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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 o f 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 Services Planning)  in ' .. . THE FACULTY OF GRADUATE- STUDIES  ... ' ,  (Department o f H e a l t h Care and E p i d e m i o l o g y )  We a c c e p t t h i s t h e s i s as c o n f o r m i n g to t h e r e q u i r e d s t a n d a r d  THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1980  c ) EOIN O'BRIEN, 1980  In p r e s e n t i n g t h i s  thesis in partial  an advanced d e g r e e a t the L i b r a r y I further for  shall  the U n i v e r s i t y  make i t  agree that  freely  of  extensive  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  this  written  thesis for  It  i s understood  f i n a n c i a l gain shall  //Wfc Qtfe  AvJi  that  not  ^ 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 , Canada V6T 1W5  the requirements I agree  r e f e r e n c e and copying of  copying or  for  that  study.  this  thesis  by t h e Head o f my D e p a r t m e n t  permission.  Department nf  of  B r i t i s h Columbia,  available for  permission for  by h i s r e p r e s e n t a t i v e s . of  fulfilment  or  publication  be a l l o w e d w i t h o u t  my  ABSTRACT  I n s u p p o r t i n g the p r o j e c t i o n o f bed r e q u i r e m e n t s f o r Newfoundland t o 1986, an e x t e n s i v e l i t e r a t u r e r e v i e w was conducted to i d e n t i f y s m a l l a r e a 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.  F o r 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 t h e 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 o r b i d i t y p a t t e r n s and l e n g t h o f s t a y c o n s t a n t ; p r o j e c t i n g t h e base and f l o w r e f e r r a l m o r b i d i t y  patterns  of f o u r h e a l t h r e g i o n s and f i n a l l y t h e p r o j e c t e d m o r b i d i t y  patterns  were combined and t r a n s l a t e d i n t o beds and a d j u s t e d 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 t h e S h o r t 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 psychiatry.  The p r e d i c t i o n o f beds u t i l i z i n g t h i s model was com-  p a r e d w i t h a bed t o p o p u l a t i o n r a t e method.  I t was demonstrated  t h a t bed r e q u i r e m e n t s do change i n r e s p e c t o f age-sex p o p u l a t i o n changes.  The r e q u i r e m e n t s a r e s t a t e d f o r each r e g i o n .  This  study  s u g g e s t s t h a t t h e model used f o r bed and p o p u l a t i o n p r o j e c t i o n s a r e u s e f u l p l a n n i n g t o o l s i n Newfoundland because o f ease i n u s e . The e l e m e n t a l p r o b l e m o f s u p p l y i n g a p o p u l a t i o n d a t a base f o r each h o s p i t a l d i s t r i c t by age and s e x was s o l v e d and i s e x p e c t e d t o be extremely  u s e f u l i n y e a r s t o come.  The u s e f u l n e s s w i l l come from  an e v a l u a t i o n o f these methods and t h e i r acceptance as f i r s t s t e p s i n the planning  process. ii  DEDICATION  I f e e l t h a t t o p u r s u e t h e w r i t i n g o f a t h e s i s i n t h e manner i n w h i c h I have r e q u i r e s a complete d e d i c a t i o n o f t i m e , thought and effort.  T h i s I have been a b l e t o do.  I have a l s o had the time t o  meet w i t h and a t t e n d t o t h e accompanying f r u s t r a t i o n s and p r e s s u r e s The c o m p l e t i o n o f t h i s t h e s i s i s i m p o r t a n t  t o me because t h e r e i s a  v e r y p e r s o n a l s a t i s f a c t i o n w h i c h i t has g i v e n and t h e r e i s a k e e n e r sense o f d i r e c t i o n t o my  life.  I t i s from my w i f e , C o n n i e , d i r e c t i o n was g i v e n .  t h a t t h i s s a t i s f a c t i o n and  I t was g i v e n by a c c e p t i n g my c o n t i n u a l  absence from hone, by. a c c e p t i n g f r u s t r a t i o n s w h i c h s u r f a c e d a t 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 s u p p o r t i n g me through and lows.  the highs  A thank-you,as a p p r e c i a t i o n , d o e s n o t s u f f i c e b e c a u s e t h e  m a j o r i t y o f t h i s t h e s i s , t h e freedom t o t h i n k and o r g a n i z e i d e a s , was encouraged and g i v e n t o 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 t o be w r i t i n g t h a n t o be c o n t e n d i n g w i t h f a m i l y , home and t h e s i s .  iii  ACKNOWLEDGEMENTS  There were many who had an i n s t r u m e n t a l p a r t i n the completion of this thesis.  I am sure they knew t h a t the a s s i s t a n c e which  they had g i v e n t o me was both important and a p p r e c i a t e d .  The v a l u e  which I impart to each and every c o n t r i b u t i o n goes f a r beyond the e x p r e s s i o n o f a word.  I s h a l l remember each and every  warmly; i t i s the s i n c e r e s t thanks  contribution  t h a t I can g i v e .  To Mort M. Warner, Ph.D., U n i v e r s i t y o f B r i t i s h Columbia, would l i k e t o g i v e a v e r y s p e c i a l thanks  I  f o r both h i s "investment"  i n an u n f o r g e t t a b l e e n t r e l a s t y e a r and the ensuing energy which he instilled  t o me.  To Dave B r y a n t , Ph.D., Memorial U n i v e r s i t y , I  would l i k e t o g i v e a p e r s o n a l thanks  f o r h i s keen c r i t i c i s m s ,  under-  s t a n d i n g and sense o f d i r e c t i o n as I sought the completion o f my thesis. I g i v e thanks t o both the Deputy M i n i s t e r , Dr. L o m e  Klippert  and A s s i s t a n t Deputy M i n i s t e r , Mr. Ambrose. Hea-rn,. e x e c u t i v e s o f t h e Newfoundland Department o f H e a l t h who have c o n t i n u a l l y t h e i r i n t e r e s t f o r and support i n my  expressed  endeavors.  I am c e r t a i n t h a t Mr. and Mrs. A r t h u r Rodd, C h a r l o t t e t o w n , P r i n c e Edward I s l a n d do n o t expect thanks.  However, I would  to take t h i s o p p o r t u n i t y to thank them because to the completion o f t h i s I would a l s o l i k e  like  they were important  thesis. to thank S t a t i s t i c s  p a r t i c u l a r l y Mr. L. L e f e b r e f o r h i s h e l p . iv  Canada o f f i c i a l s ,  I would l i k e to acknowl-  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 o f t h e Canadian H o s p i t a l A s s o c i a t i o n ' s l i b r a r y s t a f f who p r o v i d e d me w i t h a t i m e l y and r e a d i n g package.  tailored  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, p r o v i d e d me w i t h census d a t a and a g r e a t d e a l of a d v i c e . I would l i k e t o thank b o t h . c o n t r i b u t e d whatever r e s o u r c e  F i n a l l y , I must thank my own s t a f f they c o u l d t o a s s i s t me i n t h i s  v  who  study.  TABLE OF CONTENTS Page ABSTRACT  i i  DEDICATION  . . . . . . . .  i i i  ACKNOWLEDGEMENTS  . .  iv  TABLE OF CONTENTS  . .  v i  LIST OF TABLES . . . . . . . . . . . . . . . . . . . . . . . . LIST OF FIGURES  . . . . . . . . . .  CURRICULUM VITAE  x xi x i i  CHAPTER I.  INTRODUCTION . •  . . . . . . . . .  The Purpose and Nature, o f t h e Study  1  H e a l t h P l a n n i n g and H e a l t h 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 o f t h e Study  7  The Study Problem . . .  10  Limitations  11  Footnotes . . . . . . . . II.  1  . . . . . ...  . . . . .  13  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 o f F a c t o r s . . . .  15  Demand and U t i l i z a t i o n :  15  F a c t o r s and Examples.  ...  S e l e c t e d F a c t o r s A s s o c i a t e d w i t h H e a l t h 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  17 ...  17  M o r b i d i t y , Age-Sex and G e o g r a p h i c a l Distribution . . . . . F o 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  18  Estimation  21  Methods o f S u b n a t i o n a l P o p u l a t i o n P r o j e c t i o n s . . . Mathematical . . . . . . . . . . . vi  . .  23 24  CHAPTER  Page Ratio.  25  Component. . . . . . . . . . .  26  Econometric  27  Other Methods  •. . . . . . . . . . . .  Accuracy of Subnational P o p u l a t i o n P r o j e c t i o n . . .  28 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 H e a l t h P l a n n i n g . . . . . .  31  Summary . . . .  34  . .  Footnotes III.  35  RESOURCE (BED) DISTRIBUTION MODELS  38  Bed P l a n n i n g Models . . . . . . . . . . . . . . . • Utilization.  ...  39  . . . .  42  . . . . . .  43  M u l t i p l e Factor Analysis Distribution Analysis Non-Formal and Consensus  38  . . . . . . .  44  Standards  45  M u l t i p l e Methodology  46  Summary o f Methods  47  D e s c r i p t i o n o f Three Bed P l a n n i n g Models a t H i g h e r P o l i c y Making L e v e l s . . . . . .  49  New Brunswick R e g i o n a l Bed D i s t r i b u t i o n a l Model. . . . . . . . . . •• . • . . . • . . . • •  50  S h o r t - t e r m Model . . . . . . . . . . . . . . . .  50  D i v i s i o n o f H o s p i t a l and M e d i c a l F a c i l i t i e s P u b l i c H e a l t h S e r v i c e s Model . . H o s p i t a l Bed Requirements: An Occupancy  51  F a c t o r D e t e r m i n a t i o n Approach 1979  52  Summary  •  •  P l a n n i n g S t u d i e s i n Newfoundland R e l a t e d t o Resource D i s t r i b u t i o n Problems A s s o c i a t e d w i t h t h e D i s t r i b u t i o n o f H e a l t h Care Resources to R u r a l Areas i n Newfoundland . Footnotes . . . . . . . . . . . . . . . • • . • • • IV.  METHODOLOGY  . . . . . . . . . . . . . . . .  Research S t r a t e g y  54 55  59 61 65 65  vii  CHAPTER  Page Research S e t t i n g  . . . . . . . . . . .  67  Data Sources. . . . . . . . . . . . . . . . . .  67  Methods o f C o l l e c t i n g Data  . . . . . . .  68  S o r t i n g o f Codes. . . . . . . . . . . . . . . .  68  P o p u l a t i o n P r o j e c t i o n Method. . . . . . . . . .  69  Hospital Inpatient Morbidity  Computer  Program  73  Manual T a b u l a t i o n o f Bed C a t e g o r i e s  . . . . . .  75  Method o f A n a l y s i s . . . . . . . .  75  Bed P r e d i c t i o n Formula.  75  Estimation of E r r o r Associated 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 Technique Footnotes. . . . . . . . . . . . . . . . . . . . . V.  ESTIMATION OF ERROR ASSOCIATED WITH THE USE OF THE RATIO METHOD  . .  81  Introduction . . . . . . . . . . . . . . . . . . .  81  Assumptions  82  Method  84  Results.  . . ... . ... . . . . . ... . ...  Footnotes. . . . . . . . . . . . . . . . . . . . . VI.  86 94  CHANGES IN BED REQUIREMENTS I N RESPECT OF POPULATION CHANGES  95  Introduction  •  95  Methods  96  Population Results  98  Bed P r e d i c t i o n R e s u l t s VII.  78 80  SUMMARY AND DISCUSSION  . . . . . 103 .  Introduction . . . . . . .  116 • • •.116  Sum o f 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 W i t h The R a t i o Method . . . . . . . . . . . . . . . . . . . . 116 Summary o f P o p u l a t i o n P r o j e c t i o n s  . . 119  Summary o f Bed P r e d i c t i o n s . . . . . . . . . . . .  120  Advantages and D i s a d v a n t a g e s o f t h e R a t i o P r o j e c t i o n Method. . . . . . . . . . . . . . . . • 122 The Advantages and D i s a d v a n t a g e s o f t h e Bed P r e d i c t i o n Model . . . . . . . . . . . . . . . . . 124 viii  Page  CHAPTER Key O b s e r v a t i o n s R e g a r d i n g the P o p u l a t i o n Projections.  . . . .  Key O b s e r v a t i o n s R e g a r d i n g t h e Bed P r e d i c t i o n Model .  126  . . .  128  . . . .  132  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 ESTIMATES OF ERROR IN THE <. 2999 POPULATION STRATUM: TO EXCLUDE.UNSTABLE CENSUS DIVISIONS AND ERRORS >. 20% 154  Future D i r e c t i o n s  from t h i s Study. . . . .  APPENDICES A.  D.  E.  F.  PROBLEMS ASSOCIATED WITH THE DISTRIBUTION OF . ...  . . .  THE ARRAY OF ESTIMATES OF ERROR PLOTTED AGAINST POPULATION SIZE . .  156  POPULATION PROJECTIONS FOR THE HEALTH REGIONS . . . .  158  BIBLIOGRAPHY  160  ix  LIST OF TABLES  TABLE V-l.  V-2.  V-3.  Page Estimation of E r r o r s Associated with the R a t i o Method. . .  87  Arcsin Percent Transformation of E r r o r E s t i m a t e s A s s o c i a t e d w i t h t h e R a t i o Method (Based on Sample) . . . . . . . . . . . .  90  T e s t f o r t h e R e l a t i o n s h i p Between the P r o p o r t i o n o f E r r o r s <. 20% and P o p u l a t i o n S i z e . . .  92  VI-1.  Summary A n a l y s i s o f P o p u l a t i o n P r o j e c t i o n s . . . . .  99  VI-2.  Newfoundland and R e g i o n a l Bed S e r v i c e Requirements: 1976, 1981, 1986 Newfoundland and R e g i o n a l Bed S e r v i c e Requirements A d j u s t e d f o r R e f e r r a l P a t t e r n s : 1976, 1981, 1986  VI-3.  VI-4. VI-5. VI-6.  VI-7.  VI-8.  VII-1.  104  104  Newfoundland and R e g i o n a l Age-Sex Bed Requirements: 1976, 1981, and 1986  108  P o p u l a t i o n Change Compared w i t h Bed S e r v i c e s Changes, Newfoundland and Regions 1976-86  109  Sex P o p u l a t i o n Changes Compared w i t h Bed S e r v i c e Changes, 1976-1986.  109  Newfoundland and R e g i o n a l Age S p e c i f i c P o p u l a t i o n and Bed S e r v i c e Changes, 1976 t o 1986  110  Comparison o f the Bed t o P o p u l a t i o n R a t i o , Bed S e r v i c e t o P o p u l a t i o n and Bed S e r v i c e Requirement w i t h Adjustment f o r R e f e r r a l . T e c h n i q u e s : Newfoundland and Regions 1976, 1981 and 1986.  112  Summary o f the 1986 T o t a l Bed Requirements f o r the Four H e a l t h Regions i n Newfoundland . . . . . .  121  x  LIST OF FIGURES  FIGURE III-l.  p  Bed Requirement Models: O u t l i n e o f Key Factors  xi  ag  e  48  CURRICULUM VITAE E o i n O ' B r i e n g r a d u a t e d from t h e U n i v e r s i t y o f P r i n c e Edward I s l a n d i n 1971 w i t h a B a c h e l o r o f B u s i n e s s A d m i n i s t r a t i o n degree. Between 1971 and 1973, Mr. O ' B r i e n was employed as a t e a c h e r a t S t . Joseph's Elementary S c h o o l i n W i n d s o r , Newfoundland.  Between  J u l y 1973 and September 1974, a f t e r b e i n g a c c e p t e d i n t o the Government o f 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 y e a r ' s r e s i d e n c y a t t h e C e n t r a l Newfoundland H o s p i t a l , Grand F a l l s , Newfoundland.  I n September 1974, Mr. O ' B r i e n e n t e r e d t h e  H e a l t h Care and E p i d e m i o l o g y ' s program o f M a s t e r s o f S c i e n c e S e r v i c e s P l a n n i n g ) a t t h e U n i v e r s i t y o f B r i t i s h Columbia.  (Health  Following  a two y e a r program he was employed i n t h e p o s i t i o n o f H o s p i t a l C o n s u l t a n t w i t h t h e Newfoundland Department of H e a l t h .  I n January  1977, Mr. O ' B r i e n 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 o f Research and S t a t i s t i c s w i t h t h e Newfoundland D e p a r t ment o f H e a l t h .  xii  CHAPTER I INTRODUCTION The Purpose and N a t u r e o f t h e Study Between 1966 and the p r e s e n t , 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 t o Newfoundland's H e a l t h 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 p o p u l a t i o n s 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.  T h i s i n f o r m a t i o n i s c u r r e n t l y n o t a v a i l a b l e t o e i t h e r the  Department o f H e a l t h o r t o r e s e a r c h e r s .  This data i s a n e c e s s i t y  f o r h e a l t h p l a n n i n g and r e s e a r c h , 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 o r absence from a h e a l t h d a t a system i s a c r i t i c a l problem. Over the y e a r s no f o r m a l i z e d mechanism has been adopted t o c a l c u l a t e t h e need f o r acute c a r e h o s p i t a l beds for. t h e P r o v i n c e o f Newfoundland.  I n s t e a d , t h e Department o f H e a l t h has r e l i e d  upon  i n t i m a t e knowledge o f the s y s t e m , i m p l i c i t methods and recommendat i o n s o f bed needs c o n t a i n e d i n v a r i o u s independent s t u d i e s .  Thus,  the Department has been h i n d e r e d i n i t s a n a l y s i s o f area-wide p a t t e r n s and i n i t s p l a n n i n g o f r e s o u r c e s f o r age and/or s e x - s p e c i f i c groups i n t h e p r o v i n c e .  D u r i n g 1979, t h e Department o f H e a l t h ' s  r e s p o n s i b i l i t i e s were expanded t o i n c l u d e t h e o p e r a t i o n o f N u r s i n g Homes.  F u t u r e p l a n n i n g f o r t h e e l d e r l y age groups o r c h r o n i c care  p a t i e n t s w i l l , o f n e c e s s i t y , r e q u i r e an age and s e x a r e a - s p e c i f i c data  file. 1  2  I t i s t h e d e s i g n o f t h i s s t u d y t o propose u s e f u l and p r a c t i c a l methods t o s o l v e t h i s problem and t o p r o v i d e a b a s i s f o r f u t u r e development.  Therefore, i t i s the study's  specific  i n t e n t t h a t 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  district  and r e g i o n be e s t a b l i s h e d and p r o j e c t e d i n t o t h e f u t u r e ;  that a  statement clinical  o f a c u t e c a r e beds w i l l be e s t a b l i s h e d by a r e a and by (bed) s e r v i c e ;  and t h a t the changes i n t h e age-sex s t r u c t u r e  of t h e p r o v i n c e and h e a l t h r e g i o n s w i l l be observed  i n r e s p e c t of  the p r e d i c t i o n o f a c u t e c a r e h o s p i t a l beds.  H e a l t h P l a n n i n g and H e a l t h S t a t i s t i c a l Systems A v e r y s i m p l e d e f i n i t i o n o f p l a n n i n g i s : "The i n t e l l i g e n t p r o c e s s t h a t precedes d e c i s i o n making."^ c a r r y i n g many i m p l i c i t meanings.  T h i s i s a t e r s e statement  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 r e v i e w r e l a t e t o t h i s p r o c e s s :  rationality,  u n c e r t a i n t y , p r e c i s i o n and c o n f u s i o n . Rationality.  R a t i o n a l i t y can be viewed  from two p e r s p e c -  2  tives.  I t i s a c h a r a c t e r i s t i c o f a p l a n n e r who combines  intelli-  gence and d a t a i n s e l e c t i n g the p r o p e r a l l o c a t i o n o f r e s o u r c e s . From t h e second p e r s p e c t i v e , i t d e s c r i b e s t h e same p r o c e s s i n w h i c h the p l a n n e r must choose a c c o r d i n g t o predetermined  constraints.  The  a b i l i t y t o r e a s o n i s r e l a t i v e t o t h e s i t u a t i o n a t hand, t o t h e l i m i t a t i o n s imposed on c h o i c e , and t o t h e s t a t e o f knowledge which i s t o be reasoned. Uncertainty.  As p l a n n i n g i n v o l v e s f o r e c a s t i n g and t h e  d e c i s i o n t o i n c r e a s e o r d e c r e a s e p r e s e n t a c t i v i t i e s , or t o a l t e r more a p p r o p r i a t e a c t i v i t i e s , t h e h i g h e s t degree o f c e r t a i n t y must be  3 c a r r i e d from the p r e s e n t to the f u t u r e .  3  T h e r e f o r e , a thorough  a n a l y s i s o f the p r e s e n t s i t u a t i o n must r e s t upon the t i m e l i n e s s , v a l i d i t y and  reliability  o f the d a t a w h i c h  the s i t u a t i o n a t hand o r the d e c i s i o n t h a t must be Precision.  availability, characterizes  taken.  Throughout the c o u r s e of the r e v i e w i t was  e v i d e n t t h a t t h e r e were a m u l t i t u d e o f f a c t o r s w h i c h determine h e a l t h related u t i l i z a t i o n levels.  To u n d e r s t a n d 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 t e c h n i q u e s such as m u l t i v a r i a t e a n a l y s e s 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 , p l a n n e r s are now  to be more o b s e r v a n t of the v a r i o u s  and  o f s p e c i f i c groups i n the p o p u l a t i o n .  d i f f e r i n g health The  desiring care needs  emphasis at a government  p o l i c y l e v e l i s changing from a r e s o u r c e d i s t r i b u t i o n w h i c h i s f o c u s e d upon the concept of bed  to the r e a l i z a t i o n t h a t the  a c t e r of the h o s p i t a l i s u n d e r g o i n g changes.  The  char-  hospital is  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 c a r e .  At  p l a n n i n g l e v e l of government, the d e l i v e r y system i s not o n l y 4 5  the  getting  6  more remote, i t i s g e t t i n g more complex. ' '  To a t t e n d  v i e w s , the q u a n t i t y o f d a t a w i l l i n c r e a s e but  to these  the need f o r p r e c i s i o n  w i l l be of g r e a t e r c o n c e r n i n the conduct o f t e c h n i c a l 7  rationality.  1  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 o f 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 i n t e r c h a n g e a b l y .  an "ought to be" o r " m e d i c a l " statement t h a t i s not economics.  Medically  consumer d e f i n e d need.  Need i s  restrained  by  d e f i n e d need does not have to agree w i t h N e i t h e r n e c e s s a r i l y equate w i t h demand.  Demand r e p r e s e n t s the a c t u a l usage o f h e a l t h r e s o u r c e s w h i c h f a l l s h o r t of or exceed the l e v e l of need.  The  may  d i f f e r e n c e between  4 demand and need d e f i n e d by t h e consumer may be i n f l u e n c e d i n some degree by s u p p l y w h i c h r e l a t e s t o m e d i c a l l y d e f i n e d 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 o f demand d i s t r i b u t i o n models. i s the e x p r e s s i o n : "need minus demand produces an unseen p a r t o f t h e 8 "iceberg. observer;  B e i n g s p e c i f i c i n v i e w reduces t h e c o n f u s i o n o f the 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 V a r i o u s Examples o f P l a n n i n g Approaches. 9 Four approaches t o h e a l t h p l a n n i n g d e s c r i b e d by Newhouse  a r e * the  p r o d u c t i o n f u n c t i o n approach; i t s v a r i a n t , t h e needs a p p r o a c h ; the market s i g n a l approach; and a m o d i f i e d v e r s i o n of t h e market approach w h i c h i s s u p p o r t e d for  signal  by a s m a l l e r a c c e s s i b l e d a t a base.  Data  the p r o d u c t i o n f u n c t i o n and needs approaches f o c u s upon t h e  h e a l t h s t a t u s o f the p o p u l a t i o n .  Data f o r t h e market and m o d i f i e d  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 i n s u r a n c e coverage.  The m o d i f i e d market approach uses a h i g h e r  c o n c e n t r a t i o n o f demographic d a t a w h i c h 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 t o more c o s t l y and as a means t o reduce the p l a n n e r ' s  surveys  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 d a t a s h o u l d be c o l l e c t e d when d a t a bases a r e becoming i n c r e a s i n g l y complex.  The c h o i c e o f any o f these  models i s n o t o n l y dependent upon the n a t u r e of the p r o b l e m b u t a l s o upon the e x i s t e n c e o f an adequate d a t a base. The common d a t a bases r e q u i r e d f o r each o f the f o u r approaches a r e 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 d a t a base d e s c r i b e s b o t h m o r b i d i t y and m o r t a l i t y i n the p o p u l a t i o n .  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 f r o m 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 d a t a base  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  provides  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  change-fertility,  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 o f the population."^  MacStavic  s t a t e s t h a t t h e s e two  d a t a bases form the  " h e a r t " o f a h e a l t h c a r e s t a t i s t i c a l system and must be s e p a r a t e interdependent data b a s e s . ^ resource,  Any  system d e l i v e r i n g a h e a l t h  must by purpose, i n f l u e n c e d i r e c t l y o r i n d i r e c t l y  health status  (and u t i l i z a t i o n ) o f i t s s e r v i c e p o p u l a t i o n .  resource  By s u b j e c t i n g  d a t a to s t a t i s t i c a l a n a l y s e s , m a t h e m a t i c a l p r o j e c t i o n and analyses  the  data to  the e f f e c t i v e n e s s o r e f f i c i e n c y o f  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 ) .  care  The  " h e a r t " o f the system must be a b l e to d e l i v e r a p p r o p r i a t e the t a s k o f d e t e r m i n i n g  but  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  this  estimation,  statistics, 12  f u t u r e f a c i l i t y needs and b a s i c r e s o u r c e  can be  conducted.  Demographic i n f o r m a t i o n as one o f t h e d a t a bases d e s e r v e s 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 o f d a t a and  characteristics.  I t was  o b s e r v e d i n the r e v i e w t h a t  p l a n n e r s are c o n c e r n i n g t h e m s e l v e s , more and more, w i t h the d i s t r i b u t i o n of resources  to d e f i n e d p o p u l a t i o n  o f t e n compare d a t a between r e g i o n o r p r o v i n c e  groups.  specific  Planners  ( f o r example, the  S t a t i s t i c s Canada d a t a 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  Morbidity).  When comparing o r i n f a c t u s i n g o r d e r i v i n g d a t a by  populations,  age  and/or sex, i t i s e s s e n t i a l t h a t p l a n n e r s know the  "source of demography and  the accompanying methods o f 13  s t a t i s t i c s d e r i v e d from them."  handling  This also implies 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.  T h i s 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 t h a t as a mentor for health planning,  a v e r y i m p o r t a n t c o n s t r u c t i s the  continuing  •development of a d a t a base w h i c h i s as c l e a r , p r e c i s e and  certain  as  6 the p l a n n e r o r d e c i s i o n maker r e q u i r e s f o r an i n f o r m e d and gent d e c i s i o n .  intelli-  T h i s c o n c l u s i o n i s a l s o p r e s e n t e d i n the Report  of  the O n t a r i o C o u n c i l o f H e a l t h on H e a l t h S t a t i s t i c s w h i c h d e s c r i b e s the needs and purposes to be s e r v e d by a h e a l t h s t a t i s t i c a l system.  14  1.  The system s h o u l d e n a b l e the i d e n t i f i c a t i o n o f h e a l t h p r o b l e m s , needs and wants o f t h e p o p u l a t i o n and s h o u l d p r o v i d e f o r the p o p u l a t i o n ' s major h e a l t h problems.  2.  The system s h o u l d p r o v i d e the data needed f o r the sound p l a n n i n g o f h e a l t h s e r v i c e s and programmes.  3.  The system s h o u l d p r o v i d e the d a t a needed f o r e f f e c t i v e and e f f i c i e n t o p e r a t i o n s and a d m i n i s t r a t i o n o f h e a l t h s e r v i c e s and programmes.  4.  The system s h o u l d p r o v i d e the d a t a f o r e v a l u a t i o n o f h e a l t h s e r v i c e s and programmes.  5.  The system s h o u l d 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 r e s e a r c h 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 r e d u c i n g d i s e a s e s w h i c h 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 o f 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 f u t u r e or a l t e r i n g  p r e s e n t systems to p r e s e n t o r 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 c o n s i d e r a b l e importance of data.  The  on the p r o c e s s e s o f a n a l y s i s and  concept of a h e a l t h s t a t i s t i c a l system, as  i n t h i s d i s c u s s i o n , i s i n t e n d e d as a comparative  presented  base f o r the v a r i o u s  p o i n t s r a i s e d to s u p p o r t the s i g n i f i c a n c e of t h i s s t u d y . importance  collection  Of  equal  i n t h e d i s c u s s i o n i s t h e c c h o i c e o f 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 o f the H o s p i t a l S e r v i c e s D i v i s i o n o f the Department. f u n c t i o n o f t h e S t a t i s t i c s D i v i s i o n had been to c a p t u r e and 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 m o r b i d i t y d a t a . was  The  analyze  Recently  there  an e x p a n s i o n of r e s p o n s i b i l i t i e s w h i c h 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 d i s s e m i n a t i o n of any  type  7 of  i n f o r m a t i o n requested by Department of H e a l t h o f f i c i a l s  researchers  i n the f i e l d ; and a p l a n n i n g  data f i l e s and  or  f u n c t i o n i n r e s e a r c h when  c o l l e c t i o n methods (under r e o r g a n i z a t i o n ) are at  s t a g e of p r o d u c i n g  t i m e l y and a c c u r a t e data.  r o l e which the D i v i s i o n i s d e v e l o p i n g  In o t h e r words,  the  the  i s b e i n g i n f l u e n c e d by a more  encompassing view of the d e l i v e r y o f h e a l t h c a r e . Therefore, the studynare  the p o i n t s r a i s e d to support  not o n l y statements of f a c t , they are p h i l o s o p h i c a l  statements o f what ought to be, the study  the s i g n i f i c a n c e of  and  as p r e s e n t e d ,  would mean t h a t  i s c o n t r i b u t i n g a g r e a t d e a l to p l a n n i n g and  research  both  i n s i d e and o u t s i d e the Department of H e a l t h .  S i g n i f i c a n c e of the Study  Together, the H o s p i t a l S e r v i c e s and  the Cottage H o s p i t a l  D i v i s i o n s of the Department of H e a l t h a r e h e l d a c c o u n t a b l e health s t a t i s t i c a l be  districts.  Each h e a l t h s t a t i s t i c a l  f o r 39  district  can  s u b d i v i d e d to h o s p i t a l community o r i t can form p a r t of a h e a l t h  region  (4 i n t o t a l ) .  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 has a h o s p i t a l  o r an a l t e r n a t i v e f a c i l i t y which i s funded o r o p e r a t e d the Department. statistical  Two  directly  by  major types o f d a t a are c o l l e c t e d f o r the h e a l t h  districts.  For each h o s p i t a l , u t i l i z a t i o n ,  personnel,  and  c o s t f i g u r e s are c o l l e c t e d from the Annual E e t u r n of H o s p i t a l s ,  and  from a more g e n e r a l a c c o u n t i n g  ments submitted  by  the h o s p i t a l s .  from the monthly f i n a n c i a l s t a t e The  second type of data i s the  I n p a t i e n t H o s p i t a l M o r b i d i t y F i l e which can i d e n t i f y d i s t r i c t h o s p i t a l and  community,  r e g i o n of p a t i e n t s , i n c l u d i n g t r a n s f e r s .  P r e s e n t l y , 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 p o p u l a t i o n by t o t a l populations  at the d i s t r i c t  and r e g i o n a l l e v e l s  (no age  and  8 sex),  and t o an age and s e x p o p u l a t i o n a t t h e p r o v i n c i a l There have been and c o n t i n u e s  level.  t o be t o o many i n s t a n c e s i n  w h i c h Department o f H e a l t h o f f i c i a l s and r e s e a r c h e r s and/or e p i d e m i o l o g i s t s , o r o t h e r r e s e a r c h e r s o u t s i d e t h e department have n o t been a b l e t o o b t a i n t h e b a s i c demographic d a t a o f age and sex f o r health 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 d e s c r i b e d  the demographic d a t a i n Newfoundland as " l i m i t e d i n scope and detail."^  I n 1973 and 1974 t h e H e a l t h P l a n n i n g and Development  Committee p u b l i s h e d f o u r r e p o r t s c o v e r i n g 21 h e a l t h districts.  statistical  I t had t h i s t o s a y : "Because t h e census t r a c t s do n o t  coincide to this s t a t i s t i c a l d i s t r i c t tical district]  [referring to health  i t i s not p o s s i b l e to obtain a population  statisbreakdown  16 by age, s e x , m a r i t a l s t a t u s o r f a m i l y s i z e . "  Unfortunately,  study group made no attempt a t s o l v i n g t h i s problem.  this  McKinsey and  Company i n 1978 were g r e e t e d w i t h t h i s problem i n a commissioned study f o r t h e S t . John's H o s p i t a l A d v i s o r y Council.''''' did  T h i s group  s o l v e t h e i r p r o b l e m and d i d p r o v i d e an age-sex p o p u l a t i o n and  p r o j e c t i o n s b u t t h i s was done f o r t h r e e l e v e l s o f care primary,  secondary and t e r t i a r y .  health s t a t i s t i c a l d i s t r i c t s  regions:  There a r e 4 h e a l t h r e g i o n s and 39  w h i c h under normal c o n d i t i o n s a r e n o t  d e f i n e d by l e v e l s o f care f o r p l a n n i n g .  B o u n d a r i e s o f these  p l a n n i n g d i v i s i o n s do n o t conform t o p r e s e n t  various  age-sex d i s t r i b u t i o n s  o f t h e p o p u l a t i o n by census d i v i s i o n s . The Department o f H e a l t h has been s u p p o r t i v e o f o b t a i n i n g an age-sex d e s c r i p t i o n o f t h e p o p u l a t i o n i n each h e a l t h district.  statistical  Resources a r e d i s t r i b u t e d t o these d i s t r i c t s  either  d i r e c t l y t h r o u g h programs w i t h i n the v a r i o u s d i v i s i o n s o f t h e Department o r through the h o s p i t a l , w h i c h i s t h e f o c a l p o i n t o f t h e  9 district.  To accommodate the measure of e f f e c t i v e n e s s and  f u r t h e r d i s t r i b u t i o n of r e s o u r c e s  to s p e c i f i c needs, aggregate  p o p u l a t i o n f i g u r e s a l o n e are not s u f f i c i e n t .  A very r e a l concern at  the p r e s e n t time i s the Department's d e s i r e to e s t i m a t e 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 of the new  to d e f i n e  region.  the e l d e r l y  T h i s a r i s e s because  r e s p o n s i b i l i t y w h i c h has been assumed by the Department  of H e a l t h f o r the o p e r a t i o n of N u r s i n g  Homes.  Four s t u d i e s by the P l a n n i n g D i v i s i o n of the Department of H e a l t h p o i n t to the need f o r new age-sex p o p u l a t i o n s  and bed  estimates  requirements.  of d i s t r i c t and/or r e g i o n Three of the  studies  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 .  I n o n l y one  go beyond 1976.  and  " I n P o p u l a t i o n 1971  1976,  does the p r o j e c t i o n  Newfoundland by  R e g i o n and H e a l t h 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 19 projected  t o 1991.  The  d i s t r i c t s are projected  o r even beyond 1981.  do not s t a t e t h e i r m e t h o d o l o g i c a l  approach.  t h a t a v a r i e t y of methods were u s e d , one y e a r l y growth r a t e .  The  to have been  p r o j e c t i o n s are i n c o m p l e t e i n t h a t  t o 1991  Health  few  These R e p o r t s  However, i t i s known  of w h i c h was  the average  r e p l i c a t i o n of these s t u d i e s would be  c u l t because t h e r e i s a l a r g e component of e x p e r i e n c e and  diffi-  judgement  involved. 1000  F i n a l l y , a s t u d y e n t i t l e d " H o s p i t a l Beds i n Newfoundland Per 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  Projected Population"  b a s i s of c u r r e n t and  d i s t r i b u t e d beds to r e g i o n s on  t o t a l population.  problems as c i t e d p r e v i o u s l y .  T h i s s t u d y s u f f e r s the same  The methodology, as c o n f i r m e d by  P l a n n i n g 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 e s t i m a t e s v a r i o u s s t u d i e s and that report.  the i n t u i t i o n and  the  the  from  e x p e r i e n c e of the w r i t e r of  The method of e s t i m a t i n g beds was  inconsistent;  in  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 m o d i f i e d  according  to f u t u r e p l a n s f o r expanding o r 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  t o " r u l e s of thumb,"  a l l o f w h i c h were  not s t a t e d i n the Report. I n the r e v i e w 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 o f the p r e c e d i n g  d i s c u s s i o n , the s i g n i f i c a n c e o f h a v i n g 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.  upon bed p r e d i c t i o n s and population,  i t i s a n t i c i p a t e d t h a t more a t t e n t i o n w i l l be g i v e n  r e g a r d t o the bed p r e d i c t i o n i t s e l f . and w i l l p r o v i d e The  to  L i t t l e has been s a i d w i t h  The p r e d i c t i o n s w i l l be  a basis f o r d i s c u s s i o n i n determining  bed  timely  require-  methods w h i c h are to be d e s i g n e d f o r t h i s s t u d y b e a r  w e i g h t because they w i l l a l l o w i n s p e c t i o n , c r i t i c i s m and ment.  focusing  the concommittant changes i n the age-sex  f u t u r e d a t a r e q u i r e m e n t s i n the p r o v i n c e .  ments.  By  improve-  I n o t h e r words, the q u a l i t y o f d a t a s h o u l d be enhanced,  t h e r e f o r e the c h a r a c t e r o f a h e a l t h p l a n n i n g d e c i s i o n s h o u l d improved under the assumption o f i n t e l l i g e n c e o r The  and  be  rationality.  Study P r o b l e m  T h i s s t u d y ' s purpose i s to e s t a b l i s h s t a n d a r d s 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 a c u t e care bed  requirements, taking 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  population.  F o r Newfoundland, the r e q u i r e m e n t s w h i c h have been i d e n t i f i e d a r e as f o l l o w s : 1.  Determine the bed s e r v i c e c a t e g o r i e s (1)  c u r r e n t and p r o j e c t e d  (2)  morbidity  years,.  d i a g n o s t i c codes.  by:  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 popul 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 p o p u l a t i o n f o r the c u r r e n t y e a r ( r e f e r e n c e y e a r ) 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 health 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 r e g i o n 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 m o r b i d i t y and r e g i o n f o r the r e f e r e n c e y e a r .  use by age,  6.  P r o j e c t bed region.  and sex f o r each  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 r e s p e c t of the a c u t e c a r e bed r e q u i r e m e n t s f o r Newfoundland.  s e r v i c e r e q u i r e m e n t s by age  sex  Limitations 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) s h o u l d be n o t e d as  they a r e i m p o r t a n t t o the a n a l y s i s o f 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 a t the h e a l t h s t a t i s t i c a l levels.  Population p r o j e c t i o n s w i l l involve aggregation :  district  of data to  r e g i o n a l l e v e l s so t h a t the a c c u r a c y o f i t s i n p u t t o m o r b i d i t y j e c t i o n s f o r r e g i o n s w i l l be enhanced. w i l l be c o n f i n e d 2.  Therefore population  pro-  analysis  t o 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 .  M o r b i d i t y i n c i d e n c e i s r e s t r i c t e d t o 1976  Inpatient morbidity  Hospital  f o r 44 a c u t e c a r e h o s p i t a l s i n Newfoundland.  3.  Newborns a r e b e i n g o m i t t e d  from the s t u d y .  4.  Beds are r e s t r i c t e d t o a c u t e 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 c a r e h o s p i t a l ) and p e d i a t r i c c l a s s i fications . 5.  Four h o s p i t a l s are b e i n g o m i t t e d  from the s t u d y .  The  beds i n these f a c i l i t i e s are c o n s i d e r e d long-term. are:  Waterford  The h o s p i t a l s  (Mental H e a l t h ) , C h i l d r e n ' s R e h a b i l i t a t i o n , S t .  P a t r i c k ' s and S t . Luke's N u r s i n g Homes. 6.  D i a g n o s t i c 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 o r b i d i t y  c l a s s i f i c a t i o n w h i c h r e q u i r e s a s p e c i f i c type o f bed to s e r v i c e o r care f o r the c l u s t e r of diagnoses.  I n o t h e r 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 o c c u r s , occupy an o b s t e t r i c a l bed by t h i s study's 7.  definition. 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 b e i n g used by t h i s  s t u d y because i t i s the c u r r e n t g e o g r a p h i c a l a r e a t h a t i s employed by the Department o f H e a l t h .  I t i s not w i t h i n the scope o f t h i s  study t o d i s c u s s 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 t h e Department o f Health.  13 Chapter  I  Footnotes  ^Stephen S i e v e r t s , " I n f l u e n c e s of Area-wide P l a n n i n g , " H o s p i t a l s 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 I n f o r m a t i o n i n the Measurement o f H e a l t h and H e a l t h Care Needs," i n Methods of H e a l t h Care E v a l u a t i o n , 3rd ed., e d i t e d by David L. S a c k e t t and M a r j o r i e S. B a s k i n (Hamilton, O n t a r i o : McMaster U n i v e r s i t y , 1974), ch. 2, pp. 1-49.  3  Robin E. M a c S t r a v i c , "How Many H o s p i t a l Beds Does V i r g i n i a Need?" V i r g i n i a M e d i c a l (January 1978): 73-75. 4 Avery C o l t , "Element of Comprehensive H e a l t h P l a n n i n g , " American J o u r n a l of' P u b l i c H e a l t h 60 ( J u l y 1970) : 1194-1204. ^Stephen S i e v e r t s , pp.  63-65.  Werner F. 0. D a e c h s e l , " R e g i o n a l H e a l t h Care P l a n n i n g , " 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 (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 f o r M e d i c a l S e r v i c e s and the Concept of Shortage," American J o u r n a l of P u b l i c H e a l t h 61 (January 1971): 46-63. g V i n c e n t e Navarro, " P l a n n i n g f o r the D i s t r i b u t i o n of P e r s o n a l H e a l t h S e r v i c e s , " P u b l i c H e a l t h Reports 84 ( J u l y 1969): 573-581. 9 J . P. Newhouse, " F o r e c a s t i n g Demand and- the P l a n n i n g of ' H e a l t h S e r v i c e s , " i n Systems Aspects of H e a l t h P l a n n i n g , ed. Norman T. J . B a i l e y and Mark Thompson (Amsterdam, O x f o r d : N o r t h - H o l l a n d P u b l i s h i n g Company, 1975), pp. 45-55. ^ M a r g a r e t B r i g h t , "The Demographic Base f o r H e a l t h P l a n n i n g , " i n H e a l t h P l 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 ( B a l t i m o r e : John Hopkins U n i v e r s i t y , 1972), pp. 138-157. ^ R o b i n E. M a c S t r a v i c , Determining H e a l t h Needs (Ann M i c h i g a n : H e a l t h A d m i n i s t r a t i o n P r e s s , 1978), pp. 73-135.  Arbor,  12 Jerome Chubin, e t a l . , eds., S t a t i s t i c s f o r Comprehensive P l a n n i n g , Report No. H.S.M. 73-1217 (Washington, D . C : U.S. Government 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  O n t a r i o C o u n c i l o f H e a l t h , Report o f the O n t a r i o C o u n c i l of H e a l t h on H e a l t h S t a t i s t i c s , P a r t I, Annex G ( O n t a r i o Department of H e a l t h , January 1969), pp. 17-23. ^ D . V. G l a s s , " S t r u c t u r e of the Newfoundland P o p u l a t i o n , " c i t e d by Right Honourable L o r d B r a i n , Royal Commission on H e a l t h , V. 3 (Government of Newfoundland, 1966), 2:34. 16 H e a l t h P l a n n i n g and Development Committee, H e a l t h Care D e l i v e r y , Reports 1-4, S t . John's: Newfoundland Department of H e a l t h , May-March, 1975. ^ M c K i n s e y and Company, P r o v i s i o n s o f C l i n i c a l S e r v i c e s and Programs i n S t . John's: A Study t o Determine Future Requirements, St. John's: S t . John's A d v i s o r y C o u n c i l , 1979. 18 A. B. Murphy, "Newfoundland P o p u l a t i o n : Census Years 1961, 1966, 1971, 1976," S t . John's: 1975 (working c o p y ) ; Idem, " P o p u l a t i o n 1971 and 1976, Newfoundland by H e a l t h Regions, 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 s , " S t . John's: 1975; Idem, "Newfoundland and Labrador P o p u l a t i o n 1966-1971, P a r t I I , 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 , " S t . John's: September 1976. 19  I d e m , " P o p u l a t i o n 1971 and  1976."  20 H e a l t h P l a n n i n g D i v i s i o n , "A Study o f C u r r e n t 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 t o P r o j e c t e d H o s p i t a l Beds i n Newfoundland P e r 1000 P r o j e c t e d P o p u l a t i o n 1980-81," St. John's: Newfoundland Department of H e a l t h , September 1975. 21 P e r s o n a l communication w i t h G. Gover, A c t i n g D i r e c t o r of P l a n n i n g , Department o f H e a l t h , 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 o f F a c t o r s I n t h e c o n t e x t o f t h i s l i t e r a t u r e r e v i e w , t h e r e were numerous s t u d i e s w h i c h examined t h e c o n t r i b u t o r y f a c t o r s w h i c h l e d t o t h e e x p r e s s i o n o f a demand f o r o r t h e u t i l i z a t i o n o f a h e a l t h c a r e 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 t h e appearance o f a shopping l i s t , i t i s e v i d e n t t h a t a p r e c i s e statement o f d e t e r m i n a n t s and r e l a t i o n s h i p s has n o t y e t been found. Even though some o f t h e 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 r e v i e w e r s a r e v e r y q u i c k t o p o i n t o u t t h a t such an i s o l a t e d view forms b u t one band o f t h e spectrum. A s y n o p t i c p i c t u r e o f these v a r i a b l e s can be o b t a i n e d by combining  the s t u d i e s of P i e r c e  headings and examples. indicate their relative  1  2 and M a c S t r a v i c .  Given below a r e  The o r d e r i n w h i c h these appear does n o t importance.  Demand and U t i l i z a t i o n : F a c t o r s and Examples  Economic: The i n d i v i d u a l ' s c o s t o f t i m e , d i s t a n c e and t r a n s p o r t a t i o n ; t h e h e a l t h system's c o s t o f r e s o u r c e s and p r i o r i t i e s ; the l e v e l o f r e s o u r c e s 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 b e h a v i o u r i n c o n f r o n t i n g the a c u t e n e s s , d e l a y , f e a r o r p r e v e n t a b i l i t y p r e s e n t i n a situation.  15  16 Demographic: The p o p u l a t i o n ' s growth, e d u c a t i o n l e v e l , c u l t u r a l o r i g i n s and age-sex s t r u c t u r e . Physical:  A p o p u l a t i o n ' s l e v e l of m o r b i d i t y o r  income,  mortality.  Organizational: The i n d i v i d u a l ' s o r p r o f e s s i o n a l ' s a c c e s s i b i l i t y to s e r v i c e s under the c o n s i d e r a t i o n 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 o f r e s o u r c e s and f a c i l i t i e s , o r degree o f 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. E n v i r o n m e n t a l : The absence of an adequate water and sewage d i s p o s a l system or the p o l l u t a n t e f f e c t s o f an i n d u s t r i a l complex. Political: The l o b b y i n g of a community f o r a h o s p i t a l when primary reason, a l t h o u g h s t a t e d as h e a l t h , i s economic (jobs). Technological: required. The  The  p r e v i o u s l i s t i n g was  o r u t i l i z a t i o n can be variables.  l e v e l of medical expertise  of numbers and  services  p r e s e n t e d to emphasize t h a t demand  c o n s i d e r e d by  a statement c o n s i s t i n g of many  M a c S t r a v i c k suggests t h a t  as m u l t i v a r i a t e  f o r the  the  i n the  future  techniques such  a n a l y s e s w i l l become more commonplace. r e l a t i o n s h i p s , the  As  s t u d i e s by H a r r i s and  an  example  Brooks  and  3 4 Beenhaker p r o v i d e a good s t a r t i n g p o i n t . studies  point  to a growing l i s t  s e l e c t i o n of what v a r i a b l e s  '  a few  only  through a n a l y s i s , are  f a c t o r s s h o u l d be  r e l a t i o n s h i p s w i t h o t h e r v a r i a b l e s , and  that  the  i s not  the same i n another s i t u a t i o n .  f o r study can  cover a broad spectrum by  f i n a l s e l e c t i o n of v a r i a b l e s  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  a n a l y s i s , and  to be  the be  possible  same i s t r u e  importance o f v a r i a b l e s  the  to  c o n s i d e r e d to  c o g n i z a n t of  i s , the  variables  these  In t h i s c o n t e x t , a study  many f a c t o r s ; t h a t necessarily  do  of v a r i a b l e s , they a l s o p o i n t  the most important f o r a . g i v e n s i t u a t i o n . which s e l e c t s but  Not  i n one The  of  situation  s e l e c t i o n of  l o g i c alone,  but  a n a l y z e d i s dependent upon e f f o r t , the  techniques  the a p p r o p r i a t e n e s s to the problem a t hand.  of  S e l e c t e d F a c t o r s A s s o c i a t e d w i t h H e a l t h 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 A l t h o u g h t h e l e v e l and s t r u c t u r e o f m o r b i d i t y a r e b e l i e v e d t o be i m p o r t a n t d e t e r m i n a n t s o f h e a l t h r e s o u r c e s u t i l i z a t i o n , m o r b i d i t y d a t a have o f t e n been o v e r l o o k e d i n t h e p l a n n i n g o f h e a l t h r e s o u r c e s . ^ [ u n d e r l i n i n g by t h e p r e s e n t w r i t e r ] . T h i s q u o t a t i o n from Navarro has a number o f key concepts which r e q u i r e f u r t h e r explanation. m o r b i d i t y a r e grounded i n age,  The l e v e l and s t r u c t u r e o f  s e x and h e a l t h c o n d i t i o n .  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 .  Morbidity  F i r s t , m o r b i d i t y i s an aggregate  term w h i c h d e s c r i b e s t h e h e a l t h s t a t u s o f t h e p o p u l a t i o n .  Second,  m o r b i d i t y i s a m o d i f i e d t e r m w h i c h d e f i n e s t h e numbers and t y p e s o f c o n d i t i o n s which are admitted institutions.  t o , o r separated  The q u o t a t i o n a l s o i m p l i e s t h a t t h e r e a r e v a r i o u s  l e v e l s or perspectives to morbidity. expressed  from, h e a l t h care  a c t u a l o r demand m o r b i d i t y  mary, secondary o r t e r t i a r y m o r b i d i t y  Some o f these l e v e l s a r e : (prevalence, i n c i d e n c e ) ; p r i ( r e s o u r c e d i s t r i b u t i o n and  degree o f s i c k n e s s ) ; and consumer o r e x p e r t d e f i n e d m o r b i d i t y t u a l o r p e r c e i v e d l e v e l s t h a t ought t o e x i s t ) .  Although  (fac-  authors  r e c o g n i z e m o r b i d i t y 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 s e a t t o o t h e r s e t s o f v a r i a b l e s .  Donabedian made r e f e r  ence t o t h i s i n a r e v i e w o f 225 s t u d i e s by a number o f r e s e a r c h e r s . I n o n l y one case was m o r b i d i t y d a t a used t o d e r i v e a statement o f resource  requirement. According  t o Doyle e t a l . ^ "the most s t a t i s t i c a l l y  signifi-  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." was  "Age  f i v e times a b e t t e r p r e d i c t o r than any o t h e r s i n g l e v a r i a b l e . "  [ P r e v i o u s 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 o n e ) , r e s i d e n c e , s e x d i f f e r e n c e s , race and age were o t h e r v a r i a b l e s c o n s i d e r e d . ]  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 r e s o u r c e s a r e , i n a l a r g e measure, b e i n g s u p p l i e d to d e a l w i t h m o r b i d i t y w h i c h i s a f u n c t i o n o f age and s e x . Examples o f t h e . r e l a t i o n s h i p between age-sex and m o r b i d i t y a r e drawn from B r i g h t , ^ Das and D a s ,  9  and Umenyi."'^  As age o r  s u r v i v a l i n c r e a s e s , t h e 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 t o m o r b i d i t y and to t h e c h r o n i c d e g e n e r a t i v e  or d e b i l i t a t i n g conditions also increases.  T h i s r e q u i r e s a s p e c i a l type o f c a r e .  Changes i n b i r t h , death and  s u r v i v a l r a t e s may w i t h i n a g e n e r a t i o n 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 r e s o u r c e s i n t h e acute care s e t t i n g , c e r e t u s p a r i b u s .  Depending  upon t h e age d i s t r i b u t i o n and number o f women i n the c h i l d - b e a r i n g y e a r s , t h e need f o r o b s t e t r i c a l s e r v i c e s may v a r y . at r i s k f o r complicated pregnancies  However, women  may d i f f e r i n age p a t t e r n s , and  require 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 o f t h e p r o s t r a t e o r r e p r o d u c t i v e organs r e q u i r e s e p a r a t e types o f beds.  C a r d i o v a s c u l a r d i s e a s e and cancers o f t h e  stomach o r upper r e s p i r a t o r y organs a r e a g e - r e l a t e d .  To c i t e more  examples would be redundant f o r l o g i c a l o n e t e l l s t h a t changes i n the age-sex d i s t r i b u t i o n o f t h e p o 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 , a t l e a s t i n t h e volume o f s e r v i c e s , i f a l l other f a c t o r s a r e held constant.  T h e r e f o r e , one o f t h e b a s i c s t e p s  f o r t h e p l a n n i n g o f h e a l t h r e s o u r c e s t o m o r b i d i t y l e v e l s i s t o know the age-sex d i s t r i b u t i o n o f t h e p o p u l a t i o n .  M o r b i d i t y , Age-Sex and G e o g r a p h i c a l  Distribution  A d i f f e r e n c e i n m o r b i d i t y 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 e t a l . who p l o t t e d  stomach cancer cases on a map o f Newfoundland. which f o l l o w e d  the c o a s t l i n e was a l s o c o n c e n t r a t e d  the e a s t c o a s t . ^ cular disease one  The observed p a t t e r n i n a pocket on  Fodor's p r e l i m i n a r y o b s e r v a t i o n s ,  on c a r d i o v a s -  r a t e s between two areas o f Newfoundland i n d i c a t e t h a t  area has twice  the r a t e o f the o t h e r , and t h i s f i n d i n g i s t r u e 12  f o r a l l age s p e c i f i c r a t e s .  A number o f c o n s u l t a n t  more n o r t h e r n  populated  and l e s s densely  record a greater proportion o f morbidity ciated with  regions  r e p o r t s on the  o f the p r o v i n c e  c o n d i t i o n s which a r e a s s o -  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  g r a t i o n when compared w i t h s t u d i e s support  the r e s t o f the p r o v i n c e .  g e n e r a l i z a t i o n s to g e o g r a p h i c a l  disinte-  Whilst  these  d i f f e r e n c e s the  a u t h o r s a l s o p o i n t to t h e important i n t e r v e n i n g v a r i a b l e s such as c u l t u r a l and e a t i n g h a b i t s . The  remoteness e x p e r i e n c e d  by some communities o f t e n accom-  pany such problems as weather, d i s t a n c e , a c c e s s i b i l i t y and d e l a y . These c o n t r i b u t e to l o n g e r s t a y s , h i g h e r consumption o f r e s o u r c e s . from l a r g e r c e n t e r s  ties.  The remoteness o f p h y s i c a l  separation  can sometimes l e a d to a lower p r o f i l e when  demands a r e expressed. recognize  c o s t i n g s e r v i c e s and more  Planners  high v i s i b i l i t y  a r e o f t e n f o r c e d p o l i t i c a l l y to  areas such as c i t i e s o r l a r g e r communi-  T h i s i s a l s o a b i a s because these communities have more  resources,  higher  tional ability. resources  l e v e l s o f s k i l l s and e d u c a t i o n In t h i s c o n t e x t  i s far easier.  rates are higher.  and more  organiza-  the development and o r g a n i z a t i o n o f  The n a t u r a l outcome i s t h a t  utilization  T h i s does not n e c e s s a r i l y mean t h a t t h e r e 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 d i f f e r e n c e i n the s e r v i c e s p r o v i d e d the urban o r r u r a l p a t i e n t .  to e i t h e r  Many s m a l l a r e a v a r i a t i o n s i n h e a l t h r e s o u r c e  utilization  13  were d e s c r i b e d by Wennberg and G o t t e l s o h n .  Some examples were:  h o s p i t a l bed r a t e s , d i s c h a r g e r a t e s , occupancy, l e n g t h o f 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 o f 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 w h i c h they make i s t h a t the p h y s i c i a n s , w h i c h they o b s e r v e d , tend t o c o n c e n t r a t e economic reasons.  i n urban areas f o r more than  P h y s i c i a n s a r e a l s o c o g n i z a n t o f t h e age s t r u c t u r e  o f a community and t h e type o f m e d i c a l p r a c t i c e w h i c h they d e s i r e . They suggest (as one reason) t h a t p h y s i c i a n s , i n g e n e r a l , do n o t move t o r u r a l s e t t i n g s because t h e r e i s a h i g h e r c o n c e n t r a t i o n o f unproductive  age groups.  Many p h y s i c i a n s do n o t l i k e t o 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 t h a t s u p p l y o f p h y s i c i a n s i s r e d u c e d ; therefore, a corresponding When M a c S t r a v i c .  reduction i n u t i l i z a t i o n i s experienced.  d i s c u s s e d t h e f a c t o r o f d i s t a n c e he c i t e d  Jarvis' 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 t o d i s t a n c e .  This  law i n c o n j u n c t i o n w i t h the p r e v i o u s d i s c u s s i o n contends t h a t d i f f e r e n t p o p u l a t i o n s by a r e a and s t r u c t u r e r e q u i r e v a r i e d s e t s o f health 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 patterns. To summarize b o t h d i s c u s s i o n s o f m o r b i d i t y by age and s e x and by g e o g r a p h i c d i s t r i b u t i o n , two p o i n t s a r e p r e s e n t e d  as b e i n g  a p p r o p r i a t e t o h e a l t h p l a n n i n g i n the Newfoundland s e t t i n g .  Sibole  s u g g e s t s t h a t t h e growth o f t h e p o p u l a t i o n has c r e a t e d a v e r y d i f f e r e n t type o f e f f e c t .  Growth i n t h e p o p u l a t i o n has f a r o u t -  s t r i p p e d the growth o f 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 n o t r e l a t e t o newer p o p u l a t i o n s and t h e r e f o r e may represent substandards, for planning.  i f and when r e s o u r c e u t i l i z a t i o n i s i n t e n d e d  The c r i t i c a l element o f t h i s v i e w i s the r e l a t i o n s h i p  between p r e s e n t  consumption and the p r e s e n t p o p u l a t i o n which i s  consuming r e s o u r c e s .  Small a r e a p o p u l a t i o n i n f o r m a t i o n i s c o n s i d e r e d  by Wennberg and G o t t l e s o h n as v i t a l  to sound h e a l t h p l a n n i n g .  In  the q u o t a t i o n t h a t f o l l o w s note the i m p l i c a t i o n t h a t t h e r e i s an absence of c u r r e n t p o p u l a t i o n a n a l y s i s r e l a t i v e to the r e s o u r c e s distributed. H e a l t h i n f o r m a t i o n about t o t a l p o p u l a t i o n i s a p r e r e q u i s i t e f o r sound p l a n n i n g , d e c i s i o n making and p l a n n i n g i n the h e a l t h care f i e l d . Experience with a p o p u l a t i o n based h e a l t h data system i n Vermont r e v e a l s t h a t t h e r e a r e wide v a r i a t i o n s i n r e s o u r c e i n p u t u t i l i z a t i o n o f s e r v i c e s and e x p e n d i t u r e s among n e i g h b o u r i n g communities. . Variations i n u t i l i z a t i o n indicate t h a t t h e r e i s c o n s i d e r a b l e u n c e r t a i n t y about the e f f e c t i v e n e s s o f d i f f e r e n t l e v e l s o f 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 o f many s m a l l  area  p o p u l a t i o n s : and as p r e v i o u s l y s t a t e d t h e r e a r e elements o f data c o l l e c t i o n t h a t r e q u i r e improving  i n the Newfoundland s i t u a t i o n .  Consequently a d i s c u s s i o n o f Newfoundland and i t s r u r a l problems o f h e a l t h resource presented  d e l i v e r y and i n t e g r a t i o n w i t h l a r g e r systems w i l l be  under a s e p a r a t e h e a d i n g i n Chapter I I I and i n Appendix A.  F o 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 E s t i m a t i o n The  term h e a l t h p l a n n i n g , by d e f i n i t i o n , must i n c l u d e some  element o f f o 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 o r e s t i m a t i o n . many p l a n n e r s  these terms are used i n t e r c h a n g e a b l y  phenomena, a q u a n t i t a t i v e s t a t e i n the f u t u r e . grapher each o f these terms i s d i s t i n c t body o f knowledge.  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 . ^ attached.  to d e s c r i b e one  To the ardent  demo-  and has i t s own s p e c i a l i z e d  K e y f i t z uses p r e d i c t i o n and f o r e c a s t as e q u i v a -  l e n t s which mean a f u t u r e statement'of  bility  To  what i s to o c c u r w i t h a  P r o j e c t i o n does n o t have a proba-  Instead i t i s c o n d i t i o n a l : " I f the b i r t h r a t e  d e c l i n e s , 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  result i s a r e s t r i c t e d forecast.  To  c a r r y the "what i f " b i r t h r a t e 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 o f the t h i s t h e s i s there and  d e c l i n e would have to be i s a population  a p r e d i c t i o n of bed  stated.  In the  p r o j e c t i o n , a morbidity  requirements.  The  future.  future i s d i s t i n c t  Determining the  which r e l a t e to h e a l t h  future  involves  tion levels.  i d e n t i f y i n g the  care u t i l i z a t i o n , and  s i t u a t i o n i s being modified  Forecasting  does not  date. the  factors  i n t e r v e n i n g by a l t e r i n g In o t h e r words,  f o r the  a l t e r current  future u t i l i z a t i o n .  future  factors.  observed changes of f a c t o r s are used to p r e d i c t the these changes w i l l have on  future  from f o r e c a s t i n g  those f a c t o r s which are amenable to adjustment. r e a l or c u r r e n t  assumption  p r e d i c t i o n a r i s e s because  a r e a l s i t u a t i o n ( c u r r e n t p a t t e r n ) i s expected a t the D e t e r m i n i n g the  case o f  impact  the  utilizaInstead, that  Specifically,  the  content of a f o r e c a s t must cover a l l a s p e c t s o f the s i t u a t i o n which i s to be  planned. 19 As B e r g w a l l e t a l .  contain projections  describe  f o r the p l a n n i n g  of f a c t s r e l a t i n g to the c u r r e n t  c o n t e n t , the period  situation.  appear as i f i n a t a b l e comparing 1979 other side.  An  and The  on one  a thorough a n a l y s i s forecast  s i d e and  encompassing f o r e c a s t s h o u l d c o n s i d e r  components: p o l i t i c a l ;  social  and  s t a t u s s e r v i c e s ; and  health: resources,  (demographic); economic; health  short l i s t  of f o r e c a s t i n g t e c h n i q u e s i s d e r i v e d 21 22 B e r g w a l l et a l . and Navarro. 1. P r e s e n t Centered (present w i l l r e p e a t ) 2.  f o r e c a s t must  Trend E x t r a p o l a t i o n  (past w i l l  repeat)  1989 the  should on  the  following  technological  (environment). A . 20 from M a c S t r a v i c r,  23 3.  Trend C o r r e l a t i o n ( p a s t 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 f a c t o r w i l l repeat)  5.  Consensus ( f u t u r e d e f i n e d by  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 e q u a t i o n s 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 event)  one  experts)  predict prior  F o r e c a s t i n g methods can a l s o be d e f i n e d 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 t o t h i s t h e s i s  a r e two methods, s o c i a l f o r e c a s t i n g (demographic and and h e a l t h p l a n n i n g .  Each o f these i n t u r n w i l l be  populations) discussed:  s o c i a l f o r e c a s t i n g i n terms o f 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 p l a n n i n g i n terms o f bed m i n a t i o n o r p r e d i c t i o n methods.  Regardless  (resource)  deter-  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 .  T h i s i s so because  p l a n n e r s 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 w h i c h a r e r e l a t e d to the i n d i v i d u a l o r groups w i t h i n the p o p u l a t i o n . a c t i v i t y r a t e , such as m o r b i d i t y by age, tion.  i s dependent upon p o p u l a -  To determine f u t u r e l e v e l s o f m o r b i d i t y by age,  the p o p u l a t i o n by age  The  i s taken i n t o account.  the growth o f 24  Bergwall et a l .  d e s c r i b e 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 o f h e a l t h p l a n n i n g . Methods o f S u b n a t i o n a l P o p u l a t i o n P r o j e c t i o n s There are v a r i o u s methods of p r o j e c t i n g p o p u l a t i o n s these can be d i v i d e d i n t o two b r o a d c a t e g o r i e s : n a t i o n a l ; and national ( l o c a l , regional, area).  The methods w h i c h are  and sub-  listed  below can be a p p l i e d t o e i t h e r c a t e g o r y .  However, t h e m e t h o d o l o g i e s  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 a r e more numerous  and a r e more  germane t o t h e t h e s i s : 1.  A r i t h m e t i c o r Geometric E x t r a p o l a t i o n Methods  2.  R a t i o Method  3.  C o r r e l a t i o n Method (Econometric)  4. 5.  Component Method Cohort S u r v i v a l Method _ , ^ „ ._vr.uuj Cohort-Component Method  6.  Other Methods  _. ™ ^ J ~ Component Methods  Many o f t h e 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 r e v i e w v e r y b r i e f l y those w h i c h apply t o t h e d e t e r m i n a t i o n  of l o c a l area  26 populations. The d i s c u s s i o n w h i c h f o l l o w s was drawn from W o l f f , 27 28 29 30 Siegel, S c h m i t t and C r o s e t t i , ' Z i t t e r and Shryock J r . j Spiegelman,  31  Grauman,  32  Bergwall  33 e t a l . , U.S. Bureau o f t h e  Census,"^^ and Gnanasekaran. M a t h e m a t i c a l P r o j e c t i o n Models i n v o l v e an assumption o f p a s t trends  and a c o n t i n u a t i o n o f t h e s e t r e n d s  as a c o n s t a n t  f u t u r e by a s p e c i f i c a n n u a l o r average amount.  i n t o the  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 i n c r e a s e o r d e c r e a s e i n a n n u a l o r average amount whereas t h e g e o m e t r i c p r o j e c t s an average annual r a t e or p e r c e n t a g e i n c r e a s e o r d e c r e a s e . are known as t r e n d c u r v e s .  A l t e r n a t i v e l y , t h e s e methods  These methods a r e 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 t o h a n d l e numerous assumptions i s v e r y Yet they a r e o f t e n u s e f u l f o r s h o r t term p r o j e c t i o n s o r q u i c k where time and c o s t a r e a t a premium and rough e s t i m a t i o n s suffice.  limited. studies  will  Of t h e v a r i o u s types o f t r e n d c u r v e s t o w h i c h d a t a a r e  f i t t e d o n l y t h e l o g i s t i c c u r v e i s suggested as s u i t a b l e f o r l o n g term p r o j e c t i o n s .  25 The  R a t i o 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 d e a l w i t h g e o g r a p h i c a l employed i n s i t u a t i o n s where areas  subdivisions.  T h i s method i s  are not d e f i n e d by b o u n d a r i e s f o r  which d a t a i s r e a d i l y a v a i l a b l e and where independent p r o j e c t i o n s of a l a r g e r r e f e r e n c e a r e a are a v a i l a b l e . l a t i n g , from census data, its  The method i n v o l v e s c a l c u -  the r a t i o o f a s m a l l e r p o p u l a t i o n a r e a to  r e f e r e n c e p o p u l a t i o n area.  The  r a t i o s may  be  a p p l i e d to  total  p o p u l a t i o n or to the age-sex s p e c i f i c p o p u l a t i o n of both areas. r a t i o which i s c a l c u l a t e d can be based upon a c o n s t a n t vation) or a trend period  (multiple observations).  (one  The  obser-  This r a t i o i s  then a p p l i e d to an independent p o p u l a t i o n p r o j e c t i o n f o r the l a r g e r area. Four d i s t i n c t R a t i o Methods are observed i n the S h o r t , Long, R a t i o C o r r e l a t i o n and  R a t i o Cohort.  The  literature:  short calcu-  l a t i o n i n v o l v e s 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 t i o n ; t h a t i s , the community may reference area.  be  c a l c u l a t e d a g a i n s t the l a r g e r  In the l o n g method the s t e p s would f o l l o w a  sequence, f o r example, community, d i s t r i c t , province.  The  r e g i o n and  county or  r a t i o c o r r e l a t i o n i n v o l v e s the c o r r e l a t i o n of  r a t i o s o f percent  change o r observed change between one  l a r g e r r e f e r e n c e area between o b s e r v a t i o n p o i n t s . has  popula-  The  a r e a and i t s r a t i o method  a l s o been used to work backwards from a p o p u l a t i o n p r o j e c t i o n  towards i t s c o n s t i t u e n t p a r t s .  The  disadvantage o f t h i s method i s  t h a t i t r e l i e s on past data as w i t h mathematical methods. it  the  can p r o v i d e  a p r o j e c t i o n , when trends  overtly optimistic.  A distinct  are examined, t h a t i s not  advantage i s the method's  i n a g i v e n s i t u a t i o n i n t h a t i t can be m o d i f i e d w i t h o u t wide v a r i a n c e i n the end product.  However,  T h i s does not imply  flexibility  producing that  the  flexibility  extends t o a l l s i t u a t i o n s .  The Component Methods a r e o f t e n used t o p r o j e c t p o p u l a t i o n s because they demonstrate a b e t t e r u n d e r s t a n d i n g  o f the f a c t o r s which  comprise p o p u l a t i o n growth and because they can p r e s e n t a f i n e r picture.  Methods can be combined so t h a t a component-cohort d e s i g n  can be u t i l i z e d t o p r o v i d e age p r o j e c t i o n s w h i c h the s i m p l e r component methods cannot p r o v i d e . From numerous o b s e r v a t i o n s o v e r t i m e , t o t a l b i r t h s ,  total  deaths and n e t m i g r a t i o n a r e p r o j e c t e d and t h e i r v a l u e s a r e s u b s t i t u t e d i n an e q u a t i o n , such t h a t t h e observed  population plus projects  b i r t h s minus p r o j e c t e d deaths, and p l u s o r minus n e t 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-  c o h o r t method i n v o l v e s t h e a p p l i c a t i o n o f a g e - s p e c i f i c v i t a l  rates  p r o j e c t i o n s t o the age-sex p o p u l a t i o n w h i c h i s to be p r o j e c t e d . Researchers  suggest t h i s method even when the component method i s  the method of c h o i c e . f e r t i l i t y and v i t a l  The c o h o r t method u t i l i z e s a g e - s p e c i f i c  r a t e s and c a r r i e s f o r w a r d the l a t e s t p o p u l a t i o n  by age t o a s p e c i f i e d date.  Some o f t h e component methods assume  zero m i g r a t i o n whereas o t h e r 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 o f the component methods i s t h a t they a r e more a n a l y t i c a l i n t h e i r treatment o f p o p u l a t i o n change because they a r e p r o j e c t i n g t h e m a j o r components o f p o p u l a t i o n change. a l s o has g r e a t e r f l e x i b i l i t y  The method  i n assumptions of f u t u r e growth.  nent methods a r e not suggested  Compo'  where t h e r e a r e a g r e a t many areas t o  p r o j e c t and when m i g r a t i o n v a r i e s f r e q u e n t l y between r e g i o n s and/or o v e r time. ability  The accuracy  o f t h i s method a l s o depends upon the a v a i l -  and p r e c i s i o n o f v i t a l s t a t i s t i c  r a t e s f o r the s m 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 o r p r o v i n c i a l r a t e s may  have t o be a p p l i e d .  these v i t a l r a t e s may  Significant shifts in  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 t o o t h e r 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 o f s i m p l e r  alter-  n a t i v e methods where t h e r e a r e a l a r g e number o f s m a l l a r e a p r o j e c tions.  I f the a n t i c i p a t e d r e s u l t s o f a l t e r n a t i v e s are  the same, t i m e , c o s t and d e t a i l m i t i g a t e  approximately  choice.  E c o n o m e t r i c 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 comparing e i t h e r the p o p u l a t i o n  t o i t s components w i t h o t h e r  by  economic  v a r i a b l e s or i n d i c a t o r s w h i c h are f e l t t o be a s s o c i a t e d w i t h popul a t i o n growth or change.  For example, a c o r r e l a t i o n may  be  applied  between m i g r a t i o n and such economic v a r i a b l e s as employment, unemployment, income o r wage l e v e l , l o c a t i o n of i n d u s t r y and prospects  o f areas.  The  economic  assumption i s t h a t p a s t 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 c o n t i n u e  i n t o the f u t u r e .  An example of  type of model i s h o l d i n g c a p a c i t y w h i c h r e l a t e s p o p u l a t i o n  this  change  w i t h the number o f d w e l l i n g u n i t s , v a c a n t d w e l l i n g u n i t s , v a c a n t o r excess l a n d , h o u s e h o l d s i z e and  topography of the l a n d .  Econometric  methods have the advantage o f u n d e r s t a n d i n g the components o f popul a t i o n w i t h a h i g h e r degree of s e n s i t i v i t y .  I t i s suggested t h a t  t h i s method l i e s more a p p r o p r i a t e l y , a t the p r e s e n t time, i n the domain o f the t r u e demographer.  The  s e n s i t i v i t y applied i n this  type of model c o u l d be demonstrated t h r o u g h c o n s i d e r a t i o n of f o l l o w i n g example: down n o r m a l l y productive dence.  The  the  When an i n d u s t r y i n a l o c a l community c l o s e s  t h e r e i s a temporary o r permanent out m i g r a t i o n o f  population age  the  f o r work o n l y o r for« work and permanent r e s i -  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  28  a f f e c t e d i n the sense of",having  a h i g h e r p e r c e n t a g e of young (unpro-  d u c t i v e ) and e l d e r l y p o p u l a t i o n  (unproductive)  defined  r e l a t i v e to newly  population. 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 f r o m  time to time.  The  analogy method examines the e x p e r i e n c e of an a r e a  w h i c h i s deemed to be s i m i l a r to the a r e a under c o n s i d e r a t i o n .  The  p a s t t r e n d s o f the " o t h e r " determines average growth p a t t e r n s i n t u r n are a p p l i e d to the a r e a under c o n s i d e r a t i o n .  The  which  apportion-  ment method, a l t h o u g h c i t e d i n many i n s t a n c e s 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 t o 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 p r o r a t e d among i t s c o n s t i t u e n t p a r t s a c c o r d i n g r e l a t i v e growth.  If a population  a r e a , the p o p u l a t i o n  their  d e c r e a s e s o r remains s t a b l e i n an  i n an a r e a remains as a c o n s t a n t .  Even v e r y  crude methods such as adding the n a t u r a l i n c r e a s e o f the to the census has been used.  to  A number o f r e s e a r c h e r s  population  have mentioned  t a k i n g the average of s e v e r a l methods i n p r o d u c i n g p r o j e c t i o n s . A l t h o u g h t h i s might p r o v i d e  a more r e l i a b l e p r o j e c t i o n , the  averaging  tends t o m i n i m i z e h i g h s and lows w h i c h might be worthy of a n a l y s i s . F i n a l l y , t h e r e i s a method c a l l e d the v i t a l r a t e s method w h i c h compares t r e n d s  i n b i r t h r a t e s , death r a t e s f o r l o c a l areas  and  compares these w i t h n a t i o n a l o r 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 c o n f i r m  that  t h e r e i s as y e t no s i n g l e method w h i c h can be a p p l i e d i n a l l s i t u a 36 tions.  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 a r e 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  t h e r e 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  a r e a data.  local  S i e g e l s t a t e d i n the 1950's t h a t " i t i s not p o s s i b l e to  29 37 forecast  the  population  Grauman,  i n the  flexible  method  of  small  geographic  1960's, a d d r e s s e d  the  areas  search  accurately."  for a  routine  and  of  a l l s i t u a t i o n s as b e i n g " l i k e the attempt to 38 c i r c l e the s q u a r e . " Gnanasekaran, i n the 1970's, suggested t h a t the "need f o r r e s e a r c h can h a r d l y be over-emphasized" i n the attempt 39 a t 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 a r e a p r o j e c t i o n s . What t h e s e a u t h o r s  c o n c l u d e i s t h a t the c o n t e n t i o n t h a t one method  i s s u p e r i o r to o t h e r s does not h o l d w a t e r because each method, r e l a t i v e to g i v e n s 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 c o n s i d e r e d as a c c u r a t e as any o t h e r method. appropriateness  of method, a c c u r a c y ,  p r o j e c t i o n s may  When e s t a b l i s h i n g the  t i m e , and c o s t c o n s i d e r a t i o n s  b a l a n c e between the s t a t e m e n t s o f c h o i c e and increased accuracy.  be  the m a r g i n a l r e t u r n of  I n o t h e r words, the ease i n method o f  simpler  f a r outweigh the more c o m p l i c a t e d measures when r e s -  u l t s a p p r o x i m a t e each o t h e r . Accuracy of Subnational P o p u l a t i o n P r o j e c t i o n There a r e a number o f w r i t e r s who  state without  testing that  the v a r i o u s p r o j e c t i o n methods a r e s i m i l a r i n t h e i r a c c u r a c y . a r e a l s o w r i t e r s who  suggest the use o f one method o v e r a n o t h e r .  o f the more encompassing t e s t s and r e p o r t s on a c c u r a c y by White  40  and S e i g e l  There  41  are  Two  provided  b o t h o f w h i c h a r e c i t e d by Gnanasekaran  42  who  s t a t e s t h a t more t e s t i n g i s r e q u i r e d . White concludes i o r edge on a c c u r a c y .  t h a t no one method p r o v i d e s a c l e a r l y  super-  I n v a r i o u s t e s t s o f the wide range of methods  a g a i n s t 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 , apportionment and ions  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 -  considering  average  percentage  of  e r r o r and  percentage  30  e r r o r s e x c e e d i n g 10% f o r b o t h the 10-year and The  20-year p r o j e c t i o n s .  r a t i o I I method assumes t h a t the p e r c e n t a g e i n c r e a s e  i n popu-  l a t i o n i n an a r e a i s the same as t h a t e x p e r i e n c e d by the  national  population.  In  t w i c e t h a t of 10-year  20-year  10-year  projections,  p r o j e c t i o n s , e r r o r s on the a v e r a g e ,  projections.  Seigel  concludes  years are u s e l e s s . e r r o r was  8.4%  or more.  The  On average p e r c e n t e r r o r i n  t h e s e methods s c o r e d i n the  whereas the o v e r a l l average was  are  5  to  6%  range  7% i n a l l 10-year p r o j e c t i o n s .  i n his  study  that  forecasts  beyond  W i t h a f o r e c a s t p e r i o d of 10 y e a r s ,  the average  w i t h more than 25% of t h e s e i n v o l v i n g e r r o r s of r a t i o method was and  the s i m p l e r  s c o r e d a t 5.7%,  the  s c o r e d 5.9%  component method was  The  average e r r o r f o r e s t i m a t e s o f 5 y e a r s o r l e s s was 10 y e a r s 9.5%.  The  t h i s to  s c o r e d a t 10.3%. 7.5%  and  for  f i n d i n g s of t h i s study  c o r r e s p o n d w i t h the f i n d i n g s p r e s e n t e d by W h i t e . u r a c y S e i g e l has  10%  cohort-survival  was  e s t i m a t e s between 5 and  15  I n terms of a c c -  say:  I n v i e w of the n e g a t i v e e v i d e n c e so f a r r e g a r d i n g the s u p e r i o r i t y of the more e l a b o r a t e o v e r the more s i m p l e r methods o f making s m a l l a r e a f o r e c a s t s , i t s h o u l d be r e c o g n i z e d t h a t no c o n s i s t e n t demand can be p r o p e r l y made a t t h i s time f o r the use of more e l a b o r a t e methods on the grounds of a c c u r a c y o f results. A b a s i c s e t of p r i n c i p l e s w h i c h promote the a c c u r a c y of 43 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 a r e drawn f r o m S e i g e l , G n a n a s e k a r a n , ^ and (a)  (b) (c)  Grauman.^  The  p r i n c i p l e s a r e as  pop44  White,  follows:  ^ E r r o r s i n c r e a s e 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 t w i c e as many e r r o r s as 10-year p r o j e c t i o n s . Rate of e r r o r s d e c r e a s e s as p o p u l a t i o n s i z e i n c r e a s e s . Rate o f e r r o r s d e c r e a s e s as o b s e r v e d economic bases become more d i v e r s i f i e d .  31 (d) There i s i n h e r e n t danger i n u t i l i z i n g a constant r a t e of growth over c o n s i s t e n t l y l o n g p e r i o d s because unique s h i f t s i n r a t e s may be missed. (e) Accuracy i s dependent upon the q u a l i t y of d a t a : t h a t i s , the a c c u r a c y o f census d a t a , v i t a l s t a t i s t i c s d a t a o r r a t e s of p r o j e c t i o n s which are r e l i e d upon. ( f ) Rate of e r r o r s tends to be l a r g e r i n areas t h a t e x p e r i e n c e wide f l u c t u a t i o n s i n m i g r a t i o n . (g) Where the p o p u l a t i o n i s c o n s i d e r e d to be s t a b l e i n b o t h p a s t and p r e s e n t , l e s s a n a l y t i c a l models may be more appropriate. (h) No one method of p o p u l a t i o n p r o j e c t i o n i s c l e a r l y s u p e r i o r . T h e r e f o r e , the c h o i c e o f method must r e s t w i t h a p p r o p r i a t e ness o f s i t u a t i o n and of time and c o s t . ( i ) The average f o r e c a s t range i s g e n e r a l l y between 10 and years.  20  ( j ) In e v a l u a t i n g a c c u r a c y , S e i g e l (1953),noted the f o l l o w i n g two p r a c t i c a l d i f f i c u l t i e s which he s t a t e d appeared q u i t e frequently. i.  "the inadequacy of the m e t h o d o l o g i c a l statement g i v e n i n a r e p o r t o r the numerous v a r i a t i o n s o f a p a r t i c u l a r method which may be employed r e n d e r i n g d i f f i c u l t o r i m p o s s i b l e the important c l a s s i f i c a t i o n i n terms o f type of method."  ii.  Note.  "the f a i l u r e of the author to s p e c i f y the a c t u a l base date of f o r e c a s t s r e n d e r i n g d i f f i c u l t o r i m p o s s i b l e the important allowance f o r the l e n g t h o f the f o r e c a s t p e r i o d . "  E r r o r s are d e f i n e d as the q u a n t i t y o f e r r o r s and as a p e r centage d i f f e r e n c e between p r o j e c t e d and a c t u a l p o p u l a t i o n figures.  The  As  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 F o r e c a s t i n g and H e a l t h P l a n n i n g  Between  s t a t e d p r e v i o u s l y , both a p r o j e c t i o n and p r e d i c t i o n are  i n v o l v e d i n a r r i v i n g at a statement of r e q u i r e d beds. was  noted t h a t p o p u l a t i o n was  planning.  I t follows  the key  Previously i t  independent v a r i a b l e i n h e a l t h  t h a t the p r e d i c t i o n p e r i o d f o r h e a l t h  planning  must n e c e s s a r i l y f o l l o w the g u i d e l i n e s e s t a b l i s h e d which enhance  the  r e l i a b i l i t y of population projections. f o r e c a s t s and p r o j e c t i o n s s h o u l d years.  Most w r i t e r s agree t h a t  f a l l between f i v e and f i f t e e n  P r o j e c t i o n s beyond t h i s p o i n t reduce a c c u r a c y  considerably.  However, p l a n n e r s and f o r e c a s t e r s a r e sometimes asked t o make p r o j e c t i o n s o f twenty y e a r s o r more.  I n these cases t h e r e has t o be an  e x p l i c i t assumption t h a t t h e f u t u r e s t a t e i s l i m i t e d .  Particularly  i n these c a s e s , a range o f h i g h , medium and l o w a r e g i v e n . upon t h e assumptions o f r e l i a b i l i t y ,  Based  t h e d e c i s i o n maker chooses h i s  projection. From the r e v i e w o f bed f o r e c a s t i n g f o r m u l a s most h e a l t h p l a n n e r s d i d n o t commit themselves t o a p e r i o d g r e a t e r than f i f t e e n years.  I n v a r i a b l y , t h e p e r i o d o f c h o i c e i s between f i v e and t e n  years.  A l t h o u g h reasons a r e n o t o f t e n g i v e n f o r f o r e c a s t  t h e r e a r e i m p l i e d assumptions w h i c h conform t o t h e o r y  length,  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 o f 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), w h i c h i n t h e o p i n i o n o f t h e w r i t e r , i s a more a p p r o p r i a t e c y c l e than a p e r i o d o v e r f i f t e e n y e a r s ( l o n g t e r m ) .  planning  In this  context,  a medium e x p e c t a t i o n o f 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 t h e t e n to f i f t e e n - y e a r c y c l e s . A l o n g term p l a n can mean the d e d i c a t i o n o f c u r r e n t t o a f u t u r e course o f a c t i o n w h i c h i s h i g h l y u n c e r t a i n .  resources  Alterna-  t i v e l y , i t may a l s 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 o f resources  w h i c h may a l s o be u n c e r t a i n ;  A l o n g term p l a n  allows  enough time f o r unexpected s h i f t s i n t h e f a c t o r s w h i c h determine demand i n t h e f u t u r e .  Examples might i n c l u d e t h e 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 o f e d u c a t i o n 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  o r income. i na field  where advances a r e v e r y r a p i d ?  There i s a heavy c o s t i m p l i c a t i o n  a t two p o i n t s f o r l o n g range p l a n s i f t h e r e i s a major d e v i a t i o n from the p l a n .  There i s the c o s t o f a l t e r a t i o n and new  plans  (and  r e s o u r c e s w h i c h might not be used f u r t h e r ) , and t h e r e i s t h e c o s t o f m o d i f y i n g systems o r r e s o u r c e s i n t r o d u c e d i n phases o f the o r i g i n a l p l a n so t h a t they conform to the new  plan.  Long range p l a n n i n g 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 t h e n o n - a r b i t r a r y i n t e r v e n t i o n o f p r i o r i t i e s and p h i l o s o p h i c a l u n d e r p i n n i n g s .  A very  decided  advantage t o l o n g range p l a n n i n g i s t h a t t h e r e i s a s p e c i f i c g o a l on the h o r i z o n .  The p a t h i n t o the f u t u r e w i t h s h o r t term p l a n s may  v e r y haphazard o r i n c r e m e n t a l i n n a t u r e . may  n o t r e l a t e to the whole.  be  I n o t h e r words, the p a r t  Long range p l a n n i n g , t h e r e f o r e , o f f e r s  a h i g h e r 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 c o o r d i n a t e d system. With the p r o p e n s i t y o f h e a l t h c a r e systems t o m a i n t a i n what they have i n r e s o u r c e s and programs, t h e r e i s an ever i n c r e a s i n g focus upon c o s t and a c c o u n t a b i l i t y , f o r example, zero base b u d g e t i n g i s b e i n g promoted f o r a l l areas of government. base b u d g e t i n g  The i n t e n t o f zero  i s t h a t programs must have t h e i r purpose and o p e r a t i n g  l e v e l j u s t i f i e d each y e a r .  I n the same v e i n , a s h o r t term p r o j e c t i o n  f o r c e s a more f r e q u e n t a p p r a i s a l .  The p a t h may  be t e n t a t i v e o r  i n c r e m e n t a l i n n a t u r e , but r e l a t i v e t o t h e d i s t r i b u t i o n o f v e r y c o s t l y r e s o u r c e s t h i s approach would tend to m i n i m i z e e r r o r .  A  t e n - y e a r p r o j e c t i o n (and to f i f t e e n y e a r s ) a l l o w s age c o h o r t s to move t o d i f f e r e n t u t i l i z a t i o n and m o r b i d i t y l e v e l s .  F i v e years  be enough time to e x p e r i e n c e d r a m a t i c changes i n m e d i c a l and technologies. sive.  may  related  To t h i s e x t e n t s h o r t term p l a n s would be more r e s p o n -  34 To summarize, the main reason s h o u l d be used i s t h a t accuracy  t h a t a s h o r t f o r e c a s t i n g term  i s s u b s t a n t i a l l y increased, ceretus  parabus i n comparison to l o n g range f o r e c a s t i n g .  Inaccuracies  may  produce s e r v i c e s and r e s o u r c e s which are both c o s t l y and u n s a t i s f a c t o r y to the p u b l i c and  government.  Summary  Initially with u t i l i z a t i o n  i t had been s t a t e d t h a t the f a c t o r s a s s o c i a t e d formed a broad  s c i e n t i f i c a l l y or l o g i c a l l y  spectrum.  These can be d e r i v e d  but s e l e c t i o n of f a c t o r s f o r a n a l y s i s  i s unique to a s i t u a t i o n , even though there may bility.  be g e n e r a l  applica-  T h i s i s so because need o r demand are " s o f t ; " t h a t i s ,  t h e r e i s a heavy r e 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 h e a l t h s t a t i s t i c a l system to f u n c t i o n p r o p e r l y i n r e l a t i o n w i t h a h e a l t h p l a n n i n g f u n c t i o n , demographic, m o r b i d i t y utilization  data must be a v a i l a b l e and  interdependent.  One  and  vital  element of f o r e c a s t i n g f u t u r e l e v e l s of r e s o u r c e s i s the n e c e s s i t y for  a thorough a n a l y s i s o f the p r e s e n t s i t u a t i o n .  Current  resources  must, t h e r e f o r e , be r e l a t e d to the c u r r e n t p o p u l a t i o n consuming these  resources. The  utilization  technique o f f o r e c a s t i n g whether i t i s p o p u l a t i o n , r a t e s o r l e v e l of r e s o u r c e s to be consumed takes i t s  d e s i g n and method from the problem of f o c u s . the c h o i c e of approach has  Of importance i s t h a t  to be c r e d i b l e ; i t has  t i o n s b e f o r e the d e c i s i o n maker f o r examination, application. are  blended.  I t i s t h r o u g h . t h i s process  to l a y i t s assumpvalidation  t h a t r e s e a r c h and  and practice  35 Chapter I I Footnotes  *"G. A. H. P i e r c e , "Bed Need D e t e r m i n a t i o n i n Canada" (Diploma T h e s i s , U n i v e r s i t y o f T o r o n t o , 1967), pp. 1-62. 2 R o b i n E. M a c S t r a v i c k , D e t e r m i n i n g H e a l t h Needs (Ann A r b o r , M i c h i g a n : H e a l t h 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 P o p u l a t i o n and H e a l t h Care Environment on H o s p i t a l U t i l i z a t i o n , " H e a l t h S e r v i c e s 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 F u t u r e H o s p i t a l Bed Needs," H o s p i t a l Management (June 1964): 47-50. ^ V i n c e n t e N a v a r r o , " P l a n n i n g f o r the D i s t r i b u t i o n of P e r s o n a l H e a l t h S e r v i c e s , " P u b l i c H e a l t h R e p o r t s 84 ( J u l y 1969): 573-581. A v e d i s Donabedian, A s p e c t s o f M e d i c a l 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 H e a l t h Care (Cambridge, Mass.: H a r v a r d U n i v e r s i t y P r e s s , 1973), pp. 532-639. ^B. C. Das and Rhea S. Das, "Some I m p l i c a t i o n s o f AgeS 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 P l a n n i n g of H o s p i t a l S e r v i c e s , " i n S t u d i e s i n Demography, eds. A s h i s h Base, P. B. D e s a i and S. P. J a i n (Chapel H i l l , N . C : U n i v e r s i t y o f N o r t h C a r o l i n a P r e s s , 1970), pp. 262-281. R a c h e l D o y l e , Joseph A. Z i e g l e r , Mary Jo G r i n s t e a d and B e r n a r d L. Green, " E s t i m a t i n g H o s p i t a l Use i n A r k a n s a s , " P u b l i c H e a l t h R e p o r t s 92 (May/June 1977): 211-216. 9 M a r g a r e t B r i g h t , "The Demographic Base f o r H e a l t h P l a n n i n g , " i n H e a l t h P l a n n i n g : Q u a l i t a t i v e A s p e c t s and Q u a n t i t a t i v e T e c h n i q u e s , ed. by W i l l i a m A. Reinke ( B a l t i m o r e : John Hopkins U n i v e r s i t y , 1972), pp. 138-157. 1 0  D a s and Das, pp.  262-281.  * '''Francis M. 0. Umenyi, Trends i n U t i l i z a t i o n o f 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 F u t u r e 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 E p i d e m i o l o g i c a l Study o f H y p e r t e n s i o n i n Newfoundland," Canadian M e d i c a l A s s o c i a t i o n _ J o u r n a l 108 (1974): 1374-1380." 13 P e r s o n a l communication w i t h Dr. J . C. Fador, E p i d e m i o l o g i s t , Community M e d i c i n e , M e m o r i a l U n i v e r s i t y , S t . John's, Newfoundland, 15 August 1979.  36 14  John Wennberg and A l a n G i t t e l s o h n , " S m a l l A r e a V a r i a t i o n s i n H e a l t h Care D e l i v e r y , S c i e n c e 182 (December 1973): 1102-1108. 1 5  R o b i n E. M a c S t r a v i c k , pp. 73-135.  16 Wayne R. S i b o l e , "The Impact o f Bed P l a n n i n g 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. 17  Standards,"  Wennberg and G i t t e l s o h n , pp. 1102-1108.  18 D a v i d F. B e r g w a l l , P h i l l i p N. Reeves and N i n a B. Woodside, I n t r o d u c t i o n t o H e a l t h P l a n n i n g (Washington, D.C.: I n f o r m a t i o n Resources P r e s s , 1974), pp. 61-76. 19 Nathan K e y f i t z , A p p l i e d M a t h e m a t i c a l Demography (New Y o r k : John W i l e y 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. M a c S t r a v i c k , pp. 73-135. 22 B e r g w a l l , Reeves and Woodside, pp. 61-76. 23 N a v a r r o , pp. 573-581. 24 B e r g w a l l , Reeves and Woodside, pp. 61-76. Ibid. 26 Meyer Z i t t e r and Henry S. Shryock, J r . , " A c c u r a c y o f Methods o f P r e p a r i n g P o s t c e n s a l P o p u l a t i o n E s t i m a t e s f o r S t a t e s and L o c a l A r e a s , " Demography 1:1, 1964, pp. 227-241. 27 R e i n h o l d W o l f f , "The F o r e c a s t i n g of P o p u l a t i o n by Census T r a c t s i n an Urban A r e a , " 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 o f S m a l l A r e a s , " Land Economics 29 (February 1953): 72-87. 29 Robert C. S c h m i t t and A l b e r t H. C r o s e t t i , " S h o r t Cut Methods o f 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 o f M a r k e t i n g 17, 1953, pp. 417-424. 30 Robert C. S c h m i t t and A l b e r t H. C r o s e t t i , " A c c u r a c y o f the R a t i o Method: R e j o i n d e r , " Land Economics 28 (May 1952) : 183-184. 31 Z i t t e r and Shryock, J r . , pp. 227-241. 32 M o r t i m e r Spiegelman, I n t r o d u c t i o n t o Demography, r e v . ed. (Cambridge, Mass.: H a r v a r d U n i v e r s i t y P r e s s , 1968), pp. 410-415. 33 John V. Grauman, " P o p u l a t i o n E s t i m a t e s and P r o j e c t i o n s , " i n The Study o f P o p u l a t i o n : An I n v e n t o r y and A p p r a i s a l , e d s . , 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 o f Chicago P r e s s , 1969), pp. 554-565.  37 34  B e r g w a l l , Reeves and Woodside, pp. 61-76.  35 Bureau of t h e Census, The Methods and M a t e r i a l s of Demography, V. 2 (Washington, D.C: U.S. Department o f Commerce, 1966), pp. 793-806. 36 K. S. Gnanasekaran, "Data Base and M e t h o d o l o g i c a l Problems i n P r e p a r i n g S m a l l A r e a 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. ^ G n a n a s e k a r a n , pp. 1-8. ^ H e l e n R. W h i t e , " E m p i r i c a l Study o f t h e A c c u r a c y o f S e l e c t e d Methods o f P r o j e c t i n g S t a t e P o p u l a t i o n s , " J o u r n a l o f 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. ^ G r a u m a n , pp. 554-565.  CHAPTER I I I RESOURCE (BED) DISTRIBUTION MODELS Bed P l a n n i n g Models P r i o r t o d i s c u s s i n g t h e v a r i o u s c a t e g o r i e s o f bed p l a n n i n g models a number o f comments a r e i n o r d e r .  I n the l i t e r a t u r e many o f  the bed p l a n n i n g , p r e d i c t i o n o r d e t e r m i n a t i o n models a r e n o t e x c l u s i v e t o t h e i r own b r a n c h o f p l a n n i n g . by t h e g e n e r i c term, " r e s o u r c e . "  The word 'bed' can be r e p l a c e d  The type of bed p l a n n i n g model,  t h e r e f o r e , d e s c r i b e s a g e n e r a l approach t o t h e d i s t r i b u t i o n of r e s o u r c e s e i t h e r i n the p r e s e n t o r i n t h e f u t u r e .  J u s t as t h e r e i s  no one r o u t i n e o r 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 a r e a  popula-  t i o n s , t h e r e i s y e t no one r o u t i n e o r s u p e r i o r model f o r d e t e r m i n i n g o r p l a n n i n g beds i n the f u t u r e . *  The c h o i c e o f a bed p l a n n i n g model  b e l o n g s t o b o t h the s i t u a t i o n and t o the d e c i s i o n maker.  The model  i s as a c c u r a t e 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 t h e n e c e s s a r y  s k i l l s and  2 d a t a t o a p p l y the model. There have been many methods developed and f u t u r e bed r e q u i r e m e n t s .  t o determine c u r r e n t  These v a r y from the v e r y s i m p l e bed t o  p o p u l a t i o n r a t i o method t o the more complex methods, w h i c h attempt t o acknowledge and i n c o r p o r a t e t h e many f a c t o r s w h i c h may be a s s o 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 g r a d u a l s h i f t from t h e aggregate p o 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 o f the p e r s p e c t i v e and model, f o u r c r i t i c i s m s  are common to both.  F i r s t , most models d e a l o n l y w i t h demand, and  t h e r e f o r e , o v e r l o o k the i n f l u e n c e of s u p p l y .  Second, demand i s  o f t e n t r e a t e d as r e p r e s e n t a t i v e o f the p o p u l a t i o n ' s m o r b i d i t y . T h i r d , demand f r e q u e n t l y i s comprised  o f few components.  d i r e c t m o r b i d i t y d a t a i s seldom u t i l i z e d c r i t i c i s m s c o u l d be handled mental  i n one  for calculations.  Fourth, These  formula but i t would be a monu-  t a s k i n time, energy and money.  More important, p l a n n e r s  d e c i s i o n makers operate under c o n s t r a i n t s .  The s t r a t e g i c  and  constraint  i n a m o d e l l i n g d e s i g n and a p p l i c a t i o n i s t h a t what i s r e l e v a n t i n one  s i t u a t i o n at one p o i n t i n time may  s i t u a t i o n o r time.  not be r e l e v a n t i n another  What i s a p p r o p r i a t e f o r the r e s e a r c h e r may  not  be p r a c t i c a l f o r the a d m i n i s t r a t o r . To c o n t i n u e the p r e s e n t d i s c u s s i o n of bed p l a n n i n g models a s i x - p a r t c l a s s i f i c a t i o n schema was of Donabedian,  3  Navarro  4  developed  and M a c S t r a v i c k .  5  from the o b s e r v a t i o n s The  types o f bed p l a n n i n g  models a r e : I) II)  Utilization Multiple Factor  III)  Distributional Analysis  IV)  Non-Formal o r Consensus  V) VI)  Standards M u l t i p l e Methodology  Utilizations T h i s method e n t a i l s the use o f a bed r e l a t e d  utilization  r a t e such as admissions, s e p a r a t i o n s o r p a t i e n t days expressed as a use r a t e per thousand  population.  The r e s u l t a n t r a t e i s then mani-  p u l a t e d by standards  through t h e use o f s i m p l e mathematics.  r a t e may be p a s t , c u r r e n t o r p r e d i c t e d .  The use  The e n t i r e formula's  calcu-  l a t i o n can be used t o a n a l y z e t h e d e f i c i e n c i e s o f t h e c u r r e n t s i t u a t i o n o r t o p r o v i d e a statement o f e x p e c t e d r e s o u r c e s . are t y p i c a l  Below  formulas:  1)  Rate x S t a n d a r d , „ . ,„ , -rrs 7TZ 3 1— = T o t a l R e q u i r e d Beds 365 x S t a n d a r d  2%  A d m i s s i o n s p e r Thousand C u r r e n t P o p u l a t i o n ( p r o j e c t e d ) x P o p u l a t i o n x Average L e n g t h o f Stay 365 days x Occupancy Rate  m  = T o t a l Required ^  Beds  Beds p e r Thousand C u r r e n t 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 The  Beds  r a t e s method i s t h e most f r e q u e n t l y encountered.  e x i s t s i n v a r i o u s forms such a s : t h e bed t o death o r b i r t h  It  ratio  which assumes a c o n s t a n t r e l a t i o n s h i p between t h e event and bed;^ and the c r i t i c a l number o f beds  ( i n two forms) w h i c h i s computed by  m u l t i p l y i n g average d a i l y census by average l e n g t h s o f s t a y and d i v i d i n g by 365 days. equals  A l t e r n a t i v e l y , average d a i l y census j u s t  t h e r e q 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 t o i n c o r p o r a t e peak p e r i o d s o r t o i n c l u d e t h e 7  waiting l i s t .  8  '  The same type o f 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 o f t h e U n i t e d S t a t e s . census, however, i s f i r s t The  The average d a i l y  a d j u s t e d by an occupancy  standard.  c r i t i c i s m s o f t h i s model a r e numerous and a r e w o r t h  d i s c u s s i n g because they a r e a l s o germane t o t h e o t h e r models.  A bed  r a t e f o r m u l a assumes t h a t i t i s t h e s i z e o f t h e p o p u l a t i o n w h i c h determines t h e beds and i s , t h e r e f o r e , a t r e n d c o r r e l a t i o n 9 to  t h e bed death r a t i o f o r m u l a s .  similar  Bed r a t e s i m p l y t h a t a l l t h e beds  are a v a i l a b l e t o t h e p o p u l a t i o n ^ and t h a t t h e beds and r e l a t e d  s e r v i c e s a r e t h e same and can meet a l l t h e p o p u l a t i o n ' s 11  morbidity patterns.  differing  12  '  The c r i t i c a l number has f a c t o r s w h i c h a r e 13  n o t independent and demand c o n s t i t u t e s a g r e a t e r number o f f a c t o r s . U s i n g c u r r e n t u t i l i z a t i o n p r o t e c t s t h e s t a t u s quo and a m p l i f i e s any d e f e c t s w h i c h a r e i n t h e system.  Of t h e standards  used i n t h e  f o r m u l a , S h o n i c k ' s r e a c t i o n i s tempered w i t h q u e s t i o n s : What i s t h e 14  p r o p e r occupancy r a t e ? average l e n g t h o f s t a y ? o r bed r a t e ? suggests t h a t s u p p l y i n f l u e n c e s demand.*"'  Beside  these  a r e advantages o f speed, o f ease, and o f f l e x i b i l i t y  Roemer  criticisms  i n adjusting  16  standards  t o produce a range o f v a l u e s . .  Donabedian s t a t e s t h a t  these methods can be used a c c u r a t e l y i n t h e hands o f a s k i l l f u l administrator or decision maker.^ The  changing p e r s p e c t i v e of many p l a n n e r s  from t h e aggregate  to t h e s p e c i f i c needs o f p o p u l a t i o n s has l e d many t o r e f i n e methods. These r e f i n e m e n t s  a r e b e i n g added t o s i m p l e formulas w h i c h  continue 18  to s u r v i v e because no s u p e r i o r method as y e t has been found. refinements  The  d i s c u s s e d below a r e 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  (1977)  d i s p l a y s a number o f r e f i n e m e n t s :  adjusting  the l e n g t h o f s t a y t o p r o v i d e a range o f bed r e q u i r e m e n t s ;  and u s i n g  a s i m p l e f o r m u l a i n c o n j u n c t i o n w i t h a thorough a n a l y s i s o f n i n e 19  v a r i a b l e s i n e s t i m a t i n g m a t e r n a l and newborn bed r e q u i r e m e n t s . M a c S t r a v i c employs a s i m p l e model w i t h f o u r c r i t e r i a o f a v a i l a b i l i t y 20  and c h o i c e o f h o s p i t a l , u n i t , and bed.  L a i n e and W i l s o n  21  and  22  Caldwell  c a l c u l a t e beds by r e g i o n u s i n g r a t e s p e r catchment popu-  l a t i o n and p a t i e n t f l o w . group standards  L a i n e 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  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 c e n s u s , 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  patterns  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 .  23'; " Karniewicz  applies  a normal d i s t r i b u t i o n to c o r o n a r y i n c i d e n c e by h o s p i t a l t o check the r e a s o n a b l e n e s s of the i n c i d e n c e w h i c h 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  Analysis  T h i s method, as d e s c r i b e d by F e l d s t e i n , i s a between c u r r e n t demand and  p o p u l a t i o n and  "relation  economic c h a r a c t e r i s t i c s .  Beds are then b u i l t t o 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 v a l u e s  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 , a g a i n ,  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 . "  to  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. g i v e a v e r y good i d e a of the c o m p l e x i t y in a hospital setting. 3-4  Brooks and  Beenhaker  of r e l a t i o n s h i p s and  factors  They p r e d i c t demand f o r 17 s e r v i c e s u s i n g  v a r i a b l e s f o r each s e r v i c e .  v a r i a b l e s f o r examination.  They had i n i t i a l l y s e l e c t e d 27  Doyle et a l .  use r e g r e s s i o n t o  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 w h i c h i s then a p p l i e d to p o p u l a t i o n and  average l e n g t h of s t a y by age  days, a f a c t o r f o r the c o n v e n t i o n f o r m u l a . been experimented w i t h and  confined Two  estimate the  t o y i e l d h o s p i t a l bed S i m u l a t i o n has  also  queuing t h e o r y has been adapted f o r s o l u 28  t i o n s to b o t h c r i t i c a l number of beds and w a i t i n g Regression,  117  s i m u l a t i o n , and  queuing t h e o r y  list. seem to be l a r g e l y  t o 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 .  r e q u i r e m e n t s of t h i s model a r e t h a t the u s e r 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 d a t a s e t 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 w h i c h he i s o b s e r v i n g .  These r e q u i r e m e n t s make the t a s k of  appli-  c a t i o n to a number of r e g i o n s or l a r g e a r e a s 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 g r e a t e r d e a l of u n d e r s t a n d i n g and  a c c u r a c y t o the p r e d i c t i o n o f demand b u t as mentioned p r e v i o u s l y i t i s r e l a t i v e t o t h e s i t u a t i o n a t hand.  However, r e g r e s s i o n  techniques  d e a l o n l y w i t h demand and t h e p o s s i b i l i t y o f o m i t t i n g a k e y 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 . Distribution Analysis T h i s model assumes t h a t t h e r e i s a p a t t e r n t o t h e p r e s e n t a t i o n o f p a t i e n t s f o r a d m i s s i o n and t h a t t h e p a t t e r n can be d e s c r i b e d by a d i s t r i b u t i o n curve.  I n s i m p l e terms, t h e c r i t i c a l number o f  beds i s a d j u s t e d w h i c h i n s u r e s t h a t t h e beds w i l l be o v e r - f i l l e d on one t o f i v e days o u t o f a hundred. the s t a n d a r d  The adjustment i s a m u l t i p l e o f  d e v i a t i o n and t h e i n s u r a n c e  i s a p r o b a b i l i t y that the  beds determined w i l l n o t be exceeded ( p a t i e n t s t u r n e d away) g i v e n the p a t t e r n o f a d m i s s i o n s each day. The method n o r m a l l y p o i s s o n d i s t r i b u t i o n , a skewed form o f t h e b i n o m i a l which r e q u i r e s c o n s i s t e n t observations  used i s the  distribution  t h a t a r e random and indepen-  30 31 dent i n n a t u r e .  '  The key advantage o f t h i s method i s t h a t t h e  number o f beds can be c a l c u l a t e d from one type o f i n f o r m a t i o n : t h e 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 t o s e r v i c e beds  w h i c h do n o t have e l e c t i v e s o r c o n t a i n a l o w e r p e r c e n t a g e o f e l e c t i v e s , s t e a d y o r l o n g term c a r e , 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 However, L i c h t e r m a n and G u l i n s o n have a p p l i e d t h e t e c h n i q u e  care.  t o each  o f t h e bed s e r v i c e s i n a h o s p i t a l on the assumption t h a t t h e e r r o r s 32 are n o t s i g n i f i c a n t .  ::>;>  As t h e average d a i l y census i n c r e a s e s t h e d i f f e r e n c e between t o t a l beds and mean number o f beds i s s m a l l e r than i t would be f o r 33 34 a smaller h o s p i t a l or service. N o r m i l e and Z i e l propose s e r v i c e s w h i c h a r e f l e x i b l e ; t h a t i s , t h e beds can be i n c r e a s e d o r d e c r e a s e d  to s u i t  the average d a i l y censusi  T h i s has an e f f e c t on occupancy 35  while maintaining  a high  service or protection l e v e l .  suggests the i n c r e a s i n g o f d a i l y census by a g g r e g a t i n g  Shonick service  catchment a r e a .  However, t h i s n o t o n l y produces e f f i c i e n c y b u t 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 a p p l i c a t i o n s of the poisson  formula.  Refinements to t h i s method i n c l u d e : a p p l i c a t i o n w i t h of distance,  occupancy and s e r v i c e l e v e l ;  concept o f d i s t i n c t p a t i e n t f a c i l i t y  38  criteria  i n c o r p o r a t i o n w i t h the  ( p a t i e n t and f a c i l i t y a r e 39  exclusive  to each o t h e r under normal c o n d i t i o n s ) ;  and a p p l i c a t i o n  to the c r i t i c a l number o f beds so t h a t an allowance i s made f o r bed t u r n o v e r 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 o r maintenance activities.  Shonick u t i l i z e s a r e f i n e d d i s t r i b u t i o n c a l l e d CENSA  which he b e l i e v e s writers  i s more r e p r e s e n t a t i v e  f e e l t h a t the p o i s s o n  than p o i s s o n .  technique s h o u l d n o t be used  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 . refinement of t h i s model i s that of s e r v i c e f o r the p o p u l a t i o n service.  unless  The more important  i t forces a perspective  to a l e v e l  w i t h e f f i c i e n c y as a f u n c t i o n of  S i m p l e r 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 articles  Clearly,  to meet s e r v i c e l e v e l s .  However, the  c i t e d demonstrate t h a t t h i s i s n o t n e c e s s a r i l y so and t h a t  s e r v i c e l e v e l s are very often  exceeded.  Non-Formal and Consensus Non-formal methods a r e those which do not apply o r mathematical models.  conventional  In many cases they w i l l a l s o l a c k  formality.  40 Donabedian d e s c r i b e s  a consensus model c a l l e d the d e l p h i  technique.  T h i s t e c h n i q u e i s a formal p r o c e s s which i n v o l v e s an o r i g i n a l of v a r i a b l e s which i s passed to a group f o r consensus.  listing  Through a  p r o c e s s of r e p e t i t i o n  and r e f i n e m e n t , a f i n a l l i s t of v a r i a b l e s i s  p r e p a r e d which has t h e consensus o f a l l members.  Some s t u d i e s have  s t a t e d t h a t i n the development o f t h e i r model, s t a n d a r d s such as bed r a t e s and occupancy from o t h e r s t u d y areas were examined. a b l y , t h i s e s t a b l i s h e d a consensus f o r the parameters or f o r the s t a n d a r d s w h i c h were to be employed.  Presum-  o f the model  Similarly, a  of p l a n n e r s o r a d m i n i s t r a t o r s i n w h i c h a bed r a t e i s d e c i d e d  meeting through  o b s e r v a t i o n and argument c o n s t i t u t e s a non-formal mechanism.  The  c h i e f d i s a d v a n t a g e of t h i s d i s t r i b u t i v e method i s t h a t i t i s h i g h l y s u b j e c t i v e even though e x p e r t s are used. are a p p l i e d may  However, the r e s u l t s  which  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 T h i s method n e c e s s a r i l y o v e r l a p s w i t h p r e v i o u s models because the b a s i c formulae i n v o l v e the c h o i c e o f an occupancy, a l e n g t h o f s t a y o r a bed r e l a t e d use r a t e s t a n d a r d .  T h i s s t a n d a r d can be  d e r i v e d by a n a l o g y , from p a s t u t i l i z a t i o n o r c u r r e n t u t i l i z a t i o n and by assumption based on e x p e r i e n c e .  The s t a n d a r d s model i s s e t a p a r t  from o t h e r s by the o v e r a l l f o r c e w h i c h a s t a n d a r d impacts on model.  In Nova S c o t i a a bed r a t i o o f 4.5  sand p o p u l a t i o n i s used.  a c u t e c a r e beds per  the thou-  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 s e p a r a t i o n s , p e r c e n t o f 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 , c u r r e n t y e a r p o p u l a t i o n s e r v e d 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 t o r e g i o n a l o r a r e a needs  y e t the d i s t r i b u t i o n i s c o n f i n e d by the s t a n d a r d o f 4.5 beds which 41 i m p l i e s t h a t a r e a needs do not d i f f e r from the s t a n d a r d . 42 The model used by L a i n e and W i l s o n  not o n l y p o i n t s t o a  r e f i n e d use of s t a n d a r d s but a l s o to the problems i n h e r e n t i n any  standard.  I n t h i s model a bed r a t i o s t a n d a r d i s chosen f o r each  r e g i o n ( d e f i n e d by a catchment p o p u l a t i o n ) . r e g i o n i s grouped by r a t e d bed s i z e .  Each h o s p i t a l i n a  An a c c e p t a b l e occupancy  s t a n d a r d 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 c a t e g o r y , a s t a n d a r d l e n g t h o f s t a y i s e s t a b l i s h e d . As i s p o i n t e d o u t i n t h e s t u d y , 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 c o u l d d e c i d e on a c c e p t a b l e standards of length of stay.  Shonick has a l r e a d y been c i t e d f o r the  comment, 'What i s proper? o r a p p r o p r i a t e ? ' S p e c i f i c r e f e r e n c e i s made t o p r o d u c t i v i t y and performance models  43  and t o an i d e a l r e s o u r c e model.  as t o t a l u t i l i z a t i o n per resource u n i t .  44  P r o d u c t i v i t y i s expressed  ( c u r r e n t o r expected) over the t o t a l c a p a c i t y , 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 , r e s o u r c e d i s t r i b u t i o n may be v e r y u n s a t i s f a c t o r y . Performance can be s u b d i v i d e d i n t o : the d i s t r i b u t i o n o f e x a c t quant i t i e s o f r e s o u r c e s t o meet the d e s i r e d s t a n d a r d j o r t h e b e s t p o s s i b l e mix o f r e s o u r c e s i s determined by a v a l u e w i t h i n t h e range of values e s t a b l i s h e d f o r a standard. as a r e n a l d i a l y s i s u n i t determines  such  i t s own u t i l i z a t i o n and p o p u l a -  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. termined.  The i d e a l r e s o u r c e u n i t  S e r v i c e p o t e n t i a l i s prede-  T h i s model can a l s o work i n r e v e r s e o r d e r .  M u l t i p l e Methodology I n t h e course o f t h e p r e s e n t d i s c u s s i o n a number o f w r i t e r s r e s o r t e d t o 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.  F o r example,  g i v e n 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 c o u l d be c a l c u l a t e d by a c o n v e n t i o n a l method and o b s t e t r i c beds c o u l d be c a l c u l a t e d through t h e p o i s s o n t e c h n i q u e .  The r e s u l t s would then be combined  for  t o t a l bed needs.  Umenyi  HJ  used b o t h c o n v e n t i o n and c o r r e l a t i o n ,  46 Slutsky  used r e g r e s s i o n , p o i s s o n and queing t h e o r y .  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 c o n v e n t i o n a l model.  The  key advantage o f these types o f s t u d i e s i s t i e d more t o t h e f l e x i b i l i t y i n a p p r o a c h i n g bed d i s t r i b u t i o n problems, n o t t o mention t h e p o s s i b i l i t y o f comparing v a r i o u s methods w i t h i n t h e s t u d y . Summary o f Methods F i g u r e 3-1 p r e s e n t s i n o u t l i n e form many o f t h e key compon e n t s which c h a r a c t e r i z e t h e models p r e v i o u s l y d i s c u s s e d . p r e s e n t e d , t h e components f o l l o w a p r e d e t e r m i n e d  order.  As However,  t h i s does n o t n e c e s s a r i l y i m p l y t h a t each i s i n t h e c o r r e c t o r d e r nor t h a t a l l t h e f a c t o r s have been c o n s i d e r e d .  Instead, i t i s  p r e s e n t e d f o r t h e purpose o f i l l u s t r a t i n g t h e v a r i o u s methods w h i c h c o u l d be u t i l i z e d i n d e t e r m i n i n g beds.  W i t h d i s c r e t i o n , and as  i l l u s t r a t e d on t h e o u t l i n e , a l i n e can be drawn between components to  d e s c r i b e 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 t h e v a r i o u s types o f bed p l a n n i n g models  b r i n g s t o g e t h e r a number o f o b s e r v a t i o n s r e l e v a n t t o b o t h t h e d e s i g n and a p p l i c a t i o n o f these models.  I n t h e more l o c a l i z e d s e t t i n g , t h e  v a r i e t y was g r e a t e r and these t e s t i f y t o t h e v e r s a t i l i t y o f t e c h n i q u e s t o 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 t e c h n i q u e s  w h i l e o t h e r s sought p r e d i c t i o n through the a n a l y s i s o f a l a r g e number o f v a r i a b l e s .  Even w i t h the s i m p l e r methods more r e f i n e m e n t s  were b e i n g added t o compliment t h e s h i f t i n g emphasis from p l a n n i n g for  an aggregate p o p u l a t i o n t o p l a n n i n g f o r a l o c a l p o p u l a t i o n . Y e t  the f o c u s o f t h e s e models i s a f o r m u l a common t o a l l (average .. census e q u a l s r e q u i r e d beds).  daily  The d i f f e r e n c e s i n approaches a r i s e  Problem  focus  1 General  Data  Orientation  Base  O CO  c ro  rt-  Qt  (—'  Oemand o r  H- » 3  n> c  O FM» It  •  *  M H M  (0 3  ro ro 3  *1  rt  1  Anal/sis  Bed  Meed  of  Data  Reouirement  Factors  Base  Model  M  S a o ro JU  O O rt  I-l I-*  ca ca  Results  Analysis  Adjustments  Oesired  And/Or  Relevant  Issues  Distribution  8*7  o f 8eds  Focus.  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 v a r i a b l e s a s s o c i a t e d with u t i l i z a t i o n ,  the d e s i g n e r  and the many q u a l i t a t i v e judgements  often required i n health planning.  ,  Each type o f model, t h e r e f o r e , has i t s own assumptions and each i n i t s own way c o n t r i b u t e s t o a b e t t e r u n d e r s t a n d i n g o f what i s or i s not relevant to d i s t r i b u t i n g resources.  As v a r i a b l e s a r e  acknowledged and s e l e c t e d , the l i m i t a t i o n s o f a bed p l a n n i n g become known.  The model's a p p l i c a t i o n i s t h e r e f o r e enhanced.  has been s t a t e d on numerous o c c a s i o n s , which i s s u p e r i o r to another.  there  The p r a c t i c a l i t y and r e s u l t s o f a bed  a v a i l a b i l i t y q u a l i t y , e t c . , which a r e the v e r y p o p u l a t i o n models.  Therefore,  As  i s as y e t no one model  p l a n n i n g model are dependent upon assumptions, s i t u a t i o n ,  left  model  data  reasons c i t e d i n  the d e s i g n o f a bed p l a n n i n g model i s  to the i n g e n u i t y and reason o f the p l a n n e r ,  under assumptions  t h a t can be v a l i d a t e d by d e c i s i o n makers who a r e a s s o c i a t e d w i t h o r know the problem.  D e s c r i p t i o n o f Three Bed P l a n n i n g Models at H i g h e r P o l i c y Making L e v e l s  The presented  f o l l o w i n g t h r e e examples o f bed p l a n n i n g models a r e  i n d e t a i l to i l l u s t r a t e both t h e approach and methods  which a r e b e i n g used a t the government o r r e g i o n a l l e v e l . models a l s o demonstrate c u r r e n t to d e a l w i t h hospital.  These  t h i n k i n g and the s h i f t i n g o f emphasis  l o c a l i z e d needs, from a h i g h e r p o l i c y l e v e l than the  These approaches would be a p p r o p r i a t e  i n t h e Newfoundland  s e t t i n g i n the sense t h a t the data i s a v a i l a b l e o r c o u l d be made a v a i l a b l e f o r use i n these approaches.  New Brunswick R e g i o n a l 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 n o t e d among areas i n t h e 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 t h e b a s i s o f observed d e f i c i e n c i e s  i n t h e p r o v i n c e , the Department o f H e a l t h d e c i d e d  t o implement a  method o f 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 , p l a n n i n g 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 b o t h the i n t e r i m o r s h o r t r u n and f o r t h e l o n g range p e r i o d s . per c a p i t a .  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  Refinements o f 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 o f o u t - o f - p r o v i n c e 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 o u t f l o w o f New Brunswick r e s i d e n t s .  A t t h e h e a r t o f t h e model i s  the c a l c u l a t i o n o f t h e n e t p o p u l a t i o n w h i c h i s a d j u s t e d f o r i t s age s t r u c t u r e r e l a t i v e t o t h e p r o v i n c i a l age s t r u c t u r e .  In both the  s h o r t term and l o n g term model, t h e r a t i o o f 5.5 beds p e r 1000 i s h e 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 , t h e f o l l o w i n g bed c a l c u l a t i o n s a r e i n c o r p o r a t e d t o s t e p 5. 1.  Beds f o r a c t u a l census p o p u l a t i o n .  2.  Beds due t o i n f l o w from o u t o f p r o v i n c e .  3.  Beds due t o i n f l o w from o t h e r  4.  Beds due t o o u t f l o w t o o t h e r  5.  T o t a l beds t o s e r v e n e t p o p u l a t i o n ( 1 + 2 + 3 ) - 4  regions. regions  These beds a r e then d i s t r i b u t e d : a c u t e , 75%; extended c a r e , 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  r e p r e s e n t p o l i c y statements as t o what s e r v i c e s s h o u l d be a v a i l a b l e i n a region.  The model e x c l u d e s  t e r t i a r y s e r v i c e , daycare,  renal  51 d i a l y s i s , hemodialysis, recovery  labour, holding, h o s t e l , d e t o x i f i c a t i o n ,  room, D.V.A. and D.N.D. beds w h i c h are c o n s i d e r e d The  separately.  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 t a r g e t f o r a c t i o n .  The  l o n g 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 o u t f l o w between r e g i o n s i s e l i m i n a t e d from the calculation.  The  i m p l i e d a s s u m p t i o n i s t h a t 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 w h i c h the m i g r a n t was D i v i s i o n of H o s p i t a l and M e d i c a l P u b l i c H e a l t h S e r v i c e s Mode  seeking.  Facilities  Donabedian drew a t t e n t i o n t o the P u b l i c H e a l t h model because of i t s v a r i o u s r e f i n e m e n t s , methods were used.  even though  Services conventional  H i s 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 d a t a  r e q u i r e m e n t s : age-sex c o m p o s i t i o n of the p o p u l a t i o n ; u t i l i z a t i o n age  and sex; a p r o j e c t e d use r a t e by age  estimate,  comprised of the p r e c e d i n g  by s e r v i c e c a t e g o r y .  The bed  and sex; and a demand  v a r i a b l e s , which i s c a l c u l a t e d  r e q u i r e m e n t s are a d j u s t e d by a d e s i r e d  occupancy l e v e l w h i c h 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 service.  by  the  Bed r e q u i r e m e n t s f o r a l l h o s p i t a l s are the summation o f  aggregate s e r v i c e r e q u i r e m e n t s .  The  services considered  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 , M e d i c a l  i n short-  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 u s i n g the same methodology. To summarize the methodology f o r a g i v e n number of h o s p i t a l s , the p r o c e d u r e 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  p r o j e c t e d on a f u t u r e 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 t h e s e t o t a l days a r e then d i v i d e d by 365 occupancy f a c t o r .  sex i s  f i g u r e , and  and m u l t i p l i e d by a d e s i r e d  A p r i o r i , t h e r e are c h r o n i c o r extended  care  52 ( l o n g s t a y p a t i e n t s ) who occupy s h o r t - t e r m beds.  These have n o t  been a d d r e s s e d i n the model even though t h e r e i s a s e p a r a t e c a l c u l a t i o n f o r l o n g - t e r m p a t i e n t s ( o v e r 65 y e a r s ) .  The m e d i c a l s u r g i c a l  days a r e c a l c u l a t e d on t h e 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  The f o l l o w i n g e x t r a c t i s t a k e n from  t e x t o f Donabedian. O b s t e t r i c a l bed u s e , short-term h o s p i t a l  D.  P r o j e c t e d number o f f e m a l e s aged 15-44 i n thousands (from a p r e v i o u s p r o j e c t i o n )  E.  D e l i v e r i e s p e r 1000 i n females aged 15-44 p e r y e a r ( c u r r e n t or p r o j e c t e d r a t e s )  FV. Length o f s t a y , i n days, p e r delivery (current o r projected values)  Average d a i l y census by type o f s e r v i c e , short-term hospitals Beds by type o f service; 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  G.  P r o j e c t e d p a t i e n t days o f 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 for o b s t e t r i c a l care (D x E x F) v 365 P r o j e c t e d beds f o r o b s t e t r i c a l c a r e a t 75% occupancy L v .75  H o s p i t a l Bed Requirements: An Occupancy D e t e r m i n a t i o n Approach 197<P  Factor  U  The • Occupancy F a c t o r D e t e r m i n a t i o n model proposed by t h e a u t h o r s was a p p l i e d t o t h e C i t y o f Chicago H e a l t h S e r v i c e A r e a and Suburban H e a l t h S e r v i c e A r e a .  The key concepts employed a r e p o i s s o n  distribution, distinct patient f a c i l i t y out  (D.P.F.), p r o t e c t i o n  level,  o f s e r v i c e beds (due t o maintenance, r e m o d e l l i n g , e t c . ) , p r o -  t e c t e d occupancy ( t h e average d a i l y census d i v i d e d by the number o f beds r e q u i r e d f o r a D.P.F.,- w h i c h r e p r e s e n t s maximum o c c u p a n c y ) . distinct patient f a c i l i t y  r e p r e s e n t s a s e r v i c e w h i c h , under normal  A  c o n d i t i o n s , cannot be o c c u p i e d by o t h e r than t h e t y p e o f p a t i e n t f o r w h i c h i t was d e s i g n e d t o s e r v e . The model w h i c h i s used t o determine bed r e q u i r e m e n t s i s g i v e n below (from t e x t pp. 6-8). 1.  Determine t h e average d a i l y census by D.P.F. Current u t i l i z a t i o n (or desired o r p r o j e c t e d ? ) .  2.  S e t 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 choice).  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 o f D.P.F. ( T h i s s t u d y used p o i s s o n f o r a l l D.P.F.'s).  4.  C a l c u l a t e the n e t r e q u i r e d beds f o r each D.P.F.  5.  Add average out o f s e r v i c e beds t o n e t r e q u i r e d beds f o r each D.P.F. and sum t h e s e t o get g r o s s r e q u i r e d beds f o r each s e t o f D.P.F.'s.  6.  D i v i d e t h e sum o f t h e average d a i l y census f o r a l l D.P.F.'s i n t h e s e t by t h e sum o f the g r o s s r e q u i r e d beds t o d e t e r m i n e t h e a p p r o p r i a t e average occupancy f o r each s e t o f D.P.F.'s.  R e t u r n i n g t o o r i g i n a l f o r m u l a i n Step #1, Average d a i l y census = r e 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 y e a r X ^ 365 = beds r e q u i r e d i n y e a r X Occupancy f a c t o r (Step #6) Beds r e q u i r e d i n y e a r X a r e c a l c u l a t e d f o r each D.P.F. c a 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) c a t e g o r i e s a r e : 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 o t h e r .  The r e q u i r e d beds w h i c h a r e determined may  be a n a l y z e d w i t h i n county b o u n d a r i e s by the s i z e o f h o s p i t a l o r D.P.F.  S i m i l a r l y , t h e components o f t h e c a l c u l a t i o n o f beds (average  d a i l y census and occupancy f a c t o r ) can be g i v e n i n t h e s e types o f analyses..  Summary The h o s p i t a l bed h e a l t h care planning.  continues  t o occupy a s t r a t e g i c p o s i t i o n i n  I t i s t o the h o s p i t a l t h a t a g r e a t p o r t i o n of  our h e a l t h c o s t s are d i r e c t e d because of the c u r a t i v e r o l e w h i c h they p l a y .  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  where a "package" of s e r v i c e s and the p o p u l a t i o n .  resources  can be d i s t r i b u t e d to  T h i s "package" i s g i v e n i n e r t i a when a p a t i e n t  o c c u p i e s a bed o r when the bed  i s expected to be f i l l e d .  and Knappenberger"^ respond t o t h e i r own beds: "The  place  Goldman  q u e s t i o n of a l l o c a t i n g  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 t o be d e r i v e d by g r o u p i n g 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 a r e a c o n v e n i e n t t o f a c i l i t i e s and 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 . " f o r resource  In u t i l i z i n g one  concept  d i s t r i b u t i o n such as beds, r i g h t l y o r w r o n g l y , the  o f comprehending the m u l t i t u d e resource  the  of v a r i o u s i n t e r a c t i n g p a r t s  task  and  r e q u i r e m e n t s i s reduced to manageable p r o p o r t i o n s . However, F e r r e r s u g g e s t s t h a t l e s s time be devoted to  f o c u s i n g upon d e t e r m i n a t i o n  o f f u t u r e l e v e l s of r e s o u r c e s .  we s h o u l d , i n s t e a d , c o n c e n t r a t e  Perhaps  on u s i n g the a v a i l a b l e r e s o u r c e s  the most e f f e c t i v e manner o r mix  in  to d e a l w i t h the problems p r e s e n t e d  52 by p a t i e n t s . It i s evident  from the r e v i e w t h a t v a r i o u s methods  m o d i f i c a t i o n s t o bed p l a n n i n g  and  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 w h i c h show r e f i n e m e n t s such as age-sex u t i l i z a t i o n r a t e s and c l i n i c a l s e r v i c e r a t e s  are  models w h i c h 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 w h i c h impact  upon demand: a p r i o r i , these models a r e s u p e r i o r . obvious  I t i s also  t h a t some methods a r e e x p e r i m e n t a l and s t i l l must be proven.  R e g a r d l e s s o f t h e method used, i t i s a t b e s t a g u i d e l i n e f o r t h e  53 p l a n n e r o r d e c i s i o n maker.  Walsh and B i c k n e l l  appropriately  conclude i n t h e i r model: " f o l l o w i n g t h e d e t e r m i n a t i o n o f beds o t h e r r e l e v a n t i s s u e s a r e c o n s i d e r e d and f u r t h e r adjustments  a r e 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 d e c i d i n g what l e v e l o f r e s o u r c e s w i l l produce an a c c e p t a b l e s t a n d a r d f o r b o t h the l o c a l and e n t i r e p o p u l a t i o n , g i v e n t h a t some o f h i s d e c i s i o n factors are s u b j e c t i v e i n nature.  Part 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 o f b o t h t h e model and i t s u s e r . P l a n n i n g S t u d i e s i n Newfoundland R e l a t e d t o Resource D i s t r i b u t i o n Pierce,in  1967, had t h i s t o say about the p r o v i n c e ' s  method o f c a l c u l a t i n g bed r e q u i r e m e n t s : I n p l a n n i n g f o r new f a c i l i t i e s the Department cons 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 . A l t h o u g h t h e r e i s no f o r m u l a o r s t a n d a r d 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 , p a s t p a t t e r n s o f 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 t o t h e Department o f H e a l t h as a p l a n n i n g e n t i t y w i t h methods developed w i t h i n a p l a n n i n g 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. F u r t h e r , an e x a m i n a t i o n o f s t a t i s t i c s and events l e a d s t o a c o n c l u s i o n t h a t t h e r e 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 s e t up p e r thousand p o p u l a t i o n i n t h e p r o v i n c e  f o r the y e a r s 1960, 1970 and 1976 were 7.9, 7.9 and 7.6, r e s p e c tively.  From 1976 t o the p r e s e n t the budget f o r t h e Department has  undergone t i g h t e n i n g .  I n t h i s same p e r i o d , o t h e r p r o v i n c e s  exper-  i e n c e d t h i s c o n s t r a i n t and a l s o q u e s t i o n e d e x i s t i n g bed l e v e l s .  The outcome was  p e r thousand p o p u l a t i o n . reduced t h e i r bed l e v e l s . and s t a f f e d was  the a p p r o p r i a t e n e s s  of  a g e n e r a l r e d u c t i o n of beds  Newfoundland and o t h e r p r o v i n c e s have By March 31, 1978,  the e x p e r i e n c e  a r a t e of 6.4  approved  f o r b o t h s h o r t term and l o n g term  beds.  Y e t , P i e r c e ' s o r i g i n a l o b s e r v a t i o n remains, i n p a r t , t o 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 r e f e r e n c e t o the B r a i n Commission Report o f  1969.  The B r a i n Commission used an analogy method w i t h  other  p r o v i n c e s and the Canadian average to e s t a b l i s h a bed r a t e of beds p e r thousand p o p u l a t i o n .  At t h a t time money was  8.0  plentiful;  t h e r e f o r e , e x p e r t o p i n i o n and statements of what ought t o 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 o f M e n t a l  56 H e a l t h S e r v i c e s , 1973. .4 s h o r t term and  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 o f  .6 l o n g 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 r e g i o n i n the p r o v i n c e .  In t h i s determination  r a t e , b o t h the census and occupancy o f each r e g i o n was  of  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  b o t h r a t i o a a n d analogy to show the g e r i a t r i c needs o f the Newfoundland p o p u l a t i o n . ^ expressed  The p r o p o r t i o n o f types of g e r i a t r i c beds  7  as a p e r c e n t a g e o f 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 e s t i m a t e d beds i n Newfoundland. Between 1973  and  1974  the H e a l t h P l a n n i n g and Development  Committee p u b l i s h e d a g e n e r a l o v e r v i e w and t h r e e r e p o r t s w h i c h 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  d e a l of d i s c u s s i o n i n these r e p o r t s f e l l upon the d e t e r m i n a t i o n bed r e q u i r e m e n t s .  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  of  methodology as t h e r e was  no statement of p r o c e d u r e .  m e t h o d o l o g i e s were employed.  Numerous sub-  Extended c a r e 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 t o 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 f a s h i o n but t h e r e were assumptions o f b o t h time and d i s t a n c e .  Beds i n use were surveyed  to determine  the number o f beds which c o u l d be a s s i g n e d t o a l e v e l of c a r e acute, convalescent).  (e.g.,  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 p r o v i d e a f i n a l e s t i m a t e beds.  of  At the core o f the c a l c u l a t i o n a r e 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 .  I n v e r y s i m p l e 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 c a s e s , l e n g t h o f s t a y and  occupancy  factor. A s t u d y , developed  by the Department o f H e a l t h P l a n n i n g  D i v i s i o n , d e a l s e x c l u s i v e l y w i t h the c u r r e n t 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 . p o p u l a t i o n (aggregate) of cases  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 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 .  I n a number  the bed d e t e r m i n a t i o n i s a d j u s t e d i n the f u t u r e a c c o r d i n g  to f u t u r e e x p e c t a t i o n s o f h e a l t h d e l i v e r y and a c c o r d i n g t o r a t e s established i n previous studies.  Beds are e s t i m a t e d f o r 1981,  on paper i t i s t h e 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 . at hand, a new important  s e t of p r o j e c t i o n s i s i n o r d e r .  As  1981  and  i s close  T h i s s t u d y i s more  f o r i t s u n d e r l y i n g 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 o f w h i c h 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 Division.  As t h e r e was  statistical district  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  o r f o r h o s p i t a l s e r v i c e s a r e a , 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 c r o s s - r e f e r e n c e d to census d i v i s i o n data.  T h i s t a s k was  done manually.  Consequently,  a partial  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 o f  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 a c c o m p l i s h e d . D u r i n g 1978,  McKinsey and Company conducted a s t u d y f o r the 60  S t . 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,  r e p o r t had not y e t been r e l e a s e d . w o r k i n g papers.  The  the  final  f o l l o w i n g comments are  from  I n the " D e t e r m i n i n g Need/Resource B a l a n c e s " of  Phase I of the p r o j e c t , the key elements f o r d e t e r m i n i n g needs were: p o 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  health  utilization  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 c a r e ; measure of needs met  the  by f a c i l i t i e s o u t s i d e S t . J o h n ' s ; and  fore-  c a s t i n g the net demand on S t . John's, T h i s p r o j e c t went beyond p r e v i o u s 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 t o d e f i n e and p r o j e c t the age-sex p o p u l a t i o n of t h r e e a r e a s . care  (primary,  secondary and  w i t h census d i v i s i o n s .  These a r e a s were d e f i n e d by l e v e l s of t e r t i a r y ) and  coincide  To c i r c u m v e n t t h i s problem, the age-sex  c o m p o s i t i o n of the s u b r e g i o n s was  c a l c u l a t e d t h r o u g h the use o f a  r a t i o method on census p r o j e c t i o n s . population  t h e r e f o r e d i d not  The  cross-referencing  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  and  obtained  from the s t u d y "Newfoundland and L a b r a d o r P o p u l a t i o n , P a r t I I , 1966/1971." daries  The  age-sex p r o j e c t i o n s were a t the care l e v e l boun-  only. A l s o i n t e r e s t i n g was  bed  requirements.  the method of d e r i v i n g and  forecasting  For the S t . John's a r e a a u t i l i z a t i o n  ( 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  rate  and sex  through  a p r o c e s s o f g r o u p i n g p a t i e n t days i n t o f o u r s e r v i c e s (the computer program was  developed by the Newfoundland Department of  The  g r o u p i n g was  The  age-sex m o r b i d i t y  Health).  performed on the Canadian 188 D i a g n o s t i c  Listing.  s e r v i c e r a t e s were m u l t i p l i e d by the age-sex  population  f i g u r e s t o produce a s e r v i c e need.  The average d a i l y  census o f t h e h o s p i t a l was t a k e n i n t o account and s u b j e c t e d r a t i o n a l e of the Poisson occupancy r a t e s .  to the  d i s t r i b u t i o n t o determine maximum r e a l i s t i c  The f i n a l e s t i m a t i o n o f bed r e q u i r e m e n t s 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 t h e maximum occupancy r a t e . A c l e a r l y d e f i n e d methodology f o r e s t i m a t i n g bed r e q u i r e m e n t s does n o t appear t o e x i s t a t t h e government l e v e l .  However, t h e r e i s  an i m p l i c i t model w h i c h u t i l i z e s a s t a n d a r d  This  rate.  standard  r a t e appears t o be a p r o d u c t 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 o t h e r 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 , t h e summation o f i n d i v i d u a l -  i z e d ( h o s p i t a l ) bed r e q u i r e m e n t s and an e x p e r i e n t i a l f e e l i n g f o r t h e needs o f areas.  In the opinion of the w r i t e r the c o n t i n u a t i o n o f  t h i s method i s f o s t e r e d by t h e r e l a t i v e s m a l l n e s s o f t h e system. T h i s s m a l l n e s s has t r a d i t i o n a l l y l e d t o c l o s e r c o n t a c t between a d m i n i s t r a t o r s and department o f 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 t h e needs i n a r e a s .  Yet there  i s t h e q u e s t i o n o f a s t a b l e bed r a t e over t h e p a s t two decades. P l a u s i b l e explanations  do e x i s t and t h e s e a r e a t t e n d e d t o i n t h e  d i s c u s s i o n to f o l l o w . Problems A s s o c i a t e d w i t h t h e D i s t r i b u t i o n o f H e a l t h Care Resources t o R u r a l Areas i n Newfoundland At l e a s t 60% o f t h e Newfoundland p o p u l a t i o n  resides 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 o r d i s t 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 o f  h e a l t h care w h i c h has t h e 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 o f  60 r e s o u r c e s found i n the urban d e l i v e r y system.  I n many r e s p e c t s , the  problems w h i c h are e x p e r i e n c e d i n r u r a l areas a r e the same as t h o s e e x p e r i e n c e d by t h e i r l a r g e r more o r g a n i z e d c o u n t e r p a r t s .  Their  d i f f e r e n c e w h i c h i s f e l t i s one i n degrees. The problems w h i c h a r i s e i n t r y i n g t o d e a l w i t h r u r a l h e a l t h 61—6 8 c a r e d e l i v e r y a r e w e l l a t t e n d e d 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 w h i c h s u r f a c e s i s t h a t the r u r a l system must be thought of as u n i q u e ; y e t 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 w h i c h i s w i l l i n g to d e p l o y r e s o u r c e s to s o l v e r u r a l system problems w i t h o u t j e o p a r d i z i n g the r i g h t s and needs o f the r u r a l p o p u l a t i o n .  T h i s t y p e o f 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 i n n o v a t i v e management and p l a n n i n g 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 c a r e d e l i v e r y a r e g i v e n below i n a combined and g e n e r a l i z e d form.  These a r e n o t meant  to be i n c l u s i v e ; i n s t e a d they form the bases o f d i s c u s s i o n i n Appendix A. Appendix A p r e s e n t s a more d e t a i l e d d i s c u s s i o n o f t h e s e l i s t e d t r a i t s and a l s o d e s c r i b e s r e l e v a n t examples a p p l i c a b l e t o t h e r u r a l s e t t i n g i n Newfoundland. 1.  Recruitment  2.  E d u c a t i o n a l maintenance  3.  Environment ( p u b l i c h e a l t h , s o c i a l , geography, e t c . )  4.'  Population structure  5.  L e a d e r s h i p and o r g a n i z a t i o n a l  6.  I m p o s i t i o n o f o t h e r system s t a n d a r d s  7.  Economic base of community  8.  A t t i t u d e s towards c o o p e r a t i o n  9.  Economic dependence on d e l i v e r y • s y s t e m  10.  Methods o f 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  activities  61 Chapter I I I Footnotes  Avedis Donabedian, Aspects o f M e d i c a l 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 H e a l t h Care (Cambridge, Mass.: Harvard U n i v e r s i t y P r e s s , 1973), pp. 532-639. 2 Rosson L. C a r d w e l l , "How to Measure M e t r o p o l i t a n Bed Needs," The Modern H o s p i t a l 103 (August 1964): 107-111, 181. 3 Donabedian, pp. 532-639.  4 V i n c e n t e Navarro, " P l a n n i n g f o r the D i s t r i b u t i o n of P e r s o n a l H e a l t h S e r v i c e s , " P u b l i c H e a l t h Reports 84 ( J u l y 1969): 573-581. "*Robin E. M a c S t r a v i c , Determining H e a l t h Needs (Ann Arbor, Mich.: H e a l t h A d m i n i s t r a t i o n P r e s s , 1978), pp. 73-135.  56 'Robin E. M a c S t r a v i c , "How Many H o s p i t a l Beds Does V i r g i n i a Need?" V i r g i n i a M e d i c a l (January 1978): 73-75. 77 'Navarro, pp. 573-581. 8 •Ibid. 9 H, P. F e r r e r , ed., The H e a l t h S e r v i c e s - A d m i n i s t r a t i o n , Research and Management (London: B u t t e r w o r t h , 1972), pp. 186-197. 10 " M a c S t r a v i c , Determining H e a l t h Needs, pp. 73-135. M a r k S. Blumberg, "DPF Concept Helps P r e d i c t Bed Needs," The Modern H o s p i t a l 97 (December 1971): 75-8}. 1 1 >  12 " • C a r d w e l l , pp. 107-111, 181. 13 " " W i l l i a m Shonick, "Understanding the Nature of the Random F l u c t u a t i o n s o f the H o s p i t a l D a i l y Census: An Important P l a n n i n g T o o l , " M e d i c a l Care 10 ( M a r c h / A p r i l , 1972): 118-137. 14 " " F e r r e r , pp. 186-197. 15 " S h o n i c k , pp. 118-137. 16 . " M i l t o n L. Roemer, Bed Supply and H o s p i t a l U t i l i z a t i o n : A N a t u r a l Experiment," H o s p i t a l s 35 (November 1961): 36-42. 17 B. M. K l e c z k o w s k i and R. P i b o u i l e a u , eds., Approaches to P l a n n i n g and Design of H e a l t h Care F a c i l i t i e s i n D e v e l o p i n g Areas, WHO O f f s e t Pub. No. 37 (Geneva: World H e a l t h O r g a n i z a t i o n ) , pp. 44-47. 18 Donabedian, pp. 532-639. 19 . C a r d w e l l , pp. 107-111, 181.  62 20  F r a n c i s M. 0. Umenyi, Trends i n U t i l i z a t i o n o f 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 F u t u r e Demand ( S t a t i s t i c s Canada: Ottawa, A p r i l 1978), pp. 1-74. 21 M a c S t r a v i c , D e t e r m i n i n g H e a l t h Needs, pp. 73-75. ,, Douglas W. P a i n e and Lawrence L. W i l s o n , The D e t e r m i n a t i o n o f A c u t e Care Bed Requirements f o r P r o v i n c i a l A c u t e Care H o s p i t a l s , " i n Systems A s p e c t s o f H e a l t h P l a n n i n g , e d s . , Norman T. J . B a i l e y and Mark Thompson (Amsterdam, O x f o r d : N o r t h - H o l l a n d P u b l i s h i n g Company, 1975), pp-. 63-76. 23 C a r d w e l l , pp. 107-111, 181. 24 ' " R i c h a r d 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 e r v i c e s Research ( S p r i n g 1974): 62-68. 25 A l f r e d J . K a r n i e w i c z , 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 „ " M a r t i n S. F e l d s t e i n , An Aggregate P l a n n i n g Model o f t h e H e a l t h Care S e c t o r , " M e d i c a l Care 5:6 (November/December): 369-381. 22  23 ""^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 o f F u t u r e 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 R a c h e l Doyle e t a l . , E s t i m a t i n g H o s p i t a l Use i n A r k a n s a s , P u b l i c H e a l t h Reports 92 (May/June 1977): 211-216. John 0. M c L a i n , A Model f o r R e g i o n a l O b s t e t r i c Bed P l a n n i n g , " H e a l t h S e r v i c e s Research 13 ( W i n t e r 1978): 378-393. 30 F e l d s t e i n , pp. 369-381. 31 and  Vernon E. Weckworth, " D e t e r m i n i n g Bed Needs from Occupancy Census F i g u r e s , " H o s p i t a l s 40 (January 1966): 52-54.  ^ ^ M i c h a e l S. L i c h t e r m a n and S h e l d o n K. G u l i n s o n , H o s p i t a l Bed Requirements: An Occupancy F a c t o r D e t e r m i n a t i o n Approach ( C h i c a g o : Chicago H o s p i t a l C o u n c i l , 1979), pp. 1-24. 33 Ibid. 34 •McLain, pp. 378-393. 35 F. R. N o r m i l e 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. 38  B l u m b e r g , pp. 75-79, 80-81.  63 39  Nancy L. G e l l e r and M i c h a e l G. Yochmowitz, " R e g i o n a l P l a n n i n g o f M a t e r n i t y S e r v i c e s , " H e a l t h S e r v i c e s Research 10 ( S p r i n g 1975): 63-75. 40 41  Shonick, pp.  118-137.  Donabedian, pp.  532-639.  42 Meeting o f P l a n n i n g and Research D i r e c t o r s , A t l a n t i c P r o v i n c e s Departments of H e a l t h , H a l i f a x , 24 November 1978. 43 Donabedian, pp. 532-639. 44 M a c S t r a v i c , Determining H e a l t h Needs, pp. 73-135. 45  Navarro, pp.  ^ U m e n y i , pp.  573-581. 1-74.  47 A. S. S l u t s k y , "Mathematical Model Used i n F o r e c a s t i n g M a t e r n i t y F a c i l i t i e s Needs," 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 (March 1977) : 54 48 Brooks and Beenhakker, pp. 47-50.  49 H o s p i t a l Bed G u i d e l i n e s Committee, I n t e r i m Report to the Department o f H e a l t h and the New Brunswick H o s p i t a l A s s o c i a t i o n on a R e g i o n a l Bed D i s t r i b u t i o n Model, New Brunswick Department o f H e a l t h , May 1973. ^ D o n a b e d i a n , pp.  532-639.  ^\,ichterman and G u l i n s o n ,  pp.  1-24.  52 Jay Goldman, H. A l l a n Knappenberger and J . C. E l l e r , " E v a l u a t i n g Bed A l l o c a t i o n P o l i c y w i t h Computer S i m u l a t i o n , Health S e r v i c e s Research 3 (Summer 1968): 119-129. 53 " F e r r e r , pp. 186-197. 11  54 " D i a n a Chapman Walsh and W i l l i a m J . B i c k n e l l , " F o r e c a s t i n g the Need f o r H o s p i t a l Beds: A Q u a n t i t a t i v e Methodology," P u b l i c H e a l t h Reports 92 (May/June 1977): 199-21D 55 G. A. H. P i e r c e , Bed Need D e t e r m i n a t i o n i n Canada: A Summary o f Methods Used by P r o v i n c i a l H o s p i t a l A u t h o r i t i e s (Diploma T h e s i s , U n i v e r s i t y o f Toronto, 1967), pp. 1-62. 56 D. V. G l a s s , " S t r u c t u r e of the Newfoundland P o p u l a t i o n , " c i t e d by. R i g h t Honourable Lord B r a i n , Royal Commission on H e a l t h , V o l . 1 (Government o f Newfoundland, 1966), 1:4-7. •^Mental H e a l t h S e r v i c e s D i v i s i o n , O u t l i n e o f Mental H e a l t h S e r v i c e s i n Newfoundland, Newfoundland Department on H e a l t h , 1973.  64 58  „ A. T. Rowe, D e v e l o p i n g 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 L a b r a d o r P o p u l a t i o n , 1966/1971, P a r t I I , 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 , " S t . John's, Newfoundland.Department of H e a l t h , September 1976. 60 A. B. Murphy, "A Study o f H o s p i t a l Beds i n Newfoundland P e r 1000 P o p u l a t i o n as Compared t o P r o j e c t e d H o s p i t a l Beds i n Newfoundland P e r 1000 P r o j e c t e d P o p u l a t i o n 1980-81," S t . John's, Newfoundland Department o f H e a l t h , September 1975. 61 McKinsey and Company. P r o v i s i o n s o f C l i n i c a l S e r v i c e s and Programs i n S t . J o h n ' s : A Study t o Determine F u t u r e Requirements, S t . J o h n ' s : S t . John's H o s p i t a l s A d v i s o r y C o u n c i l , 1979. (Working papers.) 62 R i g h t Honourable L o r d B r a i n , R o y a l Commission on H e a l t h , 3 v o l s . , S t . John's: Government o f Newfoundland and L a b r a d o r , 1966. 63 J u l i a n A. W a l l e r , "RuralSEmergency Care - Problems and P r o s p e c t s , " American J o u r n a l of P u b l i c H e a l t h 63 ( J u l y 1973): 631-634. 64 J u l i a n A. W a l l e r , " U r b a n - O r i e n t e d Methods: F a i l u r e t o S o l v e Rural'JEmergency Care Problems," J o u r n a l o f American M e d i c a l 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 , " H e a l t h S e r v i c e s 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 o f P u b l i c H e a l t h 64 (September/October 1973): 500-502. Ibid. 6 6  ^ S t e p h e n P o r t n o y and W i l l i a m L. Casady, " R u r a l H e a l t h 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. B l a c k , " M e d i c a l S e r v i c e s f o r I s o l a t e d A r e a s , " Canadian F a m i l y 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 , " R u r a l S e r v i c e Elements F a l l C o o r d i n a t i o n , " 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 I V  METHODOLOGY Research S t r a t e g y There were a number o f v e r y i n f l u e n t i a l f a c t o r s which cont r i b u t e d t o t h e d e s i g n o f b o t h t h e study and i t s component methods. The  t i m i n g and need f o r a new s e t o f bed e s t i m a t e s was a p p r o p r i a t e  because t h e o n l y e s t i m a t e s a v a i l a b l e t o t h e Department o f H e a l t h were f o r a p e r i o d e n d i n g i n 1981.  The method t h a t was used by t h e  P l a n n i n g D i v i s i o n was a bed t o p o p u l a t i o n r a t i o p r o j e c t e d i n t o t h e future.  Both o p i n i o n o f the w r i t e r and o f authors  l i t e r a t u r e , predisposed  reviewed  i n the  the w r i t e r t o attempt a d e s i g n o f a bed  p r e d i c t i o n model t h a t 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 i n v o l v e m e n t w i t h v a r i o u s s t u d i e s d u r i n g 1978 and 1979,  i n t h e c a p a c i t y o f s u p p l y i n g d a t a to r e q u e s t s by p l a n n e r s and  r e s e a r c h e r s , i t became i n c r e a s i n g l y apparent t h a t one v e r y v i t a l d a t a f i l e was m i s s i n g f o r p l a n n i n g and r e s e a r c h .  T h i s f i l e was t h e  age-sex p o p 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 . T h i s view was n o t o n l y supported  by e p i d e m i o l o g i s t s and r e s e a r c h e r s  but t h e Department o f H e a l t h was v e r y i n t e r e s t e d i n o b t a i n i n g agesex d a t a 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 t h e age-sex d a t a q u i c k l y because i t was i n the m i d s t o f p l a n n i n g f o r the o p e r a t i o n o f N u r s i n g Home f a c i l i t i e s i n t h e 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 c o n s t r u c t a d e s i g n  w h i c h r e s t e d upon assumptions of what ought to be; p o r a t e statements  i t had  to i n c o r -  of a c c u r a c y or ranges among s t a n d a r d s so t h a t the  r e a d e r or d e c i s i o n maker c o u l d a d j u s t r e s u l t s o r methods to d e a l w i t h the problem a t hand. D u r i n g 1978, McKinsey and Company conducted f o r the S t . John's H o s p i t a l s A d v i s o r y C o u n c i l . programs were developed for t h e i r requests.  a s t u d y of needs  A number of computer  by the Department of H e a l t h to c o l l e c t d a t a  As the p r e s e n t study e v o l v e d , i t became e v i d e n t  t h a t one of the programs c o u l d be u t i l i z e d v e r y e f f e c t i v e l y i f a m o d i f i c a t i o n s were made to i t .  few  I n a d d i t i o n , the parameter of an age-sex  p o 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 c o u l d be e a s i l y i n c o r p o r a t e d 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.  I n t h i s sense, the d e s i g n of the s t u d y u n f o l d e d  and was  a l s o the i m p o r t a n t consequence of need.  (being more a n a l y t i c a l ) was  naturally  The methodology  c o n s i d e r e d to be an enhancement over  p r e v i o u s bed to p o p u l a t i o n method.  T h i s o p i n i o n c o u l d not be  the  left  unchallenged. Common and v i t a l to each method was p o p u l a t i o n growth. bed t o p o p u l a t i o n method c o n s i d e r e d o n l y aggregate  The  p o p u l a t i o n whereas  the p r e s e n t s t u d y c o n s i d e r e d the growth of the p o p u l a t i o n as comp r i s e d of age and sex movements. and  the s t u d y , t h e r e f o r e , had  The d e s i g n of b o t h the methodology  to f o c u s upon comparison of methods by  showing i f t h e r e 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 a c u t e c a r e beds o r a c u t e c a r e bed  types.  I n so d o i n g , the problem o f 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 p o p u l a t i o n s to the h e a l t h d i s t r i c t s was  also s a t i s f i e d .  67 Research S e t t i n g The the P r o v i n c e  study was conducted between J u l y and December o f 1979 i n o f Newfoundland and L a b r a d o r .  The f o c u s o f t h e s t u d y  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 r e g i o n s  i n the c a l c u l a t i o n o f h o s p i t a l a c u t e c a r e beds.  N e i t h e r h o s p i t a l s n o r h e a l t h d i s t r i c t s were s u r v e y e d d i r e c t l y f o r data.  Instead  o f t h e m a j o r i t y o f t h e d a t a was r e t r i e v e d ( o r g e n e r a t e d )  from Department o f H e a l t h d a t a  files.  Data Sources I n some cases i t was v e r y d i f f i c u l t t o l o c a t e methods or materials.  C o n s e q u e n t l y i t i s i m p o r t a n t t h a t some o f t h e d a t a  s o u r c e s be e x p l i c i t l y s t a t e d so t h a t 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 d a t a c o l l e c t i o n . U n i v e r s a l T r a n s v e r s e M e r c a t o r (U.T.M.).  This i s the tech-  n i c a l name o f a system o f c o d i n g 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 B e t t e r Use Development D i v i s i o n , Ottawa w h i c h c r o s s r e f e r e n c e s w i t h the census code f i l e . a l s o be o b t a i n e d  Cross-reference  codes can  from t h e Department o f H e a l t h P l a n n i n g D i v i s i o n  p r i o r t o and f o l l o w i n g t h e major census d i v i s i o n and subsequent changes i n 1966 t h r o u g h the r e p o r t s e n t i t l e d : Labrador P o p u l a t i o n s :  "Newfoundland and  1961, 1966, 1971, 1976 .Health  D i s t r i c t s " and "Newfoundland and Labrador P o p u l a t i o n s : Health  Statistical Districts." Census Data Tapes.  1  Statistical 1961 and 1966  '  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 o f Newfoundland and t h e Geography Department  68 of Memorial U n i v e r s i t y have 1976  and  1971  Hospital Inpatient Morbidity.  census t a p e s .  Data i s coded and  stored  tape by the S t a t i s t i c s D i v i s i o n of the Department o f H e a l t h .  on Two  c o d i n g 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  D i s e a s e s , E i g h t h 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 Diagnostic  Listing  Population  188  (C-188). Figures.  Both census and p r o j e c t i o n s are  avail-  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 o r f r o m the census tapes mentioned p r e v i o u s l y . L e n g t h o f Stay and  Inpatient Morbidity  Rates.  Both types of  d a t a 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 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  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 s t a y . D i v i s i o n a l s o produces the C-188 for  from t h e  age  and  The  by l e n g t h of s t a y and  and  Statistics separation  sex. Methods of C o l l e c t i n g Data  S o r t i n g o f Codes As a major e f f o r t had been made a t c r o s s - r e f e r e n c i n g d i v i s i o n s and was  census  s u b d i v i s i o n s t o 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  d e c i d e d t o 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 p r e s e n t 2  study.  '•  '  From the c r o s s - r e f e r e n c e  community was district.  t r a n s p o s e d by age  and  w h i c h was  a v a i l a b l e , each census  sex to i t s a p p r o p r i a t e  Each community's p o p u l a t i o n was  compared to the  health population  f i g u r e s p r o v i d e d 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 b e i n g conducted, the i n c l u s i o n of  each community and enumeration a r e a was checked a g a i n s t a Newfoundl a n d map o f 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 . c a r r i e d o u t f o r 1971 and 1976. Normally  T h i s p r o c e d u r e was  T r a n s p o s i t i o n e r r o r was  t h i s e r r o r reaches a p p r o x i m a t e l y  5%.  expected.  The e r r o r r a t e w h i c h  was employed f o r t h i s study was t h a t t h e summation o f h o s p i t a l d i s t r i c t t o t a l s would n o t exceed t h e thousandth o f a p e r c e n t when compared w i t h t h e Census f o r Newfoundland.  error  T h i s c r i t e r i a was  met and was i n t e n d e d as a r e l i a b i l i t y measure f o r f u t u r e r e s e a r c h e r s . I n d i s c u s s i o n s w i t h demographers t h e c r i t e r i a e s t a b l i s h e d was v e r y 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 c h o i c e o f method was t h e s h o r t form o f t h e R a t i o  Method w i t h a r e f i n e m e n t The  r a t i o refinement  w h i c h i s suggested i n t h e l i t e r a t u r e  review.  was an o b s e r v e d change i n t h e 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 p e r i o d s o v e r an o b s e r v e d 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 p e r i o d s . T h i s r a t i o a l l o w s n o t o n l y a b s o l u t e change b u t i t a l s o a l l o w s an age-sex group's p e r c e n t a g e o f t h e t o t a l p o p u l a t i o n t o i n c r e a s e o r decrease.  The c h o i c e i n u s i n g t h i s r e f i n e m e n t was, t h e r e f o r e , t h e  r e a s o n f o r r e j e c t i n g o t h e r r a t i o methods.  The s h o r t form d e s c r i b e s  a method o f c a l c u l a t i n g l o c a l p o p u l a t i o n s a g a i n s t 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 c o n s i d e r e d as an a l t e r n a t i v e . However, t h e degree o f d e t a i l r e q u i r e d f o r t h e l o c a l l e v e l combined w i t h an absence o f c u r r e n t 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 ( t h e i n v e r s e o f mort a l i t y ) , and f e r t i l i t y o r m i g r a t i o n r a t e s p o i n t e d t o t h e c h o i c e o f  a n o t h e r model.  The  u s e r s 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 o t h e r methods. o t h e r words, i t s a c c u r a c y i n the s h o r t run would not be t i a l l y b e t t e r than t h a t produced by o t h e r methods.  In  substan-  However, i n the  l o n g run t h i s model would be e x p e c t e d t o a c h i e v e b e t t e r r e s u l t s than s i m p l e r methods such as a r i t h m e t i c , g e o m e t r i c and  ratio.  A priori,  on a n a l y t i c a l grounds t h i s model w i t h good assumptions s h o u l d produce superior results. r e v i e w and  These comments were c o n f i r m e d i n the  literature  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  a t Memorial U n i v e r s i t y .  I n d e s c r i b i n g the problems to be  come, such as the s o r t i n g of two s p e c i f i c data,  codes and  the r a t i o method was  s h o r t term p r o j e c t i o n was  over-  the l a c k of a v a i l a b l e  considered  a l o g i c a l choice.  chosen because i t i n c r e a s e d  the  A  accuracy  of the p The r o j e rc at ti io on . method t h r o u g h the use of an independent  and  a v a i l a b l e s e t o f p r o v i n c i a l age-sex p o p u l a t i o n  considered  cohort model i n one f i g u r e .  the f a c t o r s r e q u i r e d of the the d i f f e r e n c e i s t h a t the any  one  projections  However,  cohort model a l l o w s v a r i o u s c h o i c e s i n  o f the f a c t o r s even though the e s t i m a t e may  be the same.  U s i n g 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 c h o i c e . t i o n number 4 from S t a t i s t i c s Canada was statistical districts.  1000  as r a t e s p e r  The  populations  Projec-  used to p r o j e c t the  health  components of the p r o j e c t i o n e x p r e s s e d f o r the p r o j e c t i o n p e r i o d of  1976-1986  are: births  a downward s h i f t from 19.6  deaths  a s l i g h t upward s h i f t from 6.2  net  a d e c l i n e from ''4.2  to  -3.5  a d e c l i n e from 13.4  to  12.4  migration  natural total  increase increase  a d e c l i n e from 9.2  to  to  8.9  18.7 to  6.3  71 Concerns about the e f f e c t s of m i g r a t i o n were b r o u g h t f o r w a r d i n the l i t e r a t u r e r e v i e w .  The  o r i g i n a l p l a n t o c o n s u l t knowledgeable  municipal planners or h o s p i t a l administrators s t a t i s t i c a l d i s t r i c t s was that l o c a l estimates r a t i o method and  rejected.  I t was  i n the v a r i o u s  health  f e l t by demographers  of m i g r a t i o n would be b i a s e d .  Choosing the  the p r o j e c t i o n f i g u r e s from Census Canada meant  t h a t m i g r a t i o n was  already being  p o i n t t h a t s h o u l d be c o n s i d e r e d  considered  i n the p o p u l a t i o n .  The  r e g a r d l e s s o f the approach t a k e n i s  t h a t 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 do s u f f e r from i n a c c u r a c i e s w h i c h 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 migration.  I r r e g a r d l e s s of t h e e s t i m a t e d  population's  a c c u r a c y of the  population  p r o j e c t i o n s w i t h i n t h i s p r e s e n t s t u d y , t h e r e a d e r s h o u l d be aware o f potential inaccuracies. A v e r y 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 t h a t S t a t i s t i c s Canada employs random r o u n d i n g . o r 5.  Any  A l l numbers end  7  in 0  number can be e x a c t o r p l u s o r minus 5; t h e r e f o r e ,  range o f v a l u e s  f o r any number i s 10.  the  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 g r e a t e r d e v i a t i o n s from census v a l u e s  or w i d e r  f l u c t u a t i o n s i n the amount o f e r r o r when s m a l l e r p o p u l a t e d 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 . province  By the v e r y g e o g r a p h i c a l  and v a r i e d p o p u l a t i o n  to d i f f e r .  nature of  d e n s i t i e s e r r o r r a t e s were e x p e c t e d  To g i v e the o b s e r v e r an e s t i m a t e  of e r r o r t h a t might be  c o n t a i n e d w i t h i n the s t u d y ' s p o p u l a t i o n p r o j e c t i o n s , the method was  t e s t e d on a h i s t o r i c a l d a t a s e t between 1966  T h i s 5 y e a r base was  the  p r o j e c t e d to 1976  a c t u a l census f i g u r e s f o r 1976.  and  ratio and  1971.  then compared a g a i n s t  The methodology f o r e s t i m a t i n g  e r r o r i s d i s c u s s e d under a s e p a r a t e t i t l e i n Chapter V. The  f o l l o w i n g f o r m u l a was  used t o c a l c u l a t e the age-sex  the  72  population projection for each health d i s t r i c t .  This formula was  derived from the sense given to d e f i n i t i o n s i n the l i t e r a t u r e review. As implied, a d e f i n i t i v e formula was Step I.  x  Phas  =  Phas  t+n  t  PNas  where Phas  Age-Sex s p e c i f i c projection within a health statistical district. - Phas  t-n - PNas^ t t-n  t  Phas _ t  n  x  [PNas , - PNas + MA] t+n t  +  Phas,. t  age-sex s p e c i f i c population of the health t i c a l d i s t r i c t for future year;  statis-  = age-sex s p e c i f i c population of the health t i c a l d i s t r i c t f o r base year;  statis-  = age-sex s p e c i f i c population of the health t i c a l d i s t r i c t for past year;  statis-  t+n  Phas  not found.  PNas^  = age-sex s p e c i f i c population of the Newfoundland projection for base year;  PNas  t-n  = age-sex s p e c i f i c population of the Newfoundland projection for past year;  t+n  age-sex s p e c i f i c population of the Newfoundland projection for future year;  PNas MA  migration adjustment i f necessary  n  number of years from base year  t  base year  as  age-sex i n t e r v a l Step I I .  This formula was repeated f o r each age-sex i n t e r v a l to structure the population i n each health s t a t i s tical district.  Step I I I .  Step IV.  Step V.  Totals were calculated f o r age i n t e r v a l (male and female) and for each sex ( a l l age intervals) and a t o t a l population i n each health s t a t i s t i c a l d i s t r i c t was presented. Steps I, II and III were repeated for the second and f i n a l year of the projection period.  For each projection year, the age sex i n t e r v a l s 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 T h i s program was a t i o n s and  developed to r e t r i e v e the number of s e p a r -  t o t a l days s t a y by age  and  sex groups.  The  separations  were c l u s t e r e d i n groups of d i a g n o s e s w h i c h have been coded t o 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  E i g h t h 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 The  program was  15 y e a r s of age  modified  the  the  Diseases.  to s u b t r a c t out a l l p a t i e n t s under  e x c e p t 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.  F u r t h e r m o d i f i c a t i o n s were employed to e x p r e s s the c l u s t e r e d separations and of  (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  c l u s t e r e d t o t a l days s t a y  (age and  sex) i n age-sex s p e c i f i c  lengths  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 a r e  g i v e n below: P e d i a t r i c s (15 y e a r s )  C-188  L i s t : 1-135;  General Medical  C-188  L i s t : 1-51;  Obstetrics  C-188  List:  136-145.  Psychiatry  C-188  List:  52-59  and  Surgical  146-188. 60-135; 146-188.  By u t i l i z i n g the computer program an i m p o r t a n t a s s u m p t i o n was  made.  The  d i a g n o s t i c c l u s t e r not o n l y r e p r e s e n t e d  c a t e g o r i e s , i t a l s o i m p l i e d an e q u i v a l e n t r e s o u r c e 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  a s p e c i f i c type of r e s o u r c e  resource  i s needed.  unit.  This  c a l c u l a t i o n w h i c h assumes  f o r the e n t i r e p o p u l a t i o n .  words, t h i s s t u d y d e f i n e s a need and  morbidity  In  other  then presumes a c e r t a i n type of  A second a s s u m p t i o n 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 . c l u s t e r s t h e r e i s o n l y one  type of r e s o u r c e  a l l the d i a g n o s t i c c o d i n g was  For the  diagnostic  w h i c h can be used.  If  c o r r e c t , a more p r e c i s e statement of  needs t o s e r v i c e i s expected. The d a t a ' s q u a l i t y was judged t o be v a l i d and r e l i a b l e , a l b e i t a b i a s e d view.  T h i s view stems from t h e w r i t e r ' s knowledge  o f t h e 1976 m o r b i d i t y 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. and  There were no q u e r i e s from S t a t i s t i c s Canada  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  consistent w i t h past experience.  This  file  has been i n p r o d u c t i o n f o r two y e a r s and has been accepted by researchers. experience  Even i f Newfoundland's d a t a d e p a r t s  d e p a r t u r e may be one o f c i r c u m s t a n c e s  from t h e N a t i o n a l and s t a n d a r d s .  The  q u e s t i o n t h a t f i n a l l y s u r f a c e s i s whether these s t a n d a r d s , w h i c h a r e j u d g e m e n t a l , a r e r i g h t o r wrong.  Use and a c c e p t a n c e o f t h e f i l e  does n o t n e c e s s a r i l y mean t h a t i t i s r e l i a b l e and/or v a l i d .  Instead  a degree o f credence can be l e n t t o t h e f i l e . . The d a t a 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 w h i c h d e l i v e r care.  Four h o s p i t a l s were e x c l u d e d  acute  from t h e study because they a r e  d e a l i n g w i t h l o n g term c a r e : W a t e r f o r d  (Mental H e a l t h ) , S t . P a t r i c k ' s  and S t . Luke's N u r s i n g Homes, and the C h i l d r e n ' s R e h a b i l i t a t i o n Centre.  Therefore,  the t o t a l number o f h o s p i t a l s was 44.  ( d i a g n o s i s ) was s o r t e d by r e s i d e n c e o r o r i g i n .  The d a t a  A sub-methodology  was e s t a b l i s h e d t o account f o r r e f e r r a l p a t t e r n s between r e g i o n s o r health s t a t i s t i c a l The  districts.  r e f e r r a l program s o r t e d each p a t i e n t by t h e h e a l t h r e g i o n  o f o r i g i n and r e g i o n i n w h i c h t h e p a t i e n t was t r e a t e d . diagnostic cluster,  The p a t i e n t ' s  age-sex and t o t a l s t a y were i d e n t i f i e d w i t h i n  each r e g i o n o f treatment  and summarized t o t h e f o u r r e f e r r a l  The m o r b i d i t y d a t a by o r i g i n was c o n v e r t e d  regions.  to a rate i n the  p o p u l a t i o n and a p p l i e d t o p o p u l a t i o n p r o j e c t i o n s f o r t h e a r e a s o f  concern.  Both bed s e r v i c e p a t t e r n s and r e f e r r a l p a t t e r n s were  combined i n each o f the p r o j e c t i o n y e a r s , t o p r o v i d e a statement o f bed needs f o r a g i v e n r e g i o n .  realistic  I f t h i s p r o c e d u r e had  not been c a r r i e d o u t , the r e f e r r a l p a t t e r n would have been e r r o n eously r e l a t e d to p o p u l a t i o n i n which treatment occurred. l o g i c a l approach was  to base t h e p a t t e r n upon s h i f t i n g  The more  populations;  p o p u l a t i o n s from w h i c h the p a t i e n t s o r i g i n a t e d . Both programs were r u n on the 1976 H o s p i t a l I n p a t i e n t d a t a file. Manual T a b u l a t i o n o f Bed  Categories  To compare the bed t o p o p u l a t i o n method w i t h the s t u d y ' s p r e d i c t i o n of beds w h i c h l e d t o a statement of the age e f f e c t upon beds, t h e Annual Returns of H o s p i t a l s f o r 1976 were c o n s u l t e d f o r the 44 h o s p i t a l s .  Each o f the h o s p i t a l s was a s s i g n e d  s t a t i s t i c a l d i s t r i c t and t o a h e a l t h r e g i o n .  to a h e a l t h  Beds i n t h i s s t u d y a r e  d e f i n e d as " s t a f f e d , " t h a t i s , a bed w h i c h 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 w h i c h s t a f f i s a v a i l a b l e whether o r  not. a c t u a l l y o c c u p i e d .  T h i s bed would be comparable t o the bed  s e r v i c e s which a r e f u l l y u t i l i z e d ,  the bed c a t e g o r i e s a r e :  M e d i c a l and S u r g i c a l U n d i s t r i b u t e d Psychiatric Obstetric Pediatrics 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 r e v i e w p o i n t e d t o a v a r i e t y o f methods w h i c h c o u l d be used t o p r e d i c t beds.  Three p a r t i c u l a r examples were  d e s c r i b e d i n d e t a i l because they r e p r e s e n t e d methods used  currently  and were a l s o methods d e s i g n e d t o meet l o c a l o r s p e c i f i c needs developed a t a h i g h e r 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 t h a n t h e hospital.  These methods d i d n o t i n f l u e n c e t h e p r e s e n t s t u d y ' s  d e s i g n b u t do c o n f i r m t h e approach which e v o l v e d from t h e i n t e r a c t i o n o f the problems. The s t u d y ' 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 s t a n d a r d s .  M o r b i d i t y r a t e s by age and sex a r e assumed t o be  r e a l i s t i c and a r e h e l d c o n s t a n t through t h e 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 o f s t a y was h e l d c o n s t a n t .  The occupancy f a c t o r  f o r each bed s e r v i c e was d e c i d e d upon by a c o m b i n a t i o n o f use r a t e s , s t a n d a r d s i n t h e l i t e r a t u r e r e v i e w and o p i n i o n . t h a t each assumption  More i m p o r t a n t i s  relates to a region; therefore, p r o v i n c i a l  s t a n d a r d s a r e t h e summation o f t h e s e .  The s t a n d a r d s t h a t a r e  u t i l i z e d a r e unique t o t h i s study and a r e n o t meant t o be i n t e r p r e t e d as p o l i c y statements f o r t h e p r o v i n c e .  I n s t e a d t h e s t u d y and  d e s i g n , as p r e v i o u s l y s t a t e d , was i n t e n d e d t o p r o v i d e 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 f o r m u l a c a l c u l a t e d t h e r e q u i r e d beds f o r each age and s e x by d i a g n o s t i c c l u s t e r and r e g i o n .  Note t h a t popu-  l a t i o n s by age and s e x were c a l c u l a t e d a t t h e h e a l t h d i s t r i c t and summed t o t h e r e g i o n a l l e v e l .  level  The bed p r e d i c t i o n r e q u i r e d two  major s t e p s : one s t e p r e l a t e d t o a l l bed s e r v i c e r e q u i r e m e n t s ; t h e o t h e r r e l a t e d t o making adjustments  t o account f o r r e f e r r a l p a t t e r n s  between r e g i o n s and t h e understatement  o f demand (which i s p r e s e n t e d '  through t h e use o f s e p a r a t i o n s ) . The bed p r e d i c t i o n f o r m u l a which was u t i l i z e d t o 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 g i v e n below:  PP r,™  _  b b K  "  BSR  x DSR a  x ALSD 5§  s  as  BD x Obsr = Bed  S e r v i c e Requirement, age-Sex S p e c i f i c  DSR_ = a r a t i o o f s e p a r a t i o n s by age and sex o v e r the as c o r r e s p o n d i n g age-sex p o p u l a t i o n w h i c h has been a d j u s t e d upwards t o r e f l e c t the a d m i s s i o n r a t e 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 L e n g t h of S t a y , D i a g n o s t i c Age Specific  BD  = Bed  a t 100% Occupancy; t h e r e f o r e , 365  0, bsr  = S t a t e d Occupancy L e v e l f o r Bed  T h i s c a l c u l a t i o n was the p r o j e c t i o n term 1976,  repeated  1981  and  and  Sex  Days  Service  f o r the t h r e e c e n s u s y y e a r s i n  1986  f o r each r e g i o n .  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 r e g i o n (4) w e r e . s u b d i v i d e d T h i s s u b d i v i s i o n was s t a y r a t e was  by t h e i r p o i n t o f o r i g i n (4  c a r r i e d out f o r each bed s e r v i c e .  e s t a b l i s h e d f o r each bed  p o i n t of o r i g i n .  T h i s r a t e was  A t o t a l days  s e r v i c e w i t h i n a r e g i o n by  a p p l i e d t o the p r o j e c t e d p o p u l a t i o n  a p p r o p r i a t e f o r the y e a r and r e g i o n of o r i g i n . g i v e n below the f i n a l p r o d u c t was was  regions)  Through the  formula  a statement o f r e f e r r a l beds w h i c h  then added t o o r s u b t r a c t e d from a g i v e n r e g i o n t o r e f l e c t  l o g i c a l movement of p a t i e n t s .  T h i s c a l c u l a t i o n was  not necessary  demonstrate the change i n bed  r e q u i r e m e n t i n r e s p e c t o f age-sex  p o 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  mation f o r regions. following  A bed s e r v i c e was  calculation:  the  then c a l c u l a t e d by  the  to  esti  where  BSR  = Bed S e r v i c e Requirement, Age-Sex S p e c i f i c 3.S  T D S  bas  ^bsr The  =  =  T  o  t  ^  a  l  c c u  D  P  a  y  a n c  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  y L e v e l f o r Bed S e r v i c e  i d e n t i f i e d bed was then s u b t r a c t e d from t h e r e g i o n o f  o r i g i n and added t o t h e r e g i o n o f r e f e r r a l i n the c o r r e s p o n d i n g categorization.  T h i s c a l c u l a t i o n was n o t n e c e s s a r y  changes i n t h e age s e x p o p u l a t i o n i n r e s p e c t o f bed  t o determine t h e requirements.  The understatement o f demand ( s e p a r a t i o n s ) was c o r r e c t e d by using regression analysis.  E i g h t y - e i g h t (covers 2 y e a r s )  t i o n s o f s e p a r a t i o n s and admissions  observa-  were r e g r e s s e d t o e s t i m a t e t h e  c o e f f i c i e n t of X ( s e p a r a t i o n s ) . Estimation 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 method.  of t e s t i n g the r a t i o  F i r s t , v e r y few a r t i c l e s , i n r e c e n t t i m e s , examine and  r e p o r t on t h e method's a c c u r a c y .  Second, t h e method has n o t 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 t o t h i s study.  Conse-  q u e n t l y , t h e r e i s a need t o g i v e t h e d e c i s i o n maker some i d e a o f accuracy  so. t h a t he/she might a d j u s t t h e f i n a l f i g u r e s w h i c h a r e  presented.  The methodology f o r e s t i m a t i n g t h e e r r o r a s s o c i a t e d w i t h  the use o f t h e r a t i o p r o j e c t i o n t e c h n i q u e  i s discussed separately i n  Chapter V so t h a t t h e methodology c a n be c l e a r l y s e p a r a t e d methods w h i c h l e a d t o t h e p r e d i c t i o n o f beds.  from t h e  This separation w i l l  a l s o focus a t t e n t i o n t o the e v a l u a t i o n o f 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 t e c h n i q u e , w h i c h i s a s u b j e c t t h a t many r e s e a r c h e r s f e e l be a t t e n d e d  t o when making p r o j e c t i o n s i n t h i s day and age.  should  79 The  f i n d i n g s and d i s c u s s i o n o f 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 p r e s e n t  the methodology  and  a n a l y z e the e s t i m a t e d e r r o r a s s o c i a t e d w i t h the use o f the R a t i o P r o j e c t i o n Method and i n d i c a t e the degree o f e r r o r t h a t can  be  expected i n the p r o j e c t i o n s of v a r i o u s s i z e d p o p u l a t i o n bases. Chapter VI w i l l a n a l y z e b o t h the p r e s e n t  and f u t u r e age and  sex  r e l a t e d p o p u l a t i o n s o f each r e g i o n and f o r the p r o v i n c e as a t o t a l . Chapter V I I w i l l a n a l y z e the bed s e r v i c e r e q u i r e m e n t s f o r each r e g i o n and the p r o v i n c e r e l a t i v e t o 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 o f the model and the h i g h l i g h t s from each of Chapters V and V I .  The  relevance of  study t o f u t u r e p l a n n i n g i n Newfoundland ( R u r a l ) 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 o f the study w i l l be examined.  If  the  80 Chapter IV Footnotes  A. B. Murphy, "Newfoundland and L a b r a d o r P o p u l a t i o n , 1966/ 1971, P a r t I I : 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 , " Newfoundland Department o f H e a l t h , September 1976 (working c o p y ) ; " P o p u l a t i o n 1971 and 1976: Newfoundland, by H e a l t h Regions 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 " (Newfoundland Department of H e a l t h , 1975). 2  Ibid.  P e r s o n a l communication w i t h Mark S h r i m p t o n , S t . John's C i t y C o u n c i l , September, 1979. ^ P e r s o n a l 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, P o p 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, C a t . No. 91-520, Ottawa, 1977, pp. 17-21. 6  Ibid.  ^ A l d e r d i c e and Courage, p e r s o n a l communications. M a r k S. Blumberg, "D.P.F. Concept H e l p s P r e d i c t Bed Needs," The Modern H o s p i t a l 97 (December 1971): 75-81. 8  CHAPTER V ESTIMATION OF ERROR ASSOCIATED WITH THE USE OF THE RATIO METHOD Introduction I t was noted p r e v i o u s l y i n t h e l i t e r a t u r e r e v i e w t h a t more a t t e n t i o n s h o u l d be g i v e n t o t h e e s t i m a t i o n o f e r r o r c o n t a i n e d i n population projection. ways.  T h i s e r r o r can be c a l c u l a t e d i n a number o f  The more d i r e c t and p r e c i s e method i s t o compare t h e p r o j e c t e d  p o p u l a t i o n s t o t h e i r f o r t h c o m i n g a c t u a l census v a l u e s .  This  tactic  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 t h e s e l e c t i o n o f p r o j e c t i o n y e a r s w h i c h a r e census d e s i g n a t e s .  Given r e a s o n a b l e assump-  t i o n s , t h i s population 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 t o a p p l y t h e  p r o j e c t i o n ' s methodology on a d a t a s e t from t h e p a s t , and p r o j e c t a p o p u l a t i o n t o a census y e a r i n t h e p a s t .  E s t i m a t i n g t h e 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 v e r y d i s t i n c t advantages. I t p r o v i d e s t h e r e s e a r c h e r w i t h a p r a c t i c a l f e e l f o r b o t h t h e d a t a and methodology.  The e s t i m a t e o f e r r o r , i n t u r n , would p r o v i d e t h e u s e r  w i t h an o p p o r t u n i t y to a c c e p t , r e j e c t o r modify the p o p u l a t i o n p r o j e c t i o n s w h i c h a r e b e i n g observed.  The r e s e a r c h e r would a l s o  enjoy t h e vantage p o i n t o f b e i n g a b l e t o m o d i f y t h e 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 o b s e r v a t i o n s .  Finally,  this  approach a l l o w s f o r a more r i g o r o u s e v a l u a t i o n o f t h e method. I f 81  82 i t i s combined w i t h p r o j e c t i o n y e a r s w h i c h c o r r e s p o n d t o census y e a r s , t h e methodology can be e v a l u a t e d b e f o r e and a f t e r , and t h e p r e l i m i n a r y e s t i m a t i o n o f t h e e r r o r i t s e l f can be e v a l u a t e d 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 review.  i n d e t a i l i n the l i t e r a t u r e  The a c c e p t a b l e l e v e l o f e r r o r w h i c h was e s t a b l i s h e d was an  a b s o l u t e mean o f 10% o r l e s s f o r a p r o j e c t i o n o f 10 y e a r s o r l e s s . A priori,  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  t h a t the a b s o l u t e 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 t h e d i f f e r e n c e between t h e v a l u e s o f a p r o j e c t i o n y e a r and i t s c o r r e s p o n d i n g census y e a r , by the v a l u e o f t h e census y e a r . The  r a t i o i s then c o n v e r t e d t o p e r c e n t .  I n cases r e p o r t e d i n t h e  l i t e r a t u r e where t h e d a t a conforms t o suggested  guidelines, the  p o p u l a t i o n bases were v e r y l a r g e ; t h a t i s , they were i n t h e 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 u l a t i o n s .  two c o n d i t i o n s tend t o decrease  the e r r o r rate.  These  T h e r e f o r e , and i n  d i r e c t comparison w i t h t h i s s t u d y ' s p r o j e c t i o n o f v e r y s m a l l popul a t i o n s by age and s e x i n t e r v a l s , a h i g h e r e r r o r r a t e may need t o be accepted.  N o t w i t h s t a n d i n g 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 o f t h e  upper l i m i t s o f the a b s o l u t e mean e r r o r i s t o t a l l y dependent upon t h e use t o w h i c h t h e p o p u l a t i o n p r o j e c t i o n i s b e i n g a p p l i e d i n t h e planning function. The a c c e p t a b l e l e v e l o f e r r o r s h o u l d a l s o be reviewed i n r e l a t i o n t o t h e p r o p e r t y o f s i n g l e e s t i m a t o r o f p o p u l a t i o n t o produce extreme v a l u e s . obvious  I f these extremes a r e e x p e c t e d then i t becomes  t h a t some form o f prudent m a n i p u l a t i o n i s r e q u i r e d .  Conse-  83 q u e n t l y , t h e o v e r a l l e s t i m a t e o f e r r o r would be l o w e r .  Alterna-  t i v e l y , i t i n f e r s t h a t t h e m a j o r i t y o f e r r o r s encountered acceptable.  are very  I n o t h e r words, the d e c i s i o n t o a c c e p t o r r e j e c t t h e  p r o j e c t i o n s s h o u l d n o t 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 o f 10%. However, t h i s g u i d e l i n e o f 10% r e p r e s e n t s t h e e x p e r i e n c e d o p i n i o n of r e s e a r c h e r s and s h o u l d c a r r y c o n s i d e r a b l e w e i g h t . The p o p u l a t i o n data from w h i c h t h e e r r o r was c a l c u l a t e d was a d j u s t e d as l i t t l e  as p o s s i b l e . . M a t h e m a t i c a l  s i g n s were f o l l o w e d  w i t h t h e e x c e p t i o n o f f o u r o b s e r v a t i o n s w h i c h had t o be a d j u s t e d . In  each case t h e magnitude and d i r e c t i o n o f change were t h e i n f l u -  encing f a c t o r s .  Two cases had n e g a t i v e p o p u l a t i o n s .  a d j u s t e d t o a s t a t e o f no change. the r e s u l t a n t e r r o r was reduced  These were  When compared w i t h census v a l u e s  t o zero.  I n t h e r e m a i n i n g two cases  the d i r e c t i o n o f change was b o t h 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  The c h o i c e o f  from a p p r o x i m a t e l y  f o l l o w i n g mathematical  100% t o 12.5%.  s i g n s ( v e r s u s l o g i c ) r e s t e d upon t h e o p i n i o n  i t would p r o v i d e a c l e a r e r p a t h f o r r e p l i c a t i o n .  I t would a l s o  p r o v i d e a p o t e n t i a l u s e r w i t h a d a t a s e t w h i c h would n o t have t o be decoded. suggests  The use o f l o g i c may enhance t h e p r o j e c t i o n s b u t i t a l s o a slzate o f i m p r e c i s i o n . The d a t a p r o v i d e d by Census Canada has some e r r o r b u i l t  it.  into  Through the p r o c e s s o f random r o u n d i n g , a l l numbers a r e rounded  e i t h e r upwards o r downwards t o 5 o r 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 r o u n d i n g e r r o r o f 4 on a base o f 100 o r 50  y i e l d s an e r r o r o f between 4% and 8%.  I n 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 y e t t h e i n t e r v a l s may add t o 15 o r 45. o c c a s i o n when t h e r a t i o method i s u s e d , t h e r e in  On  a r e z e r o growth r a t e s  these i n t e r v a l s when i t i s e v i d e n t t h a t such i s n o t the case.  84 Method 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  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  asso1966  and  1971 numerous census s u b d i v i s i o n s underwent boundary changes.  The  t a s k of p r o v i d i n g e q u i v a l e n t 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 o r g a n i z e t o 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.  W h i l e 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 d u r i n g t h i s p e r i o d . was  comprised of 22 age-sex i n t e r v a l s .  Each census d i v i s i o n  Thus, f o r Newfoundland, t h e r e  are 10 census d i v i s i o n s and a t o t a l o f 220 age-sex i n t e r v a l s . chosen and a l t e r n a t i v e s t r a t e g y was  t o v i e w each o f these  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.  The  age-sex  In so c h o o s i n g , and i n the  c o n t e x t o f Newfoundland's s m a l l e r p o p u l a t e d  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 w h i c h i s e x p e c t e d to g i v e extremes o f h i g h v a r i a n c e and h i g h e r a b s o l u t e mean e r r o r s . The e r r o r was One  c a l c u l a t e d f o r these 220 age sex  hundred and n i n e t y - t h r e e o f 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 p r o v i d e a more p r e c i s e e s t i m a t e o f e r r o r , t h a t  i s , f o r l a r g e r p o p u l a t i o n b a s e s , the 220 to  intervals.  3 age i n t e r v a l s  (sex combined).  e s t i m a t e o f e r r o r was  calculated.  i n t e r v a l s were compressed  For t h i s compressed s e t the F u r t h e r i n t h i s attempt t o p r o v i d e  a p i c t u r e o f 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  calculated for  the t o t a l p o p u l a t i o n o n l y (both sexes) i n each census d i v i s i o n . The e s t i m a t e o f e r r o r was First,  i t was  d e r i v e d from sampling.  c o n s i d e r i n g the e n t i r e d a t a s e t . s e t was  a l s o c a l c u l a t e d i n two ways.  p r e s e n t e d was  The  because i t was  Second, i t was  d e r i v e d by  reason t h a t the e n t i r e d a t a not c o s t l y i n time to do so  and  85 because i t was The  a n t i c i p a t e d t h a t a l a r g e sample would be r e q u i r e d .  l a r g e sample was  the v a r i a n c e was  expected  f o r the p o p u l a t i o n s under 3000 because  a n t i c i p a t e d to be l a r g e and i n the r e m a i n i n g  v a l s over 3000 t h e r e was  v e r y l i t t l e e f f o r t r e q u i r e d to use  inter-  the  t o t a l number o f v a l u e s . The  t o t a l sample was  94 and c o n s i s t e d o f : 83 from the 0-2,999  s t r a t u m ; 5 from the 3,000-9,999 s t r a t u m and 6 from the 10,000 and 1 2 oversstratum.  The methods used to determine the sample s i z e '  are  g i v e n 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 o f p o p u l a t i o n  and  presentation of e r r o r i s : 0 3,000 -  2,999 9,999  10,000 - 24,999 25,000 - 49,000  T  _ . .„ I n c e r t a i n s i t u a t i o n s the s t r a t u m are combined to  1 0  '  0 0  °  +  50,000 - 74,999 75,000 + I t has been s t a t e d t h a t the r a t i o method i s expected produce extreme e r r o r s .  T h i s b e i n g the c a s e , t h e r e s h o u l d be  to higher  than normal d i s t r i b u t i o n o f e r r o r s a t b o t h t a i l s of the d i s t r i b u t i o n . As p a r t o f the methodology the e s t i m a t i o n of e r r o r p r e s e n t e d i n the 3 4 s a m p l i n g was  transformed  u s i n g the A r c s i n  percent.  '  The A r c s i n  Vpercent t r a n s f o r m a t i o n s h o u l d p u l l the extreme v a l u e s towards the meanj. t h a t i s , i t s h o u l d n o r m a l i z e the d a t a .  In o t h e r words, the  r e a l q u e s t i o n which i s t o be proposed i s whether t r a n 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 o f t h i s type of d a t a . Although  o b v i o u s , the a b s o l u t e mean.error i s f a r more impor-  t a n t i n d e t e r m i n i n g the c h a r a c t e r of the e r r o r .  The mean w i t h s i g n s  c o n s i d e r e d i s -not an a p p r o p r i a t e f i g u r e t o examine because p o s i t i v e  86 v a l u e s tend t o c a n c e l out n e g a t i v e v a l u e s .  T h e r e f o r e t h e mean w i l l  approach t h e v a l u e o f z e r o . The e s t i m a t i o n o f e r r o r i s p r e s e n t e d through t h e f o l l o w i n g s t a t i s t i c s : t h e a b s o l u t e mean e r r o r , the s t a n d a r d e r r o r (SE) o f t h e mean, t h e c o n f i d e n c e l i m i t s and t h e number o f e r r o r s under o r e q u a l t o 10%. As n o t e d p r e v i o u s l y i n t h e methodology t h e r e was a s u g g e s t i o n t h a t t h e random r o u n d i n g p r o c e s s was b i a s e d .  To t e s t t h i s  observa-  t i o n , 594 o b s e r v a t i o n s were r e s t r u c t u r e d t o a 3x2 c o n t i n g e n c y t a b l e and s u b j e c t e d t o a C h i Square a n a l y s i s .  See Appendix C.  F i n a l l y t o t e s t e r r o r i n r e l a t i o n t o p o 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 o f e r r o r s o f 10%  o r under were compared w i t h p o p u l a t i o n s i z e i n a c o n t i n g e n c y The e x p e c t e d c o n c l u s i o n was t h a t t h e r e would be-a-  table.  relationship  such  t h a t the count o f e r r o r s under o r e q u a l t o 10% i n c r e a s e d as p o p u l a tion size increased.  To examine the r e l a t i o n s h i p between the s i z e  o f e r r o r and p o 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 a c c o r d i n g t o popul a t i o n s t r a t u m t o f i r s t determine o r c o r r e l a t i o n was e x p e c t e d  the array o f p o i n t s .  Aggression  t o be c a r r i e d o u t .  Results  T a b l e V-'l g i v e s v a r i o u s p r e s e n t a t i o n s o f t h e e s t i m a t e s o f e r r o r a s s o c i a t e d w i t h t h e use o f t h e r a t i o p r o j e c t i o n t e c h n i q u e . The v a r i e t y o f t a b l e s stems from b o t h 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 o f the age-sex i n t e r v a l s . e r r o r based upon sampling. e r r o r was 12.0% ± 1 . 6 (SE).  T a b l e V-1A d e s c r i b e s t h e e s t i m a t e o f From a-sample o f 94, t h e mean a b s o l u t e As t h e p o p u l a t i o n s i z e i n c r e a s e s , t h e  mean a b s o l u t e e r r o r i s reduced  from 13.0% t o 5.2%.  Thus i t would  87 Table V - l E s t i m a t i o n o f E r r o r s A s s o c i a t e d W i t h The R a t i o Method A.  Age Sex I n t e r v a l s (based on sampling) N  Stratum 0 - 2,999 3,000 - 9,000 10,000 + Total  B.  13.0 %  1.8  51  5  6.32  2.6  3  6  5.2  2.1  5  94  12.0  9  1.60  59  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  30  7.4  1.4  23  9.7%  1.1  8  T o t a l P o p u l a t i o n s ( f o r census d i v i s i o n s ) 25,000 - 49,999  8  5.1%  50,000 - 74,999  1  3.4  -  1  75,000 +  1  2.3  -  1  10  4.6  1.0  10  Age-Sex I n t e r v a l s (by census d i v i s i o n ) 0 - 2,999 3,000 - 9,999 10,000 + Total  a  NO. E r r o r s <. 10%  83  0 - 2,999  Total  D.  S.E.  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 )  Total  C.  |M|.  193  13.2%  1.3  123  14  5.5  1.4  10  13  6.5  1.8  11  220  12.3  1.2  144  R a t i o method was used t o p r o j e c t a 1976 p o 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 ) . Projected v a l u e s compared w i t h c o r r e s p o n d i n g census v a l u e s f o r 1976 g i v e s e r r o r e x p r e s s e d as a p e r c e n t o f the 1976 census v a l u e . 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 p e r d i v i s i o n .  88 appear, s u p e r f i c i a l l y , t h a t a r e l a t i o n s h i p e x i s t e d between t h e s i z e o f t h e p o p u l a t i o n and t h e s i z e o f t h e e r r o r . a l s o suggested  Indirectly this i s  by t h e p r o p o r t i o n a l count o f e r r o r s i n each s t r a t u m  under o r e q u a l t o 10%. However, the o n l y r e l i a b l e f i g u r e s e x p r e s s e d are those from t h e 0-2999 p o p u l a t i o n s t r a t u m because t h e r e i s a s u f f i c i e n t l y l a r g e number o f o b s e r v a t i o n s . The  sample r e s u l t s i n T a b l e V-1A compare r e a s o n a b l y w e l l t b  the t o t a l d a t a s e t e s t i m a t e d i n Table V-1D.  Two hundred and twenty  o b s e r v a t i o n s y i e l d e d a mean a b s o l u t e e r r o r o f 12.3% ± 1.2. r a t e o f e r r o r s under o r e q u a l t o 10% was .65 (144/220). s i m i l a r t o a r a t e o f .63 e s t a b l i s h e d i n t h e sample.  The  This i s  Tables V-1A and  IB a l s o 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 o r p r o p o r t i o n o f e r r o r s under o r e q u a l t o 10%. W h i l e t h e number o f o b s e r v a t i o n s decreases  w i t h population s i z e , the standard  d e v i a t i o n s i n d i c a t e t h a t t h e spread o f v a l u e s around t h e mean decreases  as t h e p o p u l a t i o n s i z e i n c r e a s e s .  T h i s decreased and  1C.  spread o f d a t a i s r e i t e r a t e d i n T a b l e s  V—IB  I n Table V - l B , t h e age-sex i n t e r v a l s were compressed t o  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 e s t i m a t e d f o r 30 i n t e r -  v a l s was a mean a b s o l u t e e r r o r o f 7.4% ± 1.4. under o r e q u a l t o 10% was .76 (23/40).  The r a t e o f e r r o r s  F o r each s t r a t u m o v e r  10,000  p o p u l a t i o n , t h e r e was a f a r g r e a t e r p r o p o r t i o n o f e r r o r s under o r e q u a l t o 10% than i n t h e p r e c e d i n g s t r a t a . t o t a l p o p u l a t i o n , g i v e s t h e same p i c t u r e .  Table V-1C, f o r t h e There was h i g h e r p r e c i s i o n .  However, t h e number o f o b s e r v a t i o n s i s v e r y low.  The mean a b s o l u t e  e r r o r o f the t o t a l p o p u l a t i o n i s 4.6% ± 1.0 and a l l e r r o r s were under o r e q u a l t o 10%.  I f a g g r e g a t i o n o f t h e d a t a i s performed p r i o r t o  p r o j e c t i o n , the p r e c i s i o n o f the p r o j e c t i o n s h o u l d be g e n e r a l l y enhanced.  89 While i t i s b o t h r e l e v a n t and i n t e r e s t i n g t o be comparing e r r o r s f o r s m a l l o r 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  esti-  mates f o r e v a l u a t i o n f a l l upon t h e 0-2999 s t r a t u m .  This  stratum  c h a r a c t e r i z e s much o f t h e Newfoundland p o p u l a t i o n .  Therefore, the  e s t i m a t e s o f v a r i a n c e and the c o n s i d e r a t i o n o f extremes f o r t h i s s t r a t u m s h o u l d weigh h e a v i l y upon t h e d e c i s i o n t o a c c e p t , r e j e c t o r modify  the population p r o j e c t i o n s . This designated  s h o u l d mean t h a t t h i s s t r a t a s h o u l d be a n a l y z e d  importance  independently.  Based upon a sample (Table V-1A), t h e a b s o l u t e mean o f t h e 0-2999 s t r a t u m was 13.0% ± 1.8.  The number o f e r r o r s e q u a l t o o r  under 10% was 5 1 , f o r a r a t e o f .54. W i t h i n t h e e s t i m a t e s o f the t o t a l d a t a s e t (Table V-1D), t h e mean f o r t h i s stratumwas 13.2% ± 1.3. In  examining  t h i s s t r a t u m w i t h i n t h e t o t a l d a t a s e t two stratagems  were f o l l o w e d .  F i r s t , two census d i v i s i o n s (44 o b s e r v a t i o n s ) w h i c h  a r e c o n s i d e r e d e c o n o m i c a l l y u n s t a b l e and d i s a d v a n t a g e d were subt r a c t e d from t h e 193,0-2999 p o p u l a t i o n o b s e r v a t i o n s .  The a b s o l u t e  mean d e c l i n e d from 13.2% t o 10.5% and t h e r e was a subsequent t i o n i n the variance.  reduc-  By e l i m i n a t i n g q u e s t i o n a b l e d a t a , 77.2% o f  t h e d a t a 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 s u g g e s t e d ,  extreme v a l u e s a r e m o d i f i e d  indi-  v i d u a l l y , a f a r b e t t e r e s t i m a t e o f the u s e f u l n e s s o f t h e p r o j e c t i o n s i s obtained. to  20%.  F o r a r u l e o f thumb the 10% g u i d e l i n e c o u l d be doubled  I f these extremes a r e s u b t r a c t e d from the 103 o b s e r v a t i o n s  o f t h e 0-2999 s t r a t u m ( T a b l e V - l D ) , the a b s o l u t e mean e r r o r drops from 13;2% ± 1.3 t o 6.4% ± .41. E i g h t y - o n e p e r c e n t o f t h e d a t a i s c o n s i d e r e d t o be c o n t r i b u t i n g t o the a c c e p t a b l e g u i d e l i n e o f 10% (see Appendix D). When the m o d i f i e d extremes a r e i n c o r p o r a t e d i n t o the d a t a t h e obvious outcome i s a p r o b a b l e and f u l l s e t o f o b s e r v a -  90  t i o n s w h i c h meet t h e a c c e p t a b l e c r i t e r i o n . these two e x e r c i s e s , as e x p e c t e d ,  The main o b s e r v a t i o n i n  i s t h a t t h e extremes do i n f l u e n c e  the e s t i m a t i o n o f e r r o r f o r t h e e n t i r e d a t a s e t .  Despite  this  i n f l u e n c e o f extreme v a l u e s , t h e r a t i o method i s a p p r o p r i a t e f o r 80% of t h e age-sex i n t e r v a l s i n t h e 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 e v a l u a t e d on l a r g e r p o p u l a t i o n b a s e s , i t can be a p p l i e d , w i t h due c a u t i o n , t o l o w e r p o p u l a t i o n bases.  Table V-2 Arcsin  ^Percent Transformation o f E r r o r Estimates A s s o c i a t e d w i t h t h e R a t i o Method (Based on Sample) Non  jM 1  N 0 -  2,999  3,000 -  9.4  - 16.6  5  6.3  2.6  0  - 20.6  6  5.2  2.1  0  - 18.0  94  12.0  1.60  8  - 16.1  Arcsin \/Percent 2,999  3,000 10,000  83 5  9,000  6  +  -  94  Total M  99% Confidence  1.8  10,000 +  0 -  S . E.  13.0%  83  9,999  Total  Transformed Limits  Retransformed  10.0%  1.4  6.5  - 14.0  1.5  3.1  o  - 13.2  1.4  2.8  0  -  9.2  1.25  5.6  9.5  - 13.7  = a b s o l u t e mean  S.E.  b e f o r e r e t r a n s f o r m a t i o n f o r s t r a t u m a r e 1.4, 3.1, 2.8 and 1.25 respectively  M - b e f o r e r e t r a n s f o r m a t i o n f o r s t r a t u m a r e 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 t r a n s f o r m a t i o n o f t h e sample e s t i m a t e s o f e r r o r . e r r o r o f 12.0% ± 1.6. 16.1%  (upper).  The o r i g i n a l sample has an a b s o l u t e mean  The 99% c o n f i d e n c e l i m i t s a r e 8% ( l o w e r ) and  The t r a n s f o r m e d  sample has an a b s o l u t e mean e r r o r o f  17.79  ± 1.25.  Upon r e t r a n s f o r m a t i o n o f A r c s i n  c o n f i d e n c e l i m i t s become 5.6% 9.2%  ± 1.25.  and  \ [ p e r c e n t v a l u e s the  13.7% w h i l e the mean e r r o r i s  The t r a n s f o r m a t i o n of the d a t a p r e s e n t s a v e r y o p t i -  m i s t i c p i c t u r e ; t h a t i s , i t p r e s e n t s a lower e s t i m a t e o f t h e e r r o r . However, i n terms of the t r a n s f o r m a t i o n n o r m a l i z i n g the d a t a , i t s u g g e s t s t h a t t h e body o f the p r o j e c t i o n s w i l l t e n d to f a l l under o r hedge around the 10% g u i d e l i n e s because t r a n s f o r m a t i o n m i n i m i z e s i n f l u e n c e s o f extremes on t h e mean.  The view as p r e s e n t e d by  the  trans-  f o r m a t i o n p a r a l l e l s to some e x t e n t the m a n i p u l a t i o n o f the o r i g i n a l d a t a s e t i n w h i c h the e r r o r s g r e a t e r than 20% were e l i m i n a t e d from t h e 0-2999 s t r a t u m . The  t r a n s f o r m a t i o n o f the e r r o r e s t i m a t e s f o r the two  p o p u l a t i o n s t r a t a does n o t enhance the a n a l y s i s . a b s o l u t e means a r e 1.5% and narrower  1.4%.  The  larger  retransformed  The 99% c o n f i d e n c e l i m i t s a r e f a r  than f o r the non t r a n s f o r m e d e s t i m a t e s .  The  retransformed  means a r e too low and n o t r e p r e s e n t a t i v e o f 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 .  F o r example, i f a w e i g h t e d  2 h i g h and 2 low v a l u e s ) was  average ( e l i m i n a t i o n o f  c o n s i d e r e d , the e s t i m a t e d a b s o l u t e mean  o f the 3,000-9,000 and the 10,000+ s t r a t a would be 4.8% r e s p e c t i v e l y , a decrease from 5.5% and The p r e c e d i n g paragraphs  and  3.1%,  6.5%.  showed t h a t the use o f the r a t i o  p r o j e c t i o n method l e a d s to a wide range o f e r r o r s and to extreme values.  T r a n s f o r m a t i o n p u l l s i n the extremes toward the mean and  t h e r e f o r e tends to h i d e them from the o b s e r v e r .  Statements  w i t h o u t t r a n s f o r m a t i o n a r e more p r a c t i c a l and u s e f u l . t a n t to be aware o f extreme v a l u e s so t h a t demographic can be made. when anomalies  presented  I t i s imporadjustments  T r a n s f o r m a t i o n , 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 occur.  92 The  t a b l e s w h i c h have been p r e s e n t e d  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 .  appear t o demonstrate  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% i n c r e a s e s as p o p u l a t i o n s i z e i n c r e a s e s .  Second, the  s i z e o f the e r r o r tends to get s m a l l e r as t h e p o p u l a t i o n  size  increases. To t e s t the 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 t i o n o f e r r o r s above and below 10% a c o n t i n g e n c y  table,(V-3,  proporwas  c o n s t r u c t e d 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 o f E r r o r s <. 10% and P o p u l a t i o n S i z e Error Size  0-2,999  <. 10%  123  > 10%  3,000-9,999  2  = 2.6;  X  2  The  Total  (64%)  10 (71%)  11 (85%)  144  70 (36%)  4 (29%)  2 (15%)  74  193 X  10,000 +  = 9.2  14  13  220  < PC(.Ol)  r e l a t i o n s h i p t h a t the p r o p o r t i o n o f e r r o r s under o r  e q u a l to 10% would i n c r e a s e as p o p u l a t i o n s i z e i n c r e a s e d was  not  2 supported  by C h i Square a n a l y s i s (P (X^ = 2.6)  s a t e f o r low c e l l frequency gency t a b l e .  the d a t a was  A g a i n , the r e l a t i o n s h i p was  > 0.25).  To compen-  c o l l a p s e d to a 2x2 c o n t i n 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 o f 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 a g a i n s t the p o p u l a t i o n s t r a t a t o f i r s t determine the a r r a y of p o i n t s . i s presented  i n Appendix E.  and p o p u l a t i o n s i z e was  The  The  graph o f p o i n t s  r e l a t i o n s h i p between s i z e of e r r o r  n o t suggested by the a r r a y .  The  form o f  d a t a i s h o r i z o n t a l w i t h h i g h 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  the and  93  low v a r i a t i o n a t h i g h p o p u l a t i o n  levels.  Y e t , c o n c l u s i o n s can be r e a c h e d .  I t appears t h a t 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 the range o f v a l u e s t o the e r r o r s  decreases.  There i s a l s o t h e appearance o f a random d i s p e r s i o n t o the e r r o r s i n each s t r a t u m .  T h i s i m p l i e s t h a t i t i s t h e demographic c h a r a c t e r i s t i c  o f the p o p u l a t i o n w h i c h i s p r o d u c i n g extreme v a l u e s .  t h e v a r i a t i o n i n e r r o r and  More i m p o r t a n t l y , t h i s f i n d i n g s u g g e s t s ,  that f o r  each a r e a b e i n g p r o j e c t e d by t h e r a t i o method, t h a t a demographic and complementary d a t a f i l e s h o u l d be developed and used t o necessary  a d j u s t m e n t s to extreme v a l u e s .  support  W i t h demographic a d j u s t -  ments to extreme v a l u e s , the r a t i o method not o n l y produces an a c c e p t a b l e l e v e l o f e r r o r s <. 10% (.80) the method does n o t appear t o i n f l u e n c e the e r r o r .  I n t h e c o n t e x t o f a p r o v i n c e c h a r a c t e r i z e d by  communities w i t h v e r y 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 d a t a 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 utilized.  The r a t i o method c a n , w i t h due c a u t i o n , g i v e p r o j e c t i o n s  w h i c h have an a c c e p t a b l e  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 C. V. Mosby Co., 1977), pp. 155-185.  ( S t . L o u i s : The  9  Frank F r e e s e , Elementary F o r e s t Sampling, A g r i c u l t u r e Handbook No. 232 ( F o r e s t S e r v i c e , U.S. Department o f 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 I n f e r e n c e , V. I (Ann A r b o r : Edwards B r o t h e r s , I n c . , 1964), pp. 505-512. ^ F r e e s e , pp. 28-36.  CHAPTER V I CHANGES IN BEL REQUIREMENTS  IN RESPECT  OF POPULATION CHANGES Introduction The purpose of t h i s study was o r i g i n a l l y i n t e n d e d t o be b o t h p r a c t i c a l and e x p e r i m e n t a l . a r e each as i m p o r t a n t  V a r i o u s subgoals w h i c h were i d e n t i f i e d  i n t h e i r own r i g h t as the end p r o d u c t .  This  study i s t h e f i r s t major use o f i n p a t i e n t m o r b i d i t y f i l e s i n r e c e n t years.  The p r i m a r y a c t i v i t y r e l a t e d t o these f i l e s has been t h e  c o l l e c t i o n of data.  I t i s o n l y through p r a c t i c a l use o f t h e f i l e s  t h a t the a p p r o p r i a t e types o f d a t a f o r p l a n n i n g can be  determined.  As was s t a t e d p r e v i o u s l y , i n s u p p o r t o f a h e a l t h p l a n n i n g d a t a b a s e , t h i s study has generated  a v e r y i m p o r t a n t p o p u l a t i o n base w h i c h can  be r e f i n e d i n t h e y e a r s ahead.  As u s e f u l p l a n n i n g t o o l s the D e p a r t -  ment o f H e a l t h has two which i t can e v a l u a t e : t h e 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 and t h e Bed P r e d i c t i o n Model. Y e t t h e key p o i n t t o be demonstrated i n t h e f i n d i n g s i s a statement t h a t bed requirements way.  s h o u l d be d e r i v e d i n a more a n a l y t i c a l  T h i s s t u d y ' s method i s expected  r e g i o n s i n a more a p p r o p r i a t e manner.  t o a s s i g n beds t o s e r v i c e and A p r i o r i , t h e r e i s t h e expec-  t a t i o n t h a t t h i s method w i l l be promoted f o r use i n t h e p r o v i n c e . In so s t a t i n g i n t h e p r o b a b l e and f u t u r e tense t h e r e i s an i m p l i c a t i o n t h a t even t h e p r e s e n t method may n o t i n f a c t be promoted from 95  96 findings. Methods The method o f p r o j e c t i n g t h e p o p u l a t i o n and p r e d i c t i n g bed r e q u i r e m e n t s 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 s e x w i t h i n f o u r d i s t i n c t bed c l u s t e r s : P e d i a t r i c s , M e d i c a l 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 . m o r b i d i t y f i g u r e s i n v o l v e d t h e 1976 admissions w h i c h were h e l d c o n s t a n t  and l e n g t h o f s t a y  i n each d i a g n o s t i c c a t e g o r y  entire projection period.  The  through the  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 r e g i o n was a summation of bed r e q u i r e m e n t s 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 r e g i o n was t h e r e -  f o r e b o t h a sum o f age and sex r e q u i r e m e n t s and d i a g n o s t i c c l u s t e r s . 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 was n o t m o d i f i e d f o r the p r o j e c t i o n s .  I n s t e a d , a l l t h e 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 r e g i o n s t o i n c r e a s e t h e p o p u l a t i o n base f o r each age-sex i n t e r v a l . the accuracy  T h i s s t e p was taken f o r two r e a s o n s :  to increase  o f the p o p u l a t i o n p r o j e c t i o n and t h e r e f o r e the p r e d i c -  t i o n o f beds; and t o c o r r e s p o n d t o be a p p l i e d t o the beds.  w i t h the l e v e l o f a n a l y s i s w h i c h was  The m o r b i d i t y d a t a was a l s o c o l l e c t e d  and c o l l a t e d t o t h e r e g i o n a l l e v e l o n l y . I n the p r e d i c t i o n o f t h e beds, a number of adjustments t o the d e r i v e d f i g u r e s were p u t i n t o e f f e c t so t h a t a more r e a l i s t i c requirementc  f o r each r e g i o n was d e f i n e d .  o f bed p r e d i c t i o n s were p r o v i d e d .  F o r each r e g i o n two s e t s  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  e x p r e s s i n g t h e t o t a l m o r b i d i t y and t h e r e f o r e bed r e q u i r e m e n t s as a function of a region's population.  R e f e r r a l s ( i n t o and out o f the  r e g i o n ) and o u t o f p r o v i n c e p a t i e n t s were t h e r e f o r e n o t r e l a t e d t o the r e g i o n s o r p r o v i n c e s from w h i c h they o r i g i n a t e d .  The second  c a l c u l a t i o n a l l o w e d f o r p r o j e c t e d changes i n o u t f l o w o f p a t i e n t s based upon changes i n the r e g i o n ' s p o p u l a t i o n .  Changes i n t h e  i n f l o w o f p a t i e n t s were;:related t o changes i n t h e p o p u l a t i o n o f r e g i o n s from w h i c h p a t i e n t s came.  These two approaches y i e l d t h e  same p r o v i n c i a l t o t a l s b u t t h e r e g i o n a l t o t a l s v a r y c o n s i d e r a b l y because o f t h e changing  flows.  p r e s e n t e d i n t a b l e format. at  Both o f t h e s e c a l c u l a t i o n s a r e  As a f u n c t i o n o f t h e work-up t o a r r i v e  these c a l c u l a t i o n s , a summation o f beds r e l a t e d t o age and s e x  i s provided. To examine t h e changes i n t h e beds r e l a t i v e t o changes i n the p o p u l a t i o n , t h e p r e d i c t e d beds a r e p r e s e n t e d by age-sex c a t e g o r i e s and a l s o by d i a g n o s t i c c l u s t e r showing p e r c e n t change i n t h e age-sex i n t e r v a l and t h e p e r c e n t change i n beds f o r t h e same age-sex interval.  The beds a r e a l s o p r e s e n t e d i n a sex breakdown t o p r o v i d e  an i n d i c a t i o n o f the type o f s e p a r a t i o n o r s e g r e g a t i o n f o r p a t i e n t privacy.  F i n a l l y , t o 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 t o p o p u l a t i o n r a t i o p r e d i c t i o n method, t h e p r e s e n t s t u d y ' s e s t i m a t e s a r e compared w i t h it,  i n a d d i t i o n t o a r e d e f i n e d bed t o p o p u l a t i o n r a t i o approach. The methodology f o r t h e bed p r e d i c t i o n s was f o l l o w e d p r e -  c i s e l y and checked f o r a c c u r a c y a t numerous s t a g e s .  Yet the f i n a l  t a l l i e s i n t h e p r o j e c t i o n y e a r s a r e d i f f e r e n t f o r t h e " w i t h " and "without" r e f e r r a l predictions. y e a r does n o t exceed 0.6%. r e p e a t e d l y checked. 0.6%.  The d i f f e r e n c e s o r e r r o r i n any one  The methodology and c a l c u l a t i o n s were  However, t h e e r r o r c o u l d n o t be reduced  below  Rounding e r r o r s s h o u l d be m i n i m a l because d e c i m a l s rounded t o  98 t e n t h s were c a r r i e d a l l the way through t h e c a l c u l a t i o n s .  More  p r o b a b l e , t h e e r r o r i s a r e s u l t o f t h e many manual t a b u l a t i o n s performed w h i c h i n v o l v e d b o t h r o u n d i n g and t r a n s c r i p t i o n . r e i t e r a t e , t h e f i g u r e s and c a l c u l a t i o n s were r e p e a t e d l y  To  checked.  The e r r o r w h i c h does n o t exceed 0.6% s h o u l d n o t h i n d e r t h e a p p l i c a t i o n o f e i t h e r d a t a o r methods t o p l a n n i n g purposes.  The e r r o r does  not d i s t o r t t h e i n t e n t o f t h i s t h e s i s w h i c h i s t o 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 t e c h n i q u e s and d a t a f o r health regions  and d i s t r i c t s  (considered  t o be s m a l l e r p o p u l a t e d  areas). Population Appendix F p r e s e n t s  Results  the p o p u l a t i o n i n t h e f o u r r e g i o n s f o r  the y e a r s 1976, 1981, and 1986.  The p o p u l a t i o n s  a r e 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 o p u l a t i o n .  T a b l e VI-1  (which i s a summary o f t h e more i m p o r t a n t o b s e r v a t i o n s  from Appendix  F) shows t h a t - t h e r e a r e remarkable s i m i l a r i t i e s between r e g i o n s . Six population  groups form t h e n u c l e u s o f t h e d i s c u s s i o n .  A l l r e g i o n s 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. T h i s i s the c o n t i n u a t i o n o f a p a t t e r n w h i c h i s a d i r e c t r e s u l t o f a declining b i r t h rate.  W h i l e t h e 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 p r e s e n t p r o j e c t i o n s assume t h a t t h i s w i l l c o n t i n u e l e a s t 1986.  u n t i l at  However d a t a i s n o t y e t a v a i l a b l e on b i r t h s f o r r e c e n t  y e a r s b u t 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 w h i c h i s v e r y marginal. off.  I t may w e l l be t h a t t h e b i r t h r a t e i s b e g i n n i n g  to l e v e l  I f t h i s i s t h e c a s e , t h e p r o j e c t i o n s o v e r t h e n e x t 5-10 y e a r s  may have to be a d j u s t e d  upwards.  In,doing  the population  projections,  the p e d i a t r i c 0-14 age i n t e r v a l s tended t o show a g r e a t d e a l o f  Table VI-1  Summary A n a l y s i s o f Population P r o j e c t i o n s , 1976 v s . 1986:  P o p u l a t i o n As Per Cent Of T o t a l , 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  25-44 H.  Stable  45-64 T.  10.5- 9.9  25-44 F.  20-44 a.g.: 38.1-45.7  6.4- 8.8 25-34 a.g. : 13.7-16.4 Stable 11.3-14.0  5.3- 6.7 20-44 a.g.: 16.7-19.9 Stable 20-44 a.g.: 20.2-25.1  7.6- 9.3 12.1-16.5 12.1-16.5 16.4-15.4 11.9-15.3  P o p u l a t i o n As D i f f e r e n c e , 1976 v s . 1986 Northern 0-14 T.  (237)  15-64 T. 65+  T.  25-44 M.  Eastern  (5243)  (13019)  9974  10735  341  3801  1877  593  25-44 F.  (5844)  Central  7261  Stable  45-64 T.  Western  20-54 a.g.: 4890  25-34 a.g.: 4772  20-44 a.g.: 4774  Stable  Stable  4567  5928  35797 7351 31003 (1561) 14094  NOTES: 1.  When two numbers appear i n each column, the f i r s t f i g u r e i s f o r 1976 and the second f i g u r e i s f o r 1986.  ^ VO  2.  a.g. = age group.  3.  (  4.  T = T o t a l , M = Male, F = Female.  ) = decline.  lido  f l u c t u a t i o n i n the amount of change. base as w i t h the s t a t u s o f o t h e r age  The  d e c l i n e o f the p e d i a t r i c  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 p o p u l a t i o n . The Northern of p e d i a t r i c 0-14  Region w i l l have  the g r e a t e s t percentage  y e a r o l d s r e l a t i v e to i t s own  a b s o l u t e numbers, i t had  Western w i t h 5,844.  The  population.  a very s l i g h t d e c l i n e .  r e g i o n s are the E a s t e r n w i t h  0-14  32.8%  The h i g h  impact  13,019, the C e n t r a l w i t h 5,243 and  i s c o n s i d e r a b l y lower than the remainder o f the P r o v i n c e . the Northern  have the g r e a t e s t percentage of c h i l d r e n 0-14  By  Region i s expected  to  (32.8%) i n comparison  to the E a s t e r n Region which should have the lowest a c t u a l people  the  E a s t e r n Region's percentage of p e d i a t r i c  the end of the p r o j e c t i o n , 1986,  237,  In  (24.5%).  the o p p o s i t e p i c t u r e i s t r u e , the Northern  In  declined  whereas the E a s t e r n d e c l i n e d 13,019. The  15-64  age groups i n c r e a s e d i n a l l r e g i o n s .  Western and E a s t e r n Regions i n c r e a s e d from 59.2% 60.9%  to 66.9%  respectively.  Both  to 65.1%  the  and  from  C o n s i s t e n t gains are shown i n t h r e e  r e g i o n s i n the neighbourhood of 7-10,000, whereas the E a s t e r n had change of 35,797.  T h i s i n c r e a s e a r i s e s because o f the 25-44 age  group which i s growing and s h i f t i n g t h i s growth to h i g h e r  age  levels.  in a l l  Between 2.6%  r e g i o n s except  a  and  3.4%  the Northern.  cohort s u r v i v a l i n e a r l y age  i n c r e a s e s were e x p e r i e n c e d These s l i g h t gains suggested  increased  groups.  I t i s i n t e r e s t i n g to observe the i n c r e a s e i n the o l d e r population  (65+years).  i n the 65+  age  In the N o r t h e r n ,  group  much l a r g e r i n c r e a s e . o f 3,801  t h e r e i s a very s l i g h t  increase  (2.9-3.0%) whereas the o t h e r r e g i o n s d i s p l a y a C e n t r a l Newfoundland demonstrates an i n c r e a s e  twice t h a t of the Western.  However, E a s t e r n i s f a r g r e a t e r  101  w i t h an i n c r e a s e of 7,351 population.  45-64 age  not i n f a c t be i n c r e a s i n g between 1986  i s c r e e p i n g upwards.  W i t h newer t e c h n o l o g i e s  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 group through c o h o r t  stable  increased  This  group, w h i c h  i n m e d i c i n e , even i f r e a c h the 65+  cohort  age  s u r v i v a l i s a l s o suggested i n the  c o n t r i b u t e s to the b u l g e i n the 25-44  survival in  the  early  stages  d i s t i n c t i v e problem i n Newfoundland i n the p a s t .  of  life  Since  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 1976.  2000.  survival.  P e d i a t r i c base (0-14) and group.  the  T h i s does not mean t h a t 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 t h e r e i s a " b u l g e , " the 25-44 y e a r age  age  and  groups are e i t h e r p r e d i c t e d as b e i n g r e l a t i v e l y  or d e c l i n i n g .  The  aging  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 t h a t  G e r i a t r i c base may The  showing more emphatic s i g n s of an  was  a  1966 to 14.6  in  W i t h t h i s s h i f t i n g d e c l i n e an emphasis had been a t t a c h e d  to  b o t h c h i l d and m a t e r n a l care through b o t h P u b l i c H e a l t h M e d i c a l Nursing  Programs.  population  Yet  the " b u l g e " and  the g r a d u a l  and  i n c r e a s e i n the  to o l d e r l e v e l s appears to be a l s o a p r o d u c t of unknown  f a c t o r s such as m i g r a t i o n .  A l t h o u g h a m i g r a t i o n component was  built  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 t h e s e p r o j e c t i o n s what the q u a n t i t y i s . The 1970.  l a t e s t f i g u r e s on m i g r a t i o n Even to e s t i m a t e  a residual  difference  f o r Newfoundland are from 1965  net gains i n the p o p u l a t i o n and between p e r i o d s  classify  i s d i f f i c u l t because  f i g u r e s on b i r t h s and deaths a r e not p r e s e n t l y o r g a n i z e d h e a l t h d i s t r i c t and  to  to  to  the the  regional levels.  A v e r y d i s t i n c t i v e f i n d i n g t h a t a r i s e s from t h i s a g i n g popul a t i o n i s the i n c r e a s e i n the number of women i n the h i g h e r  risk  102  c h i l d bearing years.  The assumption o f i n c r e a s e s i n h i g h r i s k p r e g -  n a n c i e s i s made i n t h e absence o f age s p e c i f i c f e r t i l i t y r a t e s w h i c h are  n o t a v a i l a b l e f o r Newfoundland  ( t h e p r e s e n t method o f computing  beds does a s s i g n d e l i v e r i e s by age o f t h e mother). of  Most n o t a b l y 3  t h e 4 r e g i o n s show a s t a b l e o r d e c l i n i n g 1 5 - 2 4 female age group.  However t h e 2 5 - 4 4 age group i n t h e C e n t r a l , Western and E a s t e r n r e g i o n s show p e r c e n t a g e i n c r e a s e s from 1 1 . 3 % t o 1 4 . 0 % ; 25.1%;  and 1 1 . 9 % t o 1 5 . 3 % ,  means a combined count o f 1986.  24,589  T r a n s l a t e d t o women, t h i s  a s c e n d i n g t o h i g h e r r i s k groups by  Two areas o f c o n c e r n a r e p r e s e n t e d i n t h e N o r t h e r n and C e n t r a l  Regions.  I n t h e N o r t h e r n Region t h e 2 0 - 5 4 age group i n c r e a s e s i t s  count by 35-44  respectively.  2 0 . 2 % to  4,890.  age group.  Nearly h a l f o f t h i s increase i s expected i n the I n t h e Western Region t h e  35-54  age group i n c r e a s e s  by a l m o s t 4 , 0 0 0 women. To summarize on t h e f i n d i n g s f o r a l l r e g i o n s : t h e p e d i a t r i c 0-14  age groups i s d e c l i n i n g ; t h e 1 5 - 6 4 age group i s i n c r e a s i n g ,  showing a s t r o n g i n c r e a s e i n b o t h t h e male and female  25-44  ages and  a s l i g h t d e c l i n e i n t h e 4 5 - 6 4 age groups; and t h e 6 5 + p o p u l a t i o n i s showing a moderate i n c r e a s e .  I n d e f e r e n c e t o s t a t i n g a moderate  i n c r e a s e i n 6 5 + ages, f i g u r e s i n t h e department show t h a t 20%  between  and 3 0 % o f the p a t i e n t days i n h o s p i t a l s a r e u t i l i z e d by t h i s  group who i n comparison t o a l l o t h e r s have t h e s m a l l e s t p e r c e n t a g e of p e o p l e i n t h e h o s p i t a l .  The consequences o f a s l i g h t o r moderate  i n c r e a s e t h e r e f o r e becomes more s i g n i f i c a n t . the  Of e q u a l c o n c e r n i s  growth i n t h e number o f women a s c e n d i n g t o h i g h e r c h i l d b e a r i n g  r i s k groups.  T h i s p a r t i c u l a r group as w e l l as o t h e r s suggest t h a t  even though bed e s t i m a t e s i n c o r p o r a t e t h e s e changes, f u r t h e r a n a l y s i s w i l l be r e q u i r e d t o a l l o w f o r t h e types and l e v e l o f c a r e w h i c h i s  103 t o accompany b o t h p a t i e n t and  bed.  Bed P r e d i c t i o n Tables VI-2  and VI-3  the f o u r h e a l t h r e g i o n s VI-2  does not a d j u s t  show the bed p r e d i c t i o n s f o r each of  f o r the p e r i o d s  the bed  1976,  p r o d u c t o f changes i n p o p u l a t i o n s  the p r o v i n c e  The  and  summarizes the changing bed  Consequently, t h e r e may  e s t a b l i s h e d by t h i s method f o r 1976. S u r g i c a l , 434;  c o n t r i b u t i o n of each bed  province  requirements of both  Figures  t a k e n from the  f o r ease and  clarity  be r o u n d i n g e r r o r s . 1986  o v e r the  At figures  T h i s f i g u r e i s comprised o f :  Respectively,  s e r v i c e would be:  major i n p u t i n t o the i n c r e a s e  the  the p e r c e n t a g e  86.1%, 11.8%, 11.6%  and  i n beds as e x p e c t e d  was  S u r g i c a l w h i c h extend a s e r v i c e component to a wide  range o f age  Eastern,  bed  O b s t e t r i c s , 60; P s y c h i a t r y , 59; and  o n l y d e c r e a s e of 48 i n P e d i a t r i c beds.  increases  the  f o r a l l c l u s t e r s ) change  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  M e d i c a l and  the  Oh  a n a l y s i s e x c l u d e s out o f  i t s four health regions.  in presentation.  The  the  i t can be seen t h a t the  t a b l e s are rounded upwards to the n e a r e s t bed  -9.4%.  Table  are h o s p i t a l i z e d i n Newfoundland.  Table VI-2  M e d i c a l and  1986.  i n the o t h e r r e g i o n s .  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  r e s i d e n t s who  and  i n t o r e g i o n a l f i g u r e s are  does t h i s , and  i n r e l a t i o n t o T a b l e VI-2.  1981  l e v e l w i t h i n each r e g i o n so t h a t  r e f e r r a l s w h i c h are i n c o r p o r a t e d  o t h e r hand, T a b l e VI-3  Results  groups.  By r e g i o n , the expected M e d i c a l and  Surgical  are i n beds: N o r t h e r n , 37; Western, 62; C e n t r a l , 106; 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  were: N o r t h e r n , 7; Western, 12; C e n t r a l , 10; and E a s t e r n , P s y c h i a t r i c increase  and  total  60.  c o m p r i s e d : the N o r t h e r n , 3; the Western, 6;  The the  Table Vl-2 Newfoundland and Regional Bed Service Requirements: 1976. 1981, 1986. Northern 1976 Medical/Surgical 145.1  Western  1981  1986  1976  19B1  164.4  181.2  239.3  269.1  Central 1986  Eastern  Newfoundland  1976  1981  1986  1976  1981  1986  1976  1981  1986  301.9  322.4  372.5  428.4  968.5  1085.4  1197.7  1675.3  1891.4  2109.2  138.8  153.2  170.4  287.1  327.3  346.6  121.7  154.8  195.9  213.4  Obstetrics  35.6  42.6  42.2  52.4  59.S  64.1  60.3  67.0  69.9  Psychiatry  12.6  14.0  14.8  24.9  27.4  30.3  37.8  42.3  46.6  79.5  112.2  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  257.3  284.9  302.5  388.0  418.6  459.3  573.9  636.7  1435.9  1587.3  1713.0  2606.7  2864.7  3111.5  lotal  525.5  Table Vl-3 Newfoundland and Regional Bed Service Requirements Adjusted For Referral Patterns: 1976. 1981, 1986. Northern  Western  Central  1976  1981  1986  1976  1981  1986  1976  125.7  142.3  155.8  213.6  241.5  271.1  245.6  Obstetrics  33.6  40.1  39.9  50.5  57.7  61.9  Psychiatry  10.6  13.7  12.5  23.8  26.0  29.1  Pediatrics  50.4  51.8  50.7  51.5  45.4  45.5  220.3  247.9  258.9  339.4  370.6  407.6  Medical/Surgical  Total  Eastern  Newfoundland  JL2S1  1986  1976  0281  1986  1976  1981  286.8  336.5  1080.3  1210.8  1332.4  1665.2  1881.4  2095.8  57.9  64.7  66.6  144.7  164.2  177.8  286.7  326.7  346.2  31.6  37.3  41.2  88.6  122.7  132.9  154.6  199.7  215.7  70.4  61.4  61.8  310.8  286.3  277.0  483.1  444.9  435.0  405.5  450.2  506.1  1624.4  1784.0  1920.1  2589.6  2852.7  3092.7  V  1986  105 C e n t r a l , 9; and t h e E a s t e r n , 32. As a n t i c i p a t e d t h e 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 d e 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 E a s t e r n , -26.  Table V I - 3 demonstrates t h e e f f e c t s o f a d j u s t i n g t h e r e f e r r a l p a t t e r n o f p a t i e n t s so t h e number o f p a t i e n t s g o i n g i n t o o r coming from a r e g i o n i s a f u n c t i o n o f b o t h t h e m o r b i d i t y and changing p o p 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  a r e added t o t h e base bed need i n a r e g i o n a s l i g h t l y p a t t e r n emerges.  different  I n comparison t o T a b l e VI-2 each r e g i o n shows a  r e d u c t i o n i n bed needs f o r t h e y e a r 1976 w i t h t h e e x c e p t i o n o f t h e E a s t e r n Region.  T h i s i s e x p e c t e d because S t . John's i n t h e E a s t e r n  Region p r o v i d e s t h e t e r t i a r y l e v e l s o f • c a r e f o r t h e p r o v i n c e .  The  m a j o r i t y o f 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 o f bed r e q u i r e m e n t s t h e r e f e r r a l adjustments reduced t h e t o t a l bed needs i n t h e f o l l o w i n g r e g i o n s f o r 1986: N o r t h e r n ,  303 t o 259;  Western, 460 t o 408; and C e n t r a l , 637 t o 507. These r e d u c t i o n s a r e seen as c o n t r i b u t o r y t o t h e i n c r e a s e i n bed r e q u i r e m e n t s f o r t h e E a s t e r n Region from 1713 t o 1921. As an o v e r a l l summary o f these two t a b l e s , t h r e e o f t h e regions w i l l experience  s m a l l adjustments t o a l l bed s e r v i c e c l a s s e s  w i t h t h e e x c e p t i o n o f t h e E a s t e r n Region.  As s t a t e d p r e v i o u s l y , t h e  E a s t e r n Region has a major f u n c t i o n o f p r o v i d i n g t e r t i a r y services.  level  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, g r e a t e r bed  r e q u i r e m e n t s a r e expected.  When these f i n d i n g s a r e r e l a t e d t o  T a b l e VI-7 w h i c h compares t h r e e methods o f 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. Northern,  The p r e s e n t bed l e v e l s i n t h e  Western and C e n t r a l r e g i o n s can more than a d e q u a t e l y  the r e d e f i n e d needs f o r 1986.  meet  Just the opposite i s projected f o r  : 106 the E a s t e r n Region.  C u r r e n t bed l e v e l s do n o t appear t o be  adequate  f o r the 1986 l e v e l o f m o r b i d i t y , the need b e i n g i n the o r d e r of a p p r o x i m a t e l y 300 beds.  Two hundred  and f i f t y - t h r e e o f these  i n the M e d i c a l and S u r g i c a l c a t e g o r y .  fall  A more e l a b o r a t e d i s c u s s i o n  of t h e s e l a t t e r o b s e r v a t i o n s 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 o f T a b l e VI-7. Table VI-3 i n t e r p r e t s bed needs i n each r e g i o n d u r i n g the p r o j e c t i o n p e r i o d by age and sex. i n the p e d i a t r i c 0-14  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  age group i s e v i d e n c e d i n a d e c l i n e i n the  p e d i a t r i c bed r e q u i r e m e n t s i n a l l r e g i o n s .  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 o f which o c c u r i n the E a s t e r n Region. averages between 3% and 5%.  The  15-64  The  decline  age group n a t u r a l l y shows  more r e q u i r e m e n t s 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 o f m o r b i d i t y eminates from o b s t e t r i c a l d i a g n o s e s . show s t r o n g changes.  T h i s p a r t i c u l a r b a s e , however, does not  I n 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 p e r c e n t a g e o f beds (49.7% t o 46.5%) a l t h o u g h the number of beds i n c r e a s e d from 202 to 236.  The Western  Region shows the g r e a t e s t i n c r e a s e i n p e r c e n t from 67.9% t o 72.9%. A g a i n i n numbers, the E a s t e r n Region i s expected to i n c r e a s e by a p p r o x i m a t e l y 192 beds and y e t t h e r e i s o n l y a m a r g i n a l i n c r e a s e i n these beds as a p e r c e n t o f t o t a l  beds.  The 65 and o v e r age group p r o v i d e s a d i s t i n c t d e p a r t u r e 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 expect a t i o n s f o r two r e g i o n s .  Both the N o r t h e r n Region and the Western  Region are expected t o have a l e s s e r percentage of beds b e i n g o c c u p i e d by p a t i e n t s 65 and o v e r , 12.0% t o 11.6%^ and 16.8% to 15.8%, respectively.  The E a s t e r n Region i s e x p e c t e d t o i n c r e a s e from  24.5%  107 to  27.8% f o r a t o t a l o f 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 t h e C e n t r a l R e g i o n w h i c h i s about 2.5 times l e s s t h a n t h a t o f the E a s t e r n a r e a . and  Y e t between 1976 and 1986, t h e 65  o v e r beds a r e e x p e c t e d to i n c r e a s e i n t h e 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% o f a l l beds whereas the E a s t e r n R e g i o n w i l l have 27.8% o f i t s beds o c c u p i e d by t h e 65 and o v e r p a t i e n t . F o l l o w i n g i s a summary o f the a n t i c i p a t e d beds a s s i g n e d to the  t h r e e age groups i n 1986.  The p e r c e n t a g e s a r e shown i n t h e  o r d e r o f 0-14, 15-64, and 65 and o v e r age groups. 68.8,  and 11.6;  Western - 11.2.,, 72.9,  46^5,  and 41.2;  and E a s t e r n , 14.4,  N o r t h e r n - 19.6 ,  and 15.8;  57.7,  C e n t r a l - 12.2.,  and 27.8.  T a b l e VI-4 a l s o s e p a r a t e s each r e g i o n ' s beds by sex.  This  w i l l g i v e an i d e a of the amount o f s e g r e g a t i o n o f beds r e q u i r e d f o r privacy.  Female beds a r e e x p e c t e d t o i n c r e a s e more than males.  the  p r o v i n c i a l l e v e l the female g a i n i s 1% o f a l l beds.  for  1986 t h e f o l l o w i n g sex p e r c e n t a g e s , i n the o r d e r o f male and  At  By r e g i o n  female a r e : N o r t h e r n , 39.4 and 60.6; Western, 39.4 and 60.5; C e n t r a l , 35.1 and 64.9; and E a s t e r n , 44.2 and 55.8. T a b l e s V I - 5 , VI-6 and VI-7 demonstrate a v e r y  distinctive  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 s e r v i c e needs.  It  appears f r o m T a b l e VI-6 t h a t by r e g i o n , changes i n the male p o p u l a t i o n have a g r e a t e r e f f e c t upon c o r r e s p o n d i n g changes i n the bed s e r v i c e requirements. For  P r o v i n c i a i l y , b o t h sexes have t h e same e f f e c t on beds.  t h e most p a r t the i n c r e a s e d s e n s i t i v i t y o f t h e males i s t h e  r e s u l t o f t h e 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. P o p u l a t i o n f i g u r e s f o r t h e 45-65 ages a r e e x p e c t e d to d e c l i n e slightly.  The o t h e r component t o 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  Table Newfoundland  and R e g i o n a l 1976,  -Western  -Horthern-  i 1976  1981  1986  0-4  17.4  17.1  17.2  21.8  1976  6.8  6.9  7.0  5.2  10-14  4.B  4.8  4.9  3.7  15-19  5.5  8.1  4.7  4.5  20-24  4.5  5.0  6.0  6.7  25-34  11.2  12.7  14.1  9.9  35-44  6.8  10.1  12.6  13.5  55-64  10. 1  10.0  10  15.8  65-69  5.3  6.3  6.6  9.7  15.3  13.2  10.3  31.4  98.7  103.7  102.0  141.4  11.5  11.3  11.3  12.9  70+ Total  0  1981 18.9 4.3 3.3 4.6 8.2 11.8  ,  1  Age-Sex and  Bed  Requirements:  190C.  Central  • <  l  Wales  5-9  1  1981  VI-4  j  -Eastern-  ,  1986  1976  1981  1986  1976  -  30.5  24.7  26.5  91.8  5  8  3.9 2.9 4.2 -8.3 13.2  5.9 4.7  5.3 5.1  5.6 2.4 7.1  5.8 3.1 8.3  4.9 4.1 S.3 3.2 9.1  50.8 35.8 34.3 30.3 56.8  14.7  17.2  4.5  4.7  4.8  51.2  15.9  15.6  9.3  9.4  9.5  81.7  11.3  12.1  36.6  11.9  44.0  13.5  46.4  58.2  149.6  161.2  149.2  159.6  11.8  12.1  22.1  19.3  14.2  55.1  i  1981  1986  86.7  88.1  44.7  41.6  32.8  29.2  35.7  32.4  58.2  59.8  73.6  75.8  62.5  83.6  81.7  81.7  63.9  67.8  177.8  Newfoundland  t  it  213.5  1976  1981  ,  i  1986  161.5  147.4  151.6  68.7  61.2  57.4  49.0  46.0  41.1  49.9  54.2  46.6  43.9  75.3  77.3  8S.0  106.4  112.2  78.0  92.0  1W.J  116.9 82.0  117.0 95.0  116.8 100.7  244.0  285.8  341.8  755.5  837.0  894.5  1144.8  1249.9  1335.1  20.3  69.3  65.7  67.1  115.8  108.  110.8  74.0 177.4  150.9  Females 0-4 5-9  5.6  5.9  6.1  3.7  2.9  2.6  3.4  3.0  2.6  33.7  29.3  27.7  46.4  41.  39.0  10-14  4.3  5.8  4.2  4.5  4.5  4.4  4.0  4.3  3.7  29.8  27.3  23.4  42.6  41.  35.7  15-19  14.5  10.3  18.5  18.1  19.5  20.4  18.4  60.7  61.7  58.3  118.  105.1  157.8  179.  185.1  225.6  268.  302.0  129.0  155.  202.4  17.3  19.1  113.2  20-24  19.3  22.9  23.9  26.9  30.8  31.7  28.3  31.9  33.3  83.3  93.4  25-34  21.9  25.9  29.7  36.2  42.6  48.0  38.7  45.8  49.5  128.8  154.4  35-44  11.7  16.4  24.5  19.1  23.4  30.9  22.1  25.6  31.6  76.1  90.4  115.4  45-54  10.1  11.0  12.6  21.3  23.4  27.2  19.8  20.9  23.2  82.7  82.7  85.8  133.9  138.  148.8  118.4  122.5  164.6  174,  180.6  67.7  78.7  55-64  8.9  9.8  10.4  19.8  21.2  22.1  23.5  24.9  25.6  112.4  6S-69  3.2  2.9  2.8  8.4  9.8  10.4  15.7  18.5  19.7  51.5  62.7  140.6  161.0  70* Total Total  Sex  121.6  144  220. 3  24 7 9  2  156  9  258 9  0  221  0  246 4  256  3  290 6  328.7  339 4  370  6  407  405  5  450  506.1  198  6  2  868 9 1624  4  96.2 174.8  93, 283  100.6 347.5  186.7  237.1 1444.8  1602.8  1757.6  2589.6  2852.7  3092.7  947  0  1025.6  1784  0  1920.1  o  oo  109  T a b l e VI-5 P o p u l a t i o n Change Compared w i t h Bed S e r v i c e s Changes Newfoundland and Regions 1976-86 Population % Change 1976-1986  Bed S e r v i c e s Change 1976-1986  Northern  17.3  17.8  Western  7.7  18.5  Central  6.4  21.1  Eastern  10.4  19.3  9.7  19.4  Region  Newfoundland  T a b l e VI-6 Sex P o p u l a t i o n Changes Compared w i t h Bed S e r v i c e Changes 1976-1986  g  l  o  n  Pop. % Change Male  B.S.C. Male %  Pop. % Change Female  B.S.C. Female %  Northern  11.0  3.9  20.1  28.9  Western  3.7  11.9  13.3  23.3  Central  3.9  14.2  9.2  26.0  Eastern  11.3  20.6  9.7  18.2  8.3  16.5  11.1  21.7  Newfoundland a  B.S.C. = Bed S e r v i c e Change  Table Population  Vl-7  C h a n y e n Compared  With  Newfoundland, W e e  o r t h o r n  II  ¥%  B%  FTo  0.5  0.5  7.6  ' i . l  'I.'I  10-1 (|  0.0  15-19  2'|.2  5-9  C  t e r n  1«5 8.2  Hod  Service  Changeo  1976-1906  e n t  r a  PA  1  E  a  B  t e r n  11%  DX  T o t  a  1  n  1 1.0  11.5  1.0  1.7  16.1  15.5  10.5  10.5  16.7  15.0  '3.1  21.6  21.0  19.8  1?.3  5.Q  28.2  27.1  1.8  9.1  6.6  13.1  26.0  't.5  3.0  7.'i  10.7  16.9  30.9  19.9  30.1  3^2  •m  20-2/1  30.9  26.1  22.0  19.7  21.2  25~3'l  30./,  32.3  31.2  32.9  20.3  27.3  3'i.0  35.3  32.0  33.1  35-'i'»  70.9  77.6  '•3-3  'i7.5  23.2  32.9  62.2  59.3  52.7  5'i.0  '»5-5'»  13.2  15.1  I ' I . O  15.0  0.3  9.0  0.7  0.8  9.2  6.2  55-6'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  25.2  2!|.0 •  21.9  22.1  27.0  27.9  27.6  25.0  32.0  21.3  '|2.3  '|2.0  6/|.1  6' .6  35.'i  36.2  '11.3  U3.0  70+  MOTES:  1.  Underlined  2.  Change  figure  indicates  1 G expreoeed  ao  negative  percent  (  chnnge  c h a n g e on  1976  population  Ill  p o p u l a t i o n where s m a l l changes i n the number o f p a t i e n t s have a c o r r espondingly  l a r g e r impact upon bed r e q u i r e m e n t .  B o t h 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 . T a b l e VI-5  compares t o t a l p o p u l a t i o n change w i t h bed  changes between 1976 T a b l e VI-5  and  i s found.  1986.  service  A s i m i l a r s e n s i t i v i t y as d e s c r i b e d i n  B o t h 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 t h a t  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 a t e x a c t l y 1:2.  On f u r t h e r e x a m i n a t i o n  i n T a b l e VI-7  i n f a c t becomes even more d r a m a t i c .  t h i s suggested r e l a t i o n s h i p  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 t h a t 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 r e q u i r e m e n t s . change.  T h i s h o l d s f o r the d i r e c t i o n o f  S t a t i s t i c a l p r o c e d u r e s a r e not n e c e s s a r y  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 e v i d e n t i n the f i g u r e s . was  the  C e r t a i n l y there  e x p e c t e d t o 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 r e q u i r e m e n t s u s i n g t h i s s t u d y ' s methodology. such a s t r i k i n g r e l a t i o n s h i p was T a b l e VI-8  not a n t i c i p a t e d f o r a l l age  compares 3 t e c h n i q u e s  r e q u i r e m e n t s f o r each r e g i o n .  The  Bed  to  groups.  a t p r e d i c t i n g the t o t a l  bed  The Bed S e r v i c e Requirement w i t h R e f -  e r r a l i s the method employed by t h i s s t u d y . the l e v e l and  However,  P o p u l a t i o n changes a f f e c t  type o f m o r b i d i t y w h i c h i n t u r n t r a n s l a t e s i n t o beds. Population  Ratio  Method  expresses  the beds i n Newfound-  l a n d ( s t a f f e d and i n o p e r a t i o n ) o v e r the p o p u l a t i o n , a r a t e w h i c h i s then m u l t i p l i e d vice  to  Population  technique. of  beds  by  The  i n the  a  projected  Rate  major formula  population.  i s , i n fact,  departure  Finally,  a  bed  to  i s that  the  initial  i s e s t a b l i s h e d by  The  Bed  population  Ser-  ratio  statement  sorting morbidity  and  Table Vl-8 Comparison of the Bed t o Population Ratio, Bed Service t o Population and Bed Service Requirement With Adjustment f o r R e f e r r a l . Tecnniqueel  Newfoundland and Regions 1976, 1981 and 1986.  — 1976— B.P.R.  -19B1-B.S.P I I B.S.R.R.  B.P.R.  -19B6 ' B.S.R.R.  B.P.R.  Northern  220 .3  396 0  220.3  247 9  422.0  Western  339.4  426 0  339.4  370 6  442.0  Central  40S 5  628 0  405.5  450 2  650.0  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  239.3  258.9  465.0  258.5  352.4  407.6  459.0  365.6  420.3  506.1  672.0  434.7  B.S.R.R. - Bed s e r v i c e requirement with r e f e r r a l , the study's method. B.P.R. - Bed t o population r a t i o method. B.S.P. Bed s e r v i c e requirement with referral,1976,expressed as a r a t i o t o the population.  113 t r a n s l a t i n g i t i n t o bed needs.  However, m o r b i d i t y and p o p u l a t i o n  a r e not a l l o w e d to i n t e r a c t i n t h e p r o j e c t i o n s . 1976  The bed to p o p u l a t i o n t e c h n i q u e g i v e s a c u r r e n t o r e s t i m a t e o f 2944 beds and assumes the occupancy r a t e o f 67%.  The bed s e r v i c e requirement  assumption o f h i g h e r o c c u p a n c i e s .  as the chosen a l t e r n a t i v e has  an  The Newfoundland occupancy u s i n g  i s a p o o l e d average of 8 3 . 7 % .  these r e q u i r e m e n t s  approximately  This figure i s  p r i m a r i l y i n f l u e n c e d by the E a s t e r n Region w h i c h had been a r b i t r a r i l y 85%.  e s t a b l i s h e d at  The bed to p o p u l a t i o n method p r e d i c t s a h i g h e r number o f beds f o r each r e g i o n w i t h t h e e x c e p t i o n o f the E a s t e r n  Region.  P r o v i n c i a l l y , t h i s method gave a h i g h e r p r e d i c t i o n than the o t h e r methods.  Note t h a t t h e r e i s an understatement of beds f o r the  Eastern area.  One  of the reasons  l e v e l f o r many of the 1494 Consequently  f o r t h i s i s t h a t the occupancy  beds f a r exceeds.the  85% occupancy l e v e l .  more m o r b i d i t y i s h a n d l e d w i t h l e s s beds.  s e r v i c e requirements  The  bed  are e s t a b l i s h e d a t an 85% occupancy l e v e l .  As  a second r e a s o n , the m o r b i d i t y f i l e forms t h e b a s i s o f the beds, not what the h o s p i t a l s s t a t e they have i n beds ( a c c o r d i n g t o the A n n u a l Returns) w h i c h may  o r may  not r e f l e c t a c t u a l needs.  For 1986  bed t o p o p u l a t i o n p r e d i c t i o n o f beds f o r the p r o v i n c e and a r e : Newfoundland, 3 2 3 7 ; N o r t h e r n , 4 6 5 ; and E a s t e r n , 1641. Western Regions.  Western, 4 5 9 ;  the  regions  Central,  An anomaly appears between the N o r t h e r n  and  The Western a r e a has t w i c e the p o p u l a t i o n y e t  l e s s beds than the N o r t h e r n a r e a .  The number o f beds i n the  672;  has  Northern  area a r e 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 rates.  C o n s i d e r i n g these f a c t o r s , and what i s a c t u a l l y needed based  on m o r b i d i t y e v i d e n c e , the bed to p o p u l a t i o n t e c h n i q u e tends  to  114 p e r p e t u a t e i n a d e q u a c i e s i n the system i f such  exist.  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 c o n s e r v a t i v e 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.  I n r e l a t i o n t o the bed to p o p u l a t i o n t e c h n i q u e t h e r e i s a  n e t d i f f e r e n c e of 397 beds.  T h i s approach a l s o produced a lower  e s t i m a t e i n each o f the r e g i o n s .  bed  A l t h o u g h i t does not i n t e r a c t w i t h  m o r b i d i t y i t does assume t h a t t h e r e s h o u l d be p r o p e r s o r t o f beds through m o r b i d i t y a t a g i v e n l e v e l of e f f i c i e n c y f o r the r a t e o r base y e a r . T h i s s t u d y proposes the bed s e r v i c e requirement w i t h r e f e r r a l t e c h n i q u e as the method w h i c h y i e l d s the b e s t r e s u l t s f o r p l a n n i n g and a l s o stands by the a r b i t r a r y c h o i c e of occupancy r a t e s 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  alter-  n a t i v e courses of a c t i o n to p r o v i d e h e a l t h c a r e to the Newfoundland population. I f the p r e s e n t l e v e l o f beds as a r a t i o . t o the p o p u l a t i o n i n each r e g i o n c o n t i n u e s ( h i s t o r i c a l l y t h e r e i s no reason to b e l i e v e t h a t 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 e s t i m a t e  the  consequences of u t i l i z i n g the bed s e r v i c e requirement  The  method.  1986 p r o v i n c i a l p r e d i c t i o n p r o v i d e d by t h i s study i s 3092 beds as compared t o the r a t i o method p r e d i c t i o n o f 3237, a d i f f e r e n c e o f approximately  144 beds o c c u r s .  R e l i a b i l i t y i s a l s o c o n f i r m e d by  p r a c t i c a l c a l c u l a t i o n of percentage  the  occupancy i n v a r i o u s h o s p i t a l s .  A g r e a t 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 e x t r e m e l y low occupancy r a t e s r a n g i n g from 12% to 50%. was  d i s c u s s e d i n the l i t e r a t u r e r e v i e w (Appendix A) t h e r e are  for this.  As reasons  The excess b o t h p r e s e n t and f u t u r e i s not n e c e s s a r i l y a  p r o d u c t of i n e f f i c i e n c i e s but a p r o d u c t of changing  roles  and  115 shifting  s t y l e s to deal w i t h p a t i e n t s .  U n f o r t u n a t e l y 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 . T h i s l a t t e r p o i n t and the key o b s e r v a t i o n s r e g a r d i n g bed p r e d i c t i o n s w i l l be d i s c u s s e d as w i t h the p o p u l a t i o n o b s e r v a t i o n i n the f i n a l c h a p t e r . practicalities  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  of the Newfoundland scene and t o the p l a n n i n g  f o r the h e a l t h c a r e scene.  role  CHAPTER V I I SUMMARY AND  DISCUSSION  Introduction The p r e s e n t study has done more than i t i n t e n d e d .  The  o r i g i n a l o b j e c t i v e s o f t h i s s t u d y were to p r o v i d e a p r e d i c t i o n o f bed needs i n the f u t u r e and to p r o v i d e b o t h a s o r t and p r o j e c t i o n o f p o p u l a t i o n by age and sex f o r h e a l t h r e g i o n s and d i s t r i c t s . more advantageous r e s u l t was  The  a focus i n p l a n n i n g p h i l o s o p h y ; t h a t  i s , a f o c u s and statement r e g a r d i n g the types o f d a t a which  are  r e q u i r e d f o r the f u t u r e and the types o f a c t i v i t i e s w h i c h must accompany these d a t a r e q u i r e m e n t s .  T h i s w i l l be e v i d e n t i n the  d i s c u s s i o n to f o l l o w : summary o f f i n d i n g s ; advantages  and d i s a d v a n -  tages of m e t h o d o l o g i e s ; p r a c t i c a l i m p l i c a t i o n s o f the f i n d i n g s  and  future 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 R a t i o Method  The a c c e p t e d g u i d e l i n e f o r the amount o f e r r o r i n the popul a t i o n p r o j e c t i o n under o r e q u a l to t e n y e a r s was 10% l e v e l i n the l i t e r a t u r e r e v i e w .  e s t a b l i s h e d a t the  The R a t i o Method was  used to  p r o j e c t an h i s t o r i c a l s e t o f census v a l u e s i n Newfoundland. r e s u l t was was  The  compared t o the a c t u a l v a l u e s i n the census y e a r w h i c h  the y e a r o f 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 116  f i v e years.  11 z E r r o r s were r e c o r d e d t o 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 t e c h n i q u e , a s i n g l e e s t i m a t o r of t h e 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  a l s o judged a c c e p t a b l e as a p l a n n i n g t o o l because i t produced an a c c e p t a b l e p r o p o r t i o n o f e r r o r under o r e q u a l t o 10% f o r a f i v e y e a r projection.  Acceptance was based upon: t h e c h a r a c t e r o f the  Newfoundland p o p u l a t i o n ; the o p i n i o n t h a t extreme v a l u e s would n e c e s s a r i l y have t o be p r u d e n t l y a d j u s t e d ; and f i n a l l y , t h a t t h e m a j o r i t y o f e r r o r s (81%) a r e under o r e q u a l t o 10% when t h e extremes are i d e n t i f i e d ( 1 9 % ) . Sampling o f the e r r o r s i n d i c a t e d t h a t t h e a b s o l u t e mean w i t h s t a n d a r d e r r o r was 12%±± 1.2.  The 0-2999 s t r a t u m w h i c h c h a r a c t e r i z e s  much o f t h e Newfoundland p o p u l a t i o n had an a b s o l u t e mean o f 13.0% ± 1.8.  C o m p a r a t i v e l y , t h e t o t a l d a t a s e t o f e r r o r s had an a b s o l u t e  mean o f 12.3% ± 1 . 2 and t h e 0-2999 s t r a t u m had an a b s o l u t e mean o f 13.2%  ± 1.3.  The p r o p o r t i o n o f e r r o r s under o r e q u a l t o 10% i n the  sample was .63 whereas i t was .65 i n t h e t o t a l d a t a s e t . The 0-2999 s t r a t u m c o n t r i b u t e d h e a v i l y towards t h e means e x p r e s s e d i n t h e p r e c e d i n g paragraphs.  This stratum a l s o t y p i f i e s  the s m a l l and s c a t t e r e d n a t u r e o f t h e Newfoundland p o p u l a t i o n . T h e r e f o r e i t was a n a l y z e d i n d e p e n d e n t l y 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 w h i c h were f e l t t o be u n p r e d i c t a b l e  b o t h d e m o g r a p h i c a l l y and e c o n o m i c a l l y were removed from t h e 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 o f e r r o r s under o r e q u a l t o  10% i n c r e a s e d from .65 t o .77. A l t e r n a t i v e l y , e r r o r s g r e a t e r o r e q u a l t o 20% were s u b t r a c t e d from t h e 193 o b s e r v a t i o n s .  Eighty-one  p e r c e n t o f t h e e r r o r s f e l l under o r e q u a l t o 10%. The a b s o l u t e mean dropped from 13.2% ± 1.2 t o 5.1% ± .4.  I f , Aas has been  suggested,  118 extremes must n e c e s s a r i l y be a d j u s t e d  then the o r i g i n a l e s t i m a t e o f  the mean o f 13.2% + 1.2 s h o u l d d e c l i n e below t h e 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 o f e r r o r s f a l l i n g under o r e q u a l t o 10% s h o u l d be improved, o v e r t h e 81% l e v e l . The  i n f e r e n c e o f an a c c e p t a b l e e s t i m a t o r  of population i s  a l s o s u p p o r t e d when the sampled e r r o r s a r e t r a n s f o r m e d by t h e A r c sin  \Jpercent  transformation.  The Arcsin,;. ^ p e r c e n t  transformation  p u l l e d extreme v a l u e s from b o t h ends o f the d i s t r i b u t i o n towards the mean.  The r e t r a n s f o r m e d mean was 9.2% compared w i t h t h e non t r a n s -  formed mean o f 12 (S.E. b e f o r e t r a n s f o r m a t i o n s  was 1.25).  Consid-  e r i n g b o t h types o f extremes t h e m a j o r i t y o f t h e d a t a hedges around the 10% g u i d e l i n e .  However, t h e t r a n s f o r m a t i o n  was c o n s i d e r e d  t o 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 m i n i m i z e d t h e i n f l u e n c e o f extreme v a l u e s on t h e mean.  These v e r y extremes would be a p o i n t o f  f o c u s because they must be i d e n t i f i e d and d e a l t w i t h by t h e demographer. No 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 t h e  p r o p o r t i o n o f e r r o r s under o r e q u a l t o 10% o f the s i z e o f e r r o r c o u l d be e s t a b l i s h e d .  The p l o t t i n g o f t h e e r r o r s d i d n o t suggest  e i t h e r a l i n e a r o r non l i n e a r r e l a t i o n s h i p . t a b l e s suggest t h a t t h e a b s o l u t e decreases w h i l e increases  mean e r r o r a n d . s i z e o f e r r o r  t h e p r o p o r t i o n o f e r r o r s under o r e q u a l t o 10%  as p o p u l a t i o n  s i z e increases.  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 . increases  S u p e r f i c i a l l y , a l l the  The p l o t t i n g o f t h e e r r o r s As t h e p o p u l a t i o n  t h e range t i g h t e n s and s h i f t s downward.  size  The s u b t l e t y o f  these r e l a t i o n s h i p s a r i s e s because Newfoundland p o p u l a t i o n s  are i n  thousands whereas s t u d i e s i n t h e 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 p o p u l a t i o n s  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 t h a t  , ,119-  the e r r o r s appear t o 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 i m p o r t a n t l y  t h i s i m p l i e s t h a t the r a t i o p r o j e c t i o n  method i s n o t i n f l u e n c i n g t h e e r r o r .  Instead  i t i s the nature o f  the p o p u l a t i o n b e i n g p r o j e c t e d w h i c h i s p r o d u c i n g t h e f l u c t u a t i o n s . T h i s s t r e n g t h e n s t h e argument f o r complementary d a t a f i l e s f o r each a r e a b e i n g p r o j e c t e d so t h a t extreme v a l u e s The planning  can be m o d i f i e d .  r a t i o p r o j e c t i o n method i s c o n s i d e r e d  t o be an a c c e p t a b l e  t o o l because t h e m a j o r i t y o f t h e e r r o r s f a l l under t h e 10%  guideline.  The p r e c i s i o n o f t h i s method i s i n c r e a s e d by  p o p u l a t i o n bases p r i o r t o p r o j e c t i o n , by s h o r t e n i n g 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 v a l u e s . method i s c o n s i d e r e d  appropriate  aggregating  the p r o j e c t i o n Therefore, the  f o r areas c h a r a c t e r i z e d by s m a l l  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 o f k e y demographic d a t a . also acceptable  It is  because i t does n o t i n f l u e n c e t h e a b s o l u t e v a l u e s o f  data being projected.  The a c c e p t a n c e o f t h i s method, however, does  not mean t h a t the p r o s p e c t i v e p r o j e c t i o n s w i l l be a c c u r a t e t h i s s t a t e can be i n f e r r e d .  although  The f i n a l t e s t o f a c c u r a c y o f t h e 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 v a l u e s .  Summary o f P o p u l a t i o n The  Projections  r a t i o method was employed t o produce t h e p r o j e c t i o n s .  To enhance t h e a c c u r a c y o f t h e p r o j e c t i o n s , and t h e r e f o r e t h e e s t i mate o f beds, t h e age s e x p o p u l a t i o n s  of health s t a t i s t i c a l  districts  were aggregated t o 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 t o p r o j e c tion. I n each o f t h e 4 h e a l t h r e g i o n s , t h e p e d i a t r i c 0-14 y e a r p o p u l a t i o n groups d e c l i n e d between 1976 and 1986. The N o r t h e r n Region had the h i g h e s t p e r c e n t a g e o f 0-14 y e a r o l d s w i t h 32.8%,  120  the l o w e s t at 2 4 . 5 % , but the g r e a t e s t  whereas the E a s t e r n Region had number i n d e c l i n e , 1 3 , 0 1 9 .  The  a l l r e g i o n s between 7 , 0 0 0 and i n c r e a s e d by 3 5 , 7 9 7 .  15-64  y e a r age  groups i n c r e a s e d i n  1 0 , 0 0 0 p e o p l e , w h i l e the  Much o f t h i s change i s t a k e n up by a  i n the 2 5 - 4 4 age group.  increase of 2 4 , 5 8 9 .  I n the 65+  i s e x p e c t e d to i n c r e a s e .  pregnancies  age group, a s l i g h t i n c r e a s e i s  However, the E a s t e r n Region i s e x p e c t i n g an a d d i t i o n a l  to t h i s group.  Region.  a total  I n the absence o f f e r t i l i t y d a t a and under the  assumption o f one b i r t h r a t e , the number o f h i g h r i s k  7,851  A dramatic  i n c r e a s e i s seen i n the C e n t r a l  I t i s a n t i c i p a t e d , however, t h a t t h e r e may  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  i n f a c t be  because o f  The  a  the  d e c l i n i n g 4 5 - 6 4 age group f o l l o w e d by an i n c r e a s e around the 2000.  age  Each o f the r e g i o n s demonstrated an i n c r e a s e i n  the number o f women.  observed.  "bulge"  S l i g h t d e c l i n e s are seen i n the 4 5 - 6 4  W i t h i n the female 2 5 - 4 4 age group, t h e r e was  groups.  Eastern  year  E a s t e r n Region shows an a g i n g p o p u l a t i o n w h i c h i s e x p e c t e d  t o grow i n the f u t u r e .  Summary o f 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 g i v e a p r e d i c t i o n o f bed needs.  interfaced with morbidity  A s e p a r a t e p r e d i c t i o n o f beds  to was  d e r i v e d 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 p a t t e r n s i n t o and out o f r e g i o n s . i s 3093 beds.  At the p r o v i n c i a l l e v e l the bed  The bed r e q u i r e m e n t s a l l o w i n g f o r r e f e r r a l s  e x c l u d i n g out of p r o v i n c e f o r each r e g i o n i n 1986 Western, 4 0 8 ;  C e n t r a l , 637;  and E a s t e r n , 1921.  based on occupancy l e v e l s o f : N o r t h e r n , 6 5 % ; 75%;  and E a s t e r n , 85%.  requirement and  a r e : Northern, These e s t i m a t e s  Western, 75%;  The p r e s e n t bed l e v e l s i n the  259; are  Central,  Northern,  121 Table V I I - l Summary o f the 1986 T o t a l Bed Requirements f o r the Four H e a l t h Regions i n Newfoundland Requirements (Beds)  Region Northern  259  Western  408  Central  637  Eastern  1921  Newfoundland  3093  F i g u r e s rounded upwards to n e a r e s t bed. 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 a d e q u a t e l y needs as p r e s e n t e d  by t h i s study.  The  l e v e l does not appear t o be adequate. be needed by  1986,  Total w i l l  meet the r e d e f i n e d  bed  E a s t e r n Region's p r e s e n t Approximately  250 o f w h i c h w i l l be m e d i c a l and  bed  300 beds w i l l surgical.  By bed s e r v i c e the p r o v i n c e i s e x p e c t e d t o show a d e c l i n e of 48 p e d i a t r i c beds and an i n c r e a s e 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 .  I n each case the E a s t e r n 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 o t h e r 3 r e g i o n s . E x c l u d i n g the E a s t e r n R e g i o n , the l a r g e s t c o n t r i b u t i o n s to bed a r e : 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,  type 12;  P s y c h i a t r i c - C e n t r a l , 9. By age  groups, the p e d i a t r i c 0-14  d e c l i n e by 48 beds p r o v i n c i a l l y .  The  group i s e x p e c t e d to  15-64  age group, on the  hand, i s a n t i c i p a t e d to i n c r e a s e by 328 beds.  This increase  other falls  a c r o s s a l l r e g i o n s , most n o t a b l y the Western and E a s t e r n Regions. Both the C e n t r a l R e g i o n , w i t h i t s d r a m a t i c  i n c r e a s e , and the  Region account f o r the moderate i n c r e a s e i n beds f o r the 65+  Eastern age  122 group.  P r o v i n c i a l l y , t h e r e q u i r e m e n t w i l l be 225 beds.  By s e x , the  s p l i t i n beds i s e x p e c t e d t o f a v o r females w h i c h shows a p r o v i n c i a l i n c r e a s e from 55.8% to 56.8% by 1986.  W i t h the e x c e p t i o n o f the  E a s t e r n R e g i o n , a l l r e g i o n s s h o u l d have between 60% to 65% o f t h e i r beds d e s i g n a t e d female. In  comparison w i t h e x i s t i n g l e v e l s o f beds, the bed p r e d i c -  t i o n s f o r t h r e e r e g i o n s i n 1986 show t h a t t h e r e w i l l s t i l l be an excess o f 206=beds.  I f p r e s e n t l e v e l s are p r o j e c t e d t h e r e would be  a g r e a t e r e x c e s s , to the tune o f 421 beds. the  The E a s t e r n Region on  o t h e r hand i s e x p e c t e d t o r e q u i r e a d d i t i o n a l beds.  p r e d i c t i o n i s 1921.  This study's  The bed t o p o p u l a t i o n r a t i o i s 1641 and the  c u r r e n t l e v e l i s 1494. The i n t e r f a c i n g o f age and sex and m o r b i d i t y d i d show t h a t bed r e q u i r e m e n t s would d i f f e r from a p r e d i c t i o n i n w h i c h t h e s e 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 o b s e r v e d ; odd i n the sense t h a t 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 p e r c e n t change i n p o p u l a t i o n was accompanied by a one p e r c e n t change i n bed requirements.  service  The change i n bed s e r v i c e i s a p r o d u c t of p o p u l a t i o n  and m o r b i d i t y by age sex c l a s s i f i c a t i o n s . Advantages and D i s a d v a n t a g e s o f the R a t i o P r o j e c t i o n Method Advantages and d i s a d v a n t a g e s 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 w h i c h a r e d i s c u s s e d a r e those w h i c h 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  r e s u l t s a l t h o u g h extreme c a l c u l a t i o n s were o b s e r v e d .  consistent This consis-  tency i s v e r y p o s i t i v e i n view o f the l a c k o f c u r r e n t d a t a w h i c h i s a v a i l a b l e i n the p r o v i n c e 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 a t e s a r e a b s e n t , 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  p e r i o d 1965-1970, and t h e b i r t h s and deaths a r e n o t o r g a n i z e d health s t a t i s t i c a l d i s t r i c t .  The use o f t h e r a t i o method  f o r more c u r r e n t i n f o r m a t i o n t o be used.  provided  The method i t s e l f i s  f l e x i b l e i n the sense t h a t e s t a b l i s h e d r a t e s can be m o d i f i e d going through elaborate procedures.  by  without  S i m i l a r l y , extreme v a l u e s can  be i m m e d i a t e l y 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 ment.  on t h e b a s i s o f complementary demographic d a t a and j u d g e -  The r a t i o method i s s i m p l e and easy t o f o l l o w even when an  ungainly  s e t of f i g u r e s requires manipulation.  provides  ease i n c a l c u l a t i o n and programming f o r computer. On t h e n e g a t i v e  This  simplicity  s i d e , t h e method i s n o t s e n s i t i v e t o r e c e n t  changes when a p a s t p e r i o d i s , f o r example, 5 y e a r s .  I t assumes the  c o n t i n u a t i o n o f a growth o r d e c l i n e r a t e a t the same r a t e . quently  Conse-  r e c e n t growth r a t e s w h i c h a r e l e v e l l i n g o r r e v e r s i n g d i r e c -  t i o n w i l l be f o r c e d a g a i n s t l o g i c . expected to continue  I n a d d i t i o n , growth r a t e s a r e  t o i n f i n i t y whereas d e c l i n i n g r a t e s a r e e x p e c t e d  t o r e a c h a p o i n t where adjustments t o z e r o v a l u e s must be made (negative p o p u l a t i o n s ) . The  I n these terms, t h e method i s i n f l e x i b l e .  r a t i o method c a n produce two r e s u l t s .  On t h e one hand  t h e r e i s a m a t h e m a t i c a l c a l c u l a t i o n w h i c h f o l l o w s s i g n s ; on t h e other,  there i s a l o g i c a l process.  I n some c a s e s , 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 y e t m a t h e m a t i c a l s i g n s d i c t a t e a growth. The population.  use o f t h i s method i s a c h o i c e f o r a s i n g l e e s t i m a t o r o r Extreme v a l u e s a r e t h e r e f o r e e x p e c t e d .  I n some s i t u a -  t i o n s i t i s more t h a n obvious t h a t the r a t i o method does n o t p e r f o r m well.  T h i s g e n e r a l l y o c c u r s i n a v e r y s m a l l p o p u l a t i o n w h i c h has  undergone a s i g n i f i c a n t change r e l a t i v e t o a minor n a t i o n a l change.  . 124 I f i n t h e f u t u r e t h e 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 , t h e p r o j e c t i o n f o r t h e l o c a l a r e a would y i e l d an extreme e r r o r . Although  t h i s study judged t h e r a t i o method as b e i n g  f u l f o r the Newfoundland s e t t i n g ,  purpose-  small populations, certainly  popu-  l a t i o n s under 3000, produce more e r r o r s o v e r 10% and a w i d e r range to the e r r o r s than l a r g e r p o p u l a t i o n s . I n t h e c o n t e x t o f age s e x i n t e r v a l s , t h i s problem i s m a g n i f i e d because t h e r e a r e many  intervals  under 1000 p o p u l a t i o n . The Advantages and D i s a d v a n t a g e s o f 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 s t u d y , a p r i o r i , i s b e t t e r t h a n t h e bed t o p o 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 i m p o s s i b l e , t o determine i f t h e model produces good r e s u l t s . Only the a p p l i c a t i o n o f i t s r e s u l t s would a l l o w t h i s c o n c l u s i o n . C e r t a i n l y t h e r e would appear t o be a b u i l t - i n b i a s t o g i v e a c o n s e r v a t i v e e s t i m a t e because i t d e a l s w i t h a demand s i t u a t i o n i n p a t i e n t morbidity experienced The  (the actual  by the p o p u l a t i o n ) .  r e a l advantage o f t h i s model i s found b o t h i n i t s ease  and f l e x i b i l i t y o f a p p l i c a t i o n w i t h i n the p l a n n i n g f u n c t i o n o f the Department.  Indeed the program was d e r i v e d from a m o r b i d i t y  w h i c h was n o t i n t e n d e d as a bed statement. translation  profile  I t i s true that the  o f such i s t u r n e d I n t o statements r e g a r d i n g beds.  What  has happened i n t h i s study i s t h a t t h e r e i s a s i m p l e and l o g i c a l a s s u m p t i o n , and i t s converse t h a t m o r b i d i t y c l a s s i f i c a t i o n s a r e a l s o 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 t o summarize m o r b i d i t y  and beds t o the 4 h e a l t h r e g i o n s u s i n g t h i s s t u d y ' s bed p r e d i c t i o n model.  W i t h t h e v e r y same program and s w i t c h i n g a s u b r o u t i n e t o  s e l e c t o r i g i n o f p a t i e n t , the type o f r e f e r r a l c o u l d a l s o be e s t a b -  125 lished.  At t h i s p o i n t i n time not a l l o f the c a l c u l a t i o n s have been  programmed.  However, i t i s b e i n g planned and w i l l a l s o be used f o r  purposes o t h e r than bed  estimates.  W i t h a s i m p l e m o d i f i c a t i o n o f p e r c e n t occupancy a t the r e g i o n a l l e v e l , a p l a n n e r , g i v e n c o n s t r a i n t s o f time and c o s t s , can b a l a n c e f i g u r e s t o d e r i v e the b e s t c o m b i n a t i o n o f 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 d i s a d v a n t a g e  a r b i t r a r i l y chosen occupancy l e v e l may  because the  not be a p r o d u c t o f needs o r  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 a p p r o p r i a t e . Whatever statement  t h i s model produces may,  i n f a c t , be i m p o s s i b l e  to a c h i e v e 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 a d d r e s s i n g p r e d i c t i o n s on the c o n s e r v a t i v e s i d e . The bed p r e d i c t i o n model, as i t s t a n d s , 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 e s t a b l i s h m e n t of a p r o v i n c i a l p o l i c y w h i c h i s a summation o f p o l i c y statements areas.  bed  from the v a r i o u s  I n o t h e r 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 f o r c e d upon  e i t h e r the p o p u l a t i o n o r r e g i o n a l p l a n n e r s .  However, because t h e r e  i s ease i n the use o f t h i s model and because i t i s p a r t of an e x i s t i n g d a t a system a t the p r o v i n c i a l l e v e l , the model has the disadvantage  o f r e q u i r i n g v e r y l i t t l e i n p u t from r e g i o n a l p l a n n e r s .  Consequently  any statement  on beds may  be c o n s i d e r e d an i m p o s i t i o n  and s u b j e c t t o an e r r o r w h i c h has n o t been addressed  through  local  experience. A very d i s t i n c t disadvantage  o f the model i s t h a t i t c a r r i e s  f o r w a r d a s t a t i c m o r b i d i t y p a t t e r n ( i n c l u d i n g l e n g t h o f s t a y ) even though a d m i s s i o n s v a r y .  L o g i c a l l y , one cannot expect the same  m o r b i d i t y p a t t e r n s b u t s e n s i b l y how t i o n t o m o r b i d i t y f o r the f u t u r e .  does one g i v e a p r e c i s e d e f i n i On the o t h e r s i d e o f the c o i n ,  *•  126 t h e r e i s the p r a c t i c a l advantage t h a t each r e g i o n i s p r o v i d e d i t s own  unique m o r b i d i t y p a t t e r n .  Therefore,  with  the needs of the popu-  l a t i o n are not imposed upon l o c a l o r r e g i o n a l a r e a s .  The  morbidity  p a t t e r n i n t h i s model assumes t h a t 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 m o r b i d i t y o r i n p a t i e n t needs.  One  s o l u t i o n to the  static  m o r b i d i t y p a t t e r n would be to a n a l y z e the h i s t o r y o f a d i a g n o s i s  (or  c l u s t e r ) and p r o j e c t a r a t e f o r each p o i n t i n the f u t u r e . Key O b s e r v a t i o n s R e g a r d i n g the Population Projections C o n s i d e r i n g Newfoundland's type and l o c a t i o n o f p o p u l a t i o n the r a t i o method s h o u l d not be used beyond 10 y e a r s populations.  f o r small area  I f p o p u l a t i o n s a r e below the 3000 l e v e l the method  c o u l d be used but i t i s s t i l l s u b j e c t t o the p e r c e n t e r r o r g u i d e 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 popul 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 o f the method a r e suggested. aggregated.  P o p u l a t i o n bases and age sex i n t e r v a l s s h o u l d  This aggregation  should increase accuracy, y e t , i t  s h o u l d p r o v i d e enough s p e c i f i c i t y to be p r a c t i c a l . combination be used.  of b o t h h o s p i t a l d i s t r i c t s and  3-4  age  For example, the intervals  T h i s s h o u l d produce an adequate p o p u l a t i o n base.  i n t e r v a l s chosen c o u l d cover the major age 55-64, 65 and over.  be  groups, 0-14,  could The  15-44,  I t might a l s o be p r e f e r a b l e t o c o n s i d e r a f i v e  y e a r e s t i m a t e r a t h e r than 10 y e a r p r o j e c t i o n .  I t would run v e r y  c l o s e to the f o u r y e a r p l a n n i n g c y c l e w h i c h i s b e i n g  inaugurated  w i t h i n each department of the Newfoundland government. r e v i s i o n of population estimates  Constant  can o n l y improve upon purpose  and  127 precision. 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 c o u l d a l s o be c o n t r o l l e d  by c h e c k i n g w i t h r e g i o n a l o r h o s p i t a l h e a l t h p l a n n e r s who involved i n a similar exercise.  I f p r o v i n c i a l estimates  might be are  derived  by checks upon economic s t a b i l i t y , h o u s i n g s t a r t s o r a c t u a l s a m p l i n g of the p o p u l a t i o n , a p o o l e d  e f f o r t might l e a d to g r e a t e r p r e c i s i o n . '  I f the e s t i m a t e i s not p o o l e d  and o p i n i o n s are asked, a degree o f  b i a s might be i n t r o d u c e d t o the d a t a s e t . T h i s s t u d y has  f o l l o w e d the m a t h e m a t i c a l p r o c e s s of c a l c u -  l a t i o n s and has m a n i p u l a t e d the d a t a as l i t t l e as p o s s i b l e .  In  o t h e r words, the d a t a base which has been used i s c o n s i d e r e d  clean  and i t s a s s o c i a t e d methodology c l e a r . u s e r can employ h i s / h e r own  From t h i s p o i n t o f v i e w  any  assumptions and a p p l y a l o g i c p r o c e s s to  the d a t a base o r 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 a p p r o p r i a t e r a t e s are then are as i m p o r t a n t  as  the  the f i n a l p r o j e c -  tions . A c c u r a c y f o r v e r y 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 r o u n d i n g process.  To the l a r g e r p r o v i n c e s  t h i s p r o c e s s would produce n e g l i -  g i b l e amounts of e r r o r but as d e s c r i b e d e a r l i e r i t c o u l d mean a o r 30%or 100%  e r r o r i n an age  20%  i n t e r v a l i n a Newfoundland community.  I f i t i s a q u e s t i o n o f c o n f i d e n t i a l i t y , are not the p r o v i n c e s c e s s i n g m o r b i d i t y d a t a w h i c h has  pro-  the c a p a b i l i t y of i d e n t i f y i n g p e o p l e  i n a community w i t h more i d e n t i f i e r s .  I t s h o u l d 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 t o r e t r i e v e d a t a from s e t s w h i c h they d i r e c t l y or i n d i r e c t l y contribute to. F i n a l l y , i t can be proposed f o r Newfoundland t h a t i n h e a l t h s h o u l d be o r g a n i z e d  planning  to the census d i v i s i o n and i t s a s s o -  c i a t e d network of s u b d i v i s i o n s and enumeration a r e a s .  T h i s recom-  mendation i n c l u d e s the r e c o r d i n g o f d a t a 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 , t o name b u t a few d i v i s i o n s .  Similarly,  H o s p i t a l Insurance s t a t i s t i c s s h o u l d be r e p o r t e d by census d i v i s i o n . I t makes c o n s i d e r a b l e sense t o change t o t h i s t y p e o f system w h i c h would then have a v a r i e t y o f d a t a a v a i l a b l e and o r g a n i z e d t o 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.  I n f o r m a t i o n from t h i s  source  might prove t o be a v e r y u s e f u l a d j u n c t t o t h e p l a n n i n g d a t a b e i n g c o l l e c t e d by t h e Department on each h e a l t h s t a t i s t i c a l Key O b s e r v a t i o n s Regarding P r e d i c t i o n Model  district.  t h e Bed  O b s e r v a t i o n s . o f o c c u p i e d beds i n the p r o v i n c e i n t h e p a s t s u p p o r t t h e f i n d i n g t h a t t h e r e a r e and w i l l c o n t i n u e t o be a f a i r number o f excess beds.  The consequences o f t h i s s t u d y o r any w h i c h  suggest cutbacks o r a d d i t i o n a l beds r e q u i r e s t h a t t h e Department o f H e a l t h accept an u n d e r t a k i n g t o modify  the bed count and t o a p p l y  a l t e r n a t i v e s t r a t e g i e s o f meeting t h e h e a l t h c a r e needs o f t h e population. U n f o r t u n a t e l y the concept o f 'bed' does n o t encompass a l l the components o f h e a l t h c a r e which a r e a s s o c i a t e d w i t h b o t h t h e bed and i t s occupant,  the p a t i e n t .  T h i s s t u d y suggests  that there are  p o t e n t i a l s a v i n g s i n terms o f c a p i t a l , manpower, and o p e r a t i n g expenses i n t h r e e o f t h e f o u r r e g i o n s . o f f s e t by an a d d i t i o n a l requirement  These p o t e n t i a l s a v i n g s a r e  o f beds i n t h e E a s t e r n  Region.  For t h r e e r e g i o n s ' t h e minimum v a l u e o f t h i s excess i n 1976  dollars  w i l l be 9.5 m i l l i o n i n 1986 to the populus  ( i n f l a t i o n not considered).  In f a i r n e s s  i n these r e g i o n s , such s a v i n g s s h o u l d i n p a r t o r  129 whole be r e t u r n e d to these areas i n the form o f 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 o f these s t r a t e g i e s ? One w h i c h i s suggested i n t h i s s t u d y ' s bed p r e d i c t i o n s i s t h a t bed a l l o c a t i o n s s h o u l d not be made d i s t i n c t i v e f o r l o n g p e r i o d s of time.• I n s t e a d they be c a p a b l e o f b e i n g i n t e r c h a n g e d between s e r v i c e s .  should  In p r a c t i c a l  terms i t means t h a t p r e s e n t management must have a degree o f 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 d e p a r t from t r a d i t i o n a l bed and alignments.  flexi-  staffing  I f h o s p i t a l s and government d e s i r e changes w h i c h are  d e s i g n e d t o reduce o r add beds, e x p e r i m e n t a l 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 e v a l u a t e d . be i n i t i a t e d through  Inducements f o r t h i s s t r a t e g y c o u l d  the s a v i n g s and e f f i c i e n c i e s w h i c h a r e  suggested.  I t i s one t h i n g to add beds but t o add them t o the E a s t e r n Region runs a g a i n s t t h e g r a i n o f many h e a l t h p r o f e s s i o n a l s o u t s i d e the r e g i o n . have  Many f e e l t h a t i n comparison t o the E a s t e r n R e g i o n they  relatively  r e c e i v e treatment  less.  ;Yet  45%  of  a l l p a t i e n t s i n Newfoundland  i n the E a s t e r n Region.  these r e g i o n s would r a i s e c o n s t e r n a t i o n . would r a i s e d i f f i c u l t i e s .  To reduce the excess i n To change e x i s t i n g p a t t e r n s  I t becomes a q u e s t i o n 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 c o o p e r a t i o n between r e g i o n a l o r h o s p i t a l h e a l t h p l a n n e r s and government h e a l t h p l a n n e r s . I t i s f e l t t h a t the e v e n t u a l approach w h i c h 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 p l a n n i n g f u n c t i o n and e x a m i n a t i o n of two way  the  r e f e r r a l l i n e s : t h e p a t i e n t must have a c c e s s  to needed m e d i c a l c a r e , and some needed'aspects o f m e d i c a l c a r e i t s t e c h n o l o g i e s may  have to be d e l i v e r e d t o the p a t i e n t .  and  I n the  . 130  c o n t e x t o f Newfoundland's d i s t i n c t i v e geography and p o p u l a t i o n i t would seem t h a t e i t h e r secondary f a c i l i t i e s w i l l have t o be b u i l t o r access  i s g o i n g t o have t o 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 a r e  desired. I t would t h e r e f o r e appear t h a t r a t i o n a l i z i n g t h e e x i s t i n g e x c e s s i v e secondary care type o f f a c i l i t i e s w i l l take t h e form o f a l t e r n a t i v e s w i t h i n a s t r o n g e r r e g i o n a l framework. the i s s u e i s t h e r e f i n e m e n t difficult  At the heart of  of a c c e s s i b i l i t y t o s e r v i c e .  It i s  t o e n v i s i o n a d r a s t i c a l l y improved access w h i c h f o l l o w s a  d i r e c t i o n f r o m p a t i e n t t o secondary o r t e r t i a r y care However, i f t h e d i r e c t i o n i s r e v e r s e d then t r a v e l l i n g  hospital. clinics,  c o n s u l t a n t s o r programs c o u l d s i g n i f i c a n t l y improve t h e a c c e s s . W i t h t h e a d d i t i o n o f improved communication t e c h n o l o g i e s , a r e g i o n a l framework c o u l d 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 b e i n g suggested i s t h a t t o r a t i o n a l i z e t h e system by c r e a t i n g a l t e r n a t i v e modes o f d e l i v e r y , i t may take some,time t o demonstrate economics and/or e f f i c i e n c i e s .  I t may a l s o be v e r y  c o s t l y t o develop these a l t e r n a t i v e s i n t h e 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 .  T h i s might o c c u r i f t h e p r e s e n t  morbidity  p a t t e r n i n r u r a l areas i s an understatement o f t h e a c t u a l s i t u a t i o n . I f t h e r e i s no c l e a r - c u t s h i f t t o an a l t e r n a t i v e mode n o r a consequent r e 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 o f d e l i v e r y , c o s t s w i l l increase. to  U n f o r t u n a t e l y , t h e monies r e q u i r e d t o ' e x p e r i m e n t and  develop systems do p l a y a s i g n i f i c a n t p a r t 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 t h e c o s t s . a r e weighed a g a i n s t  proposed a c t i o n s t h e i n e f f i c i e n c i e s w h i c h appear t o be so e x p e n s i v e  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 t o the p a t i e n t s , as systems t h a t ought t o be.  Herein l i e s  one of the many dilemmas o f t e n f a c e d  by h e a l t h c a r e a d m i n i s t r a t o r s and p l a n n e r s . T h i s s t u d y makes a statement t h a t a r e a l s i t u a t i o n o f m o r b i d i t y w i l l a r i s e i n 1981 and 1986 w h i c h can be t r a n s l a t e d i n t o b o t h the  number and t y p e s of beds.  I t s u n d e r l y i n g premises a r e : t h e  p r e s e n t m o r b i d i t y p a t t e r n s w i l l remain c o n s t a n t ; the p o p u l a t i o n p r o j e c t i o n s have r e a s o n a b l e assumptions and an a c c e p t a b l e l e v e l o f p r e c i s i o n ; and f i n a l l y , the assumptions o f occupancy s t a n d a r d s 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 .  A l t h o u g h the bed p r e d i c -  t i o n s are g i v e n i n the absence of a p r o b a b i l i t y s t a t e m e n t , the e n t i r e p r o c e s s 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 t h a t the bed p r e d i c t i o n s f o r 1981 and 1986 w i l l a d e q u a t e l y cope w i t h the m o r b i d i t y p a t t e r n e x p e c t e d i n 1986.  T h e r e f o r e 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 a t t a c h e d , a l b e i t , not s p e c i f i e d . Y e t the p r o j e c t i o n s and p r e d i c t i o n s w h i c h a r e reached w i t h i n the  scope of t h i s s t u d y i n v o l v e many assumptions w h i c h have n o t been  p u t to the t e s t .  To be e f f e c t i v e f o r p l a n n i n g 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 e v a l u a t e d .  More i m p o r t -  a n t l y , the model w i l l p r o b a b l y r e q u i r e more o f human a c c e p t a n c e than l o g i c because i t eminated from a s i n g l e s o u r c e and d i d n o t i n v o l v e the  i n p u t o f h e a l t h p r o f e s s i o n a l s around the p r o v i n c e .  does have the f l e x i b i l i t y  T h i s model  to b r o a c h 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 o f beds f o r t h e p r o v i n c e i s a summation o f r e g i o n a l bed r e q u i r e m e n t s .  Although assumptions'are general i n  n a t u r e when a p p l i e d t o a r e g i o n a l a n a l y s i s o f t h i s t y p e , the assumpt i o n s are unique t o each r e g i o n and the r e s u l t i n g d i s t r i b u t i o n o f r e s o u r c e s t o each r e g i o n t a k e s p l a c e w i t h the same d i s t i n c t i o n .  132 T h e r e f o r e , 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 p r o v i d e b a s i s f o r d i s c u s s i o n and c o o p e r a t i o n between r e g i o n and  the  government.  F u t u r e D i r e c t i o n s from t h i s Study While population 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  district  was  overshadowed by the p o p u l a t i o n arid m o r b i d i t y 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 t o a h e a l t h d a t a base f o r p l a n n i n g i s p a r a mount.  The s o r t e d p o p u l a t i o n by d i s t r i c t  step i n d e f i n i n g who  needs and who  h e a l t h care resources.  age and sex i s the  initial  consumes o r ought to consume  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 o f making s m a l l a r e a p r o j e c t i o n s and to o b t a i n and b l e n d p o p u l a t i o n p r o j e c t i o n s o r 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 s o u r c e s .  Regardless  o f the method  employed, the p o p u l a t i o n d a t a base w i l l have t o have a d j u n c t  files  w h i c h w i l l a l l o w f o r d e c i s i o n r u l e s o r m o d i f i c a t i o n to the p r o j e c tions.  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  s e p a r a t e f i l e s on: v i t a l s t a t i s t i c s ,  w i l l have to have  economic growth and  prospects,  s c h o o l e n r o l l m e n t s , employment, h o u s i n g s t a r t s and hydro o r hook-ups.  telephone  The c o l l a t i o n o f these types o f d a t a w i l l r e q u i r e the  development o f a methodology w h i c h w i l l h e l p t o g a t h e r 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 s t e p i n e s t a b l i s h i n g a decent m o r b i d i t y base and t h 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 o f 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 o f d i f f e r e n t diagnoses  o v e r the p a s t .  In so d o i n g ,  one  might be a b l e t o p r e d i c t a p r o s p e c t i v e t r e n d i n m o r b i d i t y a t some f u t u r e date.  T h i s type o f adjustment c o u l d then be i n c o r p o r a t e d  i n t o the model. I t i s a l s o e n v i s i o n e d t h a t 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 w i d e r range.  Therefore,  a more s p e c i f i c statement of bed r e q u i r e m e n t s . w i l l be designed  the model w i l l The  give  program o u t p u t  so t h a t the p a r t i c u l a r s o f each d i a g n o s i s a r e  avail-  a b l e , and a summation t o a bed c l u s t e r w i l l y i e l d a statement o f b o t h 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 p a r a g r a p h , 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 t r u e o f the bed p r e d i c t i o n .  I n terms o f making a c o n t r i b u t i o n i n h e a l t h p l a n n i n g f o r beds, t h i s model w i l l be proposed as-a method to e v a l u a t e .  The e v e n t u a l i n t e n t  i s a c c e p t a n c e and r e f o r m u l a t i o n o f the model and p r o c e s s e s would a l l o w f o r i n p u t from the  regions.  I n d o i n g the bed p r e d i c t i o n s (and the a c c u r a c y  and  t i m e l i n e s s of primary  were p o i n t s o f f o c u s .  the p o p u l a t i o n .  p o p u l a t i o n projections)...,  and secondary data  I t would have been f a r b e t t e r to  m o r b i d i t y r a t e s f r o m 1978  which  sources  present  to more a c c u r a t e l y r e f l e c t the needs o f  Developing  these h e a l t h p l a n n i n g d a t a bases i n the  p r o v i n c e 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 o f c o l l e c t i o n , p r o c e s s i n g and The  output.  d a t a sources w h i c h c o n t r i b u t e d t o b o t h the p o p u l a t i o n  p r o j e c t i o n and m o r b i d i t y d a t a are from secondary s o u r c e s . accuracy  o f S t a t i s t i c s Canada census f i g u r e s must be  The  questioned.  So, t o o , must the i n p a t i e n t m o r b i d i t y w h i c h i s r e p o r t e d i n summary form from each h o s p i t a l .  I t stands  to r e a s o n ,  t h a t some p o p u l a t i o n  areas w i t h i n the p r o v i n c e w i l l have t o be sampled and  t h a t the  pro-  v i n c i a l m o r b i d i t y 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 r e g i o n s w i l l have to be e v a l u a t e d the 1981  and  1986  populations.  against  134 F i n a l l y , t h e r e are t h r e e p l a n n i n g d i s t r i c t s w h i c h are t i n c t i n the p r o v i n c e .  These a r e : the h e a l t h s t a t i s t i c a l ,  and the f e d e r a l e l e c t o r a l .  dis-  the census  I f the department does not c o n s i d e r the  a d o p t i o n o f the census d i v i s i o n as the p l a n n i n g b a s e , an attempt to l i n k these p l a n n i n g e n t i t i e s w i l l need to be  sought.  Because of the v e r y p r a c t i c a l n a t u r e of t h i s t h e s i s , s u b j e c t matter and i n t e r e s t must n e c e s s a r i l y c o n t i n u e i n t o future.  the  the  T h i s d i r e c t i o n w i l l be r e q u i r e d by h e a l t h p l a n n i n g as a  n a t u r a l but i m p o r t a n t 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 o f t h e p r o v i n c e o f Newfoundland can be c h a r a c t e r i z e d as b e i n g r u r a l .  The B r a i n Commission observed t h a t 63% o f t h e  p o p 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 o f l e s s than 100 i n h a b i t a n t s and o v e r 50% o f t h e p o p u l a t i o n l i v e d i n 1300 c o a s t a l settlements.^"  I n March 1978 t h e P r o v i n c i a l Ambulance Programme i n  i t s annual r e p o r t e x c l u d e d  g e o g r a p h i c a l p r o x i m i t y t o h o s p i t a l based  ambulance programmes and e s t i m a t e d  t h e r u r a l p o p u l a t i o n a t 340,000.  T h i s f i g u r e c o n s t i t u t e s 60% o f t h e p o p u l a t i o n .  Even w i t h t h e  r e s e t t l e m e n t programmes c a r r i e d o u t o v e r t h e l a s t decade, and t h e known l a r g e m i g r a t i o n s a s s o c i a t e d w i t h c l o s u r e s o f i n d u s t r i e s , t h e r u r a l has s t a y e d r u r a l .  ^  T r a n s p o r t a t i o n and communication have improved, y e t each study s i n c e t h a t by L o r d B r a i n has taken t h e time t o d i s c u s s t h e c o n t i n u i n g problems o f d i s t r i b u t i n g r e s o u r c e s  to the r u r a l  setting.  I n v a r i a b l y each study d i s c u s s e s e q u i t a b l e d i s t r i b u t i o n i n terms o f a v a i l a b i l i t y and access  to services.  Distance  from p r i m a r y and  secondary l e v e l s o f care has been t h e most a c c e p t a b l e method o f d e f i n i n g t h e r u r a l problem.  I n many cases t h i s d i s t a n c e cannot be  overcome because communities a r e g e o g r a p h i c a l l y i s o l a t e d o r remote. Systems and s t r u c t u r e f o r d e l i v e r y o f h e a l t h care t o r u r a l tions are evident  popula-  (from a u t h o r ' s work f i l e s ) .  P u b l i c H e a l t h N u r s i n g c a r r i e s a C u r a t i v e Care Programme t o a l l segments o f t h e p o p u l a t i o n i n t h r e e g e o g r a p h i c a l areas where t h e r e i s no a v a i l a b l e p r o f e s s i o n a l medical s e r v i c e t o o u t l y i n g areas. T u b e r c u l o s i s 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 w h i c h i s l o c a l i z e d t o t h e N o r t h e r n Region  138 of t h e P r o v i n c e . 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. D e n t a l H e a l t h S e r v i c e s p r o v i d e s a n e t annual income to d e n t i s t s who p r a c t i c e i n the s m a l l e r r u r a l a r e a s . The C e n t r a l Pharmacy o f t h e Department o f H e a l t h w i l l m a i l drugs t o i n d i v i d u a l s i n the p o p u l a t i o n where p h a r m a c i s t s a r e n o t 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 d i s p e n s e drugs i n s m a l l e r communities. The P r o v i n c i a l Food Bank m a i l s s p e c i a l and/or h a r d to obtain d i e t s f o r metabolic disorders. 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 t h r o u g h t h e m a i l from C e n t r a l Pharmacy. The C o t t a g e H o s p i t a l System s t i l l remains and f u n c t i o n s t o s e r v e t h e r u r a l and i s o l a t e d a r e a s o f Newfoundland. There a r e 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 o f 365 beds. These h o s p i t a l s a r e a d m i n i s t e r e d and s u p p l i e d w i t h r e s o u r c e s by the Department of H e a l t h . The E d u c a t i o n D i v i s i o n has d e c e n t r a l i z e d t o r e g i o n a l depots f o r t h e d i s s e m i n a t i o n o f e d u 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 c o v e r s 60 commun i t i e s i n Newfoundland.  i  The A i r Ambulance Programme conveyed o v e r 5,000 p a t i e n t s i n a d d i t i o n t o emergency s u p p l i e s and physicians or s p e c i a l i s t s . The M e d i c a l S e r v i c e s D i v i s i o n has p l a c e d a r e g i o n a l M e d i c a l H e a l t h O f f i c e r on the West Coast w i t h t h e purpose o f 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 a r e r e g i o n a l h o s p i t a l s t h r o u g h o u t . t h e p r o v i n c e . A l t h o u g h r e g i o n a l i z a t i o n i s n o t 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 v o l u n t a r y b a s i s . C l i n i c s and N u r s i n g S t a t i o n s have been c o n s t r u c t e d f o r i s o l a t e d areas. These o p e r a t e w i t h one p h y s i c i a n and/or n u r s e . I n many cases o n l y 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 a l 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 o f t h e h e a l t h . , system i s t h a t i t i s i n t e g r a t e d i n d e s i g n  i n t h e sense t h a t , w i t h  139 few e x c e p t i o n s , most f a c i l i t i e s a r e h o s p i t a l s . 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  n e c e s s a r y t o e s t a b l i s h a secondary t i o n and topography  This i s a product  l e v e l of c a r e because the i s o l a -  p r e v e n t e d a c c e s s t o the l a r g e r c e n t e r s .  These  s m a l l h o s p i t a l s have c o n t i n u e d t o s u r v i v e to the p r e s e n t even though t r a n s p o r t a t i o n and communication have improved in their service roles. the Department o f H e a l t h . Cottage H o s p i t a l s .  and d e s p i t e a change  F u r t h e r i n t e g r a t i o n i s b e i n g d i s c u s s e d by Boards a r e b e i n g suggested  f o r the  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 o f 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 t h e s e p r o p o s a l s 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 e v e n t u a l s u c c e s s , i f adopted,  i s dependent upon  the r e c o g n i t i o n of b o t h problems and s o u r c e s o f 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 .  I n t h i s c o n t e x t , a number o f examples are  p r e s e n t e d from the l i t e r a t u r e .  These examples a r e i n t e n d e d 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 e x p e r ienced. 1. Manpower s h o r t a g e s , environment and r e c r u i t m e n t difficulties. 2.  E d u c a t i o n maintenance i n c u r r e n t methods and s k i l l s f o r h e a l t h c a r e , p e r s o n n e l and boards and the c o r r e ponding e d u c a t i o n o f government o f f i c i a l s r e g a r d i n g rural characteristics.  3.  Development o f 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 a t t e n d 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 a d o p t i o n 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 , a c c u r a c y and use o f i n f o r mation to d e f i n e need o r t o know where and how to p r o c u r e a d v i c e , and t o r e v i e w o r m o n i t o r care ( e . g . , surgery l e v e l s ) .  5.  R e d u c t i o n of independence, "chauvanism," a i r o f 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 , t o f u l l y  140 take advantage o f c o o p e r a t i o n 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 o f 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 t h e means o f t r a n s p o r t a t i o n w h i c h f o s t e r d i s t r i b u t i o n o f r e s o u r c e s i n terms o f 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 o f 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 p e r s o n n e l and s e r v i c e p r o c e d u r e s t a n d a r d s on s m a l l e r systems.  8.  Development o f h e a l t h r e l a t e d e n v i r o n m e n t a l a r e a s such as w a t e r 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 m i g r a t i o n because o f employment o p p o r t u n i t i e s and c u r r e n t movement o f urban d w e l l e r s 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 w h i c h may be a f f e c t e d by low income, h i g h unemployment and work m i g r a t i o n s .  12.  Method o f f i n a n c i n g , r e s o u r c e s and p e r s o n n e l may d i c t a t e p l e n t i f u l b u t i n a p p r o p r i a t e r e s o u r c e s , o r may m o d i f y s e r v i c e t h r o u g h 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 v e r s u s f e e f o r s e r v i c e payments.  13.  Time and work misuse o f p r o f e s s i o n a l s because o f s h o r t a g e s i n s u p p o r t p e r s o n n e l o r o t h e r f a c t o r s such as d i s t a n c e and t r a n s p o r t a t i o n and weather w h i c h create delay. The problems e n c o u n t e r e d by one community a r e n o t n e c e s s a r i l y  the problems o f a n o t h e r 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 a r e problems w h i c h h i n d e r o r f a c i l i t a t e  inte-  g r a t i o n w i t h t h e o v e r a l l p o l i c y o f p r o v i d i n g h e a l t h care t o t h e population.  As the t h e s i s i s f o c u s i n g upon i n p a t i e n t beds by r e g i o n  i n Newfoundland, t h e r e a r e , i n t h e o p i n i o n o f t h e w r i t e r , t h e h i g h e r impact problems.  O b s e r v a t i o n s r e l e v a n t t o these problems a r e drawn  from t h e e x p e r i e n c e o f 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 o f H e a l t h and Government a t t e m p t e d t o c l o s e down two  141 smaller h o s p i t a l s .  The  communities i n v o l v e d p r e s e n t e d  s i t i o n t o the p r o p o s a l s . l o b b y i n g p o s i t i o n was  As recounted  by o f f i c i a l s ,  s t i f f oppo-  the  primary  t h a t h o s p i t a l s were c e n t r e s o f 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 N o r t h e r n Newfoundland and L a b r a d o r , are a r e a s o f low c a p i t a income and h i g h unemployment. p r o p o r t i o n of n a t i v e peoples.  The  per  These a r e a s a l s o have a h i g h e r  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 d e s c r i b e d as remote p o c k e t s o f 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 d i s e a s e s h i g h e r t h a n normal. These a r e a s a l s o have d i f f i c u l t y :  izational skills. for  i n a t t r a c t i n g p e r s o n n e l w i t h organ-  W i t h o u t s k i l l s and r e s o u r c e s , the  and o p e r a t i o n o f h e a l t h care systems becomes  responsibility  difficult.  I n s u l a r i t y and Independence o f H e a l t h Care P r o f e s s i o n a l s . There a r e a number of f a c t o r s w h i c h c o n t r i b u t e t o t h i s s i t u a t i o n : long t r a d i t i o n of having  the same f a c i l i t y  a  i n the community, the  l a c k o f peer c o n t a c t , a l e s s t h a n o p t i m a l 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 o f the i n d i v i d u a l . p r o p o s a l f o r r e g i o n a l i z a t i o n i n 1972 was the Department o f H e a l t h . has o c c u r r e d . t r a t o r s met  adopted, i n p r i n c i p l e ,  In the C e n t r a l r e g i o n d u r i n g 1974  and  1975  r e g i o n a l i z a t i o n so t h a t they c o u l d e s t a b l i s h t h e i r own The  a i r o f c o o p e r a t i o n was  a t t i t u d e that p r e v a i l e d . Although  by  S i n c e t h a t time no f o r m a l r e g i o n a l i z a t i o n  to d i s c u s s 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  and s t r u c t u r e s .  A  (The w r i t e r was  formal  procedures  a b s e n t ; i t was  present  adminis-  a jealous  at the meetings.)  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 v e r y s e l e c t e d  s e r v i c e s , t h e r e are s t i l l g e s t u r e s a g a i n s t  cooperation.  142 P o l i t i c a l Intervention.  There have been many o c c a s i o n s  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 o r community l o b b y i n g have bypassed Department o f H e a l t h to t h e M i n i s t e r .  Going o u t s i d e  when  groups  channels t o p r e s e n t a p o s i t i o n  c h a n n e l s , i n the o p i n i o n o f t h e  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 t h a t a r e n o t always f a v o r a b l e f o r the a d m i n i s t r a t o r s o r communities. Manpower S h o r t a g e s. across  the p r o v i n c e .  There i s a s h o r t a g e o f n u r s e s , p a r t i c u l a r l y  d u r i n g the summer months. for  Every y e a r t h e same c o m p l a i n t i s h e a r d  One 200-bed h o s p i t a l c l o s e s down a ward  two months each y e a r as a s o l u t i o n t o t h i s problem.  cottage  One o f the  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 ,  threa-  tened t o c l o s e down a l l beds because they c o u l d n o t r e c r u i t n u r s e s . P a r t o f t h e problem l i e s w i t h t h e l a r g e r h o s p i t a l s w h i c h can o f f e r a more a t t r a c t i v e employment package. i s the r a p i d t u r n o v e r and  A n o t h e r element o f t h e p r o b l e m  o f f o r e i g n graduates who a r e r e c r u i t e d .  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 t h a t Newfoundland  i s a gateway t o 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 a r e formed p r i o r t o m i g r a t i o n . has  Time  aptly described  Black^  t h e problem f o r p h y s i c i a n s h o r t a g e s i n Newfound-  land. Transportation  Distance  and Weather.  There s t i l l a r e areas  i n t h e p r o v i n c e where i t i s v e r y d i f f i c u l t t o v i s i t o r from w h i c h i t i s d i f f i c u l t t o r e f e r a p a t i e n t t o a t e r t i a r y care  center.  N o r t h e r n Newfoundland and L a b r a d o r i s p a r t i c u l a r l y prone t o t h e s e problems.  I n an e v a l u a t i o n o f bed needs f o r one h o s p i t a l , t h e  r e g i o n a l c e n t e r , t h e average l e n g t h o f s t a y had t o be a d j u s t e d by a minimum f i g u r e o f two days w h i c h a l l o w e d  f o r necessary delay.  From  the C e n t r a l R e g i o n , t h e d i s t a n c e t o t e r t i a r y care c o u l d i n v o l v e 250  road m i l e s o r 60 m i l e s to the a i r p o r t . Report f o r 1978  The  P r o v i n c i a l Ambulance  s t a t e s t h a t i t conveyed 9,610  patients  m i l e s f o r an average o f 141 m i l e s per p a t i e n t . program conveyed 5,317 a l l separations  patients.  out of  R e l a t i v e Smallness of System.  advancement are l i m i t e d . administration,  a i r ambulance  I n t o t a l t h i s r e p r e s e n t s 14%  i n c l u d i n g newborn and  i n Newfoundland are s m a l l .  The  1,356,713  of  province.  For the most p a r t  hospitals  C o n s e q u e n t l y , the o p p o r t u n i t i e s  for  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  of s t a y i n g at a p o s i t i o n f o r a l o n g time.  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  For  those  administrative  s k i l l s i n the c o n t e x t 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 Integration.  Some of the problems e x i s t i n g f o r  b o t h r u r a l and u r b a n 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 of s e r v i c e s f o r p l a n n i n g .  As d e t e r m i n a n t s o f demand, a number o f  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 income and  integration  l e v e l s , h i g h unemployment,  l e s s s a n i t a r y environments.  low  A health plan for t h i s area  s h o u l d n e c e s s a r i l y i n v o l v e a t l e a s t s i x government departments: Health,  E d u c a t i o n , R u r a l Development, P u b l i c Works, E x e c u t i v e  C o u n c i l , and  Social Services.  Recent developments a t the  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 . t i o n s were t r a n s f e r r e d from S o c i a l S e r v i c e s  and  Cabinet  N u r s i n g Home o p e r a R e h a b i l i t a t i o n to  Health. Lack of S k i l l s o f H o s p i t a l P e r s o n n e l .  I n v a r i a b l y , the  C o n s u l t a n t Reports o f H o s p i t a l Surveys recommend the u p g r a d i n g of administrative  skills.  z a t i o n a l mess was was  I n one  discovered.  not k e e p i n g c u r r e n t  and was  h o s p i t a l v i s i t e d r e c e n t l y an The  f e e l i n g was  t h a t the  organi-  administrator  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 w h i c h p e o p l e are i n j o b s w i t h o u t  144 the n e c e s s a r y 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 o f Funds. tighter.  Consequently,  I n the 1970's budgets had become  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 o r  e x p e r i m e n t a l methods has been v e r y r e s t r i c t e d .  The system, b o t h  urban and r u r a l , acknowledges v e r y l i t t l e change, i n mode o f delivery.  C o n s t r a i n t has a l s o l e d to s h o r t a g e s i n manpower w i t h i n  the Department o f H e a l t h .  T h i s s h o r t a g e i s meant i n terms o f v i t a l  areas such as budget r e v i e w .  I n the c o n t e x t of the p r e s e n t day  to  day a c t i v i t i e s , v e r y few people have the time to " p l a y " and e x p e r i ment w i t h i d e a s o r a l t e r n a t i v e s . D e c i s i o n Making Approach o f Government.  Numerous s t u d i e s  p o i n t t o 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 c a r e d e l i v e r y i n Newfoundland.  T h i s does not f o s t e r i n t e g r a t e d p l a n n i n g .  In the  p a s t , a s i d e from the c o t t a g e h o s p i t a l s , budgets were n e g o t i a t e d . The p o l i t i c a l v o i c e o r squeaky w h e e l sometimes managed to get a g r e a t e r share of the p i e .  T h e r e f o r e , developments a t the h o s p i t a l  l e v e l were dependent upon the course o f n e g o t i a t i o n s . i s changing  i n t h a t the budget i s determined  argument o f the a l l o t m e n t .  This a t t i t u d e  f o r a l l , p r i o r to  any  T h i s does promote a w i d e r view o f the  system but development s t i l l h i n g e s on a v a i l a b l e funds and remoteness.  Perhaps a b i g g e r f a c t o r i s the l a c k of p e r s o n n e l f o r key  areas t o m o n i t o r and p l a n systems. concerned  C u r r e n t e f f o r t s by n e c e s s i t y a r e  w i t h day to day o p e r a t i o n s .  C o n c e n t r a t i o n o f F a c i l i t i e s and C o s t s .  A l t h o u g h t h e r e are  many s m a l l e r h o s p i t a l s i n Newfoundland, many are not a t t e n d e d 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 t h a t  as t h e r e are no s e r i o u s p r o b l e m s , e v e r y t h i n g i s o p e r a t i n g i n an e f f e c t i v e manner.  Much o f the c o n c e r t e d e f f o r t s a t the government  l e v e l f a l l t o t h e 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 island.  These h o s p i t a l s would account  f o r 62% o f t h e approved beds  and between 70-80% o f t h e s e p a r a t i o n s . The problems encountered varied.  by r u r a l areas may be many and  O f t e n the problems a r e t h e same between urban and r u r a l  a r e a s ; t h e d i f f e r e n c e i s one o f degree.  What i s i m p o r t a n t i n the  p l a n n i n g c o n t e x t i s t o be aware o f t h e a c t u a l and p o t e n t i a l ence between and w i t h i n r e g i o n s o r a r e a s .  differ-  I n 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 s p 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 c o n s i d e r e d i n the d i s t r i b u t i o n of resources.  I t i s n o t enough t o e v a l u a t e s p e c i f i c needs and  d e c i d e t h a t r e s o u r c e s s h o u l d be d i s t r i b u t e d . how and t o whom he i s d i s t r i b u t i n g r e s o u r c e s .  The p l a n n e r must know Therefore, the  a n a l y s i s o f demographic d a t a r e l a t i v e t o t h e r u 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 t o the development o f o r g a n i z a t i o n and s k i l l s needed t o ' h a n d l e the d i s t r i b u t i o n o f r e s o u r c e s .  146 Appendix A Footnotes These f o o t n o t e s have been c i t e d i n the t e x t o f Chapter I I I . Theref o r e the b i b l i o g r a p h i c e n t r i e s f o r t h e s e f o o t n o t e s a r e i n C h a p t e r I I I of the B i b l i o g r a p h y . '''Right Honourable L o r d B r a i n , R o y a l Commission on H e a l t h , 3 v o l s . , S t . John's: Government of Newfoundland and L a b r a d o r , 1966, 1:1. 2 J u l i a n A. W a l l e r , " R u r a l Emergency Care - Problems and P r o s p e c t s , " American J o u r n a l o f P u b l i c H e a l t h 63 ( J u l y 1973): 631-634. 3 J u l i a n A. W l l e r , " U r b a n - O r i e n t e d Methods: F a i l u r e to S o l v e R u r a l Emergency Care Problems," J o u r n a l o f American M e d i c a l A s s o 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 , " H e a l t h S e r v i c e s 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 o f P u b l i c H e a l t h 64 (September/October 1973) : 500-502. 5  I b i d . , pp. 500-502.  Stephen P o r t n o y and W i l l i a m L. Casady, " R u r a l H e a l t h 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. D o u g l a s P. B l a c k , " M e d i c a l S e r v i c e s f o r I s o l a t e d A r e a s , " Canadian F a m i l y P h y s i c i a n (February 1973): 91-95. 7  Robert L. Kane and S i s t e r Diane M o e l l e r , " R u r a l S e r v i c e Elements F a l l C o o r d i n a t i o n , " 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  148APPENDIX B DETERMINATION OF SAMPLE SIZE W i t h o u t knowing t h e v a r i a n c e of o b s e r v a t i o n s , a sample from these o b s e r v a t i o n s cannot be d e t e r m i n e d w i t h o u t g u e s s w o r k .  1  As  t h e r e a r e no s t u d i e s i n Newfoundland c o n c e r n i n g e s t i m a t e s o f 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 i d e a  of v a r i a n c e c o u l d n o t be o b t a i n e d . To e s t i m a t e v a r i a n c e f o r t h e e s t i m a t e s of e r r o r w h i c h were o r g a n i z e d t o f o u r p o p u l a t i o n s t r a t u m a 25% random sample was from each s t r a t u m . for  taken  The v a r i a n c e and s t a n d a r d d e v i a t i o n was c a l c u l a t e d  each s t r a t u m . I t was a n t i c i p a t e d t h a t two sampling  employed.  s t r a t e g i e s would be  I n t h e lower p o p u l a t i o n s t r a t u m , v a r i a n c e and number o f  extremes were expected  t o 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 s t r a t u m . s t r a t u m was t o be sampled i n d e p e n d e n t l y  As a f i r s t s t r a t e g y , t h i s of t h e r e m a i n i n g  two s t r a t u m .  Second, f o r t h e 2 l a r g e r s t r a t u m a sample s i z e was t o 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 w e i g h t i n g  of b o t h number and v a r i a n c e i n d e t e r m i n i n g what t h e a p p r o p r i a t e p o r t i o n of t h e sample s h o u l d be a s s i g n e d t o each  stratum.  Note t h a t t h e 25% random sample t o e s t i m a t e t h e v a r i a n c e was r e t u r n e d t o t h e s e t of o b s e r v a t i o n s .  Subsequent sampling was random  w i t h i n each s t r a t u m . 3 The f o l l o w i n g f o r m u l a  was u t i l i z e d  t o d e t e r m i n e t h e sample  s i z e i n t h e -2999 p o p u l a t i o n s t r a t u m and i n t h e ±3000 p o p u l a t i o n strata.  149  where  n  = sample s i z e  t  = s t u d e n t ' s t v a l u e , .99 c o n f i d e n c e l e v e l a t degrees o f freedom 2  S  = v a r i a n c e (S = s t a n d a r d d e v i a t i o n )  L  = c o n f i d e n c e i n t e r v a l a t ,01 s i g n i f i c a n c e  To determine t h e optimum a l l o c a t i o n f o r each s t r a t a 4 3,000 p o p u l a t i o n the f o l l o w i n g f o r m u l a was employed. N =  h  above  x S, * h  h=l  where  ft  n  =  sample s i z e (optimum a l l o c a t i o n ) a s s i g n e d t o each s t r a t a  N, = i n d i v i d u a l s i n each s t r a t u m h 2 S, = v a r i a n c e i n each s t r a t u m h n  = sample s i z e a l r e a d y d e t e r m i n e d  The 25% sample produced t h e f o l l o w i n g v a l u e s : S  SE  n  N  <2999 p o p u l a t i o n  17.59  2.49  50  193  >.3000 p o p u l a t i o n  5.41  1.44  14  27  The c o n f i d e n c e 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 a b s o l u t e v a l u e 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 v a l u e  has been e s t a b l i s h e d a t .005 f o r degrees o f freedom. The sample s i z e s w h i c h were d e t e r m i n e d a r e : <2999 p o 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, r e a d j u s t e d t o 11, see below) The optimum a l l o c a t i o n o f t h e 10 samples from t h e £.3000 s t r a t a a r e :  . 15G the 3000-9999 stratum was a s s i g n e d 5 (4.1) and the 10,000 and over stratum was a s s i g n e d 6 (5.9).  151 Appendix B Footnotes The f o l l o w i n g r e f e r e n c e s 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 o f t h e 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 Mosby Co., 1977), pp. 225.  ( S t . L o u i s : C. B.  2 Frank F r e e s e , Elementary F o r e s t Sampling, A g r i c u l t u r a l Handbook No. 232. ( F o r e s t 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 ^ F r e e s e , 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  Total  Males  98 (97.5)  113 (111.5)  86 (88)  297  Females  97 (97.5  110 (111.5)  90 (88)  297  Total X  2  195  = .136; X  Method:  2 g 3  223  176  594  = 2 0 0 8 . 1 <.01  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 t h e t o t a l age sex p o p u l a t i o n depart u r e s w i t h t h e t o t a l s were r e c o r d e d a s : -, + and 0. A l l u n o r g a n i z e d s u b d i v i s i o n s were i n c l u d e d .  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.  B.  C.  D.  1.2999 A l l Census D i v i s i o n s N  |M|  193  13.2  S  SE  17.9  1.3  <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|  149  10.5  £2999 A l l Census D i v i s i o n s  S  SE  12.7  1.0  A l l E r r o r s 220% e x c l u d e d  N  |M/  S  SE  157  6.4  5.1  .41  Summary o f E r r o r s  >20%  N  |M|  37  42.1  S 23.3  SE 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  Size  «l  of£*An* vs. &PUIAT1OM S/T£  ».» j V  4 -I  1$  I  * i i  j&j  m ||" ||'  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  0-4 Not them  10-14  15-19 F  M  20-24  F  M  25-34 F  35-44  M  F  M  55-64 F  H  T  H  51025  3420  3265  3415  3250  3170  2885  2770  2590  2785  2805  4765  4270  2750  2070  1865  1981  55415  3388  324B  3429  3432  3170  2885  3037  3086  3670  3320  5387  5090  3153  2899  1865  1986  59071  3398  3254  3436  3499  3170  28B5  2319  1804  3846  3471  5981  5804  3905  4334  1865  1976  F  M  r 14 35  M 1140  70+  65-69 F 915  r  M  F  335  240  430  455  1580  1131  10X1  394  215  362  644  1870  1125  1088  421  203  266  909  1560  1685  Western 1976  98415  5300  50B0  5990  5645  6715  6275  6080  5840  4550  4615  7060  6890  4820  4560  4013  3B05  1110  3910  1060  945  1981  102188  4575  4604  4919  4439  5967  6411  6288  5127  5516  5272  8245  8050  5261  5584  4015  4170  3221  3109  1237  1114  1815  1999  1986  105998  4806  4789  43(.8  3994  5241  6564  5728  4902  5712  5465  9377  8927  6085  7356  4015  4900  3288  3235  1317  1193  2175  2442  1976  122965  6805  6420  7675  7330  7955  7490  7325  6B05  5355  5235  8530  8350  5860  5545  5290  4860  4260  3980  1565  1385  2360  2530  1901  127453  54B9  5531  6894  6413  8394  7974  7629  7036  6515  5891  9843  9585  5941  6401  5270  5135  4346  4196  1766  1620  2911  3315  1986  1J1B?6  5903  5873  6505  6084  7030  6397  6771  6388  6750  6088  11117  10535  6120  7927  5270  5725  4410  4343  1864  1732  3703  4323  Central  Eastern 1976  285270 14160 13315  15505  145(10  H.520  16015  15935  15420  13385  13455  21230  21000  13460  12930  12210  11975  11375 11260  4100  4000  5850  7840  1981  299067 13901 12784  13172  12647  14905  14213  16426  15727  15462  15032  28031  25284  16853  15335  12210  11915  11628 11B57  4760  5126  6853  8845  1986  313074 13984 12990  12204  11935  13337  12176  15110  14945  15877  15496  28404  28526  23195  19498  12210  12155  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 o r g a n i z e d t o t h e c h a p t e r The.chief  level.  r e a s o n f o r t h i s type o f o r g a n i z a t i o n i s t h a t the r e f e r e n c e s  by c h a p t e r , - n a t u r a l l y b u t n e a t l y o r g a n i z e t o s u b j e c t h e a d i n g s . F o l l o w i n g t h i s schema, b i b l i o g r a p h i c e n t r i e s w h i c h appear i n more than one c h a p t e r w i l l be a b b r e v i a t e d  to a short b i b l i o g r a p h i c entry.  I f an author has more than one e n t r y the s h o r t e n t r y w i l l surname, s h o r t t i t l e and date.  I f an a u t h o r has o n l y one e n t r y o n l y  the surname and date w i l l appear. the w o r k ( s ) have been f u l l y  give  Both s h o r t e n t r i e s i n d i c a t e t h a t  referenced i n preceding  entries.  Chapter I Planning B r i g h t , Margaret. "The Demographic Base f o r H e a l t h P l a n n i n g . " I n H e a l t h P l a n n i n g : Q u a l i t a t i v e A s p e c t s and Q u a n t i t a t i v e Techniques, pp. 138-157. E d i t e d by W i l l i a m A. Reinke. B a l t i m o r e : John Hopkins U n i v e r s i t y , 1972. Chubin, Jerome; Knee, J u n i o r K.; C r y s t a l , R o y a l L.; and S l a d e , V a l e d a , eds?, S t a t i s t i c s f o r Comprehensive P l a n n i n g . Report Number H.S.M. 73-1217. Washington, D.C: Government P r i n t i n g Office . C o l t , Avery. "Elements o f Comprehensive H e a l t h P l a n n i n g . " American J o u r n a l o f P u b l i c H e a l t h 60 ( J u l y 1970) 1194-1204. D a e c h s e l , Werner F. 0. " R e g i o n a l H e a l t h Care P l a n n i n g . " A d m i n i s t r a t i o n i n Canada (December 1972) : 25-28.  Hospital  G l a s s , D. V. " S t r u c t u r e o f the Newfoundland P o p u l a t i o n . " C i t e d by R i g h t Honourable L o r d B r a i n . R o y a l Commission on H e a l t h . 3 v o l s . S t . John's: Government o f Newfoundland, 1966, 2:34. Gover, G. A c t i n g D i r e c t o r o f P l a n n i n g . P e r s o n a l communication. Newfoundland Department o f H e a l t h , August 1, 1979.  162 H e a l t h P l a n n i n g and Development Committee. H e a l t h Care D e l i v e r y : G e n e r a l Overview. S t . John's: Newfoundland Department o f H e a l t h , May, 1973.  St.  . Report I , Grand F a l l s I n s t i t u t i o n a l Bed Requirements. J o h n ' s : Newfoundland Department o f H e a l t h , March, 1973.  . Report I I , H e a l t h F a c i l i t i e s Programs and O r g a n i z a t i o n a l Requirements: E a s t e r n Newfoundland Region. S t . J o h n ' s : Newfoundl a n d Department o f H e a l t h , November, 1973. . R e p o r t I I I , H o s p i t a l Requirements: Western Newfoundland Region. S t . J o h n ' s : Newfoundland Department o f H e a l t h , March, 1974. Health Planning Division. 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