S ervices Research (Spring 1974): 62-68. 25 A l f r e d J . Karniewicz, J r . , E s t i m a t i n g Coronary Care Bed Needs," H o s p i t a l s 44 (September 1970): 51-53. 26 „ "Ma r t i n S. F e l d s t e i n , An Aggregate Planning Model of the Health Care Sector," Medical Care 5:6 (November/December): 369-381. 23 ""^George H. Brooks and Hen r i L. Beenhakker, "A New Technique f o r P r e d i c t i o n of Future H o s p i t a l Bed Needs," H o s p i t a l Management v (June 1964), 47-50. 28 Rachel Doyle et a l . , E s t i m a t i n g H o s p i t a l Use i n Arkansas, P u b l i c Health Reports 92 (May/June 1977): 211-216. John 0. McLain, A Model f o r Regional O b s t e t r i c Bed Plannin g , " Health Services Research 13 (Winter 1978): 378-393. 30 F e l d s t e i n , pp. 369-381. 31 Vernon E. Weckworth, "Determining Bed Needs from Occupancy and Census F i g u r e s , " H o s p i t a l s 40 (January 1966): 52-54. ^^Michael S. Lichterman and Sheldon K. Gulinson, H o s p i t a l  Bed Requirements: An Occupancy Factor Determination Approach (Chicago: Chicago H o s p i t a l C o u n c i l , 1979), pp. 1-24. 33 I b i d . 34 •McLain, pp. 378-393. 35 F. R. Normile and H. A. Z i e l , J r . , "Too Many OB Beds?" H o s p i t a l s 44 (1970): 61. 3 6 S h o n i c k , pp. 118-137. 37 Weckworth, pp. 52-54. 3 8Blumberg, pp. 75-79, 80-81. 63 39 Nancy L. G e l l e r and Michael G. Yochmowitz, "Regional Planning of Maternity Services," Health Services Research 10 (Spring 1975): 63-75. 40 Shonick, pp. 118-137. 41 Donabedian, pp. 532-639. 42 Meeting of Planning and Research Di r e c t o r s , A t l a n t i c Provinces Departments of Health, H a l i f a x , 24 November 1978. 43 Donabedian, pp. 532-639. 44 MacStravic, Determining Health Needs, pp. 73-135. 45 Navarro, pp. 573-581. ^Umenyi, pp. 1-74. 47 A. S. Slutsky, "Mathematical Model Used i n Forecasting Maternity F a c i l i t i e s Needs," Hospital Administration i n Canada (March 1977) : 54 48 Brooks and Beenhakker, pp. 47-50. 49 Hospital Bed Guidelines Committee, Interim Report to the  Department of Health and the New Brunswick Hospital Association on  a Regional Bed D i s t r i b u t i o n Model, New Brunswick Department of Health, May 1973. ^Donabedian, pp. 532-639. ^\,ichterman and Gulinson, pp. 1-24. 52 Jay Goldman, H. A l l a n Knappenberger and J . C. E l l e r , "Evaluating Bed A l l o c a t i o n P o l i c y with Computer Simulation, 1 1 Health  Services Research 3 (Summer 1968): 119-129. 53 " Ferrer, pp. 186-197. 54 " D i a n a Chapman Walsh and William J. B i c k n e l l , "Forecasting the Need f o r Hospital Beds: A Quantitative Methodology," P u b l i c  Health Reports 92 (May/June 1977): 199-21D 55 G. A. H. Pierce, Bed Need Determination i n Canada: A  Summary of Methods Used by P r o v i n c i a l Hospital Authorities (Diploma Thesis, University of Toronto, 1967), pp. 1-62. 56 D. V. Glass, "Structure of the Newfoundland Population," c i t e d by. Right Honourable Lord Brain, Royal Commission on Health, Vol. 1 (Government of Newfoundland, 1966), 1:4-7. •^Mental Health Services D i v i s i o n , Outline of Mental Health  Services i n Newfoundland, Newfoundland Department on Health, 1973. 64 58 „ A. T. Rowe, Developing a G e r i a t r i c Programme f o r Newfoundland," i n Summation and H i g h l i g h t s : G e r i a t r i c Symposium (25 November 1975), pp. 3-7. 59 A. B, Murphy, "Newfoundland and Labrador P o p u l a t i o n , 1966/1971, P a r t I I , Health S t a t i s t i c a l D i s t r i c t s , " St. John's, Newfoundland.Department of H e a l t h , September 1976. 60 A. B. Murphy, "A Study of H o s p i t a l Beds i n Newfoundland Per 1000 P o p u l a t i o n as Compared to P r o j e c t e d H o s p i t a l Beds i n Newfoundland Per 1000 P r o j e c t e d Population 1980-81," St. John's, Newfoundland Department of H e a l t h , September 1975. 61 McKinsey and Company. P r o v i s i o n s of C l i n i c a l Services  and Programs i n St. John's: A Study to Determine Future Requirements, St. John's: St. John's H o s p i t a l s Advisory C o u n c i l , 1979. (Working papers.) 62 Right Honourable Lord B r a i n , Royal Commission on H e a l t h , 3 v o l s . , St. John's: Government of Newfoundland and Labrador, 1966. 63 J u l i a n A. W a l l e r , "RuralSEmergency Care - Problems and Prospects," American J o u r n a l of P u b l i c Health 63 ( J u l y 1973): 631-634. 64 J u l i a n A. W a l l e r , "Urban-Oriented Methods: F a i l u r e to Solve Rural'JEmergency Care Problems," J o u r n a l of American Medical  A s s o c i a t i o n 226 (December 1973): 1441-1446. 65 E l i z a b e t h H i s c o t t , "Health Services i n Four I s o l a t e d D i s t r i c t s , " Canadian J o u r n a l of P u b l i c Health 64 (September/October 1973): 500-502. 6 6 I b i d . ^ S t e p h e n Portnoy and W i l l i a m L. Casady, "Rural Health Program P r i o r i t i e s , " H o s p i t a l s 50 (March 1976): 68-71. 68 Douglas P. Black, "Medical Services f o r I s o l a t e d Areas," Canadian Family P h y s i c i a n (February 1973): 91-95. 69 Robert L. Kane and S i s t e r Diane M o e l l e r , "Rural S e r v i c e Elements F a l l C o o r dination," H o s p i t a l s 48 (October 1974): 79-83. r 7 0 B l a c k , pp. 91-95. CHAPTER IV METHODOLOGY Research Strategy There were a number of very i n f l u e n t i a l f a c t o r s which con-t r i b u t e d to the design of both the study and i t s component methods. The timing and need f o r a new set of bed estimates was appropriate because the only estimates a v a i l a b l e to the Department of Health were f o r a p e r i o d ending i n 1981. The method that was used by the Planning D i v i s i o n was a bed to popul a t i o n r a t i o p r o j e c t e d i n t o the fut u r e . Both o p i n i o n of the w r i t e r and of authors reviewed i n the l i t e r a t u r e , predisposed the w r i t e r to attempt a design of a bed p r e d i c t i o n model that was more a n a l y t i c a l i n d e f i n i n g l o c a l needs. Through involvement w i t h various s t u d i e s during 1978 and 1979, i n the cap a c i t y of supplying data to requests by planners and researchers, i t became i n c r e a s i n g l y apparent that one very v i t a l data f i l e was miss i n g f o r planning and research. This f i l e was the age-sex pop u l a t i o n s t r u c t u r e f o r the h e a l t h s t a t i s t i c a l d i s t r i c t s . This view was not only supported by ep i d e m i o l o g i s t s and researchers but the Department of Health was very i n t e r e s t e d i n o b t a i n i n g age-sex data f o r these p o p u l a t i o n u n i t s . Beyond t h i s , the Department needed the age-sex data q u i c k l y because i t was i n the midst of planning f o r the operation of Nursing Home f a c i l i t i e s i n the province. 65 66 The u n d e r l y i n g premise was t h e r e f o r e to construct a design which rested upon assumptions of what ought to be; i t had to i n c o r -porate statements of accuracy or ranges among standards so that the reader or d e c i s i o n maker could adjust r e s u l t s or methods to d e a l w i t h the problem at hand. During 1978, McKinsey and Company conducted a study of needs f o r the St. John's H o s p i t a l s Advisory C o u n c i l . A number of computer programs were developed by the Department of Health to c o l l e c t data f o r t h e i r requests. As the present study evolved, i t became evident that one of the programs could be u t i l i z e d very e f f e c t i v e l y i f a few m o d i f i c a t i o n s were made to i t . In a d d i t i o n , the parameter of an age-sex po p u l a t i o n s o l u t i o n f o r the h e a l t h s t a t i s t i c a l d i s t r i c t s could be e a s i l y incorporated i n t o t h i s program to p r e d i c t f u t u r e bed r e q u i r e -ments. In t h i s sense, the design of the study unfolded n a t u r a l l y and was a l s o the important consequence of need. The methodology (being more a n a l y t i c a l ) was considered to be an enhancement over the previous bed to p o p u l a t i o n method. This o p i n i o n could not be l e f t unchallenged. Common and v i t a l to each method was p o p u l a t i o n growth. The bed to p o p u l a t i o n method considered only aggregate p o p u l a t i o n whereas the present study considered the growth of the p o p u l a t i o n as com-p r i s e d of age and sex movements. The design of both the methodology and the study, t h e r e f o r e , had to focus upon comparison of methods by showing i f there were any e f f e c t s of the age-sex s t r u c t u r e movement upon the a l l o c a t i o n of t o t a l acute care beds or acute care bed types. In so doing, the problem of p r o v i d i n g c u r r e n t and p r o j e c t e d age-sex populations to the h e a l t h d i s t r i c t s was a l s o s a t i s f i e d . 67 Research S e t t i n g The study was conducted between J u l y and December of 1979 i n the Province of Newfoundland and Labrador. The focus of the study was upon h e a l t h s t a t i s t i c a l d i s t r i c t f o r p o p u l a t i o n p r o j e c t i o n s and upon h e a l t h regions i n the c a l c u l a t i o n of h o s p i t a l acute care beds. Neither h o s p i t a l s nor h e a l t h d i s t r i c t s were surveyed d i r e c t l y f o r data. Instead of the m a j o r i t y of the data was r e t r i e v e d (or generated) from Department of Health data f i l e s . Data Sources In some cases i t was very d i f f i c u l t to l o c a t e methods or m a t e r i a l s . Consequently i t i s important that some of the data sources be e x p l i c i t l y s t a t e d so that f u t u r e s t u d i e s w i l l have an e a s i e r time i n data c o l l e c t i o n . U n i v e r s a l Transverse Mercator (U.T.M.). This i s the tech-n i c a l name of a system of coding h e a l t h s t a t i s t i c a l d i s t r i c t s and communities. There i s an i n t e r n a l program a v a i l a b l e from S t a t i s t i c s Canada, CANSIM Be t t e r Use Development D i v i s i o n , Ottawa which c r o s s -references w i t h the census code f i l e . Cross-reference codes can a l s o be obtained from the Department of Health Planning D i v i s i o n p r i o r to and f o l l o w i n g the major census d i v i s i o n and subsequent changes i n 1966 through the re p o r t s e n t i t l e d : "Newfoundland and Labrador Populations: 1961, 1966, 1971, 1976 .Health S t a t i s t i c a l D i s t r i c t s " and "Newfoundland and Labrador Po p u l a t i o n s : 1961 and 1966 Health S t a t i s t i c a l D i s t r i c t s . " 1 ' Census Data Tapes. Both C e n t r a l S t a t i s t i c s D i v i s i o n , Execu-t i v e C o u n c i l , Government of Newfoundland and the Geography Department 68 of Memorial U n i v e r s i t y have 1976 and 1971 census tapes. H o s p i t a l I n p a t i e n t M o r b i d i t y . Data i s coded and s t o r e d on tape by the S t a t i s t i c s D i v i s i o n of the Department of Health. Two coding schemes are employed: the I n t e r n a t i o n a l C l a s s i f i c a t i o n of Diseases, Eighth E d i t i o n , and a c o l l a p s e d v e r s i o n , the Canadian 188 D i a g n o s t i c L i s t i n g (C-188). Po p u l a t i o n Figures. Both census and p r o j e c t i o n s are a v a i l -able from S t a t i s t i c s Canada p u b l i c a t i o n s or from the census tapes mentioned p r e v i o u s l y . Length of Stay and I n p a t i e n t M o r b i d i t y Rates. Both types of data are a v a i l a b l e from S t a t i s t i c s Canada P u b l i c a t i o n s and from the PAS P r o f e s s i o n a l A c t i v i t y Study, Commission on P r o f e s s i o n a l and H o s p i t a l A c t i v i t i e s p u b l i c a t i o n s on l e n g t h of stay. The S t a t i s t i c s D i v i s i o n also produces the C-188 by length of stay and s e p a r a t i o n f o r age and sex. Methods of C o l l e c t i n g Data S o r t i n g of Codes As a major e f f o r t had been made at c r o s s - r e f e r e n c i n g census d i v i s i o n s and s u b d i v i s i o n s to the h e a l t h s t a t i s t i c a l d i s t r i c t , i t was decided to u t i l i z e t h i s work f o r the b e n e f i t of the present 2 '• study. ' From the cross-reference which was a v a i l a b l e , each census community was transposed by age and sex to i t s appropriate h e a l t h d i s t r i c t . Each community's po p u l a t i o n was compared to the p o p u l a t i o n f i g u r e s provided i n the o r i g i n a l s o r t . As t h i s t r a n s p o s i t i o n was being conducted, the i n c l u s i o n of each community and enumeration area was checked against a Newfound-land map of Health S t a t i s t i c a l D i s t r i c t s . This procedure was c a r r i e d out f o r 1971 and 1976. T r a n s p o s i t i o n e r r o r was expected. Normally t h i s e r r o r reaches approximately 5%. The e r r o r r a t e which was employed f o r t h i s study was that the summation of h o s p i t a l d i s t r i c t t o t a l s would not exceed the thousandth of a percent e r r o r when compared w i t h the Census f o r Newfoundland. This c r i t e r i a was met and was intended as a r e l i a b i l i t y measure f o r f u t u r e researchers. In d i s c u s s i o n s w i t h demographers the c r i t e r i a e s t a b l i s h e d was very acceptable. P o p u l a t i o n P r o j e c t i o n Method The f i n a l choice of method was the short form of the Ratio Method w i t h a refinement which i s suggested i n the l i t e r a t u r e review. The r a t i o refinement was an observed change i n the l o c a l age-sex s p e c i f i c p o p u l a t i o n between two periods over an observed change i n the p r o v i n c i a l age-sex s p e c i f i c p o p u l a t i o n between two periods. This r a t i o allows not only absolute change but i t a l s o allows an age-sex group's percentage of the t o t a l p o p u l a t i o n to increase or decrease. The choice i n usi n g t h i s refinement was, t h e r e f o r e , the reason f o r r e j e c t i n g other r a t i o methods. The short form describes a method of c a l c u l a t i n g l o c a l populations against a n a t i o n a l t o t a l i n s t e a d of c a l c u l a t i n g through a h i e r a r c h y of l e v e l s . The C o h o r t - S u r v i v a l Method was considered as an a l t e r n a t i v e . However, the degree of d e t a i l r e q u i r e d f o r the l o c a l l e v e l combined w i t h an absence of current and a v a i l a b l e age-sex s p e c i f i c (and by l o c a l area) v i t a l s t a t i s t i c s , s u r v i v a l r a t e s (the i n v e r s e of mor-t a l i t y ) , and f e r t i l i t y or m i g r a t i o n r a t e s pointed to the choice of another model. The users of the c o h o r t - s u r v i v a l method gave i t a 3 medium range of p r o j e c t i o n when compared to other methods. In other words, i t s accuracy i n the short run would not be substan-t i a l l y b e t t e r than that produced by other methods. However, i n the long run t h i s model would be expected to achieve b e t t e r r e s u l t s than simpler methods such as a r i t h m e t i c , geometric and r a t i o . A p r i o r i , on a n a l y t i c a l grounds t h i s model w i t h good assumptions should produce s u p e r i o r r e s u l t s . These comments were confirmed i n the l i t e r a t u r e review and i n d i s c u s s i o n s w i t h demographers w i t h i n the Government 4 and at Memorial U n i v e r s i t y . In d e s c r i b i n g the problems to be over-come, such as the s o r t i n g of two codes and the l a c k of a v a i l a b l e s p e c i f i c data, the r a t i o method was considered a l o g i c a l choice. A short term p r o j e c t i o n was chosen because i t increased the accuracy of the p r o j e c t i o n . a v a i l a b l e set of p r o v i n c i a l age-sex popu l a t i o n p r o j e c t i o n s considered the f a c t o r s r e q u i r e d of the cohort model i n one f i g u r e . However, the d i f f e r e n c e i s that the cohort model allows various choices i n any one of the f a c t o r s even though the estimate may be the same. Using the p r o j e c t i o n from S t a t i s t i c s Canada l i m i t s choice. P r o j e c -t i o n number 4 from S t a t i s t i c s Canada was used to p r o j e c t the h e a l t h s t a t i s t i c a l d i s t r i c t s . The components of the p r o j e c t i o n expressed as r a t e s per 1000 populations f o r the p r o j e c t i o n p e r i o d of 1976-1986 are: The r a t i o method through the use of an independent and b i r t h s a downward s h i f t from 19.6 to 18.7 deaths a s l i g h t upward s h i f t from 6.2 to 6.3 net m i g r a t i o n a d e c l i n e from ''4.2 to -3.5 n a t u r a l increase a d e c l i n e from 13.4 to 12.4 t o t a l increase a d e c l i n e from 9.2 to 8.9 71 Concerns about the e f f e c t s of m i g r a t i o n were brought forward i n the l i t e r a t u r e review. The o r i g i n a l p lan to consult knowledgeable municipal planners or h o s p i t a l a d m i n i s t r a t o r s i n the various h e a l t h s t a t i s t i c a l d i s t r i c t s was r e j e c t e d . I t was f e l t by demographers that l o c a l estimates of m i g r a t i o n would be biased. Choosing the r a t i o method and the p r o j e c t i o n f i g u r e s from Census Canada meant that m i g r a t i o n was already being considered i n the p o p u l a t i o n . The p o i n t that should be considered regardless of the approach taken i s that small population p r o j e c t i o n s do s u f f e r from i n a c c u r a c i e s which a r i s e i n p a r t from the sometimes u n p r e d i c t a b i l i t y of a population's m i g r a t i o n . I r r e g a r d l e s s of the estimated accuracy of the p o p u l a t i o n p r o j e c t i o n s w i t h i n t h i s present study,the reader should be aware of p o t e n t i a l i n a c c u r a c i e s . A very key c o n s i d e r a t i o n w i t h the p r o j e c t i o n s i s that S t a t i s t i c s Canada employs random rounding. 7 A l l numbers end i n 0 or 5. Any number can be exact or plus or minus 5; t h e r e f o r e , the range of values f o r any number i s 10. S i m i l a r l y , the p r o j e c t i o n s were expected to show grea t e r d e v i a t i o n s from census values or wider f l u c t u a t i o n s i n the amount of e r r o r when smaller populated h e a l t h d i s t r i c t s were p r o j e c t e d . By the very geographical nature of the province and v a r i e d p o p u l a t i o n d e n s i t i e s e r r o r rates were expected to d i f f e r . To give the observer an estimate of e r r o r that might be contained w i t h i n the study's po p u l a t i o n p r o j e c t i o n s , the r a t i o method was t e s t e d on a h i s t o r i c a l data set between 1966 and 1971. This 5 year base was p r o j e c t e d to 1976 and then compared against the a c t u a l census f i g u r e s f o r 1976. The methodology f o r e s t i m a t i n g e r r o r i s discussed under a separate t i t l e i n Chapter V. The f o l l o w i n g formula was used to c a l c u l a t e the age-sex 72 population projection for each health d i s t r i c t . This formula was derived from the sense given to definitions in the literature review. As implied, a definitive formula was not found. Step I. Age-Sex specific projection within a health s t a t i s t i c a l d i s t r i c t . Phas xPhas - Phas = t t-n t+n PNas - PNas^ t t-n x [PNas , - PNas + MA] + Phas,. t+n t t where Phas t+n PNas MA n t as t-n t+n age-sex specific population of the health s t a t i s -t i c a l d i s t r i c t for future year; Phast = age-sex specific population of the health statis-t i c a l d i s t r i c t for base year; Phas t_ n = age-sex specific population of the health sta t i s -t i c a l d i s t r i c t for past year; PNas^ = age-sex specific population of the Newfoundland projection for base year; PNas = age-sex specific population of the Newfoundland projection for past year; age-sex specific population of the Newfoundland projection for future year; migration adjustment i f necessary number of years from base year base year age-sex interval Step II. This formula was repeated for each age-sex interval to structure the population in each health sta t i s -t i c a l d i s t r i c t . Step III. Totals were calculated for age interval (male and female) and for each sex ( a l l age intervals) and a total population in each health s t a t i s t i c a l d i s t r i c t was presented. Step IV. Steps I, II and III were repeated for the second and f i n a l year of the projection period. Step V. For each projection year, the age sex intervals were summed for a l l health s t a t i s t i c a l d i s t r i c t within a health region. 73 H o s p i t a l I n p a t i e n t M o r b i d i t y Computer Program This program was developed to r e t r i e v e the number of separ-a t i o n s and t o t a l days stay by age and sex groups. The separations were c l u s t e r e d i n groups of diagnoses which have been coded to the Canadian D i a g n o s t i c L i s t i n g (C-188), a c o l l a p s e d v e r s i o n of the Eighth E d i t i o n of the I n t e r n a t i o n a l C l a s s i f i c a t i o n of Diseases. The program was modified to s u b t r a c t out a l l p a t i e n t s under 15 years of age except those i n an o b s t e t r i c a l d i a g n o s t i c category. Further m o d i f i c a t i o n s were employed to express the c l u s t e r e d separations (age and sex) i n age-sex s p e c i f i c r a t e s per 100,000 p o p u l a t i o n and c l u s t e r e d t o t a l days stay (age and sex) i n age-sex s p e c i f i c lengths of stay. The d i a g n o s t i c c l u s t e r s and the d i a g n o s t i c code numbers are given below: P e d i a t r i c s (15 years) C-188 L i s t : 1-135; 146-188. General Medical and S u r g i c a l C-188 L i s t : 1-51; 60-135; 146-188. O b s t e t r i c s C-188 L i s t : 136-145. P s y c h i a t r y C-188 L i s t : 52-59 By u t i l i z i n g the computer program an important assumption was made. The d i a g n o s t i c c l u s t e r not only represented m o r b i d i t y c a t e g o r i e s , i t a l s o i m p l i e d an equivalent resource u n i t . This c o n t r a s t s w i t h a bed r a t e to p o p u l a t i o n c a l c u l a t i o n which assumes a s p e c i f i c type of resource f o r the e n t i r e p o p u l a t i o n . In other words, t h i s study def i n e s a need and then presumes a c e r t a i n type of resource i s needed. A second assumption a r i s e s and i s s i m i l a r to 8 Blumberg's D i s t i n c t i v e P a t i e n t F a c i l i t y . For the d i a g n o s t i c c l u s t e r s there i s only one type of resource which can be used. I f a l l the d i a g n o s t i c coding was c o r r e c t , a more p r e c i s e statement of needs to s e r v i c e i s expected. The data's q u a l i t y was judged to be v a l i d and r e l i a b l e , a l b e i t a biased view. This view stems from the w r i t e r ' s knowledge of the 1976 morbidity f i l e , i t s p r e p a r a t i o n e d i t and f i n a l acceptance by S t a t i s t i c s Canada. There were no queries from S t a t i s t i c s Canada and the s t a f f r e s p o n s i b l e f o r i t s p r e p a r a t i o n were s a t i s f i e d t h a t the f i l e was i n t e r n a l l y c o n s i s t e n t w i t h past experience. This f i l e has been i n production f o r two years and has been accepted by researchers. Even i f Newfoundland's data departs from the N a t i o n a l experience departure may be one of circumstances and standards. The question that f i n a l l y surfaces i s whether these standards, which are judgemental, are r i g h t or wrong. Use and acceptance of the f i l e does not n e c e s s a r i l y mean that i t i s r e l i a b l e and/or v a l i d . Instead a degree of credence can be l e n t to the f i l e . . The data was c a l c u l a t e d f o r i n s t i t u t i o n s which d e l i v e r acute care. Four h o s p i t a l s were excluded from the study because they are deali n g w i t h long term care: Waterford (Mental H e a l t h ) , St. P a t r i c k ' s and St. Luke's Nursing Homes, and the Children's R e h a b i l i t a t i o n Centre. Therefore, the t o t a l number of h o s p i t a l s was 44. The data (diagnosis) was sorted by residence or o r i g i n . A sub-methodology was e s t a b l i s h e d to account f o r r e f e r r a l patterns between regions or h e a l t h s t a t i s t i c a l d i s t r i c t s . The r e f e r r a l program sorted each p a t i e n t by the h e a l t h region of o r i g i n and region i n which the p a t i e n t was t r e a t e d . The p a t i e n t ' s d i a g n o s t i c c l u s t e r , age-sex and t o t a l stay were i d e n t i f i e d w i t h i n each region of treatment and summarized to the four r e f e r r a l regions. The m o r b i d i t y data by o r i g i n was converted to a r a t e i n the pop u l a t i o n and a p p l i e d to po p u l a t i o n p r o j e c t i o n s f o r the areas of concern. Both bed s e r v i c e patterns and r e f e r r a l p a t t e r n s were combined i n each of the p r o j e c t i o n years,to provide a r e a l i s t i c statement of bed needs f o r a given region. I f t h i s procedure had not been c a r r i e d out, the r e f e r r a l p a t t e r n would have been erron-eously r e l a t e d to population i n which treatment occurred. The more l o g i c a l approach was to base the p a t t e r n upon s h i f t i n g p o p u l a t i o n s ; populations from which the p a t i e n t s o r i g i n a t e d . Both programs were run on the 1976 H o s p i t a l I n p a t i e n t data f i l e . Manual Tabulation of Bed Categories To compare the bed to pop u l a t i o n method w i t h the study's p r e d i c t i o n of beds which l e d to a statement of the age e f f e c t upon beds, the Annual Returns of H o s p i t a l s f o r 1976 were consulted f o r the 44 h o s p i t a l s . Each of the h o s p i t a l s was assigned to a h e a l t h s t a t i s t i c a l d i s t r i c t and to a h e a l t h region. Beds i n t h i s study are defined as " s t a f f e d , " that i s , a bed which i s a c t u a l l y a v a i l a b l e f o r p a t i e n t accommodation and f o r which s t a f f i s a v a i l a b l e whether or not. a c t u a l l y occupied. This bed would be comparable to the bed s e r v i c e s which are f u l l y u t i l i z e d , the bed categories are: Medical and S u r g i c a l U n d i s t r i b u t e d P s y c h i a t r i c O b s t e t r i c P e d i a t r i c s Method of A n a l y s i s Bed P r e d i c t i o n Formula The l i t e r a t u r e review pointed to a v a r i e t y of methods which could be used to p r e d i c t beds. Three p a r t i c u l a r examples were described i n d e t a i l because they represented methods used c u r r e n t l y and were al s o methods designed to meet l o c a l or s p e c i f i c needs developed at a higher a d m i n i s t r a t i v e and p o l i c y l e v e l than the h o s p i t a l . These methods d i d not i n f l u e n c e the present study's design but do confirm the approach which evolved from the i n t e r a c t i o n of the problems. The study's bed p r e d i c t i o n model i s i n f a c t a statement w i t h many standards. M o r b i d i t y r a t e s by age and sex are assumed to be r e a l i s t i c and are hel d constant through the p r e d i c t i o n p e r i o d . S i m i l a r l y , l e n g t h of stay was he l d constant. The occupancy f a c t o r f o r each bed s e r v i c e was decided upon by a combination of use r a t e s , standards i n the l i t e r a t u r e review and opinion . More important i s that each assumption r e l a t e s to a r e g i o n ; t h e r e f o r e , p r o v i n c i a l standards are the summation of these. The standards that are  u t i l i z e d are unique to t h i s study and are not meant to be i n t e r - preted as p o l i c y statements f o r the province. Instead the study and design, as p r e v i o u s l y s t a t e d , was intended to provide a base f o r making d e c i s i o n s . The bed p r e d i c t i o n formula c a l c u l a t e d the re q u i r e d beds f o r each age and sex by d i a g n o s t i c c l u s t e r and region. Note that popu-l a t i o n s by age and sex were c a l c u l a t e d at the h e a l t h d i s t r i c t l e v e l and summed to the r e g i o n a l l e v e l . The bed p r e d i c t i o n r e q u i r e d two major steps: one step r e l a t e d to a l l bed s e r v i c e requirements; the other r e l a t e d to making adjustments to account f o r r e f e r r a l p a t t e r n s between regions and the understatement of demand (which i s presented' through the use of s e p a r a t i o n s ) . The bed p r e d i c t i o n formula which was u t i l i z e d to c a l c u l a t e age-sex beds f o r each d i a g n o s t i c s e r v i c e i s given below: PP x DSR x ALSD r , ™ _ a s 5§ as b b K " BD x Obsr BSR = Bed Service Requirement, age-Sex S p e c i f i c DSR_ = a r a t i o of separations by age and sex over the corresponding age-sex p o p u l a t i o n which has been adjusted upwards to r e f l e c t the admission r a t e as PP = P r o j e c t e d P o p u l a t i o n ; Age-Sex S p e c i f i c as DSR = D i a g n o s t i c H o s p i t a l M o r b i d i t y Rate; Age-Sex S p e c i f i c ALSD = Average Length of Stay, D i a g n o s t i c Age and Sex S p e c i f i c BD = Bed at 100% Occupancy; t h e r e f o r e , 365 Days 0, = Stated Occupancy Le v e l f o r Bed Service b s r This c a l c u l a t i o n was repeated f o r the three censusyyears i n the p r o j e c t i o n term 1976, 1981 and 1986 f o r each region. To accommodate the r e f e r r a l p a t t e r n s , p a t i e n t s t r e a t e d i n each region (4) were.subdivided by t h e i r p o i n t of o r i g i n (4 regions) This s u b d i v i s i o n was c a r r i e d out f o r each bed s e r v i c e . A t o t a l days stay r a t e was e s t a b l i s h e d f o r each bed s e r v i c e w i t h i n a region by p o i n t of o r i g i n . This r a t e was a p p l i e d to the p r o j e c t e d p o p u l a t i o n appropriate f o r the year and region of o r i g i n . Through the formula given below the f i n a l product was a statement of r e f e r r a l beds which was then added to or subtracted from a given region to r e f l e c t the l o g i c a l movement of p a t i e n t s . This c a l c u l a t i o n was not necessary to demonstrate the change i n bed requirement i n respect of age-sex po p u l a t i o n changes, but i t was c o n s i s t e n t w i t h the l o g i c of bed e s t i mation f o r regions. A bed s e r v i c e was then c a l c u l a t e d by the f o l l o w i n g c a l c u l a t i o n : where BSR = Bed Ser v i c e Requirement, Age-Sex S p e c i f i c 3.S T D S b a s = T o t a l D a y s S t a y b y B e d S e r v i c e ; Age-Sex S p e c i f i c ^bsr = ^ c c u P a n c y L e v e l f o r Bed Service The i d e n t i f i e d bed was then subtracted from the region of o r i g i n and added to the region of r e f e r r a l i n the corresponding c a t e g o r i z a t i o n . This c a l c u l a t i o n was not necessary to determine the  changes i n the age sex population i n respect of bed requirements. The understatement of demand (separations) was correct e d by using r e g r e s s i o n a n a l y s i s . E i g h t y - e i g h t (covers 2 years) observa-t i o n s of separations and admissions were regressed to estimate the c o e f f i c i e n t of X ( s e p a r a t i o n s ) . E s t i m a t i o n of E r r o r Associated w i t h the Ratio  P o p u l a t i o n P r o j e c t i o n Technique There were two reasons i n support of t e s t i n g the r a t i o method. F i r s t , very few a r t i c l e s , i n recent times, examine and report on the method's accuracy. Second, the method has not been used on h e a l t h s t a t i s t i c a l d i s t r i c t s p r i o r to t h i s study. Conse-quently, there i s a need to give the d e c i s i o n maker some idea of accuracy so. that he/she might adjust the f i n a l f i g u r e s which are presented. The methodology f o r e s t i m a t i n g the e r r o r a s s o c i a t e d w i t h the use of the r a t i o p r o j e c t i o n technique i s discussed s e p a r a t e l y i n Chapter V so that the methodology can be c l e a r l y separated from the methods which l e a d to the p r e d i c t i o n of beds. This separation w i l l a l s o focus a t t e n t i o n to the e v a l u a t i o n of a p o p u l a t i o n r a t i o p r o j e c -t i o n technique, which i s a subject that many researchers f e e l should be attended to when making p r o j e c t i o n s i n t h i s day and age. 79 The f i n d i n g s and d i s c u s s i o n of r e s u l t s w i l l f o l l o w i n Chapters V, VI and V I I . Chapter V w i l l present the methodology and analyze the estimated e r r o r associated w i t h the use of the Ratio P r o j e c t i o n Method and i n d i c a t e the degree of e r r o r that can be expected i n the p r o j e c t i o n s of various s i z e d p o p u l a t i o n bases. Chapter VI w i l l analyze both the present and f u t u r e age and sex r e l a t e d populations of each region and f o r the province as a t o t a l . Chapter V I I w i l l analyze the bed s e r v i c e requirements f o r each region and the province r e l a t i v e to the changing p o p u l a t i o n s t r u c t u r e . Chapter V I I w i l l h i g h l i g h t the major l i m i t a t i o n s of the model and the h i g h l i g h t s from each of Chapters V and VI. The relevance of the study to f u t u r e planning i n Newfoundland (Rural) w i l l be discussed. F i n a l l y , f u t u r e a p p l i c a t i o n s of the study w i l l be examined. If 80 Chapter IV Footnotes A. B. Murphy, "Newfoundland and Labrador P o p u l a t i o n , 1966/ 1971, Part I I : Health S t a t i s t i c a l D i s t r i c t s , " Newfoundland Department of He a l t h , September 1976 (working copy); "Population 1971 and 1976: Newfoundland, by Health Regions and Health S t a t i s t i c a l D i s t r i c t s " (Newfoundland Department of Healt h , 1975). 2 I b i d . Personal communication w i t h Mark Shrimpton, St. John's C i t y C o u n c i l , September, 1979. ^Personal communications w i t h demographers Dr. A. A l d e r d i c e , Memorial U n i v e r s i t y ; and Mr. George Courage and Mr. Hugh R i d d l e r , C e n t r a l S t a t i s t i c s D i v i s i o n , Newfoundland Government, September 1979. " ' s t a t i s t i c s Canada, Pop u l a t i o n P r o j e c t i o n s f o r Canada and  the P r o v i n c e s , 1976-2001, Cat. No. 91-520, Ottawa, 1977, pp. 17-21. 6 I b i d . ^ A lderdice and Courage, personal communications. 8Mark S. Blumberg, "D.P.F. Concept Helps P r e d i c t Bed Needs," The Modern H o s p i t a l 97 (December 1971): 75-81. CHAPTER V ESTIMATION OF ERROR ASSOCIATED WITH THE USE OF THE RATIO METHOD In t r o d u c t i o n I t was noted p r e v i o u s l y i n the l i t e r a t u r e review that more a t t e n t i o n should be given to the e s t i m a t i o n of e r r o r contained i n pop u l a t i o n p r o j e c t i o n . This e r r o r can be c a l c u l a t e d i n a number of ways. The more d i r e c t and p r e c i s e method i s to compare the p r o j e c t e d populations to t h e i r forthcoming a c t u a l census values. This t a c t i c r e q u i r e s a w a i t i n g p e r i o d and n e c e s s i t a t e s the s e l e c t i o n of p r o j e c -t i o n years which are census designates. Given reasonable assump-t i o n s , t h i s p o p u l a t i o n p r o j e c t i o n w i l l stand u n t i l i t i s evaluated at some f u t u r e p e r i o d . An a l t e r n a t i v e approach i s to apply the p r o j e c t i o n ' s methodology on a data s et from the past, and p r o j e c t a pop u l a t i o n to a census year i n the past. Estimating the e r r o r by f o l l o w i n g t h i s l a t t e r approach has very d i s t i n c t advantages. I t provides the researcher w i t h a p r a c t i c a l f e e l f o r both the data and methodology. The estimate of e r r o r , i n t u r n , would provide the user w i t h an opportunity to accept, r e j e c t or modify the po p u l a t i o n p r o j e c t i o n s which are being observed. The researcher would a l s o enjoy the vantage po i n t of being able to modify the p r o j e c t i o n approach based upon h i s own p r a c t i c a l observations. F i n a l l y , t h i s approach allows f o r a more rigorous e v a l u a t i o n of the method. I f 81 82 i t i s combined w i t h p r o j e c t i o n years which correspond to census years, the methodology can be evaluated before and a f t e r , and the p r e l i m i n a r y e s t i m a t i o n of the e r r o r i t s e l f can be evaluated f o r v a l i d i t y and r e l i a b i l i t y . Assumptions The r a t i o method was reviewed i n d e t a i l i n the l i t e r a t u r e review. The acceptable l e v e l of e r r o r which was e s t a b l i s h e d was an absolute mean of 10% or l e s s f o r a p r o j e c t i o n of 10 years or l e s s . A p r i o r i , a s h o r t e r p r o j e c t i o n p e r i o d should give the expectation that the absolute mean e r r o r would decrease. The e r r o r i s c a l c u l a t e d by d i v i d i n g the d i f f e r e n c e between the values of a p r o j e c t i o n year and i t s corresponding census year, by the value of the census year. The r a t i o i s then converted to percent. In cases reported i n the l i t e r a t u r e where the data conforms to suggested g u i d e l i n e s , the popul a t i o n bases were very l a r g e ; that i s , they were i n the m i l l i o n s . In a d d i t i o n , these cases o f t e n p r o j e c t e d t o t a l p o p ulations. These two c o n d i t i o n s tend to decrease the e r r o r r a t e . Therefore, and i n d i r e c t comparison w i t h t h i s study's p r o j e c t i o n of very s m a l l popu-l a t i o n s by age and sex i n t e r v a l s , a higher e r r o r r a t e may need to be accepted. Notwithstanding t h i s o p i n i o n , the a c c e p t a b i l i t y of the upper l i m i t s of the absolute mean e r r o r i s t o t a l l y dependent upon the use to which the p o p u l a t i o n p r o j e c t i o n i s being a p p l i e d i n the planning f u n c t i o n . The acceptable l e v e l of e r r o r should a l s o be reviewed i n r e l a t i o n to the property of s i n g l e estimator of po p u l a t i o n to produce extreme values. I f these extremes are expected then i t becomes obvious that some form of prudent manipulation i s req u i r e d . Conse-83 quently, the o v e r a l l estimate of e r r o r would be lower. A l t e r n a -t i v e l y , i t i n f e r s that the m a j o r i t y of e r r o r s encountered are very acceptable. In other words, the d e c i s i o n to accept or r e j e c t the p r o j e c t i o n s should not f a l l s o l e l y upon a s t r i c t g u i d e l i n e of 10%. However, t h i s g u i d e l i n e of 10% represents the experienced o p i n i o n of researchers and should c a r r y considerable weight. The p o p u l a t i o n data from which the e r r o r was c a l c u l a t e d was adjusted as l i t t l e as p o s s i b l e . . Mathematical signs were fo l l o w e d w i t h the exception of four observations which had to be adjusted. In each case the magnitude and d i r e c t i o n of change were the i n f l u -encing f a c t o r s . Two cases had negative populations. These were adjusted to a s t a t e of no change. When compared w i t h census values the r e s u l t a n t e r r o r was reduced to zero. In the remaining two cases the d i r e c t i o n of change was both i l l o g i c a l and l a r g e . These two e r r o r s were reduced from approximately 100% to 12.5%. The choice of f o l l o w i n g mathematical signs (versus l o g i c ) r ested upon the o p i n i o n i t would provide a c l e a r e r path f o r r e p l i c a t i o n . I t would a l s o provide a p o t e n t i a l user w i t h a data s et which would not have to be decoded. The use of l o g i c may enhance the p r o j e c t i o n s but i t a l s o suggests a slzate of i m p r e c i s i o n . The data provided by Census Canada has some e r r o r b u i l t i n t o i t . Through the process of random rounding, a l l numbers are rounded e i t h e r upwards or downwards to 5 or 0. This e r r o r i s n e g l i g i b l e w i t h very l a r g e populations but i t i s c l e a r l y v i s i b l e i n small p o p u l a t i o n bases. A rounding e r r o r of 4 on a base of 100 or 50 y i e l d s an e r r o r of between 4% and 8%. In some s i t u a t i o n s a t o t a l p o p u l a t i o n might be 30 yet the i n t e r v a l s may add to 15 or 45. On occasion when the r a t i o method i s used,there are zero growth r a t e s i n these i n t e r v a l s when i t i s evident that such i s not the case. Method 84 An a l t e r n a t i v e s t r a t e g y was developed to t e s t e r r o r s asso-c i a t e d w i t h the r a t i o p o p u l a t i o n p r o j e c t i o n method. Between 1966 and 1971 numerous census s u b d i v i s i o n s underwent boundary changes. The task of providing equivalent u n i t s f o r comparison would be complex and d i f f i c u l t , p a r t i c u l a r l y i n t r y i n g to organize to the h e a l t h s t a t i s t i c a l d i s t r i c t area. While s u b d i v i s i o n s changed, the census d i v i s i o n remained s t a b l e during t h i s p e r i o d . Each census d i v i s i o n was comprised of 22 age-sex i n t e r v a l s . Thus, f o r Newfoundland, there are 10 census d i v i s i o n s and a t o t a l of 220 age-sex i n t e r v a l s . The chosen and a l t e r n a t i v e s t r a t e g y was to view each of these age-sex i n t e r v a l s as a d i s t r i c t p o p u l a t i o n base. In so choosing, and i n the context of Newfoundland's s m a l l e r populated communities, the r a t i o method can be viewed as o p e r a t i n g i n a s i t u a t i o n which i s expected to give extremes of high variance and higher absolute mean e r r o r s . The e r r o r was c a l c u l a t e d f o r these 220 age sex i n t e r v a l s . One hundred and n i n e t y - t h r e e of these i n t e r v a l s had a p o p u l a t i o n base under 3000. To provide a more p r e c i s e estimate of e r r o r , that i s , f o r l a r g e r p o p u l a t i o n bases, the 220 i n t e r v a l s were compressed to 3 age i n t e r v a l s (sex combined). For t h i s compressed set the estimate of e r r o r was c a l c u l a t e d . Further i n t h i s attempt to provide a p i c t u r e of e r r o r i n l a r g e r p o p u l a t i o n s , e r r o r was c a l c u l a t e d f o r the t o t a l p o p u l a t i o n only (both sexes) i n each census d i v i s i o n . The estimate of e r r o r was a l s o c a l c u l a t e d i n two ways. F i r s t , i t was derived from sampling. Second, i t was derived by c o n s i d e r i n g the e n t i r e data s e t . The reason that the e n t i r e data set was presented was because i t was not c o s t l y i n time to do so and 85 because i t was a n t i c i p a t e d that a l a r g e sample would be r e q u i r e d . The l a r g e sample was expected f o r the populations under 3000 because the variance was a n t i c i p a t e d to be l a r g e and i n the remaining i n t e r -v a l s over 3000 there was very l i t t l e e f f o r t r e q u i r e d to use the t o t a l number of values. The t o t a l sample was 94 and c o n s i s t e d of: 83 from the 0-2,999 stratum; 5 from the 3,000-9,999 stratum and 6 from the 10,000 and 1 2 oversstratum. The methods used to determine the sample s i z e ' are given i n Appendix B. The b a s i c scheme f o r the s t r a t i f i c a t i o n of p o p u l a t i o n and p r e s e n t a t i o n of e r r o r i s : 0 - 2,999 3,000 - 9,999 T _ . .„ -In c e r t a i n s i t u a t i o n s the 10,000 - 24,999 stratum are combined to 25,000 - 49,000 1 0 ' 0 0 ° + 50,000 - 74,999 75,000 + I t has been s t a t e d that the r a t i o method i s expected to produce extreme e r r o r s . This being the case, there should be higher than normal d i s t r i b u t i o n of e r r o r s at both t a i l s of the d i s t r i b u t i o n . As p a r t of the methodology the e s t i m a t i o n of e r r o r presented i n the 3 4 sampling was transformed using the A r c s i n percent. ' The A r c s i n Vpercent transformation should p u l l the extreme values towards the meanj. that i s , i t should normalize the data. In other words, the r e a l question which i s to be proposed i s whether tran s f o r m a t i o n a s s i s t s i n the a n a l y s i s of t h i s type of data. Although obvious, the absolute mean.error i s f a r more impor-tant i n determining the character of the e r r o r . The mean w i t h signs considered i s -not an appropriate f i g u r e to examine because p o s i t i v e 86 values tend to cancel out negative values. Therefore the mean w i l l approach the value of zero. The e s t i m a t i o n of e r r o r i s presented through the f o l l o w i n g s t a t i s t i c s : the absolute mean e r r o r , the standard e r r o r (SE) of the mean, the confidence l i m i t s and the number of e r r o r s under or equal to 10%. As noted p r e v i o u s l y i n the methodology there was a suggestion that the random rounding process was biased. To t e s t t h i s observa-t i o n , 594 observations were r e s t r u c t u r e d to a 3x2 contingency t a b l e and subjected to a Chi Square a n a l y s i s . See Appendix C. F i n a l l y to t e s t e r r o r i n r e l a t i o n to po p u l a t i o n s i z e two s t a t i s t i c a l procedures were performed. The count of e r r o r s of 10% or under were compared w i t h p o p u l a t i o n s i z e i n a contingency t a b l e . The expected c o n c l u s i o n was that there would be-a- r e l a t i o n s h i p such that the count of e r r o r s under or equal to 10% increased as popula-t i o n s i z e increased. To examine the r e l a t i o n s h i p between the s i z e of e r r o r and po p u l a t i o n s i z e , e r r o r s were p l o t t e d according to popu-l a t i o n stratum to f i r s t determine the array of p o i n t s . Aggression or c o r r e l a t i o n was expected to be c a r r i e d out. Results Table V-'l gives various presentations of the estimates of e r r o r a s s o c i a t e d w i t h the use of the r a t i o p r o j e c t i o n technique. The v a r i e t y of t a b l e s stems from both s t r a t i f i c a t i o n and o r g a n i z a t i o n of the age-sex i n t e r v a l s . Table V-1A describes the estimate of e r r o r based upon sampling. From a-sample of 94, the mean absolute e r r o r was 12.0% ±1.6 (SE). As the po p u l a t i o n s i z e i n c r e a s e s , the mean absolute e r r o r i s reduced from 13.0% to 5.2%. Thus i t would 87 Table V - l Es t i m a t i o n of E r r o r s Associated With The Ratio Method A. Age Sex I n t e r v a l s (based on sampling) Stratum N | M | . S.E. NO. E r r o r s <. 10% 0 - 2,999 83 13.0 % 1.8 51 3,000 - 9,000 5 6.32 2.6 3 10,000 + 6 5.2 2.1 5 T o t a l 94 12.0 1.60 59 B. Three Age I n t e r v a l s ^ ( f o r 10 census d i v i s i o n s ) 0 - 2,999 9 9.7% 2.9 6 3,000 - 9,999 2 10.8 6.3 1 10,000 - 24,999 15 7.0 2.0 12 25,000 - 49,999 3 4.7 1.4 3 50,000 - 74,999 1 4.6 - 1 T o t a l 30 7.4 1.4 23 C. T o t a l Populations ( f o r census d i v i s i o n s ) 25,000 - 49,999 8 5.1% 1.1 8 50,000 - 74,999 1 3.4 - 1 75,000 + 1 2.3 - 1 T o t a l 10 4.6 1.0 10 D. Age-Sex I n t e r v a l s (by census d i v i s i o n ) 0 - 2,999 193 13.2% 1.3 123 3,000 - 9,999 14 5.5 1.4 10 10,000 + 13 6.5 1.8 11 T o t a l 220 12.3 1.2 144 a R a t i o method was used to p r o j e c t a 1976 po p u l a t i o n from a 1966-1971 base (22 age-sex i n t e r v a l s times 10 census d i v i s i o n s ) . P r o j e c t e d values compared w i t h corresponding census values f o r 1976 gives e r r o r expressed as a percent of the 1976 census value. Compressed age i n t e r v a l s : 0-14, 15-64, 65+5 3 i n t e r v a l s per d i v i s i o n . 88 appear, s u p e r f i c i a l l y , that a r e l a t i o n s h i p e x i s t e d between the s i z e of the population and the s i z e of the e r r o r . I n d i r e c t l y t h i s i s also suggested by the p r o p o r t i o n a l count of e r r o r s i n each stratum under or equal to 10%. However, the only r e l i a b l e f i g u r e s expressed are those from the 0-2999 popu l a t i o n stratum because there i s a s u f f i c i e n t l y l a r g e number of observations. The sample r e s u l t s i n Table V-1A compare reasonably w e l l tb the t o t a l data set estimated i n Table V-1D. Two hundred and twenty observations y i e l d e d a mean absolute e r r o r of 12.3% ± 1.2. The rate of e r r o r s under or equal to 10% was .65 (144/220). This i s s i m i l a r to a r a t e of .63 e s t a b l i s h e d i n the sample. Tables V-1A and IB also suggest a r e l a t i o n s h i p between p o p u l a t i o n s i z e and e i t h e r e r r o r s i z e or p r o p o r t i o n of e r r o r s under or equal to 10%. While the number of observations decreases w i t h p o p u l a t i o n s i z e , the standard d e v i a t i o n s i n d i c a t e that the spread of values around the mean decreases as the population s i z e i n creases. This decreased spread of data i s r e i t e r a t e d i n Tables V—IB and 1C. In Table V-lB, the age-sex i n t e r v a l s were compressed to three i n t e r v a l s before p r o j e c t i o n . The e r r o r estimated f o r 30 i n t e r -v a l s was a mean absolute e r r o r of 7.4% ± 1.4. The r a t e of e r r o r s under or equal to 10% was .76 (23/40). For each stratum over 10,000 po p u l a t i o n , there was a f a r greater p r o p o r t i o n of e r r o r s under or equal to 10% than i n the preceding s t r a t a . Table V-1C, f o r the t o t a l p o p u l a t i o n , gives the same p i c t u r e . There was higher p r e c i s i o n . However, the number of observations i s very low. The mean absolute e r r o r of the t o t a l p opulation i s 4.6% ± 1.0 and a l l e r r o r s were under or equal to 10%. I f aggregation of the data i s performed p r i o r to p r o j e c t i o n , the p r e c i s i o n of the p r o j e c t i o n should be g e n e r a l l y enhanced. 89 While i t i s both r e l e v a n t and i n t e r e s t i n g to be comparing e r r o r s f o r s m a l l or l a r g e p o p u l a t i o n s , the r e a l and p r a c t i c a l e s t i -mates f o r e v a l u a t i o n f a l l upon the 0-2999 stratum. This stratum c h a r a c t e r i z e s much of the Newfoundland pop u l a t i o n . Therefore, the estimates of variance and the c o n s i d e r a t i o n of extremes f o r t h i s stratum should weigh h e a v i l y upon the d e c i s i o n to accept, r e j e c t or modify the popu l a t i o n p r o j e c t i o n s . This designated importance should mean that t h i s s t r a t a should be analyzed independently. Based upon a sample (Table V-1A), the absolute mean of the 0-2999 stratum was 13.0% ± 1.8. The number of e r r o r s equal to or under 10% was 51, f o r a rat e of .54. W i t h i n the estimates of the t o t a l data set (Table V-1D), the mean f o r t h i s stratumwas 13.2% ± 1.3. In examining t h i s stratum w i t h i n the t o t a l data set two stratagems were followed. F i r s t , two census d i v i s i o n s (44 observations) which are considered economically unstable and disadvantaged were sub-t r a c t e d from the 193,0-2999 pop u l a t i o n observations. The absolute mean d e c l i n e d from 13.2% to 10.5% and there was a subsequent reduc-t i o n i n the vari a n c e . By e l i m i n a t i n g questionable data, 77.2% of the data f e l l w i t h i n the 10% g u i d e l i n e . I f as has been suggested, extreme values are modified i n d i -v i d u a l l y , a f a r b e t t e r estimate of the usefulness of the p r o j e c t i o n s i s obtained. For a r u l e of thumb the 10% g u i d e l i n e could be doubled to 20%. I f these extremes are subtracted from the 103 observations of the 0-2999 stratum (Table V - l D ) , the absolute mean e r r o r drops from 13;2% ± 1.3 to 6.4% ± .41. Eighty-one percent of the data i s considered to be c o n t r i b u t i n g to the acceptable g u i d e l i n e of 10% (see Appendix D). When the modified extremes are incorp o r a t e d i n t o the data the obvious outcome i s a probable and f u l l set of observa-90 t i o n s which meet the acceptable c r i t e r i o n . The main observation i n these two e x e r c i s e s , as expected, i s that the extremes do i n f l u e n c e the e s t i m a t i o n of e r r o r f o r the e n t i r e data s e t . Despite t h i s i n f l u e n c e of extreme v a l u e s , the r a t i o method i s appropriate f o r 80% of the age-sex i n t e r v a l s i n the lower p o p u l a t i o n c l a s s e s . Although the r a t i o method has been evaluated on l a r g e r p o p u l a t i o n bases, i t can be a p p l i e d , w i t h due c a u t i o n , to lower p o p u l a t i o n bases. Table V-2 A r c s i n ^ P e r c e n t Transformation of E r r o r Estimates Associated w i t h the Ratio Method (Based on Sample) Non Transformed N j M 1 S . E. 99% Confidence L i m i t s 0 - 2 , 9 9 9 8 3 1 3 . 0 % 1.8 9 . 4 - 1 6 . 6 3 , 0 0 0 - 9 , 9 9 9 5 6 . 3 2 . 6 0 - 2 0 . 6 1 0 , 0 0 0 + 6 5 . 2 2 . 1 0 - 1 8 . 0 T o t a l 94 1 2 . 0 1 . 6 0 8 - 1 6 . 1 A r c s i n \/Percent Retransformed 0 - 2 , 9 9 9 83 1 0 . 0 % 1 . 4 6 . 5 - 1 4 . 0 3 , 0 0 0 - 9 , 0 0 0 5 1 . 5 3 . 1 o - 1 3 . 2 1 0 , 0 0 0 + 6 - 1 . 4 2 . 8 0 - 9 . 5 T o t a l 94 9 . 2 1 . 2 5 5 . 6 - 1 3 . 7 M = absolute mean S.E. before r e t r a n s f o r m a t i o n f o r stratum are 1.4, 3.1, 2.8 and 1.25 r e s p e c t i v e l y M :- before r e t r a n s f o r m a t i o n f o r stratum are 18.4°, 7.0°, 6.8° and 17.7°i r e s p e c t i v e l y Table V^2 compares o r i g i n a l i n t e r p r e t a t i o n and transformation of the sample estimates of e r r o r . The o r i g i n a l sample has an absolute mean e r r o r of 12.0% ± 1.6. The 99% confidence l i m i t s are 8% (lower) and 16.1% (upper). The transformed sample has an absolute mean e r r o r of 17.79 ± 1.25. Upon retra n s f o r m a t i o n of A r c s i n \[percent values the confidence l i m i t s become 5.6% and 13.7% w h i l e the mean e r r o r i s 9.2% ± 1.25. The transformation of the data presents a very o p t i -m i s t i c p i c t u r e ; that i s , i t presents a lower estimate of the e r r o r . However, i n terms of the transformation n o r m a l i z i n g the data, i t suggests that the body of the p r o j e c t i o n s w i l l tend to f a l l under or hedge around the 10% g u i d e l i n e s because transformation minimizes the i n f l u e n c e s of extremes on the mean. The view as presented by t r a n s -formation p a r a l l e l s to some extent the manipulation of the o r i g i n a l data set i n which the e r r o r s greater than 20% were e l i m i n a t e d from the 0-2999 stratum. The transformation of the e r r o r estimates f o r the two l a r g e r p o p u l a t i o n s t r a t a does not enhance the a n a l y s i s . The retransformed absolute means are 1.5% and 1.4%. The 99% confidence l i m i t s are f a r narrower than f o r the non transformed estimates. The retransformed means are too low and not r e p r e s e n t a t i v e of the e r r o r s d i s p l a y e d i n these s t r a t a . For example, i f a weighted average ( e l i m i n a t i o n of 2 high and 2 low values) was considered, the estimated absolute mean of the 3,000-9,000 and the 10,000+ s t r a t a would be 4.8% and 3.1%, r e s p e c t i v e l y , a decrease from 5.5% and 6.5%. The preceding paragraphs showed that the use of the r a t i o p r o j e c t i o n method leads to a wide range of e r r o r s and to extreme values. Transformation p u l l s i n the extremes toward the mean and the r e f o r e tends to hide them from the observer. Statements presented without transformation are more p r a c t i c a l and u s e f u l . I t i s impor-tant to be aware of extreme values so that demographic adjustments can be made. Transformation, t h e r e f o r e , has low d i a g n o s t i c a b i l i t i e s when anomalies occur. 92 The t a b l e s which have been presented appear to demonstrate two r e l a t i o n s h i p s w i t h p o p u l a t i o n s i z e . F i r s t , the p r o p o r t i o n of e r r o r s <L-10% increases as p o p u l a t i o n s i z e i n creases. Second, the s i z e of the e r r o r tends to get smaller as the p o p u l a t i o n s i z e i n c r e a s e s . To t e s t the r e l a t i o n s h i p between pop u l a t i o n s i z e and propor-t i o n of e r r o r s above and below 10% a contingency t a b l e , ( V - 3 , was constructed as f o l l o w s : Table V-3 Test f o r the R e l a t i o n s h i p Between the P r o p o r t i o n of E r r o r s <. 10% and P o p u l a t i o n Size E r r o r S i z e 0-2,999 3,000-9,999 10,000 + T o t a l <. 10% 123 (64%) 10 (71%) 11 (85%) 144 > 10% 70 (36%) 4 (29%) 2 (15%) 74 193 14 13 220 X 2 = 2.6; X 2 = 9.2 < PC(.Ol) The r e l a t i o n s h i p that the p r o p o r t i o n of e r r o r s under or equal to 10% would increase as p o p u l a t i o n s i z e increased was not 2 supported by Chi Square a n a l y s i s (P (X^ = 2.6) > 0.25). To compen-sate f o r low c e l l frequency the data was c o l l a p s e d to a 2x2 c o n t i n -gency t a b l e . Again, the r e l a t i o n s h i p was not supported. To t e s t the second r e l a t i o n s h i p between the s i z e of e r r o r and p o p u l a t i o n s i z e , the e r r o r s were p l o t t e d against the p o p u l a t i o n s t r a t a to f i r s t determine the array of p o i n t s . The graph of p o i n t s i s presented i n Appendix E. The r e l a t i o n s h i p between s i z e of e r r o r and p o p u l a t i o n s i z e was not suggested by the array. The form of the data i s h o r i z o n t a l w i t h high v a r i a t i o n at low p o p u l a t i o n l e v e l s and 93 low v a r i a t i o n at high p o p u l a t i o n l e v e l s . Yet, conclusions can be reached. I t appears that as the popu l a t i o n s i z e increases the range of values to the e r r o r s decreases. There i s a l s o the appearance of a random d i s p e r s i o n to the e r r o r s i n each stratum. This i m p l i e s that i t i s the demographic c h a r a c t e r i s t i c of the pop u l a t i o n which i s producing the v a r i a t i o n i n e r r o r and extreme values. More i m p o r t a n t l y , t h i s f i n d i n g suggests, that f o r  each area being p r o j e c t e d by the r a t i o method, that a demographic  and complementary data f i l e should be developed and used to support  necessary adjustments to extreme values. With demographic a d j u s t -ments to extreme va l u e s , the r a t i o method not only produces an acceptable l e v e l of e r r o r s <. 10% (.80) the method does not appear to i n f l u e n c e the e r r o r . In the context of a province c h a r a c t e r i z e d by communities w i t h very low p o p u l a t i o n s , and i n s i t u a t i o n s where demographic data i s l a c k i n g , the r a t i o p r o j e c t i o n method can be u t i l i z e d . The r a t i o method can, w i t h due c a u t i o n , give p r o j e c t i o n s which have an acceptable l e v e l of p r e c i s i o n f o r planning. 94 Chapter V Footnotes ^ l v a n R. F e i n s t e i n , C l i n i c a l B i o s t a t i s t i c s (St. L o u i s : The C. V. Mosby Co., 1977), pp. 155-185. 9 Frank Freese, Elementary Forest Sampling, A g r i c u l t u r e Handbook No. 232 (Forest S e r v i c e , U.S. Department of A g r i c u l t u r e ) , December 1962, pp. 28-36. o Jerome R. C. L i , S t a t i s t i c a l Inference, V. I (Ann Arbor: Edwards Brothers, Inc., 1964), pp. 505-512. ^Freese, pp. 28-36. CHAPTER VI CHANGES IN BEL REQUIREMENTS IN RESPECT OF POPULATION CHANGES In t r o d u c t i o n The purpose of t h i s study was o r i g i n a l l y intended to be both p r a c t i c a l and experimental. Various subgoals which were i d e n t i f i e d are each as important i n t h e i r own r i g h t as the end product. This study i s the f i r s t major use of i n p a t i e n t morbidity f i l e s i n recent years. The primary a c t i v i t y r e l a t e d to these f i l e s has been the c o l l e c t i o n of data. I t i s only through p r a c t i c a l use of the f i l e s that the appropriate types of data f o r planning can be determined. As was s t a t e d p r e v i o u s l y , i n support of a h e a l t h planning data base, t h i s study has generated a very important p o p u l a t i o n base which can be r e f i n e d i n the years ahead. As u s e f u l planning t o o l s the Depart-ment of Health has two which i t can evalua t e : the Ratio P o p u l a t i o n P r o j e c t i o n Method and the Bed P r e d i c t i o n Model. Yet the key p o i n t to be demonstrated i n the f i n d i n g s i s a statement that bed requirements should be derived i n a more a n a l y t i c a l way. This study's method i s expected to assign beds to s e r v i c e and regions i n a more appropriate manner. A p r i o r i , there i s the expec-t a t i o n that t h i s method w i l l be promoted f o r use i n the province. In so s t a t i n g i n the probable and future tense there i s an i m p l i c a -t i o n that even the present method may not i n f a c t be promoted from 95 96 f i n d i n g s . Methods The method of p r o j e c t i n g the population and p r e d i c t i n g bed requirements has been d e t a i l e d i n Chapter IV e n t i t l e d Methodology. The bed p r e d i c t i o n model b r i e f l y i n v o l v e d p r o j e c t i n g i n p a t i e n t m o r b i d i t y by age and sex w i t h i n four d i s t i n c t bed c l u s t e r s : Pedia-t r i c s , Medical and S u r g i c a l , P s y c h i a t r i c , and O b s t e t r i c s . The morbidity f i g u r e s i n v o l v e d the 1976 admissions and length of stay which were h e l d constant i n each d i a g n o s t i c category through the e n t i r e p r o j e c t i o n p e r i o d . The t o t a l beds f o r each d i a g n o s t i c c l u s t e r i n each region was a summation of bed requirements f o r each age-sex i n t e r v a l . The t o t a l f o r a l l beds w i t h i n a region was there-f o r e both a sum of age and sex requirements and d i a g n o s t i c c l u s t e r s . The Ratio P o p u l a t i o n P r o j e c t i o n Method was not modified f o r the p r o j e c t i o n s . Instead, a l l the h o s p i t a l d i s t r i c t s were combined to t h e i r r e s p e c t i v e regions to increase the popu l a t i o n base f o r each age-sex i n t e r v a l . This step was taken f o r two reasons: to increase the accuracy of the popu l a t i o n p r o j e c t i o n and ther e f o r e the p r e d i c -t i o n of beds; and to correspond w i t h the l e v e l of a n a l y s i s which was to be a p p l i e d to the beds. The mor b i d i t y data was also c o l l e c t e d and c o l l a t e d to the r e g i o n a l l e v e l only. In the p r e d i c t i o n of the beds, a number of adjustments to the derived f i g u r e s were put i n t o e f f e c t so that a more r e a l i s t i c requirementc f o r each region was defined. For each region two sets of bed p r e d i c t i o n s were provided. The f i r s t c a l c u l a t i o n i n v o l v e d expressing the t o t a l m o rbidity and t h e r e f o r e bed requirements as a f u n c t i o n of a region's p o p u l a t i o n . R e f e r r a l s ( i n t o and out of the region) and out of province p a t i e n t s were t h e r e f o r e not r e l a t e d to the regions or provinces from which they o r i g i n a t e d . The second c a l c u l a t i o n allowed f o r p r o j e c t e d changes i n outflow of p a t i e n t s based upon changes i n the region's population. Changes i n the i n f l o w of p a t i e n t s were;:related to changes i n the popu l a t i o n of regions from which p a t i e n t s came. These two approaches y i e l d the same p r o v i n c i a l t o t a l s but the r e g i o n a l t o t a l s vary considerably because of the changing flows. Both of these c a l c u l a t i o n s are presented i n t a b l e format. As a f u n c t i o n of the work-up to a r r i v e at these c a l c u l a t i o n s , a summation of beds r e l a t e d to age and sex i s provided. To examine the changes i n the beds r e l a t i v e to changes i n the p o p u l a t i o n , the p r e d i c t e d beds are presented by age-sex cate-gories and al s o by d i a g n o s t i c c l u s t e r showing percent change i n the age-sex i n t e r v a l and the percent change i n beds f o r the same age-sex i n t e r v a l . The beds are also presented i n a sex breakdown to provide an i n d i c a t i o n of the type of s e p a r a t i o n or segregation f o r p a t i e n t p r i v a c y . F i n a l l y , to demonstrate whether t h i s e n t i r e method y i e l d s s u b s t a n t i a l l y d i f f e r e n t r e s u l t s from a bed to popu l a t i o n r a t i o p r e d i c t i o n method, the present study's estimates are compared w i t h i t , i n a d d i t i o n to a redefined bed to po p u l a t i o n r a t i o approach. The methodology f o r the bed p r e d i c t i o n s was followed pre-c i s e l y and checked f o r accuracy at numerous stages. Yet the f i n a l t a l l i e s i n the p r o j e c t i o n years are d i f f e r e n t f o r the "w i t h " and "without" r e f e r r a l p r e d i c t i o n s . The d i f f e r e n c e s or e r r o r i n any one year does not exceed 0.6%. The methodology and c a l c u l a t i o n s were  repeatedly checked. However, the e r r o r could not be reduced below 0.6%. Rounding e r r o r s should be minimal because decimals rounded to 98 tenths were c a r r i e d a l l the way through the c a l c u l a t i o n s . More probable, the e r r o r i s a r e s u l t of the many manual t a b u l a t i o n s performed which i n v o l v e d both rounding and t r a n s c r i p t i o n . To r e i t e r a t e , the f i g u r e s and c a l c u l a t i o n s were repeatedly checked. The e r r o r which does not exceed 0.6% should not hinder the a p p l i c a -t i o n of e i t h e r data or methods to planning purposes. The e r r o r does not d i s t o r t the i n t e n t of t h i s t h e s i s which i s to develop and u t i l i z e p o p u l a t i o n p r o j e c t i o n and bed p r e d i c t i o n techniques and data f o r h e a l t h regions and d i s t r i c t s (considered to be sm a l l e r populated areas). P o p u l a t i o n Results Appendix F presents the p o p u l a t i o n i n the four regions f o r the years 1976, 1981, and 1986. The populations are shown by age i n t e r v a l f o r each sex and f o r the t o t a l p opulation. Table VI-1 (which i s a summary of the more important observations from Appendix F) shows that-there are remarkable s i m i l a r i t i e s between regions. S i x p o p u l a t i o n groups form the nucleus of the d i s c u s s i o n . A l l regions show a d e c l i n e i n the p e d i a t r i c 0-14 age groups. This i s the c o n t i n u a t i o n of a p a t t e r n which i s a d i r e c t r e s u l t of a d e c l i n i n g b i r t h r a t e . While the b i r t h r a t e has s t e a d i l y d e c l i n e d , the present p r o j e c t i o n s assume that t h i s w i l l continue u n t i l at l e a s t 1986. However data i s not yet a v a i l a b l e on b i r t h s f o r recent years but f i g u r e s r e l e a s e d i n 1976 show a d e c l i n e which i s very marginal. I t may w e l l be that the b i r t h r a t e i s beginning to l e v e l o f f . I f t h i s i s the case, the p r o j e c t i o n s over the next 5-10 years may have to be adjusted upwards. In,doing the popu l a t i o n p r o j e c t i o n s , the p e d i a t r i c 0-14 age i n t e r v a l s tended to show a great deal of Table VI-1 Summary Analysis of Population Projections, 1976 vs. 1986: Population As Per Cent Of Total, 1976 and 1986 Northern Western Central Eastern 0-14 T. 38.3-32.8 35.5-28.7 35.6-28.1 31.4-24.5 15-64 T. 59.1-62.5 58.1-61.7 59.2-65.1 60.9-66.9 65+ T. Stable 6.4- 8.8 5.3- 6.7 7.6- 9.3 25-44 H. Stable 25-34 a.g. : 20-44 a.g.: 12.1-16.5 13.7-16.4 16.7-19.9 12.1-16.5 45-64 T. 10.5- 9.9 Stable Stable 16.4-15.4 25-44 F. 20-44 a.g.: 11.3-14.0 20-44 a.g.: 11.9-15.3 38.1-45.7 20.2-25.1 Population As Difference, 1976 vs. 1986 Northern Western Central Eastern 0-14 T. (237) (5844) (5243) (13019) 15-64 T. 7261 9974 10735 35797 65+ T. 341 3801 1877 7351 25-44 M. Stable 25-34 a.g.: 20-44 a.g.: 31003 4772 4774 45-64 T. 593 Stable Stable (1561) 25-44 F. 20-54 a.g.: 4567 5928 14094 4890 NOTES: 1. When two numbers appear in each column, the f i r s t figure i s for 1976 and the second figure is for 1986. ^ VO 2. a.g. = age group. 3. ( ) = decline. 4. T = Total, M = Male, F = Female. l i d o f l u c t u a t i o n i n the amount of change. The decline of the p e d i a t r i c base as with the status of other age i n t e r v a l s i s r e l a t e d to the movement of a s i n g l e v a r i a b l e , the Newfoundland population. The Northern Region w i l l have 32.8% the greatest percentage of p e d i a t r i c 0-14 year olds r e l a t i v e to i t s own population. In absolute numbers, i t had a very s l i g h t decline. The high impact regions are the Eastern with 13,019, the Central with 5,243 and the Western with 5,844. The Eastern Region's percentage of p e d i a t r i c 0-14 i s considerably lower than the remainder of the Province. By the end of the projection, 1986, the Northern Region i s expected to have the greatest percentage of c h i l d r e n 0-14 (32.8%) i n comparison to the Eastern Region which should have the lowest (24.5%). In actual people the opposite p i c t u r e i s true, the Northern declined 237, whereas the Eastern declined 13,019. The 15-64 age groups increased i n a l l regions. Both the Western and Eastern Regions increased from 59.2% to 65.1% and from 60.9% to 66.9% respectively. Consistent gains are shown i n three regions i n the neighbourhood of 7-10,000, whereas the Eastern had a change of 35,797. This increase arises because of the 25-44 age group which i s growing and s h i f t i n g t h i s growth to higher age l e v e l s . Between 2.6% and 3.4% increases were experienced i n a l l regions except the Northern. These s l i g h t gains suggested increased cohort s u r v i v a l i n early age groups. It i s i n t e r e s t i n g to observe the increase i n the older popu-l a t i o n (65+years). In the Northern, there i s a very s l i g h t increase i n the 65+ age group (2.9-3.0%) whereas the other regions display a much larger increase. Central Newfoundland demonstrates an increase of 3,801 twice that of the Western. However, Eastern i s f a r greater 101 w i t h an increase of 7,351 showing more emphatic signs of an aging p o p u l a t i o n . I t would seem from the p o p u l a t i o n p r o j e c t i o n s that the G e r i a t r i c base may not i n f a c t be i n c r e a s i n g between 1986 and 2000. The 45-64 age groups are e i t h e r p r e d i c t e d as being r e l a t i v e l y s t a b l e or d e c l i n i n g . This does not mean that the g e r i a t r i c base i s not i n c r e a s i n g f o r there i s a "bulge," the 25-44 year age group, which i s creeping upwards. With newer technologies i n medicine, even i f numbers were s m a l l e r , p r o p o r t i o n a t e l y more may reach the 65+ age group through cohort s u r v i v a l . The increased cohort s u r v i v a l i s a l s o suggested i n the P e d i a t r i c base (0-14) and c o n t r i b u t e s to the bulge i n the 25-44 age group. This s u r v i v a l i n the e a r l y stages of l i f e was a d i s t i n c t i v e problem i n Newfoundland i n the past. Since 1966 Newfoundland's i n f a n t m o r t a l i t y r a t e d e c l i n e d from 28;1 to 14.6 i n 1976. With t h i s s h i f t i n g d e c l i n e an emphasis had been attached to both c h i l d and maternal care through both P u b l i c Health Medical and Nursing Programs. Yet the "bulge" and the gradual increase i n the p o p u l a t i o n to o l d e r l e v e l s appears to be a l s o a product of unknown f a c t o r s such as migration. Although a m i g r a t i o n component was b u i l t i n t o the p r o j e c t i o n s by assuming the S t a t i s t i c s Canada p r o j e c t i o n s i t cannot be determined i n these p r o j e c t i o n s what the q u a n t i t y i s . The l a t e s t f i g u r e s on m i g r a t i o n f o r Newfoundland are from 1965 to 1970. Even to estimate net gains i n the p o p u l a t i o n and to c l a s s i f y a r e s i d u a l d i f f e r e n c e between periods i s d i f f i c u l t because the f i g u r e s on b i r t h s and deaths are not p r e s e n t l y organized to the h e a l t h d i s t r i c t and r e g i o n a l l e v e l s . A very d i s t i n c t i v e f i n d i n g that a r i s e s from t h i s aging popu-l a t i o n i s the increase i n the number of women i n the higher r i s k 1 0 2 c h i l d b earing years. The assumption of increases i n high r i s k preg-nancies i s made i n the absence of age s p e c i f i c f e r t i l i t y r a t e s which are not a v a i l a b l e f o r Newfoundland (the present method of computing beds does a s s i g n d e l i v e r i e s by age of the mother). Most notably 3 of the 4 regions show a s t a b l e or d e c l i n i n g 1 5 - 2 4 female age group. However the 2 5 - 4 4 age group i n the C e n t r a l , Western and Eastern regions show percentage increases from 1 1 . 3 % to 1 4 . 0 % ; 2 0 . 2 % to 2 5 . 1 % ; and 1 1 . 9 % to 1 5 . 3 % , r e s p e c t i v e l y . Translated to women, t h i s means a combined count of 2 4 , 5 8 9 ascending to higher r i s k groups by 1 9 8 6 . Two areas of concern are presented i n the Northern and C e n t r a l Regions. In the Northern Region the 2 0 - 5 4 age group increases i t s count by 4 , 8 9 0 . Nearly h a l f of t h i s increase i s expected i n the 3 5 - 4 4 age group. In the Western Region the 3 5 - 5 4 age group increases by almost 4 , 0 0 0 women. To summarize on the f i n d i n g s f o r a l l r egions: the p e d i a t r i c 0 - 1 4 age groups i s d e c l i n i n g ; the 1 5 - 6 4 age group i s i n c r e a s i n g , showing a strong increase i n both the male and female 2 5 - 4 4 ages and a s l i g h t d e c l i n e i n the 4 5 - 6 4 age groups; and the 6 5 + p o p u l a t i o n i s showing a moderate increase. In deference to s t a t i n g a moderate increase i n 6 5 + ages, f i g u r e s i n the department show that between 2 0 % and 3 0 % of the p a t i e n t days i n h o s p i t a l s are u t i l i z e d by t h i s group who i n comparison to a l l others have the sma l l e s t percentage of people i n the h o s p i t a l . The consequences of a s l i g h t or moderate increase t h e r e f o r e becomes more s i g n i f i c a n t . Of equal concern i s the growth i n the number of women ascending to higher c h i l d b e a r i n g r i s k groups. This p a r t i c u l a r group as w e l l as others suggest that even though bed estimates in c o r p o r a t e these changes, f u r t h e r a n a l y s i s w i l l be required to a l l o w f o r the types and l e v e l of care which i s 103 to accompany both p a t i e n t and bed. Bed P r e d i c t i o n Results Tables VI-2 and VI-3 show the bed p r e d i c t i o n s f o r each of the four h e a l t h regions f o r the periods 1976, 1981 and 1986. Table VI-2 does not adjust the bed l e v e l w i t h i n each region so that the r e f e r r a l s which are incorporated i n t o r e g i o n a l f i g u r e s are the product of changes i n populations i n the other regions. Oh the other hand, Table VI-3 does t h i s , and i t can be seen that the bed t o t a l s ( w i t h i n each d i a g n o s t i c c l u s t e r and f o r a l l c l u s t e r s ) change i n r e l a t i o n to Table VI-2. The a n a l y s i s excludes out of province r e s i d e n t s who are h o s p i t a l i z e d i n Newfoundland. Table VI-2 summarizes the changing bed requirements of both the province and i t s four h e a l t h regions. Figures taken from the t a b l e s are rounded upwards to the nearest bed f o r ease and c l a r i t y i n p r e s e n t a t i o n . Consequently, there may be rounding e r r o r s . At the p r o v i n c i a l l e v e l 504 beds w i l l be needed by 1986 over the f i g u r e s e s t a b l i s h e d by t h i s method f o r 1976. This f i g u r e i s comprised o f : Medical and S u r g i c a l , 434; O b s t e t r i c s , 60; P s y c h i a t r y , 59; and the only decrease of 48 i n P e d i a t r i c beds. R e s p e c t i v e l y , the percentage c o n t r i b u t i o n of each bed s e r v i c e would be: 86.1%, 11.8%, 11.6% and -9.4%. The major input i n t o the increase i n beds as expected was Medical and S u r g i c a l which extend a s e r v i c e component to a wide range of age groups. By r e g i o n , the expected Medical and S u r g i c a l increases are i n beds: Northern, 37; Western, 62; C e n t r a l , 106; and Eastern, 293. The r e g i o n a l O b s t e t r i c a l c o n t r i b u t i o n s to the t o t a l were: Northern, 7; Western, 12; C e n t r a l , 10; and Eastern, 60. The P s y c h i a t r i c increase comprised: the Northern, 3; the Western, 6; the Newfoundland Table Vl-2 and Regional Bed Service Requirements: 1976. 1981, 1986. Northern Western Central Eastern Newfoundland 1976 1981 1986 1976 19B1 1986 1976 1981 1986 1976 1981 1986 1976 1981 1986 Medical/Surgical 145.1 164.4 181.2 239.3 269.1 301.9 322.4 372.5 428.4 968.5 1085.4 1197.7 1675.3 1891.4 2109.2 Obstetrics 35.6 42.6 42.2 52.4 59.S 64.1 60.3 67.0 69.9 138.8 153.2 170.4 287.1 327.3 346.6 Psychiatry 12.6 14.0 14.8 24.9 27.4 30.3 37.8 42.3 46.6 79.5 112.2 121.7 154.8 195.9 213.4 Pediatrics 64.0 63.9 64.3 71.4 62.6 63.0 105.0 92.1 91.B 249.1 231.5 223.2 489.5 450.1 442.3 l o t a l 257.3 284.9 302.5 388.0 418.6 459.3 525.5 573.9 636.7 1435.9 1587.3 1713.0 2606.7 2864.7 3111.5 Table Vl-3 Newfoundland and Regional Bed Service Requirements Adjusted For Referral Patterns: 1976. 1981, 1986. Northern Western Central Eastern Newfoundland 1976 1981 1986 1976 1981 1986 1976 JL2S1 1986 1976 0281 1986 1976 1981 1986 Medical/Surgical 125.7 142.3 155.8 213.6 241.5 271.1 245.6 286.8 336.5 1080.3 1210.8 1332.4 1665.2 1881.4 2095.8 Obstetrics 33.6 40.1 39.9 50.5 57.7 61.9 57.9 64.7 66.6 144.7 164.2 177.8 286.7 326.7 346.2 Psychiatry 10.6 13.7 12.5 23.8 26.0 29.1 31.6 37.3 41.2 88.6 122.7 132.9 154.6 199.7 215.7 Pediatrics 50.4 51.8 50.7 51.5 45.4 45.5 70.4 61.4 61.8 310.8 286.3 277.0 483.1 444.9 435.0 Total 220.3 247.9 258.9 339.4 370.6 407.6 405.5 450.2 506.1 1624.4 1784.0 1920.1 2589.6 2852.7 3092.7 V 105 C e n t r a l , 9; and the Eastern, 32. As a n t i c i p a t e d the P e d i a t r i c p o p u l a t i o n decreased and t h e r e f o r e , beds de c l i n e d i n each r e g i o n : Northern, -1; Western, -9; C e n t r a l , -14; and Eastern, -26. Table VI-3 demonstrates the e f f e c t s of a d j u s t i n g the r e f e r r a l p a t t e r n of p a t i e n t s so the number of p a t i e n t s going i n t o or coming from a region i s a f u n c t i o n of both the morbidity and changing pop u l a t i o n i n the region of o r i g i n . When these a d j u s t i n g f i g u r e s are added to the base bed need i n a region a s l i g h t l y d i f f e r e n t p a t t e r n emerges. In comparison to Table VI-2 each region shows a red u c t i o n i n bed needs f o r the year 1976 w i t h the exception of the Eastern Region. This i s expected because St. John's i n the Eastern Region provides the t e r t i a r y l e v e l s of•care f o r the province. The ma j o r i t y of r e f e r r a l adjustments r e q u i r e M e d i c a l / S u r g i c a l beds. In terms of bed requirements the r e f e r r a l adjustments reduced the t o t a l bed needs i n the f o l l o w i n g regions f o r 1986: Northern, 303 to 259; Western, 460 to 408; and C e n t r a l , 637 to 507. These reductions are seen as c o n t r i b u t o r y to the increase i n bed requirements f o r the Eastern Region from 1713 to 1921. As an o v e r a l l summary of these two t a b l e s , three of the regions w i l l experience small adjustments to a l l bed s e r v i c e c l a s s e s w i t h the exception of the Eastern Region. As s t a t e d p r e v i o u s l y , the Eastern Region has a major f u n c t i o n of p r o v i d i n g t e r t i a r y l e v e l s e r v i c e s . Coupled w i t h a f a r l a r g e r p o p u l a t i o n base, greater bed requirements are expected. When these f i n d i n g s are r e l a t e d to Table VI-7 which compares three methods of d e r i v i n g bed needs, a very i n t e r e s t i n g observation occurs. The present bed l e v e l s i n the Northern, Western and C e n t r a l regions can more than adequately meet the redefined needs f o r 1986. Jus t the opposite i s p r o j e c t e d f o r : 106 the Eastern Region. Current bed l e v e l s do not appear to be adequate f o r the 1986 l e v e l of m o r b i d i t y , the need being i n the order of approximately 300 beds. Two hundred and f i f t y - t h r e e of these f a l l i n the Medical and S u r g i c a l category. A more elaborate d i s c u s s i o n of these l a t t e r observations w i l l be e n t e r t a i n e d i n the d i s c u s s i o n of Table VI-7. Table VI-3 i n t e r p r e t s bed needs i n each region during the p r o j e c t i o n p e r i o d by age and sex. The p r e d i c t e d p o p u l a t i o n d e c l i n e i n the p e d i a t r i c 0-14 age group i s evidenced i n a d e c l i n e i n the p e d i a t r i c bed requirements i n a l l r egions. P r o v i n c i a l l y the d e c l i n e i s 49 beds, 34 of which occur i n the Eastern Region. The d e c l i n e averages between 3% and 5%. The 15-64 age group n a t u r a l l y shows more requirements f o r beds because i t i s comprised of a l a r g e r p o p u l a t i o n base and because a l a r g e p o r t i o n of morbidity eminates from o b s t e t r i c a l diagnoses. This p a r t i c u l a r base, however, does not show strong changes. In f a c t , the C e n t r a l Region between 1976 and 1986 shows a d e c l i n e i n i t s percentage of beds (49.7% to 46.5%) although the number of beds increased from 202 to 236. The Western Region shows the greatest increase i n percent from 67.9% to 72.9%. Again i n numbers, the Eastern Region i s expected to increase by approximately 192 beds and yet there i s only a marginal increase i n these beds as a percent of t o t a l beds. The 65 and over age group provides a d i s t i n c t departure from the p o p u l a t i o n p r o j e c t i o n f i n d i n g s , and t h e r e f o r e , the expec-t a t i o n s f o r two regions. Both the Northern Region and the Western Region are expected to have a l e s s e r percentage of beds being occu-pied by p a t i e n t s 65 and over, 12.0% to 11.6%^ and 16.8% to 15.8%, r e s p e c t i v e l y . The Eastern Region i s expected to increase from 24.5% 107 to 27.8% f o r a t o t a l of 137 beds.' What i s i n t e r e s t i n g i s the 65 and over p o p u l a t i o n f o r the C e n t r a l Region which i s about 2.5 times l e s s than that of the Eastern area. Yet between 1976 and 1986, the 65 and over beds are expected to increase i n the C e n t r a l by 75 beds and w i l l c o n s t i t u t e 41.2% of a l l beds whereas the Eastern Region w i l l have 27.8% of i t s beds occupied by the 65 and over p a t i e n t . F o l l o w i n g i s a summary of the a n t i c i p a t e d beds assigned to the three age groups i n 1986. The percentages are shown i n the order of 0-14, 15-64, and 65 and over age groups. Northern - 19.6 , 68.8, and 11.6; Western - 11.2.,, 72.9, and 15.8; C e n t r a l - 12.2., 46^5, and 41.2; and Eastern, 14.4, 57.7, and 27.8. Table VI-4 al s o separates each region's beds by sex. This w i l l give an idea of the amount of segregation of beds r e q u i r e d f o r p r i v a c y . Female beds are expected to increase more than males. At the p r o v i n c i a l l e v e l the female gain i s 1% of a l l beds. By region f o r 1986 the f o l l o w i n g sex percentages, i n the order of male and female are: Northern, 39.4 and 60.6; Western, 39.4 and 60.5; C e n t r a l , 35.1 and 64.9; and Eastern, 44.2 and 55.8. Tables VI-5, VI-6 and VI-7 demonstrate a very d i s t i n c t i v e s e n s i t i v i t y between population change and bed s e r v i c e needs. I t appears from Table VI-6 that by region, changes i n the male p o p u l a t i o n have a greater e f f e c t upon corresponding changes i n the bed s e r v i c e requirements. P r o v i n c i a i l y , b o t h sexes have the same e f f e c t on beds. For the most part the increased s e n s i t i v i t y of the males i s the r e s u l t of the 25-45 age group because i t s major i n f l u e n c e i n the bed changes a r i s e s from i t s p a r t i c i p a t i o n i n . M e d i c a l / S u r g i c a l beds. Popu l a t i o n f i g u r e s f o r the 45-65 ages are expected to d e c l i n e s l i g h t l y . The other component to t h i s s e n s i t i v i t y i s the g e r i a t r i c T a b l e V I - 4 N e w f o u n d l a n d a n d R e g i o n a l A g e - S e x B e d R e q u i r e m e n t s :  1 9 7 6 , 1 9 8 1 a n d 1 9 0 C . W a l e s 0 - 4 5 - 9 1 0 - 1 4 1 5 - 1 9 2 0 - 2 4 2 5 - 3 4 3 5 - 4 4 5 5 - 6 4 6 5 - 6 9 70+ T o t a l 1 9 7 6 1 7 . 4 6 . 8 4 . B 5 . 5 4 . 5 1 1 . 2 6 . 8 1 0 . 1 5 . 3 1 5 . 3 - H o r t h e r n -1 9 8 1 1 7 . 1 6 . 9 4 . 8 8 . 1 5 . 0 1 2 . 7 1 0 . 1 1 0 . 0 6 . 3 1 3 . 2 i l 1 9 8 6 1 9 7 6 1 7 . 2 7 . 0 4 . 9 4 . 7 6 . 0 1 4 . 1 1 2 . 6 1 0 0 6 . 6 1 0 . 3 2 1 . 8 5 . 2 3 . 7 4 . 5 6 . 7 9 . 9 1 3 . 5 1 5 . 8 9 . 7 3 1 . 4 - W e s t e r n 1 , C e n t r a l j , • < i t 1 9 8 1 1 9 8 6 1 9 7 6 1 9 8 1 1 9 8 6 1 9 7 6 1 8 . 9 1 5 - 8 3 0 . 5 2 4 . 7 2 6 . 5 9 1 . 8 4 . 3 3 . 9 5 . 9 5 . 3 4 . 9 5 0 . 8 3 . 3 2 . 9 4 . 7 5 . 1 4 . 1 3 5 . 8 4 . 6 4 . 2 5 . 6 5 . 8 S . 3 3 4 . 3 8 . 2 - 8 . 3 2 . 4 3 . 1 3 . 2 3 0 . 3 1 1 . 8 1 3 . 2 7 . 1 8 . 3 9 . 1 5 6 . 8 1 4 . 7 1 7 . 2 4 . 5 4 . 7 4 . 8 5 1 . 2 1 5 . 9 1 5 . 6 9 . 3 9 . 4 9 . 5 8 1 . 7 1 1 . 3 1 2 . 1 1 1 . 9 1 3 . 5 1 4 . 2 5 5 . 1 3 6 . 6 4 4 . 0 4 6 . 4 5 8 . 2 7 4 . 0 1 5 0 . 9 - E a s t e r n -1 9 8 1 8 6 . 7 4 4 . 7 3 2 . 8 3 5 . 7 5 8 . 2 7 3 . 6 6 2 . 5 8 1 . 7 6 3 . 9 1 9 8 6 8 8 . 1 4 1 . 6 2 9 . 2 3 2 . 4 5 9 . 8 7 5 . 8 8 3 . 6 8 1 . 7 6 7 . 8 1 7 7 . 8 2 1 3 . 5 t N e w f o u n d l a n d , i i 1 9 7 6 1 9 8 1 1 9 8 6 1 6 1 . 5 1 4 7 . 4 1 5 1 . 6 6 8 . 7 6 1 . 2 5 7 . 4 4 9 . 0 4 6 . 0 4 1 . 1 4 9 . 9 5 4 . 2 4 6 . 6 4 3 . 9 7 5 . 3 7 7 . 3 8 S . 0 1 0 6 . 4 1 1 2 . 2 7 8 . 0 9 2 . 0 1 W . J 1 1 6 . 9 1 1 7 . 0 1 1 6 . 8 8 2 . 0 9 5 . 0 1 0 0 . 7 2 4 4 . 0 2 8 5 . 8 3 4 1 . 8 9 8 . 7 1 0 3 . 7 1 0 2 . 0 1 4 1 . 4 1 4 9 . 6 1 6 1 . 2 1 4 9 . 2 1 5 9 . 6 1 7 7 . 4 7 5 5 . 5 8 3 7 . 0 8 9 4 . 5 1 1 4 4 . 8 1 2 4 9 . 9 1 3 3 5 . 1 F e m a l e s 0 - 4 5 - 9 1 0 - 1 4 1 5 - 1 9 2 0 - 2 4 2 5 - 3 4 3 5 - 4 4 4 5 - 5 4 5 5 - 6 4 6 S - 6 9 7 0 * T o t a l T o t a l S e x 1 1 . 5 5 . 6 4 . 3 1 4 . 5 8 . 9 3 . 2 1 1 . 3 5 . 9 5 . 8 1 7 . 3 1 9 . 3 2 2 . 9 2 1 . 9 2 5 . 9 1 1 . 7 1 6 . 4 1 0 . 1 1 1 . 0 9 . 8 2 . 9 1 1 . 3 6 . 1 4 . 2 1 0 . 3 2 3 . 9 2 9 . 7 2 4 . 5 1 2 . 6 1 0 . 4 2 . 8 1 2 . 9 3 . 7 4 . 5 1 8 . 5 2 6 . 9 3 6 . 2 1 9 . 1 2 1 . 3 1 9 . 8 8 . 4 1 1 . 8 2 . 9 4 . 5 1 9 . 1 3 0 . 8 4 2 . 6 2 3 . 4 2 3 . 4 2 1 . 2 9 . 8 1 2 . 1 2 . 6 4 . 4 1 8 . 1 3 1 . 7 4 8 . 0 3 0 . 9 2 7 . 2 2 2 . 1 1 0 . 4 2 2 . 1 3 . 4 4 . 0 1 9 . 5 2 8 . 3 3 8 . 7 2 2 . 1 1 9 . 8 2 3 . 5 1 5 . 7 1 9 . 3 3 . 0 4 . 3 2 0 . 4 3 1 . 9 4 5 . 8 2 5 . 6 2 0 . 9 2 4 . 9 1 8 . 5 2 0 . 3 2 . 6 3 . 7 1 8 . 4 3 3 . 3 4 9 . 5 3 1 . 6 2 3 . 2 2 5 . 6 1 1 2 . 4 1 9 . 7 6 9 . 3 3 3 . 7 2 9 . 8 6 0 . 7 8 3 . 3 5 1 . 5 6 5 . 7 2 9 . 3 2 7 . 3 6 1 . 7 9 3 . 4 1 2 8 . 8 1 5 4 . 4 7 6 . 1 8 2 . 7 1 1 8 . 4 6 2 . 7 6 7 . 1 2 7 . 7 2 3 . 4 5 8 . 3 9 0 . 4 1 1 5 . 4 8 2 . 7 6 7 . 7 1 1 5 . 8 4 6 . 4 4 2 . 6 1 1 3 . 2 9 6 . 2 1 5 7 . 8 1 7 4 . 8 2 2 5 . 6 1 2 9 . 0 8 5 . 8 1 3 3 . 9 1 2 2 . 5 1 6 4 . 6 7 8 . 7 1 4 0 . 6 1 6 1 . 0 1 8 6 . 7 2 3 7 . 1 1 0 8 . 4 1 . 4 1 . 1 1 8 . 1 7 9 . 2 6 8 . 1 5 5 . 1 3 8 . 1 7 4 , 9 3 , 2 8 3 1 1 0 . 8 3 9 . 0 3 5 . 7 1 0 5 . 1 1 8 5 . 1 3 0 2 . 0 2 0 2 . 4 1 4 8 . 8 1 8 0 . 6 1 0 0 . 6 3 4 7 . 5 1 2 1 . 6 144 2 1 5 6 9 1 9 8 0 2 2 1 0 2 4 6 4 2 5 6 3 2 9 0 6 3 2 8 . 7 8 6 8 9 9 4 7 0 1 0 2 5 . 6 1 4 4 4 . 8 1 6 0 2 . 8 1 7 5 7 . 6 2 2 0 . 3 24 7 9 2 5 8 9 3 3 9 4 3 7 0 6 4 0 7 6 4 0 5 5 4 5 0 2 5 0 6 . 1 1 6 2 4 4 1 7 8 4 0 1 9 2 0 . 1 2 5 8 9 . 6 2 8 5 2 . 7 3 0 9 2 . 7 o oo 109 Table VI-5 Pop u l a t i o n Change Compared w i t h Bed Services Changes Newfoundland and Regions 1976-86 Region Northern Western C e n t r a l Eastern Newfoundland Po p u l a t i o n % Change 1976-1986  17.3 7.7 6.4 10.4 9.7 Bed Services Change 1976-1986 17.8 18.5 21.1 19.3 19.4 Table VI-6 Sex P o p u l a t i o n Changes Compared w i t h Bed Service Changes 1976-1986 Pop. % Change B.S.C. Pop. % Change B.S.C. g l o n Male Male % Female Female % Northern 11.0 3.9 20.1 28.9 Western 3.7 11.9 13.3 23.3 C e n t r a l 3.9 14.2 9.2 26.0 Eastern 11.3 20.6 9.7 18.2 Newfoundland 8.3 16.5 11.1 21.7 aB.S.C. = Bed Service Change T a b l e V l - 7 P o p u l a t i o n Chanyen Compared With Hod S e r v i c e Changeo Newfoundland, 1 9 7 6 - 1 9 0 6 II o r t h o r n W e e t e r n C e n t r a 1 E a B t e r n T o t a 1 ¥% B% FTo 1«5 PA DX 11% n 0 . 5 0 . 5 7 . 6 8 . 2 1 1 . 0 11 .5 1.0 1.7 5.Q 5 - 9 ' i . l ' I . ' I 2 8 . 2 2 7 . 1 1 6 . 1 15.5 1 0 . 5 1 0 . 5 1 6 . 7 1 5 . 0 10-1 (| 0 . 0 1 .8 9 .1 6 . 6 13.1 ' 3 . 1 2 1 . 6 2 1 . 0 1 9 . 8 1 ? . 3 15-19 2 ' | . 2 2 6 . 0 ' t . 5 3 . 0 7 . ' i 3^ 2 •m 20-2/1 3 0 . 9 2 6 . 1 2 2 . 0 1 9 . 7 2 1 . 2 1 0 . 7 1 6 . 9 3 0 . 9 1 9 . 9 3 0 . 1 2 5 ~ 3 ' l 3 0 . / , 3 2 . 3 3 1 . 2 3 2 . 9 2 0 . 3 2 7 . 3 3 ' i . 0 3 5 . 3 3 2 . 0 3 3 . 1 3 5 - ' i ' » 7 0 . 9 7 7 . 6 ' • 3 - 3 ' i 7 . 5 2 3 . 2 3 2 . 9 6 2 . 2 5 9 . 3 5 2 . 7 5 ' i . 0 '»5-5'» 1 3 . 2 15.1 I ' I . O 1 5 . 0 0 . 3 9 . 0 0 . 7 0 . 8 9 . 2 6 . 2 5 5 - 6 ' t 7 . 7 7.1 8 . ' i 0 . 6 6 . 2 6 . 6 6.1 6 . 1 2 . 6 6 . 7 6 5 - 6 9 8 . 5 0 . 3 2 5 . 2 2!| .0 • 2 1 . 9 2 2 . 1 2 7 . 0 2 7 . 9 2 7 . 6 2 5 . 0 70+ 3 2 . 0 2 1 . 3 ' | 2 . 3 ' | 2 . 0 6/|.1 6 ' ( . 6 3 5 . ' i 3 6 . 2 '11.3 U 3 . 0 MOTES: 1. U n d e r l i n e d f i g u r e i n d i c a t e s n e g a t i v e chnnge 2 . Change 1 G e x p r e o e e d ao p e r c e n t change on 1976 p o p u l a t i o n I l l p o p u l a t i o n where small changes i n the number of p a t i e n t s have a c o r r -espondingly l a r g e r impact upon bed requirement. Both the C e n t r a l and Eastern areas d i s p l a y t h i s c h a r a c t e r i s t i c . Table VI-5 compares t o t a l p o p u l a t i o n change w i t h bed s e r v i c e changes between 1976 and 1986. A s i m i l a r s e n s i t i v i t y as described i n Table VI-5 i s found. Both t a b l e s suggest c o r r e l a t e d f i g u r e s such that a 1% p o p u l a t i o n change t r a n s l a t e s i n t o a 2% bed change. What i s odd i s the p r o v i n c i a l r e l a t i o n s h i p of p o p u l a t i o n to bed change at e x a c t l y 1:2. On f u r t h e r examination i n Table VI-7 t h i s suggested r e l a t i o n s h i p i n f a c t becomes even more dramatic. By age and sex, i n v a r i a b l y , there i s a 1 to 1 r e l a t i o n s h i p so that a 1% change i n the p o p u l a t i o n y i e l d s a 1% change i n bed requirements. This holds f o r the d i r e c t i o n of the change. S t a t i s t i c a l procedures are not necessary because the s t r e n g t h of the r e l a t i o n s h i p i s s e l f evident i n the f i g u r e s . C e r t a i n l y there was expected to be a s e n s i t i v i t y between changes i n the p o p u l a t i o n and bed s e r v i c e requirements using t h i s study's methodology. However, such a s t r i k i n g r e l a t i o n s h i p was not a n t i c i p a t e d f o r a l l age groups. Table VI-8 compares 3 techniques at p r e d i c t i n g the t o t a l bed requirements f o r each region. The Bed S e r v i c e Requirement w i t h Ref- e r r a l i s the method employed by t h i s study. P o p u l a t i o n changes a f f e c t the l e v e l and type of m o r b i d i t y which i n t u r n t r a n s l a t e s i n t o beds. The Bed to P o p u l a t i o n R a t i o Method expresses the beds i n Newfound-lan d ( s t a f f e d and i n operation) over the p o p u l a t i o n , a r a t e which i s then m u l t i p l i e d by a p r o j e c t e d p o p u l a t i o n . F i n a l l y , The Bed Ser- v i c e to P o p u l a t i o n Rate i s , i n f a c t , a bed to p o p u l a t i o n r a t i o technique. The major departure i s that the i n i t i a l statement of beds i n the formula i s e s t a b l i s h e d by s o r t i n g m o r b i d i t y and Table Vl-8 Comparison of the Bed to Population Ratio, Bed Service to Population and Bed Service Requirement With Adjustment for Referral. Tecnniqueel Newfoundland and Regions 1976, 1981 and 1986. — 1976— B.P.R. B.S.P I I B.S.R.R. -19B1--B.P.R. ' B.S.R.R. -19B6 B.P.R. Northern 220 .3 396 0 220.3 247 9 422.0 239.3 258.9 465.0 258.5 Western 339.4 426 0 339.4 370 6 442.0 352.4 407.6 459.0 365.6 Central 40S 5 628 0 405.5 450 2 650.0 420.3 506.1 672.0 434.7 Eastern 1624 4 1494 0 1624.4 1784 0 1567.0 1703.0 1920.1 1641.0 1782.0 Newfoundland 2589. 6 2944. 0 2589.6 2852. 7 3067;O 2715.0 3092.7 3237.0 2840.8 B.S.R.R. - Bed service requirement with r e f e r r a l , the study's method. B.P.R. - Bed to population r a t i o method. B.S.P. Bed service requirement with referral,1976,expressed as a r a t i o to the population. 113 t r a n s l a t i n g i t i n t o bed needs. However, morbidity and p o p u l a t i o n are not allowed to i n t e r a c t i n the p r o j e c t i o n s . The bed to p o p u l a t i o n technique gives a current or 1976 estimate of 2 9 4 4 beds and assumes the occupancy r a t e of approximately 67%. The bed s e r v i c e requirement as the chosen a l t e r n a t i v e has an assumption of higher occupancies. The Newfoundland occupancy using these requirements i s a pooled average of 8 3 . 7 % . This f i g u r e i s p r i m a r i l y i n f l u e n c e d by the Eastern Region which had been a r b i t r a r i l y e s t a b l i s h e d at 8 5 % . The bed to p o p u l a t i o n method p r e d i c t s a higher number of beds f o r each region w i t h the exception of the Eastern Region. P r o v i n c i a l l y , t h i s method gave a higher p r e d i c t i o n than the other methods. Note that there i s an understatement of beds f o r the Eastern area. One of the reasons f o r t h i s i s that the occupancy l e v e l f o r many of the 1494 beds f a r exceeds.the 85% occupancy l e v e l . Consequently more morbidity i s handled w i t h l e s s beds. The bed s e r v i c e requirements are e s t a b l i s h e d at an 85% occupancy l e v e l . As a second reason, the morbidity f i l e forms the b a s i s of the beds, not what the h o s p i t a l s s t a t e they have i n beds (according to the Annual Returns) which may or may not r e f l e c t a c t u a l needs. For 1986 the bed to p o p u l a t i o n p r e d i c t i o n of beds f o r the province and regions are: Newfoundland, 3 2 3 7 ; Northern, 4 6 5 ; Western, 4 5 9 ; C e n t r a l , 6 7 2 ; and Eastern, 1 6 4 1 . An anomaly appears between the Northern and Western Regions. The Western area has twice the p o p u l a t i o n yet has l e s s beds than the Northern area. The number of beds i n the Northern area are i n f l u e n c e d by i s o l a t i o n , weather, t r a v e l and lower occupancy r a t e s . Considering these f a c t o r s , and what i s a c t u a l l y needed based on morbidity evidence, the bed to p o p u l a t i o n technique tends to 114 perpetuate inadequacies i n the system i f such e x i s t . The bed s e r v i c e requirement w i t h r e f e r r a l to p o p u l a t i o n  p r e d i c t i o n i s more conservative i n e s t i m a t i n g the p r o v i n c i a l r e q u i r e -ments. In r e l a t i o n to the bed to p o p u l a t i o n technique there i s a net d i f f e r e n c e of 397 beds. This approach a l s o produced a lower bed estimate i n each of the regions. Although i t does not i n t e r a c t w i t h morbidity i t does assume that there should be proper s o r t of beds through morbidity at a given l e v e l of e f f i c i e n c y f o r the r a t e or base year. This study proposes the bed s e r v i c e requirement w i t h r e f e r r a l  technique as the method which y i e l d s the best r e s u l t s f o r planning and a l s o stands by the a r b i t r a r y choice of occupancy rates as d e s i r a b l e l e v e l s of e f f i c i e n c y . This forces c o n s i d e r a t i o n of a l t e r -n a t i v e courses of a c t i o n to provide h e a l t h care to the Newfoundland popu l a t i o n . I f the present l e v e l of beds as a r a t i o . t o the p o p u l a t i o n i n each region continues ( h i s t o r i c a l l y there i s no reason to b e l i e v e that i t w i l l s u b s t a n t i a l l y change), i t i s p o s s i b l e to estimate the consequences of u t i l i z i n g the bed s e r v i c e requirement method. The 1986 p r o v i n c i a l p r e d i c t i o n provided by t h i s study i s 3092 beds as compared to the r a t i o method p r e d i c t i o n of 3237, a d i f f e r e n c e of approximately 144 beds occurs. R e l i a b i l i t y i s a l s o confirmed by the p r a c t i c a l c a l c u l a t i o n of percentage occupancy i n various h o s p i t a l s . A great many h o s p i t a l s i n Newfoundland f a l l i n t o the s m a l l e r v a r i e t y and have extremely low occupancy r a t e s ranging from 12% to 50%. As was discussed i n the l i t e r a t u r e review (Appendix A) there are reasons f o r t h i s . The excess both present and future i s not n e c e s s a r i l y a product of i n e f f i c i e n c i e s but a product of changing r o l e s and 115 s h i f t i n g s t y l e s to deal w i t h p a t i e n t s . Unfortunately the wrong s t a t i s t i c i s measuring t h i s changing a c t i v i t y . This l a t t e r p o i n t and the key observations regarding bed p r e d i c t i o n s w i l l be discussed as w i t h the p o p u l a t i o n observation i n the f i n a l chapter. The d i s c u s s i o n w i l l r e l a t e the f i n d i n g s to the p r a c t i c a l i t i e s of the Newfoundland scene and to the planning r o l e f o r the h e a l t h care scene. CHAPTER VII SUMMARY AND DISCUSSION I n t r o d u c t i o n The present study has done more than i t intended. The o r i g i n a l o b j e c t i v e s of t h i s study were to provide a p r e d i c t i o n of bed needs i n the f u t u r e and to provide both a s o r t and p r o j e c t i o n of p o p u l a t i o n by age and sex f o r h e a l t h regions and d i s t r i c t s . The more advantageous r e s u l t was a focus i n planning philosophy; that i s , a focus and statement regarding the types of data which are r e q u i r e d f o r the f u t u r e and the types of a c t i v i t i e s which must accompany these data requirements. This w i l l be evident i n the d i s c u s s i o n to f o l l o w : summary of f i n d i n g s ; advantages and disadvan-tages of methodologies; p r a c t i c a l i m p l i c a t i o n s of the f i n d i n g s and f u t u r e plans. Summary-, of E r r o r E s t i m a t i o n A s s o c i a t e d With  The Ratio Method The accepted g u i d e l i n e f o r the amount of e r r o r i n the popu-l a t i o n p r o j e c t i o n under or equal to ten years was e s t a b l i s h e d at the 10% l e v e l i n the l i t e r a t u r e review. The Ratio Method was used to p r o j e c t an h i s t o r i c a l set of census values i n Newfoundland. The r e s u l t was compared to the a c t u a l values i n the census year which was the year of p r o j e c t i o n . The p r o j e c t i o n p e r i o d was f i v e years. 116 11 z -E r r o r s were recorded to s t r a t i f i e d p o p u l a t i o n bases. The r a t i o p o p u l a t i o n p r o j e c t i o n technique, a s i n g l e estimator of the p o p u l a t i o n , d i d produce extreme e r r o r s as expected. I t was also judged acceptable as a planning t o o l because i t produced an acceptable p r o p o r t i o n of e r r o r under o r equal to 10% f o r a f i v e year p r o j e c t i o n . Acceptance was based upon: the character of the Newfoundland p o p u l a t i o n ; the op i n i o n that extreme values would n e c e s s a r i l y have to be prudently adjusted; and f i n a l l y , that the ma j o r i t y of e r r o r s (81%) are under or equal to 10% when the extremes are i d e n t i f i e d (19%). Sampling of the e r r o r s i n d i c a t e d that the absolute mean w i t h standard e r r o r was 12%±± 1.2. The 0-2999 stratum which c h a r a c t e r i z e s much of the Newfoundland p o p u l a t i o n had an absolute mean of 13.0% ± 1.8. Comparatively, the t o t a l data set of e r r o r s had an absolute mean of 12.3% ±1.2 and the 0-2999 stratum had an absolute mean of 13.2% ± 1.3. The p r o p o r t i o n of e r r o r s under or equal to 10% i n the sample was .63 whereas i t was .65 i n the t o t a l data s e t . The 0-2999 stratum c o n t r i b u t e d h e a v i l y towards the means expressed i n the preceding paragraphs. This stratum a l s o t y p i f i e s the small and s c a t t e r e d nature of the Newfoundland p o p u l a t i o n . Therefore i t was analyzed independently p a r t i c u l a r l y f o r extreme values. Two census d i v i s i o n s which were f e l t to be unpr e d i c t a b l e both demographically and economically were removed from the 193 e r r o r s i n t h i s stratum. The p r o p o r t i o n of e r r o r s under or equal to 10% increased from .65 to .77. A l t e r n a t i v e l y , e r r o r s greater or equal to 20% were subtracted from the 193 observations. Eighty-one percent of the e r r o r s f e l l under or equal to 10%. The absolute mean dropped from 13.2% ± 1.2 to 5.1% ± .4. I f , Aas has been suggested, 118 extremes must n e c e s s a r i l y be adjusted then the o r i g i n a l estimate of the mean of 13.2% + 1.2 should d e c l i n e below the 10% g u i d e l i n e . S i m i l a r l y the p r o p o r t i o n of e r r o r s f a l l i n g under or equal to 10% should be improved, over the 81% l e v e l . The i n f e r e n c e of an acceptable estimator of po p u l a t i o n i s a l s o supported when the sampled e r r o r s are transformed by the Arc-s i n \Jpercent transformation. The Arcsin,;. ^ p e r c e n t transformation p u l l e d extreme values from both ends of the d i s t r i b u t i o n towards the mean. The retransformed mean was 9.2% compared w i t h the non t r a n s -formed mean of 12 (S.E. before transformations was 1.25). Consid-e r i n g both types of extremes the m a j o r i t y of the data hedges around the 10% g u i d e l i n e . However, the transformation was considered to be i m p r a c t i c a l f o r e r r o r a n a l y s i s because i t minimized the i n f l u e n c e of extreme values on the mean. These very extremes would be a po i n t of focus because they must be i d e n t i f i e d and dealt w i t h by the demo-grapher. p r o p o r t i o n of e r r o r s under or equal to 10% of the s i z e of e r r o r could be e s t a b l i s h e d . The p l o t t i n g of the e r r o r s d i d not suggest e i t h e r a l i n e a r or non l i n e a r r e l a t i o n s h i p . S u p e r f i c i a l l y , a l l the ta b l e s suggest that the absolute mean e r r o r and.size of e r r o r decreases w h i l e the p r o p o r t i o n of e r r o r s under or equal to 10% increases as po p u l a t i o n s i z e i n c r e a s e s . The p l o t t i n g of the e r r o r s i n d i r e c t l y supports t h i s r e l a t i o n s h i p . As the po p u l a t i o n s i z e increases the range t i g h t e n s and s h i f t s downward. The s u b t l e t y of these r e l a t i o n s h i p s a r i s e s because Newfoundland populations are i n thousands whereas st u d i e s i n the l i t e r a t u r e o f f e r t h i s r e l a t i o n s h i p from populations i n the m i l l i o n s . What i s a l s o i n t e r e s t i n g i s that No r e l a t i o n s h i p between po p u l a t i o n s i z e and e i t h e r the , ,119-the e r r o r s appear to be randomly l o c a t e d w i t h i n each s t r a t a and range. More importantly t h i s i m p l i e s that the r a t i o p r o j e c t i o n method i s not i n f l u e n c i n g the e r r o r . Instead i t i s the nature of the p o p u l a t i o n being p r o j e c t e d which i s producing the f l u c t u a t i o n s . This strengthens the argument f o r complementary data f i l e s f o r each area being p r o j e c t e d so that extreme values can be modified. The r a t i o p r o j e c t i o n method i s considered to be an acceptable planning t o o l because the m a j o r i t y of the e r r o r s f a l l under the 10% g u i d e l i n e . The p r e c i s i o n of t h i s method i s increased by aggregating p o p u l a t i o n bases p r i o r to p r o j e c t i o n , by shortening the p r o j e c t i o n p e r i o d and by j u d i c i o u s l y a d j u s t i n g extreme values. Therefore, the method i s considered appropriate f o r areas c h a r a c t e r i z e d by small s c a t t e r e d p o p u l a t i o n bases and l a c k of key demographic data. I t i s a l s o acceptable because i t does not i n f l u e n c e the absolute values of data being p r o j e c t e d . The acceptance of t h i s method, however, does not mean that the prospective p r o j e c t i o n s w i l l be accurate although t h i s s t a t e can be i n f e r r e d . The f i n a l t e s t of accuracy of the r a t i o method w i l l come i n i t s f i r s t comparison w i t h a c t u a l census values. Summary of Popu l a t i o n P r o j e c t i o n s The r a t i o method was employed to produce the p r o j e c t i o n s . To enhance the accuracy of the p r o j e c t i o n s , and th e r e f o r e the e s t i -mate of beds, the age sex populations of h e a l t h s t a t i s t i c a l d i s t r i c t s were aggregated to t h e i r r e s p e c t i v e r e g i o n a l l e v e l p r i o r to p r o j e c -t i o n . In each of the 4 h e a l t h r e g i o n s , the p e d i a t r i c 0-14 year popu l a t i o n groups d e c l i n e d between 1976 and 1986. The Northern Region had the highest percentage of 0-14 year olds w i t h 32.8%, 120 whereas the Eastern Region had the lowest at 2 4 . 5 % , but the greatest number i n d e c l i n e , 1 3 , 0 1 9 . The 1 5 - 6 4 year age groups increased i n a l l regions between 7 , 0 0 0 and 1 0 , 0 0 0 people, w h i l e the Eastern increased by 3 5 , 7 9 7 . Much of t h i s change i s taken up by a "bulge" i n the 2 5 - 4 4 age group. S l i g h t d e c l i n e s are seen i n the 4 5 - 6 4 age groups. W i t h i n the female 2 5 - 4 4 age group, there was a t o t a l increase of 2 4 , 5 8 9 . Each of the regions demonstrated an increase i n the number of women. In the absence of f e r t i l i t y data and under the assumption of one b i r t h r a t e , the number of high r i s k pregnancies i s expected to increase. In the 65+ age group, a s l i g h t increase i s observed. However, the Eastern Region i s expecting an a d d i t i o n a l 7 , 8 5 1 to t h i s group. A dramatic increase i s seen i n the C e n t r a l Region. I t i s a n t i c i p a t e d , however, that there may i n f a c t be a s l i g h t decrease i n t h i s p o p u l a t i o n a f t e r 1986 because of the d e c l i n i n g 4 5 - 6 4 age group followed by an increase around the year 2 0 0 0 . The Eastern Region shows an aging p o p u l a t i o n which i s expected to grow i n the f u t u r e . Summary of Bed P r e d i c t i o n s The p r o j e c t e d p o p u l a t i o n was i n t e r f a c e d w i t h morbidity to give a p r e d i c t i o n of bed needs. A separate p r e d i c t i o n of beds was derived by a l l o w i n g f o r p r o p o r t i o n a l changes i n the r e f e r r a l patterns i n t o and out of regions. At the p r o v i n c i a l l e v e l the bed requirement i s 3 0 9 3 beds. The bed requirements a l l o w i n g f o r r e f e r r a l s and excluding out of province f o r each region i n 1986 are: Northern, 2 5 9 ; Western, 4 0 8 ; C e n t r a l , 6 3 7 ; and Eastern, 1 9 2 1 . These estimates are based on occupancy l e v e l s o f : Northern, 6 5 % ; Western, 7 5 % ; C e n t r a l , 75%; and Eastern, 8 5 % . The present bed l e v e l s i n the Northern, 121 Table V I I - l Summary of the 1986 T o t a l Bed Requirements f o r the Four Health Regions i n Newfoundland Region Requirements (Beds) Northern 259 Western 408 C e n t r a l 637 Eastern 1921 Newfoundland 3093 Figures rounded upwards to nearest bed. T o t a l w i l l not agree w i t h r e g i o n a l f i g u r e s . Western and C e n t r a l Regions can adequately meet the redefined bed needs as presented by t h i s study. The Eastern Region's present bed l e v e l does not appear to be adequate. Approximately 300 beds w i l l be needed by 1986, 250 of which w i l l be medical and s u r g i c a l . 48 p e d i a t r i c beds and an increase i n m e d i c a l - s u r g i c a l beds, o b s t e t -r i c a l beds and p s y c h i a t r y beds of 434, 60 and 59 beds r e s p e c t i v e l y . In each case the Eastern Region c o n t r i b u t e s more beds to the f i g u r e because i t has a f a r l a r g e r p o p u l a t i o n base than the other 3 regions. Excluding the Eastern Region, the l a r g e s t c o n t r i b u t i o n s to bed type are: M e d i c a l - S u r g i c a l - C e n t r a l , 106; O b s t e t r i c a l - Western, 12; P s y c h i a t r i c - C e n t r a l , 9. d e c l i n e by 48 beds p r o v i n c i a l l y . The 15-64 age group, on the other hand, i s a n t i c i p a t e d to increase by 328 beds. This increase f a l l s across a l l regions, most notably the Western and Eastern Regions. Both the C e n t r a l Region, w i t h i t s dramatic i n c r e a s e , and the Eastern Region account f o r the moderate increase i n beds f o r the 65+ age By bed s e r v i c e the province i s expected to show a d e c l i n e of By age groups, the p e d i a t r i c 0-14 group i s expected to 122 group. P r o v i n c i a l l y , the requirement w i l l be 225 beds. By sex, the s p l i t i n beds i s expected to favor females which shows a p r o v i n c i a l increase from 55.8% to 56.8% by 1986. With the exception of the Eastern Region, a l l regions should have between 60% to 65% of t h e i r beds designated female. In comparison w i t h e x i s t i n g l e v e l s of beds, the bed p r e d i c -t i o n s f o r three regions i n 1986 show that there w i l l s t i l l be an excess of 206=beds. I f present l e v e l s are p r o j e c t e d there would be a greater excess, to the tune of 421 beds. The Eastern Region on the other hand i s expected to r e q u i r e a d d i t i o n a l beds. This study's p r e d i c t i o n i s 1921. The bed to p o p u l a t i o n r a t i o i s 1641 and the current l e v e l i s 1494. The i n t e r f a c i n g of age and sex and morbidity d i d show that bed requirements would d i f f e r from a p r e d i c t i o n i n which these v a r i a b l e s had not been used. An "odd" degree of s e n s i t i v i t y between p o p u l a t i o n change and bed change was observed; odd i n the sense that i n v a r i a b l y , and i n the same d i r e c t i o n , a one percent change i n pop u l a t i o n was accompanied by a one percent change i n bed s e r v i c e requirements. The change i n bed s e r v i c e i s a product of p o p u l a t i o n and morbidity by age sex c l a s s i f i c a t i o n s . Advantages and Disadvantages of the  Ratio P r o j e c t i o n Method Advantages and disadvantages were o u t l i n e d i n the l i t e r a t u r e review. However, those which are discussed are those which have the b e n e f i t of h i n d s i g h t . The r a t i o method does produce c o n s i s t e n t r e s u l t s although extreme c a l c u l a t i o n s were observed. This c o n s i s -tency i s very p o s i t i v e i n view of the l a c k of current data which i s a v a i l a b l e i n the province f o r making any type of p r o j e c t i o n s . Fer-123 t i l i t y r ates are absent, the l a t e s t m i g r a t i o n f i g u r e s are f o r the pe r i o d 1965-1970, and the b i r t h s and deaths are not organized by h e a l t h s t a t i s t i c a l d i s t r i c t . The use of the r a t i o method provided f o r more current i n f o r m a t i o n to be used. The method i t s e l f i s f l e x i b l e i n the sense that e s t a b l i s h e d r a t e s can be modified without going through elaborate procedures. S i m i l a r l y , extreme values can be immediately s e l e c t e d by employing a d e c i s i o n r u l e and can be modified on the b a s i s of complementary demographic data and judge-ment. The r a t i o method i s simple and easy to f o l l o w even when an ungainly set of f i g u r e s r e q u i r e s manipulation. This s i m p l i c i t y provides ease i n c a l c u l a t i o n and programming f o r computer. On the negative s i d e , the method i s not s e n s i t i v e to recent changes when a past p e r i o d i s , f o r example, 5 years. I t assumes the co n t i n u a t i o n of a growth or d e c l i n e r a t e at the same r a t e . Conse-quently recent growth rates which are l e v e l l i n g or r e v e r s i n g d i r e c -t i o n w i l l be forced against l o g i c . In a d d i t i o n , growth ra t e s are expected to continue to i n f i n i t y whereas d e c l i n i n g r a t e s are expected to reach a p o i n t where adjustments to zero values must be made (negative p o p u l a t i o n s ) . In these terms, the method i s i n f l e x i b l e . The r a t i o method can produce two r e s u l t s . On the one hand there i s a mathematical c a l c u l a t i o n which f o l l o w s s i g n s ; on the other, there i s a l o g i c a l process. In some cases, l o g i c d i c t a t e s a d e c l i n i n g p o p u l a t i o n yet mathematical signs d i c t a t e a growth. The use of t h i s method i s a choice f o r a s i n g l e estimator or pop u l a t i o n . Extreme values are therefore expected. In some s i t u a -t i o n s i t i s more than obvious that the r a t i o method does not perform w e l l . This g e n e r a l l y occurs i n a very small p o p u l a t i o n which has undergone a s i g n i f i c a n t change r e l a t i v e to a minor n a t i o n a l change. . 124 I f i n the future the n a t i o n a l p o p u l a t i o n changes s i g n i f i c a n t l y , the p r o j e c t i o n f o r the l o c a l area would y i e l d an extreme e r r o r . Although t h i s study judged the r a t i o method as being purpose-f u l f o r the Newfoundland s e t t i n g , small p o p u l a t i o n s , c e r t a i n l y popu-l a t i o n s under 3000, produce more e r r o r s over 10% and a wider range to the e r r o r s than l a r g e r populations. In the context of age sex i n t e r v a l s , t h i s problem i s magnified because there are many i n t e r v a l s under 1000 po p u l a t i o n . The Advantages and Disadvantages of the  Bed P r e d i c t i o n Model The bed p r e d i c t i o n model u t i l i z e d i n t h i s study, a p r i o r i , i s b e t t e r than the bed to po p u l a t i o n model. Yet i t i s d i f f i c u l t , i f not impossible, to determine i f the model produces good r e s u l t s . Only the a p p l i c a t i o n of i t s r e s u l t s would allow t h i s c o n c l u s i o n . C e r t a i n l y there would appear to be a b u i l t - i n b i a s to give a conser-v a t i v e estimate because i t deals w i t h a demand s i t u a t i o n (the a c t u a l i n p a t i e n t m orbidity experienced by the p o p u l a t i o n ) . The r e a l advantage of t h i s model i s found both i n i t s ease and f l e x i b i l i t y of a p p l i c a t i o n w i t h i n the planning f u n c t i o n of the Department. Indeed the program was derived from a morbidity p r o f i l e which was not intended as a bed statement. I t i s true that the t r a n s l a t i o n of such i s turned Into statements regarding beds. What has happened i n t h i s study i s that there i s a simple and l o g i c a l assumption, and i t s converse that morbidity c l a s s i f i c a t i o n s are also bed c l a s s i f i c a t i o n s . I t was r e l a t i v e l y easy to summarize morbidity and beds to the 4 h e a l t h regions using t h i s study's bed p r e d i c t i o n model. With the very same program and swi t c h i n g a subroutine to s e l e c t o r i g i n of p a t i e n t , the type of r e f e r r a l could a l s o be estab-125 l i s h e d . At t h i s p o i n t i n time not a l l of the c a l c u l a t i o n s have been programmed. However, i t i s being planned and w i l l a l s o be used f o r purposes other than bed estimates. With a simple m o d i f i c a t i o n of percent occupancy at the r e g i o n a l l e v e l , a planner, given c o n s t r a i n t s of time and c o s t s , can balance f i g u r e s to derive the best combination of b e n e f i t s , economy and e f f i c i e n c y . However t h i s too can be a disadvantage because the a r b i t r a r i l y chosen occupancy l e v e l may not be a product of needs or demands but i n s t e a d might be a b i a s not n e c e s s a r i l y appropriate. Whatever statement t h i s model produces may, i n f a c t , be impossible to achieve p o l i t i c a l l y , p a r t i c u l a r l y i f i t i s addressing p r e d i c t i o n s on the conservative s i d e . The bed p r e d i c t i o n model, as i t stands, i s advantageous i n t h a t i t s p r i n c i p l e s d i c t a t e the establishment of a p r o v i n c i a l bed p o l i c y which i s a summation of p o l i c y statements from the various areas. In other words, the p r o v i n c i a l p r e d i c t i o n i s not forced upon e i t h e r the p o p u l a t i o n or r e g i o n a l planners. However, because there i s ease i n the use of t h i s model and because i t i s part of an e x i s t i n g data system at the p r o v i n c i a l l e v e l , the model has the *• disadvantage of r e q u i r i n g very l i t t l e input from r e g i o n a l planners. Consequently any statement on beds may be considered an i m p o s i t i o n and subject to an e r r o r which has not been addressed through l o c a l experience. A very d i s t i n c t disadvantage of the model i s that i t c a r r i e s forward a s t a t i c morbidity p a t t e r n ( i n c l u d i n g length of stay) even though admissions vary. L o g i c a l l y , one cannot expect the same morbidity patterns but s e n s i b l y how does one give a p r e c i s e d e f i n i -t i o n to morbidity f o r the f u t u r e . On the other s i d e of the c o i n , 126 there i s the p r a c t i c a l advantage that each region i s provided w i t h i t s own unique morbidity p a t t e r n . Therefore, the needs of the popu-l a t i o n are not imposed upon l o c a l or r e g i o n a l areas. The morbidity p a t t e r n i n t h i s model assumes that what has been h o s p i t a l i z e d r e q u i r e d h o s p i t a l i z a t i o n and what d i d not r e q u i r e h o s p i t a l i z a t i o n had no morbidity or i n p a t i e n t needs. One s o l u t i o n to the s t a t i c m o r bidity p a t t e r n would be to analyze the h i s t o r y of a diagnosis (or c l u s t e r ) and p r o j e c t a rate f o r each p o i n t i n the f u t u r e . Key Observations Regarding the  P o p u l a t i o n P r o j e c t i o n s Considering Newfoundland's type and l o c a t i o n of p o p u l a t i o n the r a t i o method should not be used beyond 10 years f o r small area populations. I f populations are below the 3000 l e v e l the method could be used but i t i s s t i l l subject to the percent e r r o r guide-l i n e and a p p l i c a t i o n w i t h due caution. I f the r a t i o method i s to be used f o r h e a l t h r e l a t e d popu-l a t i o n p r o j e c t i o n s i n Newfoundland two m o d i f i c a t i o n s of the method are suggested. P o p u l a t i o n bases and age sex i n t e r v a l s should be aggregated. This aggregation should increase accuracy, y e t , i t should provide enough s p e c i f i c i t y to be p r a c t i c a l . For example, the combination of both h o s p i t a l d i s t r i c t s and 3-4 age i n t e r v a l s could be used. This should produce an adequate p o p u l a t i o n base. The i n t e r v a l s chosen could cover the major age groups, 0-14, 15-44, 55-64, 65 and over. I t might a l s o be p r e f e r a b l e to consider a f i v e year estimate r a t h e r than 10 year p r o j e c t i o n . I t would run very close to the four year planning c y c l e which i s being inaugurated w i t h i n each department of the Newfoundland government. Constant r e v i s i o n of p o p u l a t i o n estimates can only improve upon purpose and 127 p r e c i s i o n . The e r r o r i n v o l v e d i n the p r o j e c t i o n s could a l s o be c o n t r o l l e d by checking w i t h r e g i o n a l or h o s p i t a l h e a l t h planners who might be i n v o l v e d i n a s i m i l a r e x e r c i s e . I f p r o v i n c i a l estimates are derived by checks upon economic s t a b i l i t y , housing s t a r t s or a c t u a l sampling of the p o p u l a t i o n , a pooled e f f o r t might l e a d to greater p r e c i s i o n . ' I f the estimate i s not pooled and opinions are asked, a degree of b i a s might be introduced to the data s e t . This study has followed the mathematical process of c a l c u -l a t i o n s and has manipulated the data as l i t t l e as p o s s i b l e . In other words, the data base which has been used i s considered clean and i t s a s s o c i a t e d methodology c l e a r . From t h i s p o i n t of view any user can employ h i s / h e r own assumptions and apply a l o g i c process to the data base or c a l c u l a t i o n s . The p o p u l a t i o n breakdown and the appropriate rates are then are as important as the f i n a l p r o j e c -t i o n s . Accuracy f o r very s m a l l p o p u l a t i o n p r o j e c t i o n s would be enhanced i f S t a t i s t i c s Canada would e l i m i n a t e the random rounding process. To the l a r g e r provinces t h i s process would produce n e g l i -g i b l e amounts of e r r o r but as described e a r l i e r i t could mean a 20% or 30%or 100% e r r o r i n an age i n t e r v a l i n a Newfoundland community. I f i t i s a question of c o n f i d e n t i a l i t y , are not the provinces pro-cessing morbidity data which has the c a p a b i l i t y of i d e n t i f y i n g people i n a community w i t h more i d e n t i f i e r s . I t should be a p r o v i n c i a l d e s i r e and r e s p o n s i b i l i t y to r e t r i e v e data from sets which they d i r e c t l y or i n d i r e c t l y c o n t r i b u t e t o . F i n a l l y , i t can be proposed f o r Newfoundland that planning i n h e a l t h should be organized to the census d i v i s i o n and i t s asso-c i a t e d network of s u b d i v i s i o n s and enumeration areas. This recom-mendation inc l u d e s the recording of data by p u b l i c h e a l t h n u r s i n g , p u b l i c h e a l t h i n s p e c t i o n , to name but a few d i v i s i o n s . S i m i l a r l y , H o s p i t a l Insurance s t a t i s t i c s should be reported by census d i v i s i o n . I t makes considerable sense to change to t h i s type of system which would then have a v a r i e t y of data a v a i l a b l e and organized to t h i s d i v i s i o n l e v e l by S t a t i s t i c s Canada. Information from t h i s source might prove to be a very u s e f u l adjunct to the planning data being c o l l e c t e d by the Department on each h e a l t h s t a t i s t i c a l d i s t r i c t . Key Observations Regarding the Bed  P r e d i c t i o n Model Observations.of occupied beds i n the province i n the past support the f i n d i n g that there are and w i l l continue to be a f a i r number of excess beds. The consequences of t h i s study or any which suggest cutbacks or a d d i t i o n a l beds req u i r e s that the Department of Health accept an undertaking to modify the bed count and to apply a l t e r n a t i v e s t r a t e g i e s of meeting the h e a l t h care needs of the popu-l a t i o n . U nfortunately the concept of 'bed' does not encompass a l l the components of h e a l t h care which are a s s o c i a t e d w i t h both the bed and i t s occupant, the p a t i e n t . This study suggests that there are p o t e n t i a l savings i n terms of c a p i t a l , manpower, and operating expenses i n three of the four regions. These p o t e n t i a l savings are o f f s e t by an a d d i t i o n a l requirement of beds i n the Eastern Region. For three regions'the minimum value of t h i s excess i n 1976 d o l l a r s w i l l be 9.5 m i l l i o n i n 1986 ( i n f l a t i o n not considered). In f a i r n e s s to the populus i n these r e g i o n s , such savings should i n pa r t or 129 whole be returned to these areas i n the form of a l t e r n a t i v e s t r a t e -gies of h e a l t h d e l i v e r y . What are some of these s t r a t e g i e s ? One which i s suggested i n t h i s study's bed p r e d i c t i o n s i s that bed a l l o c a t i o n s should not be made d i s t i n c t i v e f o r long periods of time.• Instead they should be capable of being interchanged between s e r v i c e s . In p r a c t i c a l terms i t means that present management must have a degree of f l e x i -b i l i t y to adapt to changing demands. S t r u c t u r a l l y , h o s p i t a l s must be s u f f i c i e n t l y f l e x i b l e to depart from t r a d i t i o n a l bed and s t a f f i n g alignments. I f h o s p i t a l s and government d e s i r e changes which are designed to reduce or add beds, experimental s i t u a t i o n s w i l l have to be e s t a b l i s h e d and evaluated. Inducements f o r t h i s s t r a t e g y could be i n i t i a t e d through the savings and e f f i c i e n c i e s which are suggested. I t i s one t h i n g to add beds but to add them to the Eastern Region runs against the g r a i n of many h e a l t h p r o f e s s i o n a l s outside the region. Many f e e l that i n comparison to the Eastern Region they have r e l a t i v e l y l e s s . ;Yet 45% of a l l p a t i e n t s i n Newfoundland r e c e i v e treatment i n the Eastern Region. To reduce the excess i n these regions would r a i s e c onsternation. To change e x i s t i n g patterns would r a i s e d i f f i c u l t i e s . I t becomes a question of i n f o r m a t i o n , p o s i t i v e i n c e n t i v e s and informed cooperation between r e g i o n a l or h o s p i t a l h e a l t h planners and government h e a l t h planners. I t i s f e l t that the eventual approach which w i l l be taken to f u r t h e r r a t i o n a l i z e the system w i l l be a f o r m a l i z e d r e g i o n a l i z a t i o n . The key to t h i s approach w i l l be on the planning f u n c t i o n and the examination of two way r e f e r r a l l i n e s : the p a t i e n t must have access to needed medical care, and some needed'aspects of medical care and i t s technologies may have to be d e l i v e r e d to the p a t i e n t . In the . 130 context of Newfoundland's d i s t i n c t i v e geography and po p u l a t i o n i t would seem that e i t h e r secondary f a c i l i t i e s w i l l have to be b u i l t or access i s going to have to improve s i g n i f i c a n t l y i f a l t e r n a t i v e s are desir e d . I t would therefore appear that r a t i o n a l i z i n g the e x i s t i n g excessive secondary care type of f a c i l i t i e s w i l l take the form of a l t e r n a t i v e s w i t h i n a stronger r e g i o n a l framework. At the heart of the i s s u e i s the refinement of a c c e s s i b i l i t y to s e r v i c e . I t i s d i f f i c u l t to e n v i s i o n a d r a s t i c a l l y improved access which f o l l o w s a d i r e c t i o n from p a t i e n t to secondary or t e r t i a r y care h o s p i t a l . However, i f the d i r e c t i o n i s reversed then t r a v e l l i n g c l i n i c s , c o nsultants o r programs could s i g n i f i c a n t l y improve the access. With the a d d i t i o n of improved communication te c h n o l o g i e s , a r e g i o n a l framework could e f f e c t a l t e r n a t i v e s and thereby r a t i o n a l i z e excess beds. What i s being suggested i s that to r a t i o n a l i z e the system by c r e a t i n g a l t e r n a t i v e modes of d e l i v e r y , i t may take some,time to demonstrate economics and/or e f f i c i e n c i e s . I t may a l s o be very c o s t l y to develop these a l t e r n a t i v e s i n the s t a r t up phases. The net e f f e c t of developing a l t e r n a t i v e s could increase the t o t a l expenditures on h e a l t h . This might occur i f the present morbidity p a t t e r n i n r u r a l areas i s an understatement of the a c t u a l s i t u a t i o n . I f there i s no c l e a r - c u t s h i f t to an a l t e r n a t i v e mode nor a conse-quent re d u c t i o n i n demand f o r t r a d i t i o n a l modes of d e l i v e r y , costs w i l l i n c r e a s e . U n f o r t u n a t e l y , the monies re q u i r e d to'experiment and to develop systems do play a s i g n i f i c a n t part i n a d e c i s i o n even i f i t i s r a t i o n a l and a l t r u i s t i c . When the costs.are weighed against proposed a c t i o n s the i n e f f i c i e n c i e s which appear to be so expensive 131 may be l e s s c o s t l y and as s a t i s f a c t o r y to the p a t i e n t s , as systems that ought to be. Herein l i e s one of the many dilemmas o f t e n faced by h e a l t h care a d m i n i s t r a t o r s and planners. This study makes a statement that a r e a l s i t u a t i o n of morbi-d i t y w i l l a r i s e i n 1981 and 1986 which can be t r a n s l a t e d i n t o both the number and types of beds. I t s u n d e r l y i n g premises are: the present m o r b i d i t y patterns w i l l remain constant; the p o p u l a t i o n p r o j e c t i o n s have reasonable assumptions and an acceptable l e v e l of p r e c i s i o n ; and f i n a l l y , the assumptions of occupancy standards have sound o p e r a t i o n a l and e f f i c i e n c y l e v e l s . Although the bed p r e d i c -t i o n s are given i n the absence of a p r o b a b i l i t y statement, the e n t i r e process l e a d i n g to the p r e d i c t i o n i m p l i e s that the bed p r e -d i c t i o n s f o r 1981 and 1986 w i l l adequately cope w i t h the morbidity p a t t e r n expected i n 1986. Therefore the p r e d i c t i o n s do i n f a c t have a p r o b a b i l i t y attached, a l b e i t , not s p e c i f i e d . Yet the p r o j e c t i o n s and p r e d i c t i o n s which are reached w i t h i n the scope of t h i s study i n v o l v e many assumptions which have not been put to the t e s t . To be e f f e c t i v e f o r planning the bed p r e d i c t i o n model and i t s components w i l l have to be evaluated. More import-a n t l y , the model w i l l probably r e q u i r e more of human acceptance than l o g i c because i t eminated from a s i n g l e source and d i d not i n v o l v e the i nput of h e a l t h p r o f e s s i o n a l s around the province. This model does have the f l e x i b i l i t y to broach t h i s p o t e n t i a l problem. The f i n a l i z e d statement of beds f o r the province i s a summation of r e g i o n a l bed requirements. Although assumptions'are general i n nature when a p p l i e d to a r e g i o n a l a n a l y s i s of t h i s type, the assump-t i o n s are unique to each region and the r e s u l t i n g d i s t r i b u t i o n of resources to each region takes place w i t h the same d i s t i n c t i o n . 132 Therefore, t h i s model has the p o t e n t i a l f l e x i b i l i t y to provide the b a s i s f o r d i s c u s s i o n and cooperation between region and government. Future D i r e c t i o n s from t h i s Study While p o p u l a t i o n s o r t i n g of h e a l t h s t a t i s t i c a l d i s t r i c t was overshadowed by the p o p u l a t i o n arid morbidity p r o j e c t i o n s and bed pre-d i c t i o n s , i t s importance to a h e a l t h data base f o r planning i s para-mount. The sorted p o p u l a t i o n by d i s t r i c t age and sex i s the i n i t i a l step i n d e f i n i n g who needs and who consumes or ought to consume h e a l t h care resources. Consequently, the i n t e n t i o n f o r the f u t u r e i s to i n v e s t i g a t e a l t e r n a t i v e methods of making small area p r o j e c -t i o n s and to o b t a i n and blend p o p u l a t i o n p r o j e c t i o n s or r e l a t e d i n f o r m a t i o n from d i f f e r e n t sources. Regardless of the method employed, the population data base w i l l have to have adjunct f i l e s which w i l l a l low f o r d e c i s i o n r u l e s or m o d i f i c a t i o n to the p r o j e c -t i o n s . Where p o s s i b l e , each h o s p i t a l d i s t r i c t w i l l have to have separate f i l e s on: v i t a l s t a t i s t i c s , economic growth and prospects, school enrollments, employment, housing s t a r t s and hydro or telephone hook-ups. The c o l l a t i o n of these types of data w i l l r e q u i r e the development of a methodology which w i l l help to gather the informa-t i o n on a c o n t i n u i n g b a s i s . The next step i n e s t a b l i s h i n g a decent morbidity base and th e r e f o r e e s t i m a t i o n and/or p r e d i c t i o n of beds i s the r e t r o s p e c t i v e a n a l y s i s of d i f f e r e n t diagnoses over the past. In so doing, one might be able to p r e d i c t a p r o s p e c t i v e trend i n morbidity at some future date. This type of adjustment could then be incorporated i n t o the model. I t i s a l s o envisioned that the d i a g n o s t i c c l u s t e r i n g denoting 133, bed type w i l l cover a wider range. Therefore, the model w i l l give a more s p e c i f i c statement of bed requirements. The program output w i l l be designed so that the p a r t i c u l a r s of each diagnosis are a v a i l -a b l e , and a summation to a bed c l u s t e r w i l l y i e l d a statement of both m o r b i d i t y and bed need. As s t a t e d i n the f i r s t paragraph, a l t e r n a t i v e methods f o r p r o j e c t i o n s w i l l be pursued. The same i s true of the bed p r e d i c t i o n . In terms of making a c o n t r i b u t i o n i n h e a l t h planning f o r beds, t h i s model w i l l be proposed as-a method to evaluate. The eventual i n t e n t i s acceptance and r e f o r m u l a t i o n of the model and processes which would allow f o r input from the regions. In doing the bed p r e d i c t i o n s (and p o p u l a t i o n projections)..., the accuracy and t i m e l i n e s s of primary and secondary data sources were p o i n t s of focus. I t would have been f a r b e t t e r to present morbidity rates from 1978 to more a c c u r a t e l y r e f l e c t the needs of the p o p u l a t i o n . Developing these h e a l t h planning data bases i n the province w i l l r e q u i r e more t e c h n o l o g i c a l adjustments to e x i s t i n g methods of c o l l e c t i o n , processing and output. The data sources which c o n t r i b u t e d to both the p o p u l a t i o n p r o j e c t i o n and morbidity data are from secondary sources. The accuracy of S t a t i s t i c s Canada census f i g u r e s must be questioned. So, too, must the i n p a t i e n t morbidity which i s reported i n summary form from each h o s p i t a l . I t stands to reason, that some po p u l a t i o n areas w i t h i n the province w i l l have to be sampled and that the pro-v i n c i a l m o rbidity p a t t e r n f o r a h o s p i t a l w i l l have to be examined against primary sources at the h o s p i t a l . Most a s s u r e d l y , the popu-l a t i o n p r o j e c t i o n s f o r the regions w i l l have to be evaluated against the 1981 and 1986 populations. 134 F i n a l l y , there are three planning d i s t r i c t s which are d i s -t i n c t i n the province. These are: the h e a l t h s t a t i s t i c a l , the census and the f e d e r a l e l e c t o r a l . I f the department does not consider the adoption of the census d i v i s i o n as the planning base, an attempt to l i n k these planning e n t i t i e s w i l l need to be sought. Because of the very p r a c t i c a l nature of t h i s t h e s i s , the subject matter and i n t e r e s t must n e c e s s a r i l y continue i n t o the f u t u r e . This d i r e c t i o n w i l l be r equired by h e a l t h planning as a n a t u r a l but important f u n c t i o n . APPENDICES 135 APPENDIX A PROBLEMS ASSOCIATED WITH THE DISTRIBUTION OF HEALTH CARE RESOURCES TO RURAL AREAS IN NEWFOUNDLAND 136 137 APPENDIX A PROBLEMS ASSOCIATED WITH THE DISTRIBUTION OF HEALTH CARE RESOURCES TO RURAL AREAS IN NEWFOUNDLAND Much of the province of Newfoundland can be c h a r a c t e r i z e d as being r u r a l . The B r a i n Commission observed that 63% of the pop u l a t i o n r e s i d e d i n communities w i t h .a p o p u l a t i o n of l e s s than 100 in h a b i t a n t s and over 50% of the po p u l a t i o n l i v e d i n 1300 c o a s t a l settlements.^" In March 1978 the P r o v i n c i a l Ambulance Programme i n i t s annual report excluded geographical p r o x i m i t y to h o s p i t a l based ambulance programmes and estimated the r u r a l p o p u l a t i o n at 340,000. This f i g u r e c o n s t i t u t e s 60% of the po p u l a t i o n . Even w i t h the resettlement programmes c a r r i e d out over the l a s t decade, and the known l a r g e migrations a s s o c i a t e d w i t h c l o s u r e s of i n d u s t r i e s , the r u r a l has stayed r u r a l . ^ Tra n s p o r t a t i o n and communication have improved, yet each study since that by Lord B r a i n has taken the time to discuss the co n t i n u i n g problems of d i s t r i b u t i n g resources to the r u r a l s e t t i n g . I n v a r i a b l y each study discusses e q u i t a b l e d i s t r i b u t i o n i n terms of a v a i l a b i l i t y and access to s e r v i c e s . Distance from primary and secondary l e v e l s of care has been the most acceptable method of d e f i n i n g the r u r a l problem. In many cases t h i s distance cannot be overcome because communities are ge o g r a p h i c a l l y i s o l a t e d or remote. Systems and s t r u c t u r e f o r d e l i v e r y of h e a l t h care to r u r a l popula-t i o n s are evident (from author's work f i l e s ) . P u b l i c Health Nursing c a r r i e s a Curative Care Programme to a l l segments of the po p u l a t i o n i n three geographical areas where there i s no a v a i l a b l e pro-f e s s i o n a l medical s e r v i c e to o u t l y i n g areas. Tuberculosis C o n t r o l c a r r i e s a BC V a c c i n a t i o n programme which i s l o c a l i z e d to the Northern Region 138 of the Province. The programme i s conducted by p u b l i c h e a l t h n u r s i n g i n the area. Dental Health Services provides a net annual income to d e n t i s t s who p r a c t i c e i n the smaller r u r a l areas. The C e n t r a l Pharmacy of the Department of Health w i l l m a i l drugs to i n d i v i d u a l s i n the po p u l a t i o n where pharmacists are not a v a i l a b l e . A l t e r n a t i v e l y , p h y s i c i a n s dispense drugs i n sm a l l e r communities. The P r o v i n c i a l Food Bank mails s p e c i a l and/or hard to o b t a i n d i e t s f o r metabolic d i s o r d e r s . C y s t i c F i b r o t i c p a t i e n t s r e c e i v e drugs through the m a i l from C e n t r a l Pharmacy. The Cottage H o s p i t a l System s t i l l remains and func-t i o n s to serve the r u r a l and i s o l a t e d areas of Newfoundland. There are 12 h o s p i t a l s w i t h a t o t a l c a p a c i t y of 365 beds. These h o s p i t a l s are adminis-tered and s u p p l i e d w i t h resources by the Department of Health. The Education D i v i s i o n has d e c e n t r a l i z e d to r e g i o n a l depots f o r the dissemination of edu c a t i o n a l m a t e r i a l s . The N u t r i t i o n D i v i s i o n has a r e g i o n a l n u t r i t i o n i s t l o c a t e d on the West Coast. The P r o v i n c i a l Ambulance Programme covers 60 commu-n i t i e s i n Newfoundland. i The A i r Ambulance Programme conveyed over 5,000 p a t i e n t s i n a d d i t i o n to emergency s u p p l i e s and ph y s i c i a n s or s p e c i a l i s t s . The Medical Services D i v i s i o n has placed a r e g i o n a l Medical Health O f f i c e r on the West Coast w i t h the purpose of o r g a n i z i n g p u b l i c h e a l t h s e r v i c e s under one s t r u c t u r e . There are r e g i o n a l h o s p i t a l s throughout.the province. Although r e g i o n a l i z a t i o n i s not f o r m a l , many h o s p i t a l s i n t e r a c t f o r s e r v i c e s on a vol u n t a r y b a s i s . C l i n i c s and Nursing S t a t i o n s have been constructed f o r i s o l a t e d areas. These operate w i t h one p h y s i c i a n and/or nurse. In many cases only a p u b l i c h e a l t h nurse i s a v a i l a b l e . What i s al s o an i n t e r e s t i n g c h a r a c t e r i s t i c of the h e a l t h . , system i s that i t i s i n t e g r a t e d i n design i n the sense t h a t , w i t h 139 few exceptions, most f a c i l i t i e s are h o s p i t a l s . This i s a product of t r a d i t i o n and geography. When these f a c i l i t i e s were b u i l t i t was necessary to e s t a b l i s h a secondary l e v e l of care because the i s o l a -t i o n and topography prevented access to the l a r g e r centers. These small h o s p i t a l s have continued to s u r v i v e to the present even though t r a n s p o r t a t i o n and communication have improved and despite a change i n t h e i r s e r v i c e r o l e s . Further i n t e g r a t i o n i s being discussed by the Department of Health. Boards are being suggested f o r the Cottage H o s p i t a l s . R e g i o n a l i z a t i o n and a f f i l i a t i o n of s m a l l e r h o s p i t a l s to l a r g e r r e f e r r a l centers i s a l s o being proposed. The outcome of these proposals i s not j u s t an a r b i t r a r y d e c i s i o n , f o r i t s eventual success, i f adopted, i s dependent upon the r e c o g n i t i o n of both problems and sources of problems p e c u l i a r 2-9 to the r u r a l s e t t i n g . In t h i s context, a number of examples are presented from the l i t e r a t u r e . These examples are intended to i n f e r r e l a t e d and complex s i t u a t i o n s i n which problems have been exper-ienced. 1. Manpower shortages, environment and recruitment d i f f i c u l t i e s . 2. Education maintenance i n current methods and s k i l l s f o r h e a l t h care, personnel and boards and the c o r r e -ponding education of government o f f i c i a l s regarding r u r a l c h a r a c t e r i s t i c s . 3. Development of l e a d e r s h i p , o r g a n i z a t i o n and c o o r d i -n a t i o n s k i l l s i n the community which attend to problem i d e n t i f i c a t i o n and s o l u t i o n and to the adoption of a l t e r n a t i v e s . 4. Development of p r e c i s i o n , accuracy and use of i n f o r -mation to define need or to know where and how to procure advice, and to review or monitor care (e.g., surgery l e v e l s ) . 5. Reduction of independence, "chauvanism," a i r of r e s i g n a t i o n , s t a t u s quo and s o c i a l t r a d i t i o n s , to f u l l y 140 take advantage of cooperation between communities, p r o f e s s i o n a l s , community o r g a n i z a t i o n s and government agencies. 6. Development of communication such as r a d i o , t e l e v i -s i o n , t r a n s p o r t a t i o n and the means of t r a n s p o r t a t i o n which f o s t e r d i s t r i b u t i o n of resources i n terms of geography, d i s t a n c e , time and weather. 7. The a p p l i c a t i o n of l a r g e r system models, r u l e s and r e g u l a t i o n s and personnel and s e r v i c e procedure standards on smaller systems. 8. Development of h e a l t h r e l a t e d environmental areas such as water and sewage systems. 9. Economic dependence on h e a l t h s e r v i c e s f o r employment. 10. Out mi g r a t i o n because of employment o p p o r t u n i t i e s and current movement of urban dwellers i n t o r u r a l (expectations r a i s e ) areas. 11. P o p u l a t i o n s t r u c t u r e by age-sex and s o c i a l o r g a n i z a -t i o n which may be a f f e c t e d by low income, high unemployment and work migra t i o n s . 12. Method of f i n a n c i n g , resources and personnel may d i c t a t e p l e n t i f u l but i n a p p r o p r i a t e resources, or may modify s e r v i c e through c o n s t r a i n t s . Would a l s o i n c l u d e s a l a r y versus fee f o r s e r v i c e payments. 13. Time and work misuse of p r o f e s s i o n a l s because of shortages i n support personnel or other f a c t o r s such as distance and t r a n s p o r t a t i o n and weather which create delay. The problems encountered by one community are not n e c e s s a r i l y the problems of another even though b a s i c demographic c h a r a c t e r i s t i c s are s i m i l a r . These are problems which hinder or f a c i l i t a t e i n t e -g r a t i o n w i t h the o v e r a l l p o l i c y of p r o v i d i n g h e a l t h care to the population. As the t h e s i s i s foc u s i n g upon i n p a t i e n t beds by region i n Newfoundland, there are, i n the o p i n i o n of the w r i t e r , the higher impact problems. Observations relevant to these problems are drawn from the experience of the w r i t e r . Economic Dependence on H o s p i t a l s . In the mid-seventies the Department of Health and Government attempted to clos e down two 141 smaller h o s p i t a l s . The communities i n v o l v e d presented s t i f f oppo-s i t i o n to the proposals. As recounted by o f f i c i a l s , the primary lobbying p o s i t i o n was that h o s p i t a l s were centres of employment. Economic and C u l t u r a l Problems. Many communities, p a r t i c -u l a r l y i n Northern Newfoundland and Labrador, are areas of low per c a p i t a income and high unemployment. These areas a l s o have a higher p r o p o r t i o n of n a t i v e peoples. The combination has r e s u l t e d i n underdevelopment p a r t i c u l a r l y i n n u t r i t i o n and s a n i t a t i o n measures. These areas have o f t e n been described as remote pockets of s o c i a l d i s i n t e g r a t i o n w i t h a t t e n d i n g s o c i a l diseases higher than normal. These a r e a s : a l s o have d i f f i c u l t y i n a t t r a c t i n g personnel w i t h organ-i z a t i o n a l s k i l l s . Without s k i l l s and resources, the r e s p o n s i b i l i t y f o r and operation of h e a l t h care systems becomes d i f f i c u l t . I n s u l a r i t y and Independence of Health Care P r o f e s s i o n a l s . There are a number of f a c t o r s which c o n t r i b u t e to t h i s s i t u a t i o n : a long t r a d i t i o n of having the same f a c i l i t y i n the community, the l a c k of peer contact, a l e s s than optimal e d u c a t i o n a l environment, the b u i l d i n g . o f kingdoms, and remoteness of the i n d i v i d u a l . A proposal f o r r e g i o n a l i z a t i o n i n 1972 was adopted, i n p r i n c i p l e , by the Department of Health. Since that time no formal r e g i o n a l i z a t i o n has occurred. In the C e n t r a l region during 1974 and 1975 adminis-t r a t o r s met to discuss v o l u n t a r y r e g i o n a l i z a t i o n p r i o r to formal r e g i o n a l i z a t i o n so t h a t they could e s t a b l i s h t h e i r own procedures and s t r u c t u r e s . The a i r of cooperation was absent; i t was a j e a l o u s a t t i t u d e that p r e v a i l e d . (The w r i t e r was present at the meetings.) Although an i n f o r m a l r e g i o n a l i z a t i o n does e x i s t f o r very s e l e c t e d s e r v i c e s , there are s t i l l gestures against cooperation. 142 P o l i t i c a l I n t e r v e n t i o n . There have been many occasions when a d m i n i s t r a t o r s , h e a l t h p r o f e s s i o n a l s or community lobbying groups have bypassed Department of Health channels to present a p o s i t i o n to the M i n i s t e r . Going outside channels, i n the opi n i o n of the w r i t e r , happens f r e q u e n t l y and produces r e a c t i o n s that are not always favorable f o r the a d m i n i s t r a t o r s or communities. Manpower Shortages. Every year the same complaint i s heard across the province. There i s a shortage of nurses, p a r t i c u l a r l y during the summer months. One 200-bed h o s p i t a l closes down a ward f o r two months each year as a s o l u t i o n to t h i s problem. One of the cottage h o s p i t a l s i n 1979, through community r e p r e s e n t a t i o n , t h r e a -tened to c l o s e down a l l beds because they could not r e c r u i t nurses. P a r t of the problem l i e s w i t h the l a r g e r h o s p i t a l s which can o f f e r a more a t t r a c t i v e employment package. Another element of the problem i s the r a p i d turnover of f o r e i g n graduates who are r e c r u i t e d . Time and time a g a i n , d i r e c t o r s and a d m i n i s t r a t o r s s t a t e that Newfoundland i s a gateway to f u r t h e r o p p o r t u n i t i e s . I t i s here where custom, language and f i n a n c i a l bases are formed p r i o r to mi g r a t i o n . Black^ has a p t l y described the problem f o r p h y s i c i a n shortages i n Newfound-land. T r a n s p o r t a t i o n Distance and Weather. There s t i l l are areas i n the province where i t i s very d i f f i c u l t to v i s i t or from which i t i s d i f f i c u l t to r e f e r a p a t i e n t to a t e r t i a r y care center. Northern Newfoundland and Labrador i s p a r t i c u l a r l y prone to these problems. In an e v a l u a t i o n of bed needs f o r one h o s p i t a l , the r e g i o n a l center, the average length of stay had to be adjusted by a minimum f i g u r e of two days which allowed f o r necessary delay. From the C e n t r a l Region, the distance to t e r t i a r y care could i n v o l v e 250 road miles or 60 miles to the a i r p o r t . The P r o v i n c i a l Ambulance Report f o r 1978 s t a t e s that i t conveyed 9,610 p a t i e n t s 1,356,713 miles f o r an average of 141 miles per p a t i e n t . The a i r ambulance program conveyed 5,317 p a t i e n t s . In t o t a l t h i s represents 14% of a l l separations i n c l u d i n g newborn and out of province. R e l a t i v e Smallness of System. For the most par t h o s p i t a l s i n Newfoundland are s m a l l . Consequently, the o p p o r t u n i t i e s f o r advancement are l i m i t e d . There i s a t r a d i t i o n , p a r t i c u l a r l y i n a d m i n i s t r a t i o n , of s t a y i n g at a p o s i t i o n f o r a long time. For those i n s m a l l e r h o s p i t a l s , the o p p o r t u n i t i e s to improve a d m i n i s t r a t i v e s k i l l s i n the context of l a r g e r h o s p i t a l s i s f a r from b r i g h t . P o l i t i c a l I n t e g r a t i o n . Some of the problems e x i s t i n g f o r both r u r a l and urban s e t t i n g s i s the l a c k of p o l i t i c a l i n t e g r a t i o n of s e r v i c e s f o r planning. As determinants of demand, a number of r u r a l areas d i s p l a y low e d u c a t i o n a l l e v e l s , high unemployment, low income and l e s s s a n i t a r y environments. A h e a l t h p l a n f o r t h i s area should n e c e s s a r i l y i n v o l v e at l e a s t s i x government departments: Health, Education, Rural Development, P u b l i c Works, Executive C o u n c i l , and S o c i a l S e r v i c e s . Recent developments at the Cabinet l e v e l i n d i c a t e a movement to some i n t e g r a t i o n . Nursing Home opera-t i o n s were t r a n s f e r r e d from S o c i a l Services and R e h a b i l i t a t i o n to Health. Lack of S k i l l s of H o s p i t a l Personnel. I n v a r i a b l y , the Consultant Reports of H o s p i t a l Surveys recommend the upgrading of a d m i n i s t r a t i v e s k i l l s . In one h o s p i t a l v i s i t e d r e c e n t l y an o r g a n i -z a t i o n a l mess was discovered. The f e e l i n g was that the a d m i n i s t r a t o r was not keeping current and was i n f a c t unaware of the s i t u a t i o n . There are a l s o known s i t u a t i o n s i n which people are i n jobs without 144 the necessary e d u c a t i o n a l and e x p e r i e n t i a l background. The A v a i l a b i l i t y of Funds. In the 1970's budgets had become t i g h t e r . Consequently, the monies a l l o t e d f o r p i l o t p r o j e c t s or experimental methods has been very r e s t r i c t e d . The system, both urban and r u r a l , acknowledges very l i t t l e change, i n mode of d e l i v e r y . C o n s t r a i n t has a l s o l e d to shortages i n manpower w i t h i n the Department of Health. This shortage i s meant i n terms of v i t a l areas such as budget review. In the context of the present day to day a c t i v i t i e s , very few people have the time to " p l a y " and e x p e r i -ment w i t h ideas or a l t e r n a t i v e s . D e c i s i o n Making Approach of Government. Numerous s t u d i e s p o i n t to the c r i s i s - o r i e n t e d approach taken i n h e a l t h care d e l i v e r y i n Newfoundland. This does not f o s t e r i n t e g r a t e d planning. In the p a s t , aside from the cottage h o s p i t a l s , budgets were negotiated. The p o l i t i c a l v o i c e or squeaky wheel sometimes managed to get a greater share of the p i e . Therefore, developments at the h o s p i t a l l e v e l were dependent upon the course of n e g o t i a t i o n s . This a t t i t u d e i s changing i n that the budget i s determined f o r a l l , p r i o r to any argument of the allotment. This does promote a wider view of the system but development s t i l l hinges on a v a i l a b l e funds and remote-ness. Perhaps a bigger f a c t o r i s the l a c k of personnel f o r key areas to monitor and p l a n systems. Current e f f o r t s by n e c e s s i t y are concerned w i t h day to day operations. Concentration of F a c i l i t i e s and Costs. Although there are many smaller h o s p i t a l s i n Newfoundland, many are not attended to i n the same f a s h i o n as the l a r g e r h o s p i t a l s . The assumption i s that as there are no s e r i o u s problems, everything i s operating i n an e f f e c t i v e manner. Much of the concerted e f f o r t s at the government l e v e l f a l l to the c i t y h o s p i t a l s and s i x l a r g e r h o s p i t a l s on the i s l a n d . These h o s p i t a l s would account f o r 62% of the approved beds and between 70-80% of the separations. The problems encountered by r u r a l areas may be many and v a r i e d . Often the problems are the same between urban and r u r a l areas; the d i f f e r e n c e i s one of degree. What i s important i n the planning context i s to be aware of the a c t u a l and p o t e n t i a l d i f f e r -ence between and w i t h i n regions or areas. In the Newfoundland s e t t i n g , geography, demographic c h a r a c t e r i s t i c s , and sp a r s e l y and v a r i e d p o p u l a t i o n d e n s i t i e s must be considered i n the d i s t r i b u t i o n of resources. I t i s not enough to evaluate s p e c i f i c needs and decide that resources should be d i s t r i b u t e d . The planner must know how and to whom he i s d i s t r i b u t i n g resources. Therefore, the a n a l y s i s of demographic data r e l a t i v e to the ru r a l - u r b a n dichotomy must throw l i g h t upon and c o n t r i b u t e to the development of o r g a n i -z a t i o n and s k i l l s needed to'handle the d i s t r i b u t i o n of resources. 146 Appendix A Footnotes These footnotes have been c i t e d i n the t e x t of Chapter I I I . There-fore the b i b l i o g r a p h i c e n t r i e s f o r these footnotes are i n Chapter I I I of the B i b l i o g r a p h y . '''Right Honourable Lord B r a i n , Royal Commission on Heal t h , 3 v o l s . , St. John's: Government of Newfoundland and Labrador, 1966, 1:1. 2 J u l i a n A. W a l l e r , "Rural Emergency Care - Problems and Prospects," American J o u r n a l of P u b l i c Health 63 ( J u l y 1973): 631-634. 3 J u l i a n A. W l l e r , "Urban-Oriented Methods: F a i l u r e to Solve Rural Emergency Care Problems," J o u r n a l of American Medical Asso- c i a t i o n 226 (December 1973): 1441-1446. 4 E l i z a b e t h H i s c o t t , "Health Services i n Four I s o l a t e d D i s t r i c t s , " Canadian J o u r n a l of P u b l i c Health 64 (September/October 1973) : 500-502. 5 I b i d . , pp. 500-502. Stephen Portnoy and W i l l i a m L. Casady, "Rural Health Program P r i o r i t i e s , " H o s p i t a l s 50 (March 1976): 68-71. 7Douglas P. Black, "Medical Services f o r I s o l a t e d Areas," Canadian Family P h y s i c i a n (February 1973): 91-95. Robert L. Kane and S i s t e r Diane M o e l l e r , "Rural S e r v i c e Elements F a l l C o o r dination," H o s p i t a l s 48 (October 1974): 79-83. 9 B l a c k , pp. 91-95. APPENDIX B DETERMINATION OF SAMPLE SIZE 147 148-APPENDIX B DETERMINATION OF SAMPLE SIZE Without knowing the v a r i a n c e of observations, a sample from these observations cannot be determined without guesswork. 1 As there are no s t u d i e s i n Newfoundland concerning estimates of e r r o r f o r p o p u l a t i o n p r o j e c t i o n s of h e a l t h s t a t i s t i c a l d i s t r i c t s , an idea of v a r i a n c e could not be obtained. To estimate v a r i a n c e f o r the estimates of e r r o r which were organized to four p o p u l a t i o n stratum a 25% random sample was taken from each stratum. The v a r i a n c e and standard d e v i a t i o n was c a l c u l a t e d f o r each stratum. I t was a n t i c i p a t e d that two sampling s t r a t e g i e s would be employed. In the lower p o p u l a t i o n stratum, v a r i a n c e and number of extremes were expected to be h i g h . F u r t h e r , the m a j o r i t y of obser-v a t i o n s would f a l l i n t o t h i s stratum. As a f i r s t s t r a t e g y , t h i s stratum was to be sampled independently of the remaining two stratum. Second, f o r the 2 l a r g e r stratum a sample s i z e was to be determined 2 and o p t i m a l l y a l l o c a t e d . Optimum a l l o c a t i o n would a l l o w weighting of both number and variance i n determining what the appropriate p o r t i o n of the sample should be assigned to each stratum. Note that the 25% random sample to estimate the v a r i a n c e was returned to the set of observations. Subsequent sampling was random w i t h i n each stratum. 3 The f o l l o w i n g formula was u t i l i z e d to determine the sample s i z e i n the -2999 po p u l a t i o n stratum and i n the ±3000 p o p u l a t i o n s t r a t a . 149 where n = sample s i z e t = student's t va l u e , .99 confidence l e v e l at degrees of freedom 2 S = variance (S = standard d e v i a t i o n ) L = confidence i n t e r v a l at ,01 s i g n i f i c a n c e To determine the optimum a l l o c a t i o n f o r each s t r a t a above 4 3,000 p o p u l a t i o n the f o l l o w i n g formula was employed. N x S, * = h h h = l where nft = sample s i z e (optimum a l l o c a t i o n ) assigned to each s t r a t a N, = i n d i v i d u a l s i n each stratum h 2 S, = variance i n each stratum h n = sample s i z e already determined The 25% sample produced the f o l l o w i n g v a l u e s : S SE n N <2999 po p u l a t i o n 17.59 2.49 50 193 >.3000 popu l a t i o n 5.41 1.44 14 27 The confidence i n t e r v a l 10 (from 0% - 10%) i s a d e s i r e d range f o r the absolute value f o r each p o p u l a t i o n p r o j e c t i o n e r r o r . The t value has been e s t a b l i s h e d at .005 f o r degrees of freedom. The sample s i z e s which were determined are: <2999 po p u l a t i o n - 83 (82.3) >.3000 p o p u l a t i o n - 11 (9.6 10, readjusted to 11, see below) The optimum a l l o c a t i o n of the 10 samples from the £.3000 s t r a t a are: . 15G the 3000-9999 stratum was assigned 5 (4.1) and the 10,000 and over stratum was assigned 6 (5.9). 151 Appendix B Footnotes The f o l l o w i n g references have been c i t e d i n Chapter V of the t e x t and have b i b l i o g r a p h i c e n t r i e s i n Chapter V of the B i b l i o g r a p h y . "'"Alvan F e i n s t e i n , C l i n i c a l B i o s t a t i s t i c s (St. L o u i s : C. B. Mosby Co., 1977), pp. 225. 2 Frank Freese, Elementary Forest Sampling, A g r i c u l t u r a l Handbook No. 232. (Forest S e r v i c e , U.S. Department of A g r i c u l t u r e ) December 1962, pp. 28-36 3 F e i n s t e i n , pp. 225 ^Freese, pp. 34-35 APPENDIX C TEST FOR BIAS IN THE RANDOM ROUNDING PROCESS EMPLOYED BY STATISTICS CANADA 152 153 APPENDIX C TEST FOR BIAS IN THE RANDOM ROUNDING PROCESS EMPLOYED BY STATISTICS CANADA Signs + o T o t a l Males 98 (97.5) 113 (111.5) 86 (88) 297 Females 97 (97.5 110 (111.5) 90 (88) 297 T o t a l 195 223 176 594 X 2 = .136; X 2 g 3 =2008.1 <.01 Method: Age Sex I n t e r v a l s f o r each s u b d i v i s i o n were summed and compared w i t h the t o t a l age sex p o p u l a t i o n depar-tures w i t h the t o t a l s were recorded as: -, + and 0. A l l unorganized s u b d i v i s i o n s were included. APPENDIX D ESTIMATES OF ERROR IN THE <2999 POPULATION STRATUM: TO EXCLUDE UNSTABLE CENSUS DIVISIONS AND ERRORS >20% i 154 155 APPENDIX D ESTIMATES OF ERROR IN THE <2999 POPULATION STRATUM: TO EXCLUDE UNSTABLE CENSUS DIVISIONS AND ERRORS >20% A. 1.2999 A l l Census D i v i s i o n s N |M| S SE 193 13.2 17.9 1.3 B. <2999 Census D i v i s i o n s w i t h d i v i s i o n s 9 and 10 removed N |M| S SE 149 10.5 12.7 1.0 C. £2999 A l l Census D i v i s i o n s A l l E r r o r s 220% excluded N |M/ S SE 157 6.4 5.1 .41 D. Summary of E r r o r s >20% N |M| S SE 37 42.1 23.3 3.8 APPENDIX E THE ARRAY OF ESTIMATES OF ERROR PLOTTED AGAINST POPULATION SIZE 156 i57 Appendix E H if w s n 11 Jo fl u i • • • *s « l 1$ j&j m ||" ||' Size of£*An* vs. &PUIAT1OM S/T£ ».» j V 4 -I * i i I APPENDIX F POPULATION PROJECTIONS FOR THE HEALTH REGIONS 158 Appendix F Population Projections For The Health Regions; By Age and Sex, Newfoundland, 1976, 1981, 1986 Not them 1976 1981 1986 Western 1976 1981 1986 Central 1976 1901 1986 Eastern 1976 1981 1986 0-4 T H F 51025 3420 3265 10-14 15-19 20-24 25-34 35-44 M 3415 3250 3170 55415 3388 324B 3429 3432 3170 59071 3398 3254 3436 3499 3170 98415 5300 50B0 5990 5645 6715 102188 4575 4604 4919 4439 5967 105998 4806 4789 43(.8 3994 5241 122965 6805 6420 7675 7330 7955 127453 54B9 5531 6894 6413 8394 F M F M F M F M F H 2885 2770 2590 2785 2805 4765 4270 2750 2070 1865 2885 3037 3086 3670 3320 5387 5090 3153 2899 1865 28B5 2319 1804 3846 3471 5981 5804 3905 4334 1865 6275 6080 5840 4550 4615 7060 6890 4820 4560 4013 6411 6288 5127 5516 5272 8245 8050 5261 5584 4015 6564 5728 4902 5712 5465 9377 8927 6085 7356 4015 7490 7325 7974 7629 1J1B?6 5903 5873 6505 6084 7030 6397 6771 6B05 5355 5235 8530 8350 5860 5545 5290 7036 6515 5891 9843 9585 5941 6401 5270 6388 6750 6088 11117 10535 6120 7927 5270 r 14 35 1580 1870 3B05 4170 4900 4860 5135 5725 285270 14160 13315 15505 145(10 H.520 16015 15935 15420 13385 13455 21230 21000 13460 12930 12210 11975 299067 13901 12784 13172 12647 14905 14213 16426 15727 15462 15032 28031 25284 16853 15335 12210 11915 313074 13984 12990 12204 11935 13337 12176 15110 14945 15877 15496 28404 28526 23195 19498 12210 12155 55-64 M F 1140 915 335 1131 10X1 394 1125 1088 421 65-69 r 240 215 203 1110 3910 1060 945 3221 3109 1237 1114 70+ M F 430 455 362 644 266 909 1560 1685 1815 1999 3288 3235 1317 1193 2175 2442 4260 3980 1565 1385 2360 2530 4346 4196 1766 1620 2911 3315 4410 4343 1864 1732 3703 4323 11375 11260 4100 4000 5850 7840 11628 11B57 4760 5126 6853 8845 11780 12236 5060 5549 8269 10263 BIBLIOGRAPHY • - a 160' 161 BIBLIOGRAPHY The b i b l i o g r a p h y has been organized to the chapter l e v e l . 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