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The impact of hospital medical day care on inpatient use Romilly, Lorna Marie 1982

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THE IMPACT OF HOSPITAL MEDICAL DAY CARE ON INPATIENT USE by LORNA MARIE ROMILLY B.A., The U n i v e r s i t y of B r i t i s h Columbia, 1968 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES Department of Health Care and Epidemiology (Health Services Planning) We accept t h i s t h e s i s as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA J u l y 1982 (c) Lorna Marie R o m i l l y , 1982 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y a v a i l a b l e for reference and study. I further agree that permission for extensive copying of t h i s thesis for s c h o l a r l y purposes may be granted by the head of my department or by his or her representatives. It i s understood that copying or pub l i c a t i o n of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department O f Hp.a1 r h C a r P anrl E p i d e m i o l o g y ("Heal th Sp.rvir.p.s P l a n n i n g The University of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date July 12th, 1982 r\ir> C I O /"7Q \ ABSTRACT The impact of the i n t r o d u c t i o n of h o s p i t a l medical day care programs on i n p a t i e n t use was s t u d i e d , to see i f there was a red u c t i o n i n average lengths of st a y , cases or p a t i e n t days, f o r those d i a g n o s t i c categories i n the programs. The p r o v i n c i a l government funded these programs to create an a l t e r n a t i v e to h o s p i t a l i z a t i o n . Studies on the is s u e of whether or not day care i s an a l t e r n a t i v e or s u b s t i t u t e s f o r i n p a t i e n t use were examined. I n t e r e s t i n ambulatory care i s growing because of the i n c r e a s i n g age of the po p u l a t i o n , i n c r e a s i n g d u r a t i o n of chronic i l l n e s s and i n c r e a s i n g costs of h o s p i t a l s e r v i c e s . Three programs at Lions Gate H o s p i t a l i n North Vancouver, B.C. were chosen: Chronic O b s t r u c t i v e Lung Disease (CO.L.D.) program, D i a b e t i c Day Care ,and the Neuro (Neurology) program. The popula^ t i o n f o r study were d i v i d e d i n t o four groups: those from North and West Vancouver who used Lions Gate H o s p i t a l , p a t i e n t s from the re s t of the Greater Vancouver Regional D i s t r i c t (G.V.R.D.) who used other G.V.R.D. h o s p i t a l s , arid to allow f o r ' s p i l l - o u t ' cases, those from North and West Vancouver who used other h o s p i t a l s i n the province and those from the r e s t of the G.V.R.D. who used Lions Gate H o s p i t a l . The methodology i n v o l v e d the use of a m u l t i p l e time s e r i e s design which would allow some comparison before and a f t e r the i n t r o d u c t i o n of the CO.L.D. program, as w e l l as comparison between the North Shore and the r e s t of the G.V.R.D. A r e g r e s s i o n a n a l y s i s , using a dummy v a r i a b l e f o r the CO.L.D. i i i program, on average length, of stay, cases and patient days showed no s t a t i s t i c a l l y s i g n i f i c a n t r e s u l t s . The data c o l l e c t i o n period, 1970 to 1979/80, does not provide conclusive answers f o r Diabetic Day Care, introduced at Lions Gate Hospital i n 1966 and i n some of the hospital s of the rest of the G.V.R.D. i n 1972, or fo r the Neuro program, introduced at Lions Gate Hospital i n 1979. However, population and age adjusted cases and patient days f o r a l l three programs are cons i s t e n t l y higher i n the rest of the G.V.R.D. when compared with North and West Vancouver and deserve further i n v e s t i g a t i o n . The implications from t h i s study, that there i s no.impact from medical day care, programs on rates of inpatient use, i s consistent with s i m i l a r studies on Diabetic Day Care and Day Care Surgery. The health care system does not seem to be able to respond to innovations of t h i s type and they are additions to e x i s t i n g services. i v TABLE OF CONTENTS ABSTRACT i i LIST OF TABLES v i LIST OF FIGURES v i i ACKNOWLEDGEMENT i x QUOTATION x CHAPTER I . INTRODUCTION 1 CHAPTER I I . AMBULATORY CARE 5 WHAT IS AMBULATORY CARE 7 WHY THE INTEREST IN AMBULATORY CARE 7 DESCRIPTION OF AMBULATORY CARE PROGRAMS AT LIONS GATE HOSPITAL 15 CHAPTER I I I . SUBSTITUTION OF MEDICAL DAY CARE FOR . INPATIENT CARE 20 EXAMINATION OF THE AVAILABLE LITERATURE 21 SPECIFIC DAY CARE PROGRAMS IN THE LITERATURE 29 CONCLUSIONS 34 CHAPTER IV. METHODOLOGY 36 DISEASES OF INTEREST 36 POPULATION FOR STUDY 39 STUDY DESIGN 40 PROCEDURE 46 LIMITATIONS OF THE STUDY 47 METHOD OF ANALYSIS 50 PRESENTATION OF DATA COLLECTED 51 CHAPTER V. FINDINGS AND ANALYSIS 55 FINDINGS OF THE STUDY 56 CO.L.D. PROGRAM 56 CONCLUSIONS 71 SUMMARY 71 DIABETIC DAY CARE 73 CONCLUSION 82 NEURO PROGRAM 83 V TABLE OF CONTENTS CONCLUSION 89 GENERAL CONCLUSIONS 90 CHAPTER VI. IMPLICATIONS FOR POLICY AND PLANNING 92 LITERATURE CITED 96 APPENDIX A. L e t t e r of Approval, John Borthwick, A d m i n i s t r a t o r , Lions Gate H o s p i t a l 105 APPENDIX B. L e t t e r of Approval, Donald S. Thomson, A s s i s t a n t Deputy M i n i s t e r , I n s t i t u t i o n a l S e r v i c e s , M i n i s t r y of Health 106 APPENDIX C. L e t t e r sent to a l l P h y s i c i a n s at Lions Gate H o s p i t a l by V a l e r i e Young, Coordinator, Medical Day Centre 107 APPENDIX D. Diagnoses Back Program ( L C D . 8th & 9th Revision) 108 Back Program, Diagnoses Average Length of Stay, Cases & P a t i e n t Days, By Year & Geographic Area 110 APPENDIX E. MEASURING THE RATE OF POPULATION GROWTH 111 APPENDIX F. POPULATION FIGURES USED IN THIS STUDY 112 APPENDIX G. ADJUSTED OR STANDARDIZED RATES 113 LIST OF TABLES Table I . Diagnoses Chronic O b s t r u c t i v e Lung Disease Program (.LCD. 8th and 9th Revision) Table I I . Diagnoses D i a b e t i c Day Care ( I . C D . 8th and 9th Revision) Table I I I . Diagnoses Neuro Program ( L C D . 8th and 9th Revision) Table IV. Geographic Areas i n the G.V.R.D. by School D i s t r i c t Table V. Changes i n Number of Males per 100 Females, S.D. #44 and #45 compared to the r e s t of the G.V.R.D. Table VI. CO.L.D. Average Length of Stay, Cases and PatientuDays, By Year and Geographic Area Table V I I . Diabetes Average Length of Stay, Cases and P a t i e n t Days, By Year and Geographic Area Table V I I I . Neuro Diagnoses Average Length of Stay, Cases and P a t i e n t Days, By Year and Geographic Area Table IX. Regression A n a l y s i s on Average Length of ' Stay, CO.L.D. P a t i e n t s i n S.D. #44 and #45 Using L.G.H. Table X. CO.L.D. Average Length of Stay, T o t a l Cases and P a t i e n t Days, By Three Year Groupings and Geographic Area Table X I . CO.L.D. Average Length of Stay, T o t a l Cases and P a t i e n t Days, By Four Year Groupings and Geographic Area Table X I I . CO.L.D. Age S p e c i f i c Rates f o r T o t a l G.V.R.D. Per 10,000 P o p u l a t i o n , 1976 V I 1 LIST OF FIGURES F i g . 1. C.O.L.D. Average Length of Stay, By Year and Geographic Area 57 F i g . 2. C.O.L.D. Cases, By Year and Geographic Area 60 F i g . 3. C.O.L.D. P a t i e n t Days, By Year and Geographic Area 61 F i g . 4. C.O.L.D. Case Rates, By Year and Geographic Area 63 F i g . 5. C.O.L.D. P a t i e n t Day Rates, By Year and Geographic Area 64 F i g . 6. C.O.L.D. Age Standardized Case Rates, By Year and Geographic Area r 65 F i g . 7. C.O.L.D. Age Standardized P a t i e n t Day Rates, By Year and Geographic Area 66 F i g . 8. C.O.L.D. Case Rates I n c l u d i n g ' S p i l l - O u t s ' , By Yelar and Geographic Area 67 F i g . 9. C.O.L.D. P a t i e n t Day Rates I n c l u d i n g ' S p i l l -Outs ', By Year and Geographic Area 68 F i g . JlO. C.O.L.D. Average Length of Stay I n c l u d i n g ' S p i l l - O u t s ' , By Year and Geographic Area 68 F i g . 11.-Diabetes Average Length of Stay, By Year and Geographic Area 74 F i g . 12. Diabetes Cases, By Year and Geographic Area 75 F i g . 13. Diabetes P a t i e n t Days, By Year and Geographic Area 76 F i g . 14. Diabetes Case Rates, By Year and Geographic Area 77 F i g . 15. Diabetes P a t i e n t Day Rates, By Year and Geographic Area 78 F i g . 16. Diabetes Case Rates I n c l u d i n g ' S p i l l - O u t s ' , By Year and Geographic Area 79 F i g . 17. Diabetes P a t i e n t Day Rates I n c l u d i n g ' S p i l l -Outs ', By Year and Geographic Area 80 V l l l LIST OF FIGURES F i g . 18. Diabetes Average Length of Stay I n c l u d i n g ' S p i l l - O u t s ' , By Year and Geographic Area 81 F i g . 19. Neuro Diagnoses Average Length of Stay, By Year and Geographic Area 84 F i g . 20. Neuro Diagnoses Cases, By Year and Geographic Area 85 F i g . 21. Neuro Diagnoses P a t i e n t Days, By Year and Geographic Area 86 F i g . 22. Neuro Diagnoses Case Rates, By Year and Geographic Area 86 F i g . 23. Neuro Diagnoses P a t i e n t Day Rates, By Year and Geographic Area 87 F i g . 24. Neuro Diagnoses Case Rates I n c l u d i n g ' S p i l l -Outs ', By Year and Geographic Area 88 F i g . 25. Neuro Diagnoses P a t i e n t Day Rates I n c l u d i n g ' S p i l l - O u t s ' , By Year and Geographic Area 88 F i g . 26. Neuro Diagnoses Average Length of Stay I n c l u d i n g ' S p i l l - O u t s ' , By Year and Geographic Area 89 F i g . 27. Cerebrovascular Disease Average Length of Stay f o r ' S p i l l - O u t s ' , By Year and Geographic Area 90 ACKNOWLEDGEMENT I wish to thank Bob Evans f o r h i s l o g i c a l , s t r a i g h t - f o r w a r d approach throughwmy o f t e n clouded mind; Annette S t a r k , . f o r hers through my sentence c o n s t r u c t i o n ; and both of them f o r t h e i r u n f a i l i n g good humour and patience. I am g r a t e f u l f o r the support of John Borthwick, V a l e r i e Young and others at Lions Gate H o s p i t a l and f o r that of Mike Nusbaum from H o s p i t a l Programs D i v i s i o n of the M i n i s t r y of Health, who provided me w i t h the computer search of the data. My husband and c h i l d r e n deserve s p e c i a l mention f o r t h e i r i n t e r e s t and forbearance through t h i s seemingly interminable proj ect. X QUOTATION I t i s a s p e c i a l c h a r a c t e r i s t i c of a l l modern s o c i e t i e s that we consciously decide on and p l a n p r o j e c t s designed to improve our s o c i a l systems. I t :. i s our u n i v e r s a l predicament that our p r o j e c t s do not always have t h e i r intended e f f e c t s . (Campbell, 1975, p. 3) 1 CHAPTER I . INTRODUCTION There i s l i t t l e evidence that the i n t r o d u c t i o n of h o s p i t a l ambulatory day care programs, such as those f o r Chronic Obstruc-t i v e Lung Disease, Cerebrovascular Disease or Diabetes Shorten the length of stay i n h o s p i t a l of p a t i e n t s w i t h those diseases, reduce the number of cases of those diseases or prevent h o s p i t a -l i z a t i o n ( E l n i c k i , 1976; Evans, 1980, Chap. 10; F r e i b e r g , 1979; Rennie, 1977). Yet they are acclaimed as cost containment devices (Newman, 1979; Somers, 1980; Timm, 1979). Because there i s a l a c k of research i n t h i s area t h i s t h e s i s w i l l explore some of the questions surrounding the impact of medical day care. S p e c i f i c a l l y : - Does h o s p i t a l medical day care (as defined i n t h i s paper) reduce average length of s t a y , the number of cases or p a t i e n t days? - Can a methodology be developed which w i l l answer t h i s ques-t i o n ? - Is there a r e l a t i o n s h i p between the use of these programs and cost savings? - What do the answers imply f o r government p o l i c y on a l t e r n a -t i v e s to i n s t i t u t i o n a l i z a t i o n ? Some h i s t o r i c a l background i s required to e x p l a i n why i n t e r e s t i n ambulatory care i s growing. I n t e r e s t i n medical day care, as an a l t e r n a t i v e to h o s p i t a l i z a t i o n , began i n the 1940s when day h o s p i t a l s were s t a r t e d i n B r i t a i n i n an. e f f o r t to d i m i n i s h the length of h o s p i t a l stay. I t was f e l t that long periods i n bed 2 were not d e s i r a b l e or necessary ( B r o c k l e h u r s t , 1976). I n t e r e s t i n Canada and the United States d i d not f o l l o w u n t i l the l a t e 1960s. U n t i l then h o s p i t a l s i n the United States "regarded o u t p a t i e n t care as a t e a c h i n g - r e l a t e d c h a r i t a b l e endeavor r a t h e r than a b a s i c component of t h e i r s e r v i c e m i s s i o n " (Block, 1979, p. 105). In the l a t e s i x t i e s i n Canada experiments w i t h day care surgery were being conducted (Shah, Robinson, K i n n i s & Davenport, 1972). As w e l l , g e r i a t r i c day h o s p i t a l s had been s t a r t e d (Farquhar & E a r l e , 1979; F i s h e r , 1974). By 1970, the Task Force Reports on the Cost of Health Services  i n Canada saw ambulatory care as "a promising a l t e r n a t i v e to the f u l l use of h o s p i t a l impatient s e r v i c e s " (Dept. of N a t i o n a l Health & Welfare, 1970). During the seventies a s e r i e s of economic s t u d i e s conducted at Ch i l d r e n ' s H o s p i t a l i n Vancouver, B. C. i d e n t i f i e d savings that were p o s s i b l e w i t h the s u b s t i t u t i o n of day care surgery f o r i n p a t i e n t care (Evans, 1980, Chapt. 10; Evans, K i n n i s & Robinson, 1978; Evans & Robinson, 1973). With the Lalonde report (1974) p o i n t i n g to changes i n the patterns of h o s p i t a l i z a t i o n , the prevalence of long-term chronic i l l n e s s became more apparent and i n t e r e s t i n a l t e r n a t i v e s to i n p a t i e n t care increased. S i m i l a r pressures on the h e a l t h system have been f e l t i n the United States and i n England and Europe ( F r i e d e r i c h , 1973; Maxwell, 1975). However, t h i s s h i f t i n emphasis d i d not change, to any great extent, the way h o s p i t a l s were funded, based on p o t e n t i a l p a t i e n t days, so there was l i t t l e i n c e n t i v e f o r h o s p i t a l s to move to ambulatory care programs (Rennie, 1977). Incentives may not have been given because of the l a c k of evidence 3 that ambulatory programs provide b e t t e r care or reduce h o s p i t a l i -z a t i o n . Much of the l i t e r a t u r e on a l t e r n a t i v e s i s c o n t r o v e r s i a l and many of the st u d i e s conducted on various programs have produced i n c o n c l u s i v e r e s u l t s . Problems i n measuring the impact of ambulatory programs and g e n e r a l i z i n g to other populations occur because ambulatory care has s e v e r a l d e f i n i t i o n s and because programs provide d i f f e r e n t s e r v i c e s . C h r i s t o f f e l and Loewenthal (1978) p o i n t to s e v e r a l problems which make ambulatory care d i f f i c u l t to evaluate: episodes of i l l n e s s , p a r t i c u l a r l y c hronic i l l n e s s , which cannot be defined e a s i l y , no s p e c i f i c diagnosis f o r ambulatory p a t i e n t s , incomplete ambulatory medical records and records which are not uniform, providers having l i t t l e c o n t r o l over the p a t i e n t ' s adherence to p r e s c r i b e d regimens and over o u t s i d e i n f l u e n c e s . I d e a l l y , e v a l u a t i o n of any h e a l t h care program should be sought by r e l a t i n g i t s o b j e c t i v e s to i t s outcomes or r e s u l t s ( S t a r f i e l d , 1973). The outcome of a h e a l t h program can be measured by assessi n g the h e a l t h s t a t u s of the users of that program. Here, the assumption i s that the impact on h e a l t h s t a t u s w i l l be r e l a t i v e l y s i m i l a r f o r both ambulatory and i n p a t i e n t care. As one o b j e c t i v e of i n t r o d u c i n g the ambulatory programs i s a re d u c t i o n i n the len g t h of stay i n h o s p i t a l the impact of these-medical day care programs on average length of st a y , number of cases and p a t i e n t days w i l l be measured. A survey of the l i t e r a t u r e on stu d i e s which assess the impact, or outcome, of various kinds of a l t e r n a t i v e s to h o s p i t a l i z a t i o n provides c o n t r a d i c t o r y answers to questions of whether or not day 4 care programs s u b s t i t u t e f o r h o s p i t a l i z a t i o n . Nor i s the r e l a t i o n -ship between cost savings and s u b s t i t u t i o n always c l e a r . This t h e s i s , as 'detailed i n Chapter IV, w i l l attempt to measure the impact of medical day care programs on i n p a t i e n t u t i l i z a t i o n by t r y i n g to i d e n t i f y what h a p p e n e d p r i o r to the programs to those s p e c i f i c disease groups now using amublatory care, what would have happened without medical day care, and what i s happening c u r r e n t l y . The trends w i l l be examined using data modified by p o p u l a t i o n i n f o r m a t i o n , other i n f o r m a t i o n on changes i n medical p r a c t i c e , prevalence of the c o n d i t i o n s , e t c . The data obtained from ten years of h o s p i t a l discharge tapes, provided by the M i n i s t r y of Heal t h , H o s p i t a l Programs D i v i s i o n , i s presented and analyzed i n Chapter V. I m p l i c a t i o n s of the a n a l y s i s f o r government p o l i c y on a l t e r n a t i v e s to i n s t i t u t i o n a l i z a t i o n are explored i n Chapter VI. 5 CHAPTER I I . AMBULATORY CARE  WHAT IS AMBULATORY CARE? The broadest d e f i n i t i o n of "ambulatory" comes from Webster's New World D i c t i o n a r y , "able to walk," the word coming from "ambulare" or to walk about. the Oxford D i c t i o n a r y adds: "place f o r w a l k i n g , s r arcade or c l o i s t e r . " However, when i t i s used i n r e l a t i o n to h e a l t h care i t covers h o s p i t a l o u t p a t i e n t care, emergency care, day care surgery, day h o s p i t a l s , and even primary care. The d e f i n i t i o n i s o f t e n broad, i n c l u d i n g a v a r i e t y of o r g a n i z a t i o n a l arrangements and l o c a t i o n s , where people o b t a i n medical s e r v i c e s of various kinds without admission to an overnight h o s p i t a l bed (Bodenheimer, 1970; Burns, 1980; F r i e d e r i c h , 1973; Loebs, 1978; Rennie, 1977). F r i e d e r i c h adds that these are " f r e e s t a n d i n g arrangements of medical p r a c t i c e to accommodate s o c i a l , 'governmental and f i n a n c i a l pressures" (p. 379). In other words, i t i s : "any k i n d of h e a l t h care o f f e r e d on an outpatient b a s i s " (Gebbie, 1976., p. 72). .. The d e f i n i t i o n i s narrow: when i t a p p l i e s to a type of s e r v i c e such as primary care i n a Neighbor-hood Health Centre ( B e l l i n , Geiger & Gibson, 1969). Home Care s e r v i c e s are i n c l u d e d by some authors (Goldsmith, 1977), but d e f i n i t e l y excluded by others (Burns, 1980). Outpatient care i s defined as a "spectrum of s e r v i c e s i n c l u d i n g h e a l t h education and maintenance, prevention of d i s e a s e s , e a r l y d i a g n o s i s , treatment, and r e h a b i l i t a t i o n " (American H o s p i t a l A s s o c i a t i o n , 1968, p. 10). L i k e o u t p a t i e n t care, day h o s p i t a l s 6 are s a i d to provide the same spectrum of s e r v i c e s , u s u a l l y i n v o l -v i n g m u l t i d i s c i p l i n a r y h e a l t h teams i n a s e t t i n g l i k e "a h o s p i t a l ward from which p a t i e n t s go home at night . . . " ( B r o c k l e h u r s t , 1 9 7 6 , p. 1 4 9 ) . Generally day h o s p i t a l s have been f o r p s y c h i a t r i c , g e r i a t r i c or p a e d i a t r i c s p e c i a l t i e s but F i s h e r (1974) describes the f i r s t day h o s p i t a l i n On t a r i o , i n 1 9 7 2 , as having 31 per cent of i t s p a t i e n t s under age 60 w i t h an age range of 40 to 99, and as p r o v i d i n g programs of r e h a b i l i t a t i o n to p a t i e n t s who o f t e n have more than one d i a g n o s i s , such as cerebrovascular disease and chronic o b s t r u c t i v e lung disease. This d e s c r i p t i o n comes c l o s e s t to the ki n d of ambulatory care provided at Lions Gate H o s p i t a l ' s Medical Day Care Centre, formerly c a l l e d "Ambulatory Care and Treatment S e r v i c e s . " I t i s , l i k e Loebs' (1978) d e f i n i t i o n : "the i n t e g r a t i v e and c e n t r a l i z e d arrange-ment f o r the s e r v i c e s i n which a m u l t i d i s c i p l i n a r y h e a l t h care team . . . work together f o r diagnosis and treatment" (p.. 2 ) ; i t i s l i k e Roemer's (1975) d e f i n i t i o n of organized ambulatory care s e r v i c e s , "a s e t t i n g i n which s e v e r a l h e a l t h personnel c o l l a b o r a t e and make d e c i s i o n s through some team process or as par t of an o r g a n i z a t i o n a l framework . . . " (p. 4 9 ) . To use Rathbone-McCuan's and E l l i o t ' s ( 1 9 7 6 - 7 7 ) approach: Medical defines the problems served; "day defines the temporal l i m i t s of the s e r v i c e s ; care placescthe s e r v i c e i n the broad f i e l d of h e a l t h and s o c i a l w e l f a r e ; and center denotes a s i n g l e l o c a t i o n where a v a r i e t y of s p e c i f i c s e r v i c e s are c l u s t e r e d " (p. 1 5 4 ) . What i s d i f f e r e n t at Lions Gate H o s p i t a l i s that the care i s mainly provided i n group programs, w i t h p h y s i c i a n s ' d i a g n o s t i c s e r v i c e s g e n e r a l l y having been 7 completed before r e f e r r a l to the programs. The h o s p i t a l medical day care: upon which t h i s t h e s i s i s based i s l i m i t e d to programs f o r groups of p a t i e n t s w i t h s i m i l a r diagnoses. Supported by a Coordinator, teams of a l l i e d h e a l t h p r o f e s s i o n a l s , w i t h C l i n i c a l D i r e c t o r s ( p h y s i c i a n s ) , provide education, r e h a b i l i t a t i o n and treatment s e r v i c e s (Young & R o m i l l y , 1981). WHY THE INTEREST IN AMBULATORY CARE? Ambulatory care programs are of i n t e r e s t because of s e v e r a l trends i n h e a l t h care: the i n c r e a s i n g age of the p o p u l a t i o n , more chronic i l l n e s s and i n c r e a s i n g costs of h o s p i t a l care. As Regenstreif (1977) says: " A l t e r a t i o n s i n any area of a complex s o c i a l system are r a r e l y t r a c e a b l e to a s i n g l e s t i m u l u s " (p. 43), and the threads of i n t e r e s t which make up the t a p e s t r y of ambula-^ . t o r y care are t i g h t l y interwoven. This i n t e r e s t has come from s e v e r a l l e v e l s of government, both f e d e r a l and p r o v i n c i a l , from p o l i t i c i a n s and M i n i s t r y o f f i c i a l s , from h e a l t h care providers l i k e h o s p i t a l s and p h y s i c i a n s and from p a t i e n t s concerned w i t h the care provided. As w e l l , a change i n care emphasis, from sickness to w e l l n e s s , from acute disease and r e s t o r a t i o n , to chronic i l l n e s s and maintenance and r e h a b i l i t a t i o n , has i m p l i c a t i o n s f o r the d e l i v e r y of care (Broisseau, 1973). Changing disease p a t t e r n s , complicated by diseases a s s o c i a t e d w i t h modern l i f e s t y l e s , and changing va l u e s , have l e d to a mix of 'high' and 'halfway' t e c h n o l o g i e s , which deal w i t h the consequences of disease or postpone death ( M a r g o l i s , 1979). Margolis adds that " c h r o n i c i t y 8 cannot be modelled along the t r a d i t i o n a l medical model" (p. 124). No longer i s i l l n e s s i t s e l f "always the p r e v a i l i n g i s s u e , " i . e . "the needs of c h r o n i c a l l y i l l persons go w e l l beyond medical c o n s i d e r a t i o n s . . ." (Lefton & L e f t o n , 1979, p. 344, 339). Government I n t e r e s t P o l i t i c i a n s and Health M i n i s t r y o f f i c i a l s are concerned about s e v e r a l trends which a f f e c t p u b l i c expenditure on h e a l t h care: Changes i n po p u l a t i o n An aging p o p u l a t i o n w i t h i m p l i c a t i o n s f o r increased h e a l t h care costs r e q u i r e s r e t h i n k i n g of n a t i o n a l h e a l t h p o l i c i e s and programs (Gross, 1978; Schlenker, 1980; Somers, 1980). - There i s increased l i f e expectancy. (As w e l l , the 'baby boom' of the 1940s w i l l be working i t s way through the system, but i t w i l l peak i n the f i r s t h a l f of the next century.) P o p u l a t i o n f o r e c a s t s p r e d i c t that the number of •'.. those over 65. w i l l : climb to 20 per cent of the po p u l a t i o n by 2031. (This may be the peak.) In 1975, those over 65 represented 8.6 per cent of the p o p u l a t i o n but u t i l i z e d 38 per cent of the t o t a l h o s p i t a l bed capacity (Lefebvre, Zsigmond & Devereaux, 1979). - The r a t i o of the o l d e r to the t o t a l p o p u l a t i o n and to the po p u l a t i o n of working, 18 to 64, w i l l r i s e . Among the e l d e r l y the proportions of the ' o l d - o l d ' , those over 75, w i l l i ncrease f a s t e r than the 'young-old', those from 65 to 74 (Somers, 1980). H o s p i t a l i z a t i o n increases w i t h age 9 and almost h a l f of those men over 75 and more than one- ; : t h i r d of women over 75 are h o s p i t a l i z e d each year. In a d d i t i o n , those over 75 stay twice to three times as long i n the h o s p i t a l (Lefebvre et a l . ) . An aging p o p u l a t i o n needs a d i f f e r e n t composition of coordinated h e a l t h s e r v i c e s and has more m u l t i p l e p a t h o l -ogies w i t h slow r e c o v e r i e s (Boulet & G r e n i e r , 1978; Gross, 1978). Impact of medical care "Reduction of m o r t a l i t y from severe or chronic i l l n e s s lengthens the average d u r a t i o n of the i l l n e s s and increases i t s frequency i n the t o t a l p o p u l a t i o n " (Zook, S a v i c k i s & Moore, 1980, p. 465). They found that repeated h o s p i t a l i -z a t i o n s f o r the same disease accounted f o r 60 per cent of a l l h o s p i t a l charges and that from 24 to 55 per cent of h o s p i t a l i z a t i o n s were more expensive than the f i r s t admis-s i o n . - A general d i s s a t i s f a c t i o n w i t h the c o n t r i b u t i o n of medical care to h e a l t h i s growing (C a r l s o n , 1978; Evans, Chap. 10, 1980; Schweitzer, 1978) and there i s "growing doubt about : the c o n t r i b u t i o n s of increased spending f o r h e a l t h s e r v i c e s to h e a l t h s t a t u s " ( B a t t i s t e l l a , 1978, p. 45). There i s a concern over the i a t r o g e n i c hazards of modern medicine ( B a t t i s t e l l a ; C a r l s o n ; I l l i c h , 1976). Carlson says that d e s p i t e elaborate s a f e t y and hygiene measures " i n f e c t i o n s contracted i n h o s p i t a l s exceed the r a t e i n the 10 average household" (p. 325). Increased costs The increased c a p a b i l i t y of medical and i n f o r m a t i o n tech-nology which could lead to increases i n cost (Schlenker, 1980) . 1 Cost containment pressures which r e f l e c t growing d i s s a t i s -f a c t i o n and concern over r a p i d l y r i s i n g costs (Berry, 1978), a need f o r resource use i n other areas l i k e energy (Fuchs, 1974), and f o r "more t a n g i b l e p o l i t i c a l b e n e f i t s " (Boulet & Gr e n i e r , 1978, p. 25). Consequently more c o n t r o l s are being placed on h o s p i t a l spending and i n n o v a t i o n although the cost containment problem i s r a r e l y c l e a r l y defined. Berry says there i s a choice of problems: 1. p r i c e i n f l a t i o n of h o s p i t a l s e r v i c e s , 2. r a t e of increase of t o t a l expenditure f o r h o s p i t a l care, 3. r e l a t i v e p r o p o r t i o n of h e a l t h expenditure, e s p e c i a l l y f o r h o s p i t a l s , i n the Gross N a t i o n a l Product, 4. growing government budget f o r h o s p i t a l s e r v i c e s . I f the cost per person i s increased w i t h no corresponding increase i n h e a l t h s t a t u s s o c i e t y might r e j e c t the increased cost of technology but i f there are improvements i n h e a l t h status s o c i e t y may be w i l l i n g to pay. 11 N a t i o n a l Government The Federal government had shown i t s concern f o r i t s growing h e a l t h budget by s e t t i n g up a Task Force on the Cost of Health Services i n 1969. In " P o l i c i e s f o r Containing Health Care Costs i n Canada," Mennie (1976) discusses a s e r i e s of f e d e r a l i n i t i a - . t i v e s . In 19 73, the provinces had r e j e c t e d the f e d e r a l o f f e r of a f i v e year Trust Fund f o r new i n i t i a t i v e s i n h e a l t h care d e l i v e r y which was part of a new f i n a n c i n g proposal but, by 1975, p r o v i n -c i a l h e a l t h m i n i s t e r s committed provinces to t a r g e t s f o r the r e d u c t i o n of active-treatment beds, bed to p o p u l a t i o n r a t i o s and numbers of p h y s i c i a n s i n r e t u r n f o r extensions of f e d e r a l s h a r i n g f o r lower cost a l t e r n a t i v e s . These n e g o t i a t i o n s r e s u l t e d i n 1976 i n a f e d e r a l o f f e r of b l o c k funds to provinces which included c o n s i d e r a t i o n of extended h e a l t h sharing f o r a l t e r n a t i v e s l i k e n u rsing homes, home care programs and ambulatory care s e r v i c e s . McClelland (1977), then M i n i s t e r of Health, i n B. C , s t a t e d V B. C.'s i n t e n t i o n was to use the f i f t y m i l l i o n d o l l a r s i t was to r e c e i v e f o r a comprehensive long term care program. P r o v i n c i a l Government The B. C. government's concern about i t s c o n t r o l of h o s p i t a l costs i n the l a t e 1970s and e a r l y 1980s l e d to a j o i n t venture w i t h the B. C. Health A s s o c i a t i o n , the H o s p i t a l Funding Study. During t h i s time, the then Planning and Development D i v i s i o n of the Health M i n i s t r y worked on a H o s p i t a l Role Study, which was to d e f i n e the s e r v i c e s each h o s p i t a l would provide. Ambulatory 12 care was i n c l u d e d i n a second d r a f t as one of the broad areas of s e r v i c e . In a d d i t i o n , the H o s p i t a l Programs D i v i s i o n was docu-menting the extent of h o s p i t a l ambulatory care i n the province. However, pressures from the Treasury Board, a change i n M i n i s t e r and Deputy M i n i s t e r of Health and an increased focus on c e n t r a -l i z e d cost r e s t r a i n t placed these plans.; in:," limbo v. At; the' v."'. present time (summer, 1982) government's i n s i s t e n c e , that h o s p i t a l s operate w i t h g r e a t l y reduced budgets from those expected, may lead to a greater i n t e r e s t i n how ambulatory care can reduce the pressure on i n p a t i e n t beds. L o c a l Governments I n t e r e s t i n the p o s s i b i l i t i e s f o r ambulatory care and i n what i s c u r r e n t l y a v a i l a b l e comes from r e g i o n a l governments and groups. The Greater Vancouver Regional H o s p i t a l D i s t r i c t set up a S t e e r i n g Committee j o i n t l y w i t h the M i n i s t r y of Health i n B. C. to look at a l l aspects of ambulatory care w i t h i n i t s r e g i o n . Lawrence Ranta, M.D. , presented a report on Day Care Surgery to that S t e e r i n g Committee i n January, 1981 and was l o o k i n g at other aspects of ambulatory care. P r e v i o u s l y , the B. C. Medical Centre, formed under p r o v i n c i a l l e g i s l a t i o n i n 1973, to coordinate programs and i n t e g r a t e f a c i l i t i e s and s e r v i c e s , attempted to define ambulatory care. P a r t of i t s mandate was "to provide new and improved resources" and one of i t s o b j e c t i v e s was "exemplary f u n c t i o n a l programs f o r ambulatory care, p r e v e n t i v e care and education . . ." (B.C.M.C, Feb., 1975). In March of 1975, the B.CM.C. formed an Ad Hoc Committee "to develop a 13 working d e f i n i t i o n , a u s e f u l c l a s s i f i c a t i o n system, and e s t a b l i s h c e r t a i n p r i o r i t i e s " f o r ambulatory care (B.C.M.C. , 19.75) . When the p r o v i n c i a l government changed, the B.C.M.C. became defunct. P r o v i d e r s of Care Some h o s p i t a l s have reacted to cost containment pressures and government i n t e r e s t i n ambulatory care by p r o v i d i n g new s e r v i c e s such as medical day care or s u r g i c a l day care, both of which can be s o l d to government as p o t e n t i a l l y cost saving. Rosengren and L e f t o n (1969) say that h o s p i t a l s may innovate i n two ways, t e c h n o l o g i c a l or i d e o l o g i c a l . , With: the'present r e s - , t r a i n t s c u r t a i l i n g high technology i n n o v a t i o n , l i k e new CAT scanners, h o s p i t a l s have moved to lower technology i n n o v a t i o n , l i k e ambulatory care programs. In support of t h i s move to com-munity type h e a l t h programs, h o s p i t a l s say they are an important community resource, have management e x p e r t i s e , medical s t a f f l e a d e r s h i p , and t r u s t e e s representing the community (Block, 1979). In the United S t a t e s , Somers (1972) goes so f a r as to say: "Only the H o s p i t a l Can Do I t A l l - Now." Because there are "grey areas of r e s p o n s i b i l i t y " between community h e a l t h and h o s p i t a l s the boundary of each system i s not c l e a r and "the pressures to be omnipotent are p e r v a s i v e " (Dartington, 1979, p. 13,23). As w e l l , when "there i s evidence of fragmentation one may expect to see compensatory pressures toward i n t e g r a t i o n " (Dartington, p. 29). Though present f i n a n c i a l i n c e n t i v e s i n the h o s p i t a l system have discouraged more of these kinds of i n n o v a t i o n s , h o s p i t a l s see government moving i n the d i r e c t i o n of ambulatory care. G.T. Sept, 14 President of the B. C. Health A s s o c i a t i o n , i n a speech to the Area Councils i n 1981 s a i d that because of cost r e s t r a i n t " w e ' l l be encouraged, no doubt, to f u r t h e r increase ambulatory care whenever p o s s i b l e " (B.C.H.A. News, 1981). r : Kast and Rosenzweig (1974) s a i d that o r g a n i z a t i o n s i n the fu t u r e would have to adapt to a turbu l e n t environment: there would be a need f o r c o n t i n u a l change and adjustment and expansion of boundaries and domains; they would continue to increase i n s i z e and complexity and d i f f e r e n t i a t e a c t i v i t i e s ; they would t r y to s a t i s f y d i v e r s e goals r a t h e r than maximize one. H o s p i t a l ' s i n t e r e s t i n more ambulatory care appears to be one of these adaptations. o R e c i p i e n t s of Care P a t i e n t s are a l s o i n t e r e s t e d i n how t h e i r care i s provided. Thomas (1978) says that there has been a change i n the past 25 years i n the pe r c e p t i o n of one's own h e a l t h , "a l o s s of c o n f i -dence i n the human form" and consequently more demand f o r h e a l t h care (p. 348). Health care has been seen as a b a s i c r i g h t ( M a r g o l i s , 19 79). H o s p i t a l ambulatory care could then be seen as an extension of necessary s e r v i c e s to provide complete comprehensive care that would allow p a t i e n t s greater access to h e a l t h care. 15 DESCRIPTION OF AMBULATORY PROGRAMS AT LIONS GATE HOSPITAL  H i s t o r y Adapting to t h i s changing environment, Lions Gate H o s p i t a l i n North Vancouver opened a new medical day care f a c i l i t y , i n i 1 . December, 1979, which c o n s i s t s of f i v e o f f i c e s , two multi-purpose seminar rooms, a minor treatment area, a gym which can be d i v i d e d i n t o three areas, a work area f o r s t a f f and a r e c e p t i o n area. This opening was the culm i n a t i o n of s e v e r a l years of work on the part of i n t e r e s t e d p h y s i c i a n s , the h o s p i t a l ' s Board and s t a f f . The o r i g i n a l a p p l i c a t i o n to the M i n i s t r y of Health f o r an expan-s i o n of s e r v i c e s to i n c l u d e "Medical Ambulatory Care and Treat-ment S e r v i c e s " was made i n 1973. This b r i e f , by O.K. L i t h e r l a n d , M.D., saw day care medicine "as r e l i e v i n g the n e c e s s i t y f o r an i n p a t i e n t admission e n t i r e l y i n many cases, shortening the length of some i n p a t i e n t s t a y s , and g i v i n g much greater scope to prevent t i v e medicine" (quoted i n Corbett, 1980, p. 90). John Hunt, an ! I n t e r n i s t at Lions Gate H o s p i t a l , had already s t a r t e d a D i a b e t i c Day Care s e r v i c e and the r e h a b i l i t a t i o n of p a t i e n t s w i t h cerebro-v a s c u l a r and chronic o b s t r u c t i v e lung disease appeared p o s s i b l e i n a day care program to R. W. B e l l - I r v i n g and O.K. L i t h e r l a n d , I n t e r n i s t s at the h o s p i t a l . Lions Gate H o s p i t a l had s t a r t e d Day Care Surgery i n 1968 and P s y c h i a t r i c Day Care i n 1971 and f e l t that a r e d u c t i o n i n h o s p i t a l lengths of stay, shortened f o r the kinds of diagnoses i n those programs, might be due to the i n t r o d u c t i o n of day care. With the c o n t r a c t i o n of h o s p i t a l 16 b u i l d i n g and capping of beds i n the 1970s i t was f e l t that f u r t h e r ambulatory programs would be necessary to reduce some w a i t i n g 2 l i s t s . The M i n i s t r y of Health's approval of the a p p l i c a t i o n f i n a l l y came i n J u l y , 1978. In a l e t t e r , dated August 24, 1978, J. Glenwright, then A s s i s t a n t Deputy M i n i s t e r , H o s p i t a l Programs, defined Day Care as: . . . an organized r e h a b i l i t a t i v e s e r v i c e f o r p a t i e n t s who come to the h o s p i t a l f o r a program of treatment which r e q u i r e s that they remain f o r e i t h e r a one h a l f day of 2% hours, or a f u l l day of 5 hours, to i n c l u d e two or more s e r v i c e s , but does not n e c e s s i t a t e formal admission as i n p a t i e n t s . The s e r v i c e s which may be provided are nur s i n g s e r v i c e s , physiotherapy, occupational therapy, speech therapy, v o c a t i o n a l c o u n s e l l i n g , p s y c h o l o g i c a l s e r v i c e , s o c i a l s e r v i c e , and any other necessary treatment s e r -v i c e provided by the h o s p i t a l , plus medical assessment which i s financed under medical insurance. He f u r t h e r r e i t e r a t e d that the purpose of the program was as "an a l t e r n a t i v e to i n p a t i e n t care not an add-on program." Medical Day Centre Programs While Lions Gate H o s p i t a l o f f e r s s e v e r a l s e r v i c e s which do not r e q u i r e admission to a h o s p i t a l bed, the ones defined as day care are o f f e r e d i n the Medical Day Centre. These are: 1. Metabolic Energy C o n t r o l Assessment a) D i a b e t i c Day Care Background i n f o r m a t i o n was obtained from a case study on the ''Development of a H o s p i t a l Ambulatory Care Centre" presented by John Borthwick, A d m i n i s t r a t o r of Lions Gate H o s p i t a l , to a Management c l a s s i n Health Services P l a n n i n g , and from Lions Gate's f i l e s . 17 b) Obesity Program 2. R e h a b i l i t a t i o n Day Care Programs a) Neuro (Neurology) Program b) Chronic O b s t r u c t i v e Lung Disease (CO.L.D.) Program c) Back Education Program d) Asthma Program Some other outpatient programs are o f f e r e d i n the Centre f o r reasons of space but do not f i t the d e f i n i t i o n of day care as given p r e v i o u s l y . In order to assess the impact of these programs three were chosen f o r a n a l y s i s : the CO.L.D. Program, D i a b e t i c Day Care, and the Neuro Program. The. c r i t e r i u m f o r s e l e c t i o n was that these programs had been operating f o r a few years and so trends, a f t e r the i n t r o d u c t i o n of a program, could be examined. The f o l l o w i n g i s a d e s c r i p t i o n of the a c t i v i t i e s and types of 3 p a t i e n t s i n the programs that are being used f o r t h i s t h e s i s : Chronic O b s t r u c t i v e Lung Disease (C.O.L.D.). ( J u l y , 1976) The team c o n s i s t s of a C l i n i c a l D i r e c t o r , Nurse, Physio-t h e r a p i s t and an Occupational Therapist. The object of the program i s to help chronic o b s t r u c t i v e lung disease p a t i e n t s cope w i t h t h e i r i l l n e s s through education, e x e r c i s e and r e l a x a t i o n . 3" These d e s c r i p t i o n s are taken from a r e p o r t , "Ambulatory Care Services at Lions Gate H o s p i t a l , " which was submitted by the A d m i n i s t r a t i o n to R. E. McDermit, then Senior A s s i s t a n t Deputy M i n i s t e r , P r o f e s s i o n a l and I n s t i t u t i o n a l S e r v i c e s , M i n i s t r y of Health, November, 1980. 18 P a t i e n t s must have recent Lung Function S t u d i e s , E.C.G.s, Blood Gases and Chest X-rays p r i o r to admission to the program. Type of P a t i e n t - P a t i e n t s w i t h demonstrated chronic obstruc-t i v e lung disease, emphysema, chronic b r o n c h i t i s . Volume of Service - The program i s h e l d two afternoons a week f o r four weeks. Average enrollment per program i s e i g h t . D i a b e t i c Day Care (1964) The program c o n s i s t s of the C l i n i c a l D i r e c t o r , a Nurse and a D i e t i t i a n . The object of the program i s to prevent h o s p i t a l i -z a t i o n . The Nurse and D i e t i t i a n assess the d i a b e t i c p a t i e n t s and run the e d u c a t i o n a l program. A t y p i c a l day, 0700 to 1700 hours, i n v o l v e s the t a k i n g of Blood Sugars, d i s c u s s i o n w i t h the Nurse or D i e t i t i a n , a snack, l e c t u r e from a Pharmacist, P h y s i c i a n or Home Care Nurse, e t c . , lunch, a group d i s c u s s i o n regarding Diabetes, a snack, exercies w i t h the P h y s i o t h e r a p i s t and a wind-up. Type of P a t i e n t - Newly diagnosed d i a b e t i c p a t i e n t s , those f o r ~ . eyetone education, those who are I n s u l i n dependent (with a Youth day every s i x t h week), and those w i t h M a t u r i t y onset Diabetes, and some r e q u i r i n g I n s u l i n i n f u s i o n . Volume of Service - A new p a t i e n t r e q u i r e s 6 to 8 v i s i t s i n the f i r s t 6 months, then 2 v i s i t s i n the next year, and then 1 v i s i t every 2 years. S t a b i l i z a t i o n takes 3 to 4 weeks i n i t i a l l y . There are an average of 10 p a t i e n t s per s e s s i o n and three sessions a week. 19 Neuro Program (June, 1979) The m u l t i d i s c i p l i n a r y : team f o r the program c o n s i s t s of the C l i n i c a l D i r e c t o r , Nurse, P h y s i o t h e r a p i s t , Occupational T h e r a p i s t , Speech Th e r a p i s t , and a S o c i a l Worker. The obje c t of the program i s to reduce the number of days p a t i e n t s remain i n the a c t i v a t i o n ward by p r o v i d i n g education and therapy on a day care b a s i s . P a t i e n t s attend f o r e i t h e r a h a l f day, two and a h a l f hour's^ : r; or a f u l l day f o r f i v e hours. They r e c e i v e a minimum of two s e r -v i c e s w i t h i n the program time. Type of P a t i e n t - About 85 per cent of the p a t i e n t s have had a cerebrovascular a c c i d e n t , the r e s t i n c l u d e diagnoses l i k e post motor vehicle*-accidents,. head i n j u r i e s , m u l t i p l e s c l e r o s i s and amyotrophic s c l e r o s i s . Volume of Service - Up to 16 p a t i e n t s can be e n r o l l e d i n the program. P a t i e n t s attend from 1 to 3 days a week and are e n r o l l e d f o r an i n d e f i n i t e time p e r i o d , i . e . u n t i l they are discharged by the p h y s i c i a n . As the approval f o r these day care programs s t i p u l a t e d , t h e i r purpose was to be an a l t e r n a t i v e to i n p a t i e n t care. The i s s u e of whether or not ambulatory care s u b s t i t u t e s f o r i n p a t i e n t care can be. examined:; i n , s everal, s t u d i e s . 20 CHAPTER I I I . SUBSTITUTION OF MEDICAL DAY CARE FOR IMPATIENT CARE Throughout the h e a l t h care l i t e r a t u r e i t i s i m p l i e d or s t a t e d that reducing i n p a t i e n t length of stay by p r o v i d i n g l e s s c o s t l y programs, w i l l reduce the o v e r a l l h e a l t h care cost. Fuchs (1974) s t a t e s that the only way to a f f e c t h o s p i t a l expenses i s by change in g one of the v a r i a b l e s : admissions, length of s t a y , or cost per p a t i e n t day. Fraser (1971) says that when h o s p i t a l s are used to c a p a c i t y " a t t e n t i o n must be focused on ways of reducing the length of h o s p i t a l stay required f o r d i f f e r e n t i l l n e s s e s " (p. 157). However, s u b s t i t u t e s a l s o cost money and savings may be i l l u s o r y , depending on the p o i n t of view taken. Evans (1980, Chap. 10) s t r e s s e s "the h i g h l y c o n d i t i o n a l nature of a l l 'cost savings' statements . . .", that 'savings' always i m p l i e s a comparison (p. 173). Both Evans and Robinson (1973) and R u s s e l l , D e v l i n , F e l l and Glass (1977) emphasize that cost savings a s s o c i a t e d w i t h an i n n o v a t i o n or r e d u c t i o n i n length of stay are dependent upon the response of the system or "the use to which rel e a s e d resources are put" ( R u s s e l l et a l . , p. 846). E l n i c k i (1976) and Rennie (1977) conclude that there are no s i g n i f i c a n t savings when s u b s t i t u t i n g a l t e r n a t i v e s f o r i n p a t i e n t care, although Rennie's "estimates of a c t u a l and maximum p o t e n t i a l savings . . . appear f a r too s m a l l . . . " (Evans, 1980, Chap. 11, p. 211). Evans concludes that i f there are to be savings from a l t e r n a t i v e s there have to be changes i n the system of d e l i v e r i n g care, such asvrmonitoring case f l o w , a d j u s t i n g bed c a p a c i t y and changing s t a f f i n g patterns (p. 216, 217). 21 EXAMINATION OF THE AVAILABLE LITERATURE The a v a i l a b l e l i t e r a t u r e on these issues was examined f o r : c l a r i f i c a t i o n of the i s s u e , f o r i n f o r m a t i o n on what does happen when a l t e r n a t i v e s to h o s p i t a l i z a t i o n are used, and f o r the r e l a -t i o n s h i p of s u b s t i t u t i o n to cost savings. This review i s not too concerned w i t h the v a r i a b l e academic r i g o r of the f o l l o w i n g s t u d i e s as most do not r e l a t e d i r e c t l y to the methodology i n t h i s t h e s i s , but only to e x p l a i n i n g why another approach to determining the impact on i n p a t i e n t use may be necessary. Rarely does a common premise underly the research e f f o r t s so an attempt i s made to show the range of comparisons, the types of s t u d i e s and the d i f f e r i n g measures of cost and outcome. Not only do the care s e r v i c e s d i f f e r i n l e v e l and i n t e n s i t y between s t u d i e s but o f t e n w i t h i n s t u d i e s as w e l l . These d i f f e r e n c e s make i t d i f f i c u l t to draw conclusions. As the U.S. Department of He a l t h , Education and Welfare r e p o r t , Home Health Care (1976) puts i t : In order to compare two forms or s e t t i n g s of care, i t i s necessary f i r s t to be sure that the l e v e l (acute, i n t e r m e d i a t e , of maintenance) and i n t e n s i t y (continuous or sporadic) of care be matched, regardless of the place i n which i t i s provided. Thus the c h a r a c t e r i s t i c s and s e r v i c e needs of both p a t i e n t groups must be comparable. Only when these elements are a l i g n e d i s i t p o s s i b l e to make deductions about the costs of care. (p. 50) Two s t u d i e s on day h o s p i t a l programs suggest ambulatory care does s u t s t i t u t e . A program at St. Mary's of the Lake H o s p i t a l i n Kingston, Ontario o f f e r s a g e r i a t r i c o u t p a t i e n t department, a day h o s p i t a l , some beds, a team approach and f i v e f u l l time house p h y s i c i a n s f o r the c h r o n i c a l l y i l l (Schuman, 22 B e a t t i e , Steed, Gibson, Merry, Campbell & Kraus, ^1978). Discharge s t a t i s t i c s , f o r three month p e r i o d s , were analyzed f o r one year p r i o r to the program and one year f o l l o w i n g . The program r e s u l t e d i n a decreased l e n g t h of stay and increased p a t i e n t turnover. Kaplan (1981) evaluated the day h o s p i t a l program at Moss R e h a b i l i t a t i o n H o s p i t a l i n P h i l a d e l p h i a to see i f p a t i e n t s could be t r e a t e d i n the day h o s p i t a l without i n c r e a s i n g t h e i r l e n g t h of stay and w i t h lower c o s t s . The program provided a f u l l array of s e r v i c e s and a p a t i e n t spent f i v e days a week, and as long as m e d i c a l l y r e q u i r e d , i n t h e r a p e u t i c a c t i v i t i e s . Kaplan emphasizes t h i s was not o u t p a t i e n t or day care but r e h a b i l i t a t i o n care. The number of p a t i e n t s , 18, was too s m a l l to make genera-l i z a t i o n s about length of stay (9 had above average length of stays and 9 below average) but he claims a 23 per cent savings i n cost based, on per diem charges. In a review of a d u l t day care research Weiler and Rathbone-McCuan (1978) report on two f e d e r a l l y funded p r o j e c t s i n the U.S. which provide day programs of h e a l t h s e r v i c e s , the Levindale Adult Treatment Center and the Lexington Center f o r C r e a t i v e L i v i n g . The L e v i n d a l e Adult Treatment Center (Rathbone-McCuan, Lotin, Levenson & Hou, 1975) evaluated p a r t i c i p a n t s s i x times i n twenty months i n a comparison among a group i n i n s t i t u t i o n a l care, a community s e r v i c e group and a group l i v i n g independently i n an apartment. Day Care was found to have a s u p e r i o r c l i n i c a l outcome to the other groups and was more c o s t - e f f e c t i v e than i n s t i t u t i o n a l care. What i s not s t r e s s e d , i n t h e i r study, i s that costs were based on per diem program ra t e s and the community 23 group, although l e s s e f f e c t i v e , had the highest c o s t - e f f e c t i v e n e s s r a t i o because i t s costs were l e s s than h a l f those of day care or i n s t i t u t i o n a l care. The Lexington Center f o r C r e a t i v e L i v i n g (Weiler, Kim & P i c k h a r d , 19 76) uses a per diem cost which i s determined from d i r e c t costs and estimates what i t might cost to s t a r t a new centre. The study's conclusions are that a d u l t day care i s e f f e c t i v e and a l e s s c o s t l y a l t e r n a t i v e to the present way of c a r i n g f o r the c h r o n i c a l l y i l l e l d e r l y . W e i l e r and Rathbone-McCuan (1978) consider day care as "an o p t i o n f o r those inappro-p r i a t e l y i n s t i t u t i o n a l i z e d " and f e e l i t i s a necessary adjunct f o r a continuum of care (p. 136). They a l s o point out that "few d e l i v e r y systems have been so e x t e n s i v e l y s t u d i e d before implemen-t a t i o n i n t o a n a t i o n a l p o l i c y as a d u l t day care" (p. 151). The research on medical day care v a r i e s i n kinds of programs compared. Those s t u d i e s i n c l u d e d here provide day care of the Model I v a r i e t y , as Weissert (1978) has l a b e l l e d i t . He d i v i d e s adult day care i n t o two d i s c r e t e models: Model I i s day care a f f i l i a t e d w i t h a h e a l t h care i n s t i t u t i o n w i t h p h y s i c a l r e h a b i l i -t a t i o n as a goal using p h y s i c i a n and a l l i e d h e a l t h p r o f e s s i o n a l s e r v i c e s ; Model I I i s multipurpose, u s u a l l y a f f i l i a t e d w i t h community s e r v i c e agencies, o f f e r i n g s o c i a l a c t i v i t i e s , a r t s and c r a f t s and s e r v i n g c l i e n t s w i t h fewer diagnosed medical problems. Weissert, Wan, L i v i e r a t o s & !Katz (1980) compared 'patients who had been randomly assigned to day care and home care and found the d i r e c t costs of home care to be l e s s . A f t e r a m u l t i -stage a n a l y s i s of the data, i . e . excluding contaminated cases, comparing users w i t h non-users, and i n c l u d i n g contaminated 24 cases, i t was decided that the i n f l u e n c e of day care on p h y s i c a l f u n c t i o n i n g was not s i g n i f i c a n t but "may have had some e f f e c t upon p r o l o n g a t i o n of l i f e " (p. 579). Day care's "impact upon i n s t i t u t i o n a l i z a t i o n i n s k i l l e d nursing f a c i l i t i e s " was considered i n c o n c l u s i v e (p. 583). In an e a r l i e r review of data Weissert (1978) had compared ten day care programs w i t h nursing home care, e s t i m a t i n g the per diems, and found ad u l t day care to be l e s s c o s t l y unless used f o r a long p e r i o d of time. Adult day care had higher d a i l y costs but was not considered more expensive than n u r s i n g homes when c o n s i d e r i n g a 'period of care', as i t was pa r t - t i m e . P a r t of the high costs of the day care was the cost of the t r a n s p o r t a t i o n provided to reach the centre. G r i m a l d i (1979) says Weissert overstates the average annual cost of n u r s i n g homes because he presumes p a t i e n t s would have been i n n u r s i n g homes f o r the e n t i r e year p e r i o d . He f i n d s the average stay i n a nursing home to be two to s i x months. However, Weissert presumes p a t i e n t s to be i n day care f o r an e n t i r e year as w e l l , but only on a part-time b a s i s . What i s not looked at i s the d i f f e r e n t times p a t i e n t s might spend i n each type of care depending on the s e r v i c e s o f f e r e d and t h e i r r a t e s of recovery. Some authors suggest that a l t e r n a t i v e s do not s u b s t i t u t e f o r i n p a t i e n t use, that they are added on to the care already provided and may even increase i n p a t i e n t use. Hammond (1979), who reviewed s e v e r a l s t u d i e s on the c o s t - e f f e c t i v e n e s s of home care, and Pegels (1980), who examined the issues of i n s t i t u t i o n a l versus n o n - i n s t i t u t i o n a l care, both suggest that the a l t e r n a t i v e of home h e a l t h care may j u s t s h i f t the costs of h e a l t h care from 25 i n s t i t u t i o n s to community s e r v i c e s and increase t o t a l costs 4 of h e a l t h care by adding a new group to the d e l i v e r y system. Evans, K i n n i s and Robinson (1978) i n a cost a n a l y s i s of a s u r g i c a l day care u n i t at the Chil d r e n ' s H o s p i t a l , found l i t t l e impact on i n p a t i e n t use. In f a c t , t o t a l s u r g i c a l a c t i v i t y had expanded. A f t e r examining s u r g i c a l day care s i n c e i t s i n c e p t i o n , Evans and Robinson (1980) conclude that " . . . the e x i s t i n g d e l i v e r y system seems incapable of r e a l i z i n g the p o t e n t i a l savings from an inn o v a t i o n such as s u r g i c a l day care. I t i s presumably incapable of r e a l i z i n g the savings from other types of in n o v a t i o n as w e l l " CP- 880). Much of the research on a l t e r n a t i v e s t r i e s to deal w i t h the question of cost but s t u d i e s use d i f f e r e n t numerators, e.g. d i r e d t and/or i n d i r e c t c o s t s , and denominators, e.g. per person, per p a t i e n t day, per episode. Some stu d i e s use per diem costs or charges which do not adequately r e f l e c t true c o s t , some use average cost per p a t i e n t day. Sometimes d i r e c t costs are measured as a l l s e r v i c e s and costs a s s o c i a t e d w i t h an i n d i v i d u a l ' s treatment (Babson, 1973); sometimes they are measured as "payments made to the h e a l t h i n d u s t r y f o r the treatment or d e t e c t i o n of i l l n e s s " (Berk & Chalmers, 1981, p. 393). I n d i r e c t costs are defined by Babson as f i x e d costs of the h o s p i t a l that are l a r g e l y independent of the types of cases. A d i f f e r e n t connotation i s _ I t may be that the authors are not i n c l u d i n g a l l i n d i r e c t costs when measuring the costs of i n s t i t u t i o n a l care which i s d i f f e r e n t from the s u b s t i t u t i o n i s s u e . 26 given by Berk and Chalmers who e x p l a i n i n d i r e c t costs as the l o s s of output " i n c u r r e d both by the p a t i e n t and by the r e l a t i v e s or f r i e n d s who may provide unpaid nursing s e r v i c e s as w e l l as r e s t r i c -t i n g t h e i r production i n t h e i r own se c t o r of the economy" (p. 393). Disagreement e x i s t s over whether or not l o s s of output to s o c i e t y should be inc l u d e d i n determining c o s t s . Berk and Chalmers i n s i s t that these costs "cannot be ignored i f the purpose of the e x e r c i s e i s to reduce the t o t a l cost of i l l n e s s . . ." to s o c i e t y as a whole (p. 393). Complicating comparisons f u r t h e r i s the f a c t that those s t u d i e s which i n c l u d e i n d i r e c t costs to s o c i e t y use d i f f e r e n t measurements: time l o s t by the p a t i e n t and the fa m i l y ( A d l e r , W a l l e r , Day, Kasap, King & Thorne, 1974), only time l o s t by the p a t i e n t (Piachaud & Weddell, 1972), time l o s t by the fa m i l y w i t h only an estimate of the p a t i e n t ' s time ( P r e s c o t t , Cuthbertson, Fenwick, Garraway & Ruckley, 1978). Some authors have reviewed groups of s t u d i e s on ambulatory care, examining both c l i n i c a l outcome and cost data. Berk and Chalmers a p p l i e d rigorous experimental standards w i t h e x p l i c i t d e f i n i t i o n s of d i r e c t and i n d i r e c t c o s t , to 109 c l i n i c a l s t u d i e s comparing ambulatory and i n p a t i e n t care. D i r e c t costs were resources used and i n d i r e c t costs were l o s s of output to the economy. They concluded that only four s t u d i e s contained s u f f i c i e n t appropriate data on which to make d e c i s i o n s : Adler et a l . , Gerson and Hughes (1976), Piachaud and Weddell, and Pr e s c o t t et a l . These were randomized c o n t r o l l e d t r i a l s w i t h data on d i r e c t and some i n d i r e c t c o s t s . In a d d i t i o n , i n only two of the matched c o n t r o l s t u d i e s were d i r e c t costs measured to Berk's and Ghalmer's standards: Creese and F i e l d e n (1977) and Stone, P a t t e r s o n & Felson . (1968). Only Creese and F i e l d e n mea-sured i n d i r e c t costs completely. However, the authors of 75 of the 109 st u d i e s concluded: lower cost i n ambulatory care w i t h a b e t t e r c l i n i c a l outcome i n the ambulatory s e t t i n g (10 s t u d i e s ) , w i t h the same c l i n i c a l outcome i n both s e t t i n g s (61 s t u d i e s ) , w i t h a b e t t e r c l i n i c a l outcome i n the i n p a t i e n t s e t t i n g (3 :n.. I; s t u d i e s ) , and w i t h an indeterminate c l i n i c a l outcome (1 study). Even the stu d i e s chosen by Berk and Chalmers as appropriate do not compare very w e l l to each other as they are of d i f f e r e n t kinds of ambulatory care, f o r example, 2 days stay i n h o s p i t a l versus 6 or 7 days stay (Adler et a l . ) or home care versus h o s p i t a l care (Gerson & Hughes). In two st u d i e s of home care compared to h o s p i t a l care both found home care to be l e s s c o s t l y although t h e i r costs were measured d i f f e r e n t l y . Gerson and Hughes s t u d i e d home care s e r -v i c e s o f f e r e d f o r s h o r t - s t a y p a t i e n t s so that the time i n home care was the same as i t would have been i n the h o s p i t a l . In some d i a g n o s t i c c a t e g o r i e s days of h o s p i t a l care were reduced and Gerson and Hughes compared the co s t , per episode of i l l n e s s , i n both s e t t i n g s . Creese and F i e l d e n s t u d i e d a sm a l l sample of sev e r e l y d i s a b l e d p a t i e n t s needing r e g u l a r mechanical help ^They assume that only randomized c o n t r o l l e d t r i a l s provide any support. This i s a very conservative p o s i t i o n and not very u s e f u l i n the f i e l d . 28 f o l l o w i n g p o l i o . They compared d i r e c t and i n d i r e c t costs per year of care and assumed people were from s i n g l e person households. Costs per p a t i e n t week, based on the operating costs of the r e s -p i r a t o r y u n i t , were compared w i t h costs of care per week that were provided At home. "The a v a i l a b l e data suggest that even w i t h such se v e r e l y dependent p a t i e n t s home care may be a more economic p r o p o s i t i o n than constant h o s p i t a l care" (p. 120). Even w i t h s t u d i e s of one k i n d of a l t e r n a t i v e such as home care, the s e r v i c e s o f f e r e d i n the programs, the study populations and the cost denominators were a l l d i f f e r e n t . Are the cost savings of s u b s t i t u t i n g a l t e r n a t i v e s i l l u s o r y ? In the short-run f i x e d h o s p i t a l costs do not change very much and t o t a l h o s p i t a l expenditures u s u a l l y go up w i t h the a d d i t i o n of an a l t e r n a t i v e form of care (Berk & Chalmers, 1981; Evans & Robinson, 1980: F r e i b e r g , 1979). Jonsson and Lindgren (1980) poi n t to the f a l l a c i e s i n e s t i m a t i n g savings of e a r l y discharge i n t hat reducing length of stay w i l l r a i s e average c o s t s , not lower them, because of the resource i n t e n s i t y i n the f i r s t few days of care and then savings w i l l depend on how the use of labour changes. They suggest costs may increase i n the primary s e c t o r and the costs to s o c i e t y w i l l i n c r e a s e . Nevertheless, there may be ways to promote savings. In the long-run i t might be p o s s i b l e to reduce the c a p i t a l costs of equipment and b u i l d i n g s i f ambulatory care i s s u b s t i t u t e d t o t a l l y f o r a p a r t i c u l a r i n p a t i e n t program. I t may be p o s s i b l e to c l o s e beds or wards i f a drop i n numbers of p a t i e n t s i s l a r g e enough. Perhaps the number of beds f o r a geographical area may be reduced 29 ( E l n i c k i , 1976; Evans & Robinson, 1980). In a d d i t i o n the b e n e f i t s of a l t e r n a t i v e s are o f t e n given short s h r i f t because they are more d i f f i c u l t to measure and i d e n t i f y and " e m p i r i c a l research . . . underestimates the b e n e f i t s and hence underestimates the b e n e f i t / c o s t r a t i o " ( F r e i b e r g , 1979, p. 485). SPECIFIC DAY CARE PROGRAMS IN THE LITERATURE There are a few s t u d i e s of the impact of s p e c i f i c day care programs on h o s p i t a l i z a t i o n , although they are r a r e and most of them do not deal w i t h c o s t s . Those chosen here r e l a t e to the programs at Lions Gate H o s p i t a l : two are programs f o r chronic airway o b s t r u c t i o n , four are D i a b e t i c Day Care and one a Stroke Day Care Centre. Chronic O b s t r u c t i v e Lung Disease Two s t u d i e s of the e f f e c t i v e n e s s of chronic airway o b s t r u c t i o n programs were found. P e t t y , Hudson & Neff (1973) d e s c r i b e a program which used p a t i e n t education, r e c o n d i t i o n i n g and b r o n c h i a l hygiene. They found reduced h o s p i t a l i z a t i o n f o r i n d i v i d u a l p a t i e n t s . Hudson, T y l e r and P e t t y (1976) assessed 44 s u r v i v o r s four years a f t e r entry i n t o a program.^ The 44 were d i v i d e d i n t o a group of 14 who had an average of 38 days of h o s p i t a l i z a t i o n ':. _ There were a t o t a l of 182 p a t i e n t s e n r o l l e d i n the program, 113 r e c e i v e d a ques t i o n n a i r e on t h e i r h o s p i t a l i z a t i o n s f o r a year p r i o r to the program and 70 returned the q u e s t i o n n a i r e . Of these 70, 44-four year s u r v i v o r s were assessed. 30 each i n the year before the program and a group of 30 p a t i e n t s who had none i n the year p r i o r to program entry. Their progress was measured at three month i n t e r v a l s the f i r s t year a f t e r the program began, then at s i x month i n t e r v a l s f o r three years. There was a d e c l i n e i n pulmonary f u n c t i o n i n both groups over the four years. The f i r s t group reduced days of h o s p i t a l i z a t i o n to an average of 12 days per year f o r a p e r i o d of four years. This f i n d i n g was s t a t i s t i c a l l y s i g n i f i c a n t . The second group increased h o s p i t a l i z a t i o n , averaging 2 days per p a t i e n t per year f o r the four years. When the data of the two groups was combined, p a t i e n t s averaged 12 days of h o s p i t a l i z a t i o n the year p r i o r to the program and 5 days per year f o r the four years a f t e r . The d i f f e r e n c e i n number of days of h o s p i t a l i z a t i o n was s i g n i f i c a n t f o r the f i r s t year a f t e r the program but not the subsequent years. The authors conclude that t h e i r study "shows a decrease i n days of h o s p i t a l i -z a t i o n f o r p a t i e n t s w i t h severe chronic airway o b s t r u c t i o n , and the decrease was maintained through four years of follow-up" Cp. 610). Based on per diem charges f o r h o s p i t a l i z a t i o n i n one of the h o s p i t a l s used by the p a t i e n t s i n t h i s study and on the p a t i e n t s ' a c t u a l lengths of stay, costs of h o s p i t a l i z a t i o n f o r the year before p a t i e n t s entered the program were estimated. The average cost of h o s p i t a l i z a t i o n s f o r the four years a f t e r the program wasx. a l s o c a l c u l a t e d . The savings were $51,120 per year. Deducted from these savings were the costs of the o u t p a t i e n t program: some p a t i e n t s r e q u i r i n g oxygen therapy, s a l a r i e s of s t a f f and i n d i r e c t 31 costs of the program. P h y s i c i a n s ' fees were not i n c l u d e d i n e i t h e r cost c a l c u l a t i o n . The savings were $20,741 per year. D i a b e t i c Day Care Though D i a b e t i c Day Care programs have been operating since the e a r l y 1960s there have not been many st u d i e s on impact. Warner and Hutton (1980), reviewing c o s t / b e n e f i t and c o s t / e f f e c -t i v e n e s s analyses i n h e a l t h care l i t e r a t u r e , note conspicuous absences, one of which i s d i a b e t i c t h e r a p i e s . Two s t u d i e s on d i a b e t i c c l i n i c s , one i n A u s t r a l i a ( M o f f i t , Fowler & Eather, 1979) and one i n C a l i f o r n i a ( M i l l e r & G o l d s t e i n , 1972), suggest s u b s t i t u t i o n . M o f f i t et a l . assessed h o s p i t a l admissions f o r d i a b e t i c s i n three month periods from October, 1974 to June, 1977 at Royal Newcastle H o s p i t a l and compared those admissions to d i a b e t i c admissions f o r other doctors i n t h e i r own h o s p i t a l and to another h o s p i t a l , Belmont. A f i v e day o u t p a t i e n t education program plus s t a b i l i z a t i o n course f o r insulin-dependent d i a b e t i c s had s t a r t e d i n September, 1975. A t o t a l of 387 p a t i e n t s were i n v o l v e d from September, 1975 to June, 1977. These p a t i e n t s were unstable d i a b e t i c s from t h e i r c l i n i c and other unnamed sources. The authors found the average length of stay i n h o s p i t a l had been reduced from 10.7 days i n the year before the program to 5.8 days during A p r i l , May and June, 1977. They c l a i m that only t h e i r u n i t had shown a steady f a l l i n bed occupancy, based on average length of s t a y , due to Diabetes. What i s v i s i b l e from t h e i r graph that they f a i l to mention i s that t h e i r bed occupancy f o r Diabetes i s over twice as 32 high i n i t i a l l y (October - December, 1974) as the other two comparison groups and only f a l l s to the l e v e l of the other two. M i l l e r and G o l d s t e i n , i n t h e i r study of the Diabetes s e c t i o n of the Los Angeles County U n i v e r s i t y of Southern C a l i f o r n i a Medical Center, found, a f t e r the i n t r o d u c t i o n of a telephone answering s e r v i c e to streamline r e f e r r a l s , the p h y s i c i a n c l i n i c p o p u l a t i o n of d i a b e t i c s had increased from 4000 ( i n 1968) to 6000 patients!(in'1970) and the number of h o s p i t a l admissions had decreased from 2680 to 1250, f o r the two year p e r i o d . The average number of h o s p i t a l days per year f o r the d i a b e t i c c l i n i c p a t i e n t s dropped from 5.6 per p a t i e n t i n 1968 to 1.74 i n 1970, the new r a t e being 64 per cent s u p e r i o r to the n a t i o n a l average. They a l s o found that the incidence of h o s p i t a l admissions was reduced by 56 per cent. In another review of a D i a b e t i c Day Care Center, i n Phoenix, A r i z o n a , Matthes (1979) s t u d i e d a group of new insulin-dependent p a t i e n t s who came to the Center every day f o r 5 days to r e c e i v e i n s u l i n and education and then returned once or twice a week u n t i l t h e i r Diabetes was r e g u l a t e d , f o r two to s i x months. The Center saw approximately 200 p a t i e n t s a year. She estimates the cost of the c l i n i c to be one-quarter to o n e - t h i r d the cost of h o s p i t a l care per p a t i e n t per year, based on the per diem charges of each type of care. Using the $95 cost per day i n the h o s p i t a l and an estimate of 10 h o s p i t a l days per year per d i a b e t i c she compares the minimum h o s p i t a l cost of $950 per year to the cost of 12 sessions i n the c l i n i c at approximately $310. These are f a i r l y rough estimates,and she does not go i n t o any more d e t a i l . 33 Gordon and Weldon ' C1973) used a d i f f e r e n t approach to evaluate the impact of D i a b e t i c Day Care Centres, which had been imple-mented i n 1969, on h o s p i t a l use i n Nova S c o t i a and found no impact. They examined time trends i n s i x yea r s , 1967-19 72, of data from the h o s p i t a l s i n d i f f e r e n t regions of the province. They f i r s t compared trends i n p a t i e n t day r a t e s between regions w i t h and without d i a b e t i c c l i n i c s and concluded that " . . . the p r o v i n c i a l h o s p i t a l system as a whole showed no response, i n terms of patient-day r a t e s , to the i n t r o d u c t i o n of the c l i n i c s and that regions w i t h the c l i n i c s had s i m i l a r experience to the regions without c l i n i c s " (p. 200). These i n v e s t i g a t o r s looked at other measures of u t i l i z a t i o n such as length of stay and found no d i f f e r e n c e between regions w i t h and without d i a b e t i c day programs although there was a f a i r l y c o n s i s t e n t downward trend i n length of stay. They a l s o examined data on d i a b e t i c s w i t h m u l t i p l e diagnoses, as a measure of increased s e v e r i t y of the disease, and found no d i f f e r e n c e between regions. Cerebrovascular Disease Although Feigenson (1979) reviews s e v e r a l s t u d i e s on stroke r e h a b i l i t a t i o n u n i t s which show that the u n i t s can s i g n i f i -c a n t l y improve a p a t i e n t ' s f u n c t i o n i n g most of the s t u d i e s are on h o s p i t a l bed u n i t s and deal w i t h c l i n i c a l outcome. However, a study i n Michigan by Oster and Kibat (1975) describes a Stroke Day Care Center w i t h 108 p a r t i c i p a n t s attending between February, 19 72 and June, 1973. H o s p i t a l records f o r a l l stroke p a t i e n t s f o r one year before the day care p r o j e c t began were 34 examined f o r comparison w i t h records one year a f t e r the program opened. No data 'are provided but the authors s t a t e that "the data d i d not i n d i c a t e that l e n g t h of stay had been s i g n i f i c a n t l y reduced by the day care p r o j e c t " (p. 66). They f e l t that the s t a t i s t i c a l v a l i d i t y of t h e i r study was impaired by the sm a l l sample and l a c k of a broad comparison base. There was "a s l i g h t cost r e d u c t i o n f o r the average Stroke Day Care Center p a t i e n t on a per diem b a s i s " compared to stroke p a t i e n t s i n beds (p. 66). CONCLUSIONS Despite d i f f e r e n c e s i n the measurement of c l i n i c a l and econo-mic outcomes, the i n t e n s i t y and l e v e l of s e r v i c e i n day care and i n p a t i e n t programs and i n the type and q u a l i t y of the s t u d i e s , a few general conclusions can be made: 1. C l i n i c a l outcome appears to be the same or b e t t e r f o r ambulatory programs when compared to h o s p i t a l i z a t i o n . 2. There may be savings i n the long run w i t h the use of ambulatory programs i f they s u b s t i t u t e f o r h o s p i t a l programs and i f there i s an appropriate system response, ( i . e . the c l o s i n g of beds), but t h i s has not u s u a l l y happened. 3. Except f o r the Gordon and Weldon (1973) study the impact on rates of i n p a t i e n t u t i l i z a t i o n has been d e a l t w i t h only b r i e f l y using i n d i v i d u a l cases and the r e s u l t s are i n c o n c l u s i v e . Because other approaches such as in-depth follow-up s t u d i e s or r e t r o s p e c t i v e s t u d i e s of p a t i e n t groups are o f t e n u n s a t i s -f a c t o r y and do not look at the t o t a l system response t h i s t h e s i s w i l l develop a methodology, s i m i l a r to Gordon, Smith and Weldon (.1973) , f o r determining the impact of medical day care programs on i n p a t i e n t use. This methodology i s o u t l i n e d i n the next chapter. 36 CHAPTER IV. METHODOLOGY In t h i s t h e s i s , average lengths of s t a y , p a t i e n t days and the number of cases of In p a t i e n t use are examined f o r diagnoses i n the three medical day care programs chosen, i . e . CO.L.D. Program, D i a b e t i c Day Care and the Neuro Program, i n an e f f o r t to determine what impact these programs had. In order to o b t a i n the necessary i n f o r m a t i o n w r i t t e n permission to use data on the day care programs and on i n p a t i e n t use at Lions Gate H o s p i t a l was obtained from the H o s p i t a l ' s A d m i n i s t r a t o r (Appendix A) and from the Hospi-t a l Programs D i v i s i o n of the M i n i s t r y of Health (Appendix B). In a d d i t i o n , a l e t t e r was sent to a l l p h y s i c i a n s w i t h v i s i t i n g p r i v i l e g e s at the h o s p i t a l , by the Coordinator, informing them of the p r o j e c t (Appendix G). DISEASES OF INTEREST 7 D i a g n o s t i c c a t e g o r i e s were taken from the program r e f e r r a l forms which are completed by the r e f e r r i n g p h y s i c i a n . To ensure that these diagnoses covered the m a j o r i t y of people l i k e l y to be i n these programs the categories were discussed w i t h the C l i n i c a l D i r e c t o r s of the programs. As seen i n Table I , I I , and I I I , these d i a g n o s t i c c a t e g o r i e s were then coded to match the I n t e r - n a t i o n a l C l a s s i f i c a t i o n of Diseases (1968 and 1979). The Data f o r the Back Program was c o l l e c t e d but not used i n t h i s t h e s i s . I t has been i n c l u d e d i n Appendix D. Medical Records Department at Lions Gate checked the l i s t i n g f o r com p a r a b i l i t y but there are s t i l l some problems t r a n s l a t i n g from one R e v i s i o n , i . e . the 8th, to the other, i . e . the 9th. Problems w i t h c o m p a r a b i l i t y are discussed i n the s e c t i o n on l i m i t a t i o n s of the study. Table I Diagnoses Chronic O b s t r u c t i v e Lung Disease Program ( L C D . 8th and 9th Revision) L C D . 8th R e v i s i o n Code # Code // L C D . 9th R e v i s i o n BRONCHITIS, EMPHYSEMA & ASTHMA CHRONIC OBSTRUCTIVE PULMONARY DISEASE & ALLIED CONDITIONS B r o n c h i t i s , u n q u a l i f i e d 490 490 B r o n c h i t i s , not s p e c i f i e d as acute or chronic Chronic B r o n c h i t i s 491 491 Emphysema 492 492 OTHER1DISEASES OF THE -UPPER RESPIRATORY TRACT B r o n c h i e c t a s i s 518 494 Other Pneumoconioses & r e l a t e d diseases (516. 0 to E x t r i n s i c a l l e r g i c 516.2) 516 495 a l v e o l i t i s 496 Chronic Airway Obstruction not elsewhere c l a s s i f i e d Table I I Diagnoses D i a b e t i c Day Care ( L C D . 8th and 9th Revision) ll.C.D. 8th R e v i s i o n Code # Code # L C D . 9th R e v i s i o n DISEASES OF OTHER ENDOCRINE GLANDS Diabetes M e l l i t u s 250 250 (250.0 - 250.9) Table I I I Diagnoses Neuro Program ( I . C D . 8th :and 9th Revision) L C D . 8th R e v i s i o n Code # Code # L C D . 9th R e v i s i o n Malignant Neoplasm of . . . b r a i n 191 Benign Neoplasm of b r a i n & other parts of nervous system.(225.0 - 225.9) 225 M e n i n g i t i s , w i t h no organ-ism s p e c i f i e d as cause 320.9 E n c e p h a l i t i s , M y e l i t i s & Encephalomyelitis 323 HEREDITARY & FAMILIAL DISEASES OF 191 (191.0 - 191.9) 225 (225.0 - 225.9) 322 323 (323.0 - 323.9) THE NERVOUS SYSTEM Other diseases of b r a i n 347.9 Hereditary diseases of the s t r i a t o p a l l i d a l system, h e r e d i t a r y chorea 331.0 Other & u n s p e c i f i e d h e r e d i -t a r y & f a m i l i a l diseases of the nervous system 333.9 Hereditary a t a x i a (332.0 - 332.9) 332 M u l t i p l e s c l e r o s i s 340 OTHER DISEASES OF CENTRAL NERVOUS 331.8 Other Ce r e b r a l degeneration (331.8 - 331.89) Cerebral: degeneration, 331.9 u n s p e c i f i e d Other extrapyramidal d i s . & abnormal movement d i s o r -333 ders (333.0,333.4, 333.5) Sp i n o c e r e b e l l a r disease 334 (334.0 - 334.9) 340 SYSTEM P a r a l y s i s agitans 342 Other c e r e b r a l p a r a l y s i s 344 Motor neurone disease (348.0 - 348.9) 348 Other diseases of s p i n a l cord 349 Other & u n s p e c i f i e d a l c o h o l i s m > 303.9 CEREBROVASCULAR DISEASE 332 Parkinson's disease (332.0 - 332.1) 342 Hemiplegia (342.0 - 342.9) Motor neuron disease 335.2 (335.20 - 335.29) 336 (336.0 & 336.1) 357.5 A l c o h o l i c polyneuropathy 430 431 I n t r a c e r e b r a l hemorrhage Other & u n s p e c i f i e d i n t r a -c r a n i a l hemorrhage (432.0 432 432.9) Occlusion & s t e n o s i s of pr e - c e r e b r a l a r t e r i e s 433 (433.0 - 433.9) (cont.) Subarachnoid haemorrhage 430 Cerebral haemorrhage 431 Occlusion of p r e - c e r e b r a l a r t e r i e s 432 Cerebral thrombosis 433 39 Table I I I (cont.) L C D . 8th R e v i s i o n . Code # Code # L C D . 9th R e v i s i o n CEREBROVASCULAR DISEASE (cont.) Occlusion of c e r e b r a l C e r e b r a l Embolism 434 434 a r t e r i e s (434.0 - 434.9) Transient c e r e b r a l :. . ischaemia 435 435 (435.0 - 435.9) Acute but i l l - d e f i n e d cerebrovascular disease 436 436 Other & i l l - d e f i n e d cere-Generalized ischaemic brovascular disease (437.0 cerebrovascular disease 437 437 - 437.9) Other & i l l - d e f i n e d cere- Late e f f e c t s of cerebrovas-b r o v a s c u l a r disease 438 438 c u l a r disease OTHER SYMPTOMS REFERRABLE TO NERVOUS SYSTEM & SPECIAL SENSES Disturbance of speech 781.5 784. 3 Aphasia 784. 5 Other speech disturbance INTRACRANIAL INJURY Subarachnoid subdural & e x t r a d u r a l haemorrhage N852 852 (852.0 - 852.5) Other & u n s p e c i f i e d i n t r a -c r a n i a l haemorrhage f o l -lowing i n j u r y N853 853 (853.0 - 853.1) I n t e r c r a n i a l i n j u r y of I n t r a c r a n i a l i n j u r y of other & u n s p e c i f i e d other & u n s p e c i f i e d nature nature N854 854 (854.0 - 854.1) POPULATION FOR STUDY (Table IV) The persons using these programs r e s i d e mainly i n School D i s t r i c t s #44-, North Vancouver, and #45, > West Vancouver. I t was decided to o b t a i n i n f o r m a t i o n on those p a t i e n t s , from School D i s t r i c t #44 and #45, who were admitted to Lions Gate H o s p i t a l w i t h these diagnoses and those who went elsewhere i n the Province f o r s e r v i c e . Data were al s o obtained on i n p a t i e n t s , w i t h these diagnoses, from the r e s t of the Greater Vancouver Regional D i s t r i c t 40 (G.V.R.D.) who were admitted to the other G.V.R.D. h o s p i t a l s . The r e s t of the G.V.R.D. inclu d e s School D i s t r i c t s #36 through #41 and #43. As w e l l , i n f o r m a t i o n was obtained on those p a t i e n t s , from the r e s t of the G.V.R.D., w i t h the diagnoses of i n t e r e s t , who were admitted to Lions Gate H o s p i t a l (L.G.H.). Table IV Geographic Areas i n the G.V.R.D. by School D i s t r i c t 36 Surrey 41 Burnaby 37 D e l t a 38 Richmond 43 Coquitlam 39 Vancouver 44 North Vancouver 40 New Westminster 45 West Vancouver I t was not p o s s i b l e to s e l e c t one or two s i m i l a r h o s p i t a l s f o r comparison because the catchment areas i n the G.V.R.D. gen-e r a l l y overlap a great d e a l , though the North Shore, i . e . School D i s t r i c t s #44 and #45, i s a f a i r l y contained area. STUDY DESIGN A m u l t i p l e time s e r i e s design was chosen f o r i t s advantages i n c o n t r o l l i n g sources o f i n t e r n a l i n v a l i d i t y , such as h i s t o r y , maturation, r e g r e s s i o n , s e l e c t i o n , and the i n t e r a c t i o n of these (Campbell & Stanley, 1963, p. 56). Information f o r each of ten years, 1970 to 1980, was c o l l e c t e d on p a t i e n t s w i t h the diagnoses of i n t e r e s t i n S.D. #44 and #45 and i n the r e s t of the G.V.R.D. The p o s s i b i l i t y of a change i n trend before and a f t e r the : 41 i n t r o d u c t i o n of a program could be studi e d f o r Lions Gate H o s p i t a l and some comparison to what was happening i n the G.V.R.D. could be made. As w e l l , the e f f e c t of p a t i e n t s l e a v i n g one area and en t e r i n g another, of ' s p i l l - o u t ' cases could be examined. The design a l s o would c o n t r o l f o r changes over time as what happens on the North Shore i n terms of prevalence of disease, medical p r a c t i c e , e t c . may w e l l happen i n the r e s t of the G.V.R.D. A m u l t i p l e time s e r i e s design, using p r e c o l l e c t e d data ( h o s p i t a l discharge tapes) i s low cost compared to other types of studied ( S h o r t e l l & Richardson, 1978; Gordon & Weldon, 1973). V a r i a b l e s of I n t e r e s t The day care programs were i n i t i a t e d to prevent h o s p i t a l i z a -t i o n or so that p a t i e n t s could be discharged e a r l i e r . A f t e r the i n t r o d u c t i o n of a program, then, there should be some re d u c t i o n i n e i t h e r length of stay i n h o s p i t a l , the number of cases or p a t i e n t days i n h o s p i t a l f o r the diagnoses included i n the programs (assuming that a l l other things are equal). The impact of a pro-gram, the independent v a r i a b l e , on i n p a t i e n t u t i l i z a t i o n , the dependent v a r i a b l e , was measured by c o l l e c t i n g data on number, of cases, p a t i e n t days and average length of stay. Anderson (1973) says: that admission r a t e s and average lengths of s t a y , the two components of p a t i e n t days, are d i f f e r e n t i a l l y a l t e r e d by the f a c t o r s a f f e c t i n g u t i l i z a t i o n , such as the demographic character-i s t i c s of the p o p u l a t i o n , etc. and behave d i f f e r e n t l y over time. For example, i n h i s study age was h i g h l y a s s o c i a t e d w i t h admission rates but not w i t h average length of stay. 42 In order to look at the impact of the program on i n p a t i e n t use, i n t e r v e n i n g v a r i a b l e s (.or other f a c t o r s which may a f f e c t u t i l i z a t i o n ) have to be examined. Roemer and Shain (1959) i d e n t i f i e d three"". types '-of f a c t o r s as p o t e n t i a l determinants of u t i l i z a t i o n : p a t i e n t determinants, h o s p i t a l determinants and p h y s i c i a n deter-minants . P a t i e n t Determinants Those f a c t o r s r e l a t i n g to p a t i e n t s i n c l u d e : incidence and prevalence of i l l n e s s , a t t i t u d e to i l l n e s s , cost to the p a t i e n t , m a r i t a l s t a t u s and housing and s o c i a l l e v e l . McKinlay (.19 72) inc l u d e s age, sex, education, r e l i g i o n , e t h n i c i t y and socioeconomic status as v a r i a b l e s a f f e c t i n g u t i l i z a t i o n and he discusses s e v e r a l s t u d i e s using the 'sociodemographic approach'. There i s disagreement over the e f f e c t of some of these f a c t o r s . Anderson found socioeconomic f a c t o r s l i k e income l e v e l , education l e v e l and et h n i c composition to have very l i t t l e impact on the use of h o s p i t a l f a c i l i t i e s i n New Mexico but found use to be s e n s i t i v e to the age s t r u c t u r e of the po p u l a t i o n . Posner and L i n (1975) found the f a c t o r of age, which i s u s u a l l y assumed to be an impor-tant determinant of length of s t a y , to have l e s s c l e a r e f f e c t s than i s u s u a l l y thought because of the many confounding i n f l u e n c e s l i k e the extent to which s o c i a l c l a s s i n f l u e n c e d age e f f e c t s , and the f a c t that the aged po p u l a t i o n tends to be ". . . lower income, more urban and of d i f f e r e n t household composition than the general p o p u l a t i o n " (p. 855). However, Lefebvre et a l . (.1979) s t a t e that higher p a r t i c i p a t i o n r a t e s , i . e . higher number of cases per. 100, 43 i n each age group, and longer s t a y s , are c h a r a c t e r i s t i c of the e l d e r l y . Gordon, Smith and Weldon (1973) i n t h e i r Nova S c o t i a study, found that although i t would be i d e a l to show u t i l i z a t i o n by age and sex, the number of s e p a r a t i o n s , even f o r the high volume c o n d i t i o n s , was f a i r l y low "and thus the numbers i n v o l v e d i n age and sex s p e c i f i c groupings would, i n most cases, be too s m a l l f o r meaningful i n t e r p r e t a t i o n " (p. 195). Obviously a l l these v a r i a b l e s could not be c o n t r o l l e d i n the present study. Attempts were made to c o n t r o l f o r changes i n p o p u l a t i o n and age s t r u c t u r e . Any changes i n the incidence and prevalence of the i l l n e s s e s under study were examined by l o o k i n g at changes i n the u t i l i z a t i o n data. Sex was not taken i n t o account p a r t l y because i t would d i v i d e the p o p u l a t i o n of p a t i e n t s i n t o very s m a l l groupings when combined w i t h separations by age and a l s o because i t i s d i f f i c u l t to o b t a i n p o p u l a t i o n f i g u r e s f o r the School D i s t r i c t s which have a l l age groupings d i v i d e d by sex. Lefebvre et a l ; ,: p r o j e c t i n g average length of stay by age and sex groups, do show d i f f e r e n c e s between males and females i n a c t u a l and p r o j e c t e d average lengths of stay but those d i f f e r e n c e s are g p a r a l l e l i n most cases'(p. 86,88). ! ' I t was p o s t u l a t e d that the r a t i o of males to females i n S.D. #44 and #45 and i n the r e s t of the G.V.R.D. would not change d r a s t i c a l l y between 1970 and 1980 and so would not a f f e c t a com-p a r i s o n of p a t i e n t days or average length of stay. To assess t h i s Q In one of t h e i r two methods of p r o j e c t i o n , females over 75 years have an i n c r e a s i n g l y higher average l e n g t h of stay than males over 75 (p. 82). 44 p o s s i b i l i t y the 1971 and 1976 census data were examined. The r a t i o of males to females i s provided i n Table V. These f i g u r e s do show that the r a t i o of males to females changes somewhat more i n the G.V.R.D. between 1971 and 1976 f o r those over 65 years than i n any other age group. As w e l l , there i s a d i f f e r e n c e i n d i r e c t i o n , as the r a t i o of males to females increases i n the over age 65 group i n S.D. #44 and #45 and decreases i n the r e s t of the G.V.R.D. There has been no c o r r e c t i o n i n t h i s t h e s i s f o r the pos-:. s i b i l i t y of a change i n the r a t i o , f r o m 1976 to 1980. Table V Changes i n Number of Males per 100 Females S.D. #44 & #45 compared to the r e s t of G.V.R.D. Number of Males per 100 Females Years 0 - 14 15 - 44 45 - 64 65+ S.D. #44 & #45 1971 104.12 100.38 96.84 66.29 1976 104.29 101.16 94.47 67.02 REST OF G.V.R.E 102.42 92.20 79.94 1971 104.59 1976 104.72 101.25 93.25 75.86 H o s p i t a l Determinants The h o s p i t a l determinants discussed by Roemer and Shain are: the supply of beds, e f f i c i e n c y of bed u t i l i z a t i o n , the f i n a n c i n g of h o s p i t a l c o s t s , a v a i l a b i l i t y of a l t e r n a t i v e bed f a c i l i t i e s and outp a t i e n t s e r v i c e s . They c l a i m that where h o s p i t a l prepayment 45 covers everyone, as shown by s t u d i e s i n Saskatchewan, the r a t e s of h o s p i t a l i z a t i o n "vary d i r e c t l y w i t h the supply of beds i n a l o c a l area" (p. 12). Anderson a l s o found the supply of h o s p i t a l beds to be the "major determinant of u t i l i z a t i o n i n an area" (p. 104). However, Luke and C u l v e r w e l l (1980) found that h o s p i t a l lengths of stay v a r i e d d i r e c t l y w i t h h o s p i t a l occupancy r a t e s contrary to their, expectations based on the r a t i o n i n g hypothesis. They suggest that " h o s p i t a l s l a c k the c a p a c i t y to respond e f f e c t i v e l y to the f l u c t u a t i n g demands placed upon t h e i r resources . . . " '(p. 60). Whether or not h o s p i t a l s respond to occupancy r a t e s does not a f f e c t the data i n t h i s t h e s i s which are adjusted f o r popula-t i o n differences.-.-The...financing of h o s p i t a l costs i s the same f o r a l l the'G.V.R.D. h o s p i t a l s . The e f f i c i e n c y or i n e f f i c i e n c y of bed u t i l i z a t i o n and the a v a i l a b l i l i t y of a l t e r n a t i v e bed f a c i l i t i e s such as other h o s p i t a l s , extended care and long term care, should be r e l a t i v e l y s i m i l a r f o r a l l these h o s p i t a l s . Outpatient s e r v i c e s i n the form of amublatory programs at Lions Gate are the indepen-dent v a r i a b l e here. A n a l y s i s of the data was complicated by the f a c t that some G.V.R.D. h o s p i t a l s have o u t p a t i e n t s e r v i c e s and these s e r v i c e s are a l l d i f f e r e n t from each other as w e l l as being d i f f e r e n t from those o f f e r e d at Lions Gate H o s p i t a l . P h y s i c i a n Determinants The p h y s i c i a n determinants are: supply of p h y s i c i a n s , method of medical remuneration, nature of community medical p r a c t i c e , medical p o l i c i e s i n the h o s p i t a l s , l e v e l of medical a l e r t n e s s and medical teaching needs (Roemer and Shain). Although the medical 46 teaching needs of the teaching h o s p i t a l s i n the G.V.R.D. would be d i f f e r e n t from Lions Gate H o s p i t a l ' s i t i s not p o s s i b l e to measure how t h i s might a f f e c t the o v e r a l l u t i l i z a t i o n i n the G.V.R.D. f o r the diagnoses of i n t e r e s t . Some attempt was made to examine the medical p o l i c i e s i n Lions Gate H o s p i t a l and the nature of communi-ty medical p r a c t i c e on the North Shore when an a l y z i n g the data but i t was not p o s s i b l e to do t h i s f o r the r e s t of the G.V.R.D. h o s p i t a l s . I t i s only of concern to t h i s t h e s i s i f these p o l i c i e s and p r a c t i c e s change over time and change d i f f e r e n t l y i n S.D. #44 and #45 from the r e s t of the G.V.R.D. PROCEDURE Assumptions about the programs' e f f e c t s are that improve-ments i n a p a t i e n t ' s knowledge of h i s / h e r c o n d i t i o n and s k i l l s f o r coping w i l l prevent or le s s e n the need f o r h o s p i t a l i z a t i o n . While there are co n t r o v e r s i e s over whether or not a change i n knowledge leads to changes i n a c t i o n or b e l i e f s (McKinlay), the end r e s u l t , i . e . a red u c t i o n i n cases or p a t i e n t days, can be measured. L i n k i n g such a r e s u l t to the programs w i l l be more d i f f i c u l t . Data C o l l e c t i o n In order to o b t a i n average length of s t a y , cases and p a t i e n t days, H o s p i t a l Programs D i v i s i o n of the M i n i s t r y of Health implemented a computerized search of h o s p i t a l discharge tapes, 47 from 1970 to 1980, f o r a l l the G.V.R.D. h o s p i t a l s , f o r the diag-noses of i n t e r e s t . As w e l l , f o r 1976, a census year, the data on diagnoses were . aategorized by -•.•age, groupings. "These were: 0 - 14, 15 - 44, 45-64, 65 - 74, 75+ A c t u a l p o p u l a t i o n f i g u r e s i n these age groupings were obtained f o r the census years of 1971 and 1976 and p r o j e c t i o n s f o r other years (B.C. Research, 1974, 1979). Because e a r l i e r p r o j e c t i o n s (1974) f o r 19 72 to 19 75 proved to be i n c o r r e c t r e v i s e d f i g u r e s were obtained by l o g a r i t h m i c a l i n t e r p o l a t i o n ( B a r c l a y , 1978). (See Appendix E.) For 1977 to 1979, p o p u l a t i o n f i g u r e s were obtained ^from B.C. S c h o o l ' D i s t r i c t P o p u l a t i o n Estimates, by Fi v e Year Age Groups. (For p o p u l a t i o n f i g u r e s used see Appendix F.) I t was d i f f i c u l t to analyze the data i n s i m i l a r age groupings w i t h d i f f e r e n t data sets so the two age groupings shown on the summarized h o s p i t a l discharge tapes, i . e . 65 - 74 and 75+, were combined i n t o one category, 65+. LIMITATIONS OF THE STUDY Threats to I n t e r n a l V a l i d i t y Most of the thr e a t s to the i n t e r n a l v a l i d i t y of the study are c o n t r o l l e d by the design. However, the i n t e r v e n i n g f a c t o r s which cannot be c o n t r o l l e d may a f f e c t the r e s u l t s i f those f a c t o r s d i f - , f e r between S.D. #44 and #45 and the r e s t of the G.V.R.D. or between the years p r i o r to a program's i n t r o d u c t i o n and a f t e r . 48 Some of these l i k e l y f a c t o r s w i l l be examined i n the a n a l y s i s . The r e s t of the G.V.R.D. was chosen to look at d i f f e r e n c e s i n long term trends, and the e f f e c t s of boundary c r o s s i n g . There are problems inherent i n the c o l l e c t i o n of data which may produce b i a s e s . The h o s p i t a l discharge tapes record the diagnosis on discharge which may be d i f f e r e n t from that w r i t t e n on a r e f e r r a l form. P a t i e n t s may be m i s c l a s s i f i e d i n e i t h e r case and diagnoses on ambulatory care r e f e r r a l forms are not always s p e c i f i e d c l e a r l y . The q u a l i t y of h o s p i t a l discharge data has been questioned by Corn (1980) and Demlo, Campbell and Brown (1978). While Demlo et a l . found i n f o r m a t i o n on h o s p i t a l admis-s i o n and discharge dates h i g h l y r e l i a b l e , 99 per cent, i t was much l e s s r e l i a b l e f o r p r i n c i p a l diagnoses, 57 per cent to 65 per cent (p. 998). They f e l t that to determine b a s i c u t i l i z a t i o n trends and lengths of s t a y , "analyses based on t h r e e - d i g i t coding or broader d i a g n o s t i c groupings may s u f f i c e " (p. 1004). However, Demlo et a l . say that "whenever discharge data i s used to measure changes i n u t i l i z a t i o n p atterns . . ." the amount of e r r o r should be assessed when measurements are taken, ". . . i n c l u d i n g the i n f l u e n c e of f a l s e negative and f a l s e p o s i t i v e diagnoses . . . " (p. 1004). In Canada, the Canadian H o s p i t a l Insurance system i s working on systematic data c o l l e c t i o n . Because Admissions forms are the same i n a l l h o s p i t a l s i n B. C. and channelled to one funding source, admission and discharge data are probably h i g h l y r e l i a b l e here, too. As i t was not p o s s i b l e to measure the i n f l u e n c e of f a l s e negative and f a l s e p o s i t i v e diagnoses any changes i n : 49 u t i l i z a t i o n patterns could be a s s o c i a t e d w i t h changes i n the r e l i a b i l i t y of the diagnoses i n t h i s study. Changes i n the measuring instrument are of concern. There are d i f f i c u l t i e s i n comparing the 8th R e v i s i o n of the I n t e r n a t i o n a l  C l a s s i f i c a t i o n of Diseases (1968) w i t h the 9th- R e v i s i o n (1979). This change took p l a c e i n January, 1979 so the data from the f i n a l year may not be comparable. For example, l a t e e f f e c t s of cerebro-v a s c u l a r disease, #438 i n the 9th R e v i s i o n does not appear i n the 8th. Although assurances were given by Lions Gate H o s p i t a l ' s Medical Records Department, that these cases had been spread through #436 - 438 p r e v i o u s l y , the dramatic increase i n 1979 d i d not seem to s u b s t a n t i a t e t h i s assumption. A computerized program f o r converting the 8th R e v i s i o n to the 9th would be necessary 9 i f more of t h i s k i n d of research were to be done. This program might increase the accuracy of determining comparable cate g o r i e s but would not help when those categories d i d not e x i s t p r e v i o u s l y . In a d d i t i o n , the f i n a l year, 1979, i s a f i s c a l y ear, A p r i l 1 s t , 19 79 to March 31st, 1980, w h i l e the other years are calendar years. Because of t h i s change i n the r e c o r d i n g of discharge data three months, January to March, 1979, are missing from t h i s data. Apparently H o s p i t a l Programs D i v i s i o n of the M i n i s t r y of Health d i d not have such a conversion program at the time these data were compiled. 50 Threats to E x t e r n a l V a l i d i t y I t would be d i f f i c u l t to p r e d i c t that any impact from these programs on i n p a t i e n t h o s p i t a l use would occur i n other h o s p i t a l s w i t h s i m i l a r programs. I f there i s no e f f e c t , even w i t h s i m i l a r programs and c o n d i t i o n s , there may s t i l l be an impact from a program i n another h o s p i t a l or area. There could be an i n t e r -a c t i o n between the type of p a t i e n t s s e l e c t e d f o r a program and the program i t s e l f and.this kind: of i n t e r a c t i o n might hinder g e n e r a l i -z a t i o n to other programs. METHOD OF ANALYSIS Data on average lengths of s t a y , cases and p a t i e n t days were examined f o r diagnoses i n the programs to see i f there were d e f i n i t e trends i n S.D. #44 and #45 before and a f t e r the programs. The CO.L.D. program began i n June, 1976, and the Neuro program i n J u l y , 1979 so there might be some measurable impact from these programs. D i a b e t i c Day Care s t a r t e d i n 1966 at Lions Gate H o s p i t a l and f i r s t s t a r t e d i n October, 1972 i n some h o s p i t a l s i n the r e s t of the G.V.R.D. (B.C. M i n i s t r y of Health, Annual Report, 1979). F i r s t the data were examined to see i f any trends could be observed and what order of magnitude they might be... This was done f o r average le n g t h of stay and then f o r cases and p a t i e n t days. Then, adjustments were made f o r p o p u l a t i o n d i f f e r e n c e s and crude rat e s per 10,000 po p u l a t i o n derived. As the crude r a t e s might be biased by d i f f e r e n c e s i n - t h e age composition of the two areas the data f o r age s t r u c t u r e by diagnoses, In 1976, were examined and age adjusted rates determined. The e f f e c t of ' s p i l l - o u t ' cases was then looked at to see i f adding them to the other r a t e s made a d i f f e r e n c e . F i n a l l y , the other f a c t o r s which might a f f e c t the ra t e s were examined. S t a t i s t i c a l Tests Least squares r e g r e s s i o n of u t i l i z a t i o n on time, w i t h u t i l i -z a t i o n measured i n r e a l numbers and n a t u r a l logs was attempted. The impact of the program was assessed by i n t r o d u c i n g a dummy v a r i a b l e (before the program = 0, a f t e r the program = 1) i n t o the re g r e s s i o n a n a l y s i s . PRESENTATION OF DATA COLLECTED Data were c o l l e c t e d and summarized on diagnoses i n three programs: the C.O.L.D. program (Table V I ) , D i a b e t i c Day Care (Table V I I ) , and the Neuro program (Table V I I I ) . The focus of the next chapter i s the C.O.L.D. program which had three years of data. D i a b e t i c Day Care and the Neuro program are a l s o discussed but to a l e s s e r extent. 52 Table VI :. C.O.L.D. Average Length of Stay, Cases & P a t i e n t Days By Year & Geographic Area S.D. #44 & 45 to L.G.H. G.V.R.D. to L.G.H. S.D. #44 & 45 to r e s t of Province Rest of G.V.R.D. to r e s t of G.V.R.D. Hosps. YEARS Pt . AvLOS Cs. Days Pt. Av.LOS Cs.Dys. P t . Av.LOS Cs.Dys. Pt. AvLOS Cs. Days 1970 AvLOS Cases Pt.Dys. 11.44 9.4 . 1075 12.25 4 49 38.81 16 621 14.40 1203 .17327 1971 AvLOS Cases Pt.Dys. 11.06 103 1139 4.20 5 21 8.84 19 168 13.22 1247 16483 1972 AvLOS Cases Pt.Dys. 8.47 92 779 59.86 7 419 11.0 13 143 13.02 1166 15185 1973 AvLOS Cases Pt.Dys. 13.28 85 1129 10.40 5 52 13.94 16 223 11.90 1076 12803 1974 AvLOS Cases Pt.Dys. 10.22 54 552 9.33 3 28 13.06 19 248 13.11 1103 14458 1975 AvLOS Cases Pt.Dys. 12.67 75 950 52.67 9 474 7.25 16 116 12.62 1002 12643 1976 AvLOS Cases Pt.Dys. 14.14 65 919 9.25 4 37 11.0 15 165 14.03 966 13553 1977 AvLOS Cases Pt.Dys. 9.10 73 664 149.0 2 298 5.32 19 101 14.03 965 13537 1978 AvLOS Cases Pt.Dys. 12.21 73 891 13.50 4 54 7.90 20 158 15.30 958 14660 1979/80 AvLOS Cases Pt.Dys. 10.60 70 742 16.0 3 48 6.0 15 90 19.66 1302 25600 53 Table VJJ-Dlabetes Average Length of Stay, Cases & P a t i e n t Days By Year & Geographic Area S.D. #44 & 45 to L.G.H. , G.V.R.D.. : to L.G.H. S.D. #44:& 43 to r e s t , o f • Province Rest of G.V.R.D. to Rest of G.V'.'R.D. Hbsps. YEARS AvLOS C S . P t . .. Days Av.LOS Cs.Pt. Dys. Av.LOS Cs.Pt. Dys. AvLOS Cs. P t . Days 1970 AvLOS Cases Pt.Dys. 12.32 111 1368 13.15 13 191 12.74 23 293 19.29 1156 22297 1971 AvLOS Cases Pt.Dys. 14.64 95 1391 15.64 11 172 19.13 23 440 20.27 1118 22657 1972 AvLOS Cases Pt.Dys. 22.53 88 1983 18.33 9 165 65.46 13 851 20.28 1216 24661 1973 AvLOS Cases Pt.Dys. 20.43 88 1798 10.25 12 123 31.73 15 476 22.93 1287 29517 1974 AvLOS Cases Pt.Dys. 24.31 94 2285 13.32 19 253 19.50 18 351 19.69 1292 25436 1975 AvLOS Cases Pt.Dys.. 18.44 84 1549 6.67 6 40 22.86 21 480 19.78 1255 24829 1976 AvLOS Cases Pt.Dys. 24.07 74 1781 9.45 11 104 15.14 29 439 21.37 1305 27885 1977 AvLOS Cases Pt.Dys. 15.32 81 1241 L3.33 9 120 13.36 25 334 20.49 1368 28029 1978 AvLOS Cases Pt.Dys. 32.19 84 2704 7.83 6 47 18.65 17 317 23.53 1332 31342 1979/80 AvLOS Cases Pt.Dys. 23.51 70 1646 38.40 5 192 8.38 21 176 24.80 1312 32535 54 Table V I I I Neuro Diagnoses ^ Average Length of Stay, Cases & P a t i e n t Days By Year & Geographic Area S.D. #44 & 45 to L.G.H. G.V.R.D. to L.G.H. S.D. #44 & 45 to r e s t of Province Rest of G.V.R.D. to r e s t of G.V.R.D. Hosps. YEARS Pt. AvLOS Cs. Days Pt . Vv.LOS Cs.Dys. P t . Av.LOS Cs.Dys. Pt. AvLOS Cs. Days 1970 AvLOS Cases Pt.Dys. 31.33 257 8053 24.40 20 488 33.81 99 3347 39.40 3364 132557 1971 AvLOS Cases Pt.Dys. 26.44 293 7746 57.10 58 3312 37.21 84 3126 40.03 3652 146174 1972 AvLOS Cases Pt.Dys. 41.34 317 13106. 167.98 54 9071 39.57 115 4550 36.65 4130 151357 1973 AvLOS Cases Pt.Dys. 57.59 321 18485 240.60 48 11549 57.39 92 5280 40.47 3750 151766 19 74 AvLOS Cases Pt.Dys. 51.88 303 15721 260.10 31 8063 36.15 102 3687 47.03 4079 191818 1975 AvLOS Cases Pt.Dys. 41.72 368 15353 L83.38 47 8619 57.89 91 5268 50.74 4356 221026 1976 AvLOS Cases Pt.Dys. 55.30 371 20516 L39.38 68 9478 47.88 96 4596 50.61 4014 203167 19 77 AvLOS Cases Pt.Dys. 61.60 377 23222 L26.61 66 8356 85.26 90 7673 61.18 4465 273182 19 78 AvLOS Cases Pt.Dys. 47.67 390 18592 57.77 65 3755 65.98 104 6862 62.08 4327 268612 1979/80 AvLOS Cases Pt.Dys. 69.94 360 25180 L99.96 53 10598 81.49 67 5460 85.09 3954 336460 CHAPTER V. FINDINGS AND ANALYSIS The questions explored using t h i s methodology were: - Does h o s p i t a l medical day care reduce average length of s t a y , number of cases or p a t i e n t days? - How adequately does t h i s methodology answer t h i s question? The time frame was chosen f o r the C.O.L.D. program a n a l y s i s but was u s e f u l f o r the D i a b e t i c Day Care a n a l y s i s as w e l l . The Neuro program data were al s o examined d e s p i t e the p r e v i o u s l y mentioned complications w i t h the 1979/80 data. As F r e i b e r g (.1979) s t a t e s : "the impact of s u b s t i t u t i n g an a l t e r n a t i v e f o r i n p a t i e n t care i s e s p e c i a l l y d i f f i c u l t to analyze and to p r e d i c t because of the i n f l u e n c e of . . . s u b t l e , n o n q u a n t i f i a b l e v a r i a b l e s " (p. 479). Often the v a r i a b l e s are assumed to a f f e c t treatment groups before and a f t e r the treatment i n the same way but Evans and Robinson (1980) say that "any inferences drawn from u t i l i z a -t i o n data under the c e t e r i s paribus assumption ( i . e . other things being equal) can only be i m p r e s s i o n i s t i c and t e n t a t i v e " (p. 877). An attempt w i l l be made to look at a l t e r n a t e explanations or . . impinging v a r i a b l e s to see i f we can get a c l e a r e r view of any p o s s i b l e causal r e l a t i o n s h i p s . FINDINGS OF THE STUDY  CO.L.D. PROGRAM Average Length of Stay, Cases and P a t i e n t Days Does the data on average length of s t a y , f o r those w i t h chronic o b s t r u c t i v e lung d i s e a s e , t e l l us anything about the CO.L.D. program's impact on i n p a t i e n t use? As there are a f u l l three years of data a f t e r the program began, i n J u l y of 1976, the questionable 1979/80 data can be ignored i f necessary. When the data on average length of stay i s graphed ( F i g . 1 ) , the graph shows a drop i n average l e n g t h of stay i n 1977 f o r S.D. #44 and #45 a f t e r the CO.L.D. program s t a r t e d , but a sub-sequent r i s e i n 1978. Average length of stay i n S.D. #44 and #45 has a general trend upwards t i l l 1976. In the r e s t of the G.V.R.D. i t f a l l s u n t i l 1973 and then s t a r t s to r i s e , t a k i n g a l a r g e jump between 1978 and 1979/80. To see i f the drop i n average l e n g t h of stay i n S.D. #44 and #45 was r e l a t e d to the i n t r o d u c t i o n of the program a r e g r e s s i o n a n a l y s i s , using a dummy v a r i a b l e f o r the program, was run on r average lengths of stay i n S.D. #44 and #45, and i n the r e s t of the G.V.R.D. None of the regressions on the G.V.R.D. data were s i g n i f i c a n t f o r any i n t e r a c t i o n s between average l e n g t h of s t a y , trend (over the ten year period) or the program (dummy v a r i a b l e ) . The r e s u l t s f o r the r e g r e s s i o n run on the data-from S.D. #44 and #45, f o r those p a t i e n t s using Lions Gate H o s p i t a l , .are reported i n Table IX. Figure 1 CO.L.D. Average Length of Stay By Year. & Geographic Area | Days 20-1 •HH 5H. Rest of GVRD to r e s t of S GVRD Hospa. S.D. #44 & 45 to L.G.H. [ 1 r 1970- 71 72 73 i r i 1 i - I 74 75 76 77 ' 78 79/80 Years Table IX Regression A n a l y s i s on Average Length of Stay CO.L.D. P a t i e n t s i n S.D. #44 & 45 Using, L.G.H. RUNS CONSTANT TREND DUMMY TREND X DUMMY I 11.030 (8.474) .0525 (.250)' I I 10.030 (5.849) .394 (.914) -2.50 (-.910) I I I 9.819 (5.322) .438 (.952) 3.283 (.305) -.676 (-.558) VARIABLES: Constant = 1.0 i n a l l years; Trend = 1 i n 1970, 2 i n 1971 to 10 i n 1979/80; Dummy = 0 i n 1970 to 1975, .5 i n 1976 ( h a l f a year of prog.) 1 i n 1977 to 1979/80. (The t r a t i o i s i n brackets.) A look at the t o t a l data f o r average l e n g t h of stay grouped i n t o three years p r i o r to the i n t r o d u c t i o n of the C.O.L.D. program 1973 - 1975, and three years a f t e r , 1976 - 1978, (Table X ) / . r e v e a l a 5 per cent r e d u c t i o n (.57 days) i n average length of stay f o r those i n S.D. #44 and #45 going to Lions Gate H o s p i t a l , a savings of 157 p a t i e n t days but only 3 fewer cases. On the other hand, the data f rom the r e s t of the G.V.R.D. shows an increase of 15 per cent i n average length of stay (1.91 days) w i t h 292 fewer cases and 1,846 more p a t i e n t days that i n 1973 - 1975. Table X C.O.L.D. Average Length of Stay, T o t a l Cases & P a t i e n t Days By Three Year Groupings & Geographic Area 1973 - 1975 1976 - 1978 AvLOS Cases Pt.Days AvLOS Cases Pt.Days S.D. # 44 & 45 To L.G.H. 12.29 214 2631 11.73 211 2474 Rest of GVRD to r e s t of GVRD Hosps. 12.54 3181 39904 14.45 2889. 41750 I f the 1979/80 questionable data are included and the data grouped by four years p r i o r to the program and a f t e r (Table X I ) , the r e s u l t s appear c o n c l u s i v e . For the four years a f t e r the program s t a r t e d there i s an 8 per cent r e d u c t i o n i n t o t a l cases and a 6 per cent r e d u c t i o n i n t o t a l p a t i e n t days, w i t h an almost 3 per cent lower average length of stay. By comparison, i n the r e s t of the G.V.R.D., despit e a 3.5 per cent decrease i n cases there i s a 22 per cent increase i n p a t i e n t days and a 27 per cent increase i n the average l e n g t h of stay. 59 Table XI C.O.L.D. Average Length of Stay, T o t a l Cases & P a t i e n t Days By Four Year Groupings & Geographic Area 1972 - 1975 1976 - 1979/80 AvLOS Cases Pt.Days AvLOS Cases Pt.Days S.D. #44 & 45 to L.G.H. 11.14 306 3410 11.44 281 3216 Rest of GVRD to r e s t of GVRD Hosps. 12.67 4347 55089 16.07 4191 67350 I f we take these f i n d i n g s s e r i o u s l y , they suggest that S.D. #44 and #45 might have gone up by 3.4 days average l e n g t h of stay f o r C.O.L.D. i f the trend followed the p a t t e r n i n the r e s t of the G.V.R.D. I f the 281 cases i n S.D. #44 and'W/ 45 from 1976 to 1979/80 are m u l t i p l i e d by the e x t r a 3.4 days, there might have been an a d d i t i o n a l 955 p a t i e n t days i n S.D. #44 and #45, i . e . 239 p a t i e n t days per year. As there are about 100 people a year i n the C.O.L.D. program t h i s would mean a savings of 2.4 days f o r each person i n the program per year. However, w i t h the data being questionable, we are not c e r t a i n that t h i s i s happening. The graphs of cases ( F i g . 2) and p a t i e n t days ( F i g 3) over the ten year p e r i o d show a s l i g h t d e c l i n e to 1974 i n S.D. #44 and #45 and then a l e v e l l i n g o f f . In the r e s t of the G.V.R.D. there i s a d e c l i n e i n cases to 1978 and i n p a t i e n t days to 1977 and then a sharp i n c r e a s e . I t could be, then, that the program has ensured that cases and p a t i e n t days do not increase i n S.D. #44 and #45, rat h e r than causing a d e f i n i t e decrease. However, a r e g r e s s i o n 60 a n a l y s i s on both S.D. #44 and #45 and the r e s t of the G.V.R.D., cases and p a t i e n t days, found t h i s data to be not s t a t i s t i c a l l y s i g n i f i c a n t . F i g u re 2 CO.L.D. Cases By Year & Geographic Area |Cases~in H^rTdrjeds; .L -J.-4. -1 • — i o : 5 H H-i-i • t-1-1 ! ! • - * -t- r 4 + 4 - t -: •• ' Rest of GVRD ' ^ , • to r e s t of •/ GVRD "Hosps. i <--+ ' t--!--t-. - f " J - . . S.D. #44 & • 45 to L.G.H. , . . , i — i T — i i i 1970 71 - 72 73 -74 75- 76•••7-7 78 79/80 Years . , . . . . . 61 Figure 3 C.O.L.D. P a t i e n t Days By Year & Geographic Area Patient, Days, - Ln^-Thousands*-25i -t—t—+-t •St! 10i -f -t-r < _i ; 4.4—; - 1 4 ] * - t h - n t - , - f T - i - t - t r H 1 V-^r : - <- --4-t t ' -t -Rest of GVRD -1* to r e s t of I GVRD Hosps. 4 - U M-r- t -I 1- 4-- + - • r - f - t • • t t J t • ••-1- j - I— I—h-t-• h- i t -;—f- -t- -I- -t—t r I-4 UM-r:; / - : 4 •! \ -f-f >-, 14--+- T-. U,-+- l -4 .. - 'S.D. #44 • & • -45 to L.G.H 1 . . J | < * 19)0 . 7-1- • 72 -73 • f 71 75 76 77 Years 78 79/80 62 Conclusions on the Raw Data There i s a l a r g e d i f f e r e n c e between the two areas on numbers of cases and p a t i e n t days but not that much d i f f e r e n c e i n average le n g t h of stay. Rather than a d e f i n i t e downward trend i t appears as i f l e n g t h of stay f a i l e d to r i s e , as i t d i d i n the r e s t of the G.V.R.D., f o r S.D. #44 and #45 p a t i e n t s going to Lions Gate H o s p i t a l . The data on average length of stay f o r both areas proved to be not s t a t i s t i c a l l y s i g n i f i c a n t . The r a p i d increase i n cases and p a t i e n t days f o r the r e s t of the G.V.R.D. i n the 1979/80 data could be due to the change i n L C D . codes but t h i s change should a l s o have a f f e c t e d Lions Gate H o s p i t a l . (A check of the raw data proved that these f i g u r e s were not mis c a l c u l a t e d . ) However, i n the 1979/80 data there was an e x t r a category, #496, chronic airway o b s t r u c t i o n , not elsewhere c l a s s i f i e d . This category had only 26 cases and 217 p a t i e n t days f o r S.D. #44 and #45 using Lions Gate H o s p i t a l , an average l e n g t h of stay of 8.35 days, but i n the r e s t of the G.V.R.D. t h i s category had 485 cases and 13,398 p a t i e n t days, an average l e n g t h of stay of 27.62 days. One can speculate on a dramatic increase i n the prevalence and s e v e r i t y of the disease but why does t h i s not occur i n S.D. #44 and #452 Again, the data f o r t h i s f i n a l year i s questionable. The b i g d i f f e r e n c e i n cases and p a t i e n t days between the two areas may be due to a d i f f e r e n c e i n p o p u l a t i o n so adjustments f o r p o p u l a t i o n were made. 63 Adjustments f o r P o p u l a t i o n D i f f e r e n c e s A d j u s t i n g f o r d i f f e r e n c e s tends to p u l l the trends together but does not change the d i r e c t i o n f o r both case rates ( F i g . 4) and p a t i e n t day rates ( F i g . 5). Figure 4 C.O.L.D. Case Rates By Year & Geographic Area lases per 10,000 Pop. 20-r 15-10H 5H ' . . • 4-Rest of GVRD to r e s t of / GVRD Hosps. S.D. #44 & 45 to L.G.H, —I 1 1 1 1 1 1 r 1971 72 73 74 75 76 77 78 79/80 Years Figure 5 CO.L.D. P a t i e n t Day Rates By Year & Geographic Area P a t i e n t Days i n Tens pe^ 10,'0.00. Pop. '. ' ' : 30-1- - - - = 25+ 2 0 i 15H • i o i Rest of GVRD .to r e s t of / GVRD Hosps. S.D. #44 •& ,45 to L.G.H. ... i . i i . i . — r — r — I 1 . i -19-71-72- 7-3 -74 75 . :76 77 78 ,79/80 , - • '. — : . _ ... Years ..... As the rat e s per 10,000 po p u l a t i o n could be biased by d i f f e r e n c e s i n the age composition of the po p u l a t i o n the age s t r u c t u r e of CO.L.D. i n p a t i e n t cases f o r 1976, a census year, was examined and age adjusted r a t e s determined f o r each year, as described i n Appendix G. Age s p e c i f i c rates were derived f o r 1976 f o r the t o t a l G.V.R.D. ( i n c l u d i n g S.D. #44 and #45) using t o t a l G.V.R.D. pop u l a t i o n f i g u r e s . . (See Table XII.) Table X I I CO.L.D. Age S p e c i f i c Rates f o r T o t a l G.V.R.D. Per 10,000 P o p u l a t i o n , 1976 0-14 15-44 45-64 65+ TOTAL Cases 6.73 1.52 12.92 46.83 9.90 P a t i e n t Days 29.06 9.00 178.35 829.80 137.20 Using these age s p e c i f i c r a t e s , standardized r a t e s f o r both areas were derived f o r the years from 1971 to 1979, f o r cases ( F i g . 6) and p a t i e n t days ( F i g . 7). Figure 6 CO.L.D. Age Standardized Case Rates By Year & Geographic Area Cases per 10,000 Pop. •; 20-1 -+-1-H - - 1 G H l I ! ] I ' ' i". -r^-rv-i-1-—h r - * * - J -T l T r T T T T t T f t +-' -4- H--- 4 - J -: - r-,-r-j 4 4y^ -i—i-4-k>--j -: . |-j-r-^ : j r | r j - t 7 l " t \ Rest of .GVRD • ' t o r e s t o f * 4-t-t-|-{—>--!--! -4 +- — i - r f-t--|-• v'GVRD Ilosps. ^rti-lTT'-t!-^-*-:-—)—I—I—'—+— -+-(—H-4-t--'--t-r-^!-H4-!-+44--"!-|--1- T ' T ^ 1 -• 1971 • 72- 73 • f W - r j75 -t-t--H-t-76 • 77• 78 -79/80 Years • • 1_L_LJ_ 66 Figure 7 C.O.L.D. Age Standardized P a t i e n t Day Rates By Year & Geographic Area 25 -H P a t i e n t Days i n Tens per 10,000 Pop. ; ^  20-\ .- 4—f-f- -I—I -4-• Rest of GVRD to r e s t of / GVRD Hbsps. -t-4-/ / JL S.D. #44 & 45 to L.G.H, 1971 72 73 74 ; 75 76 Years 77 78 79/80 Stand a r d i z i n g the ra t e s f o r age d i f f e r e n c e s does not seem to change the p r e v i o u s l y i d e n t i f i e d trends. ' S p i l l - O u t ' Cases What happens to the trends i f those cases who l e f t the North Shore to go to other h o s p i t a l s i n the p r o v i n c e , or who l e f t the r e s t of the G.V.R.D. to go to Lions Gate H o s p i t a l , are added to the case and p a t i e n t day r a t e s ? There appear to be no changes i n the trends when ' s p i l l - o u t s ' are added to case r a t e s ( F i g - 8) and p a t i e n t day rat e s ( F i g . 9 ) . When the average length of stay of these t o t a l s i s graphed ( F i g . 10) the same general trend appears as i n Figure 1, i . e . a s l i g h t downward trend i n S.D. #44 and #45 from 1976. Figure 8 C.O.L.D. Case Rates I n c l u d i n g ' S p i l l - O u t s " By Year and Geographic Area L Ca'ses- per 10,000 Pop. I ' l l 33? 40 - - H -*-* -t +-}•+")-+"•" i t * i " * f"t-4--I- —t 1 + - ( • 1 I : :U:tT.l - - M -T |--| ;.f4- f-4rt----f-T(--t-t-r4'-4--i.-'- '''4 i f4—+ 1971 72 - 73i ; i i -H - i - i-i- r + T * ~ _L •"" :74-T T l 75 • 76 • 77 .. Years Rest of GVRD , j to ; a l l GVRD t -v* Ho sp s. ( i n c . '/ L.G.H.) - . S.D. #44 & . 45 -to a l l . [~7Z- Hpsps. ' i n i 1 + J province * 78 79/80 However, average length of stay f o r a l l p a t i e n t s i n S.D. #44 and #45 i s higher i n 1970, when .'.spill-outs' are in c l u d e d , and draws the trend l i n e up, making i t almost p a r a l l e l to that f o r the r e s t of the G.V.R.D. This change creates the appearance of a sharper drop i n 1977, away from the trend i n the r e s t of the G.V.R.D. I t may po i n t to some e f f e c t from the C.O.L.D. program. (See F i g . 10.) 68 Figure 9 CO.L.D. P a t i e n t Day Rates I n c l u d i n g ' S p i l l - O u t s ' By Year & Geographic Area P a t i e n t Days i n Tens per "10,000' Pop. * Rest of GVRD I to a l l GVRD ? Hosps. ( i n c . 7 L.G.H.) / S.D. #44 & 45 to a l l Hosps. i n . province ! 1971. j'l li • ih ll 76 77 718 79/80 Years Figure 10 CO.L.D. Average Length of Stay I n c l u d i n g ' S p i l l - O u t s ' By Year & Geographic Area ~ RestTof GVRD . to a l l GVRD * /-Hosps. ( i n c . • - L.G.H.) * : S.D. #44 & * 45 to a l l •.Hosps. . i n ; p r o v i n c e U i J - ; - _ ^ , U ^ - U . - . . ' • ! . . I . . l . I I i . ;~1970-71 72- 73- , 74- -75- 76 - 77 , 78 79/80 f • -r-Thr Years 69 Conclusions A d j u s t i n g f o r age d i f f e r e n c e s and f o r ' s p i l l - o u t ' cases does not appear to a f f e c t the r e s u l t s shown by the raw data, but there i s d e f i n i t e l y something different"happening i n the two areas. Even i f the f i n a l year of data i s omitted the same trend occurs, i . e . average length of stay r i s i n g i n the r e s t of the G.V.R.D. and f a l l i n g s l i g h t l y or f a i l i n g to r i s e i n S.D. #44 and #45. More p u z z l i n g t h a n i t h i s trend i s the b i g d i f f e r e n c e i n standardized case and p a t i e n t day r a t e s between the two areas. P a t i e n t day rate s i n the G.V.R.D. are sometimes 100 per cent or more higher than those i n S.D. #44 and #45, over the years. Other Factors A f f e c t i n g U t i l i z a t i o n P a t i e n t - D i s e a s e Determinants Changes i n numbers of cases or i n p a t i e n t days might have been a f f e c t e d by a change i n the prevalence of CO.L.D. When prevalence i s measured by admissions to the h o s p i t a l by disease group per 10,000 p o p u l a t i o n , then, the prevalence of CO.L.D. d i d not change i n the ten year span stu d i e d here, remaining at l e s s than .0 7 per cent f o r S.D. #44 and #45 and l e s s than .13 per cent f o r the r e s t of the G.V.R.D. I t might be p o s t u l a t e d t h a t , although the prevalence d i d not change, there was an increase i n the s e v e r i t y of the cases using i n p a t i e n t care which r e q u i r e d longer s t a y s , p a r t i c u l a r l y i n the G.V.R.D. However, i f p a t i e n t s are admitted more f r e q u e n t l y i n the G.V.R.D. t h i s might a l s o account f o r the increase i n cases. The age of the p a t i e n t appears to be a l a r g e f a c t o r i n : :_ . 70 i n p a t i e n t use, i . e . those over 65 used 76 per cent of the t o t a l C.O.L.D. p a t i e n t days i n S.D. #44 and #45. Because of the i n c r e a -s i n g p o p u l a t i o n over 65, i n both areas one might expect an increase i n p a t i e n t days and average length of stay but i t i s hard to e x p l a i n the jump i n p a t i e n t days i n the r e s t of the G.V.R.D. H o s p i t a l Determinants An increase of one h o s p i t a l bed to 1000 po p u l a t i o n appears to increase average l e n g t h of stay by one day (Anderson, 1973). I t could be p o s t u l a t e d , then, that a decrease i n the number of beds at Lions Gate H o s p i t a l might decrease the average l e n g t h of stay. In January, 1978, beds were decreased from 485 to 456 so a drop i n len g t h of stay might be expected. This occurs f o r the Neuro p a t i e n t s but not f o r those w i t h C.O.L.D. or f o r the D i a b e t i c p a t i e n t s . Bed capacity changed i n s e v e r a l of the G.V.R.D. h o s p i t a l s i n 1978 so i t i s d i f f i c u l t to r e l a t e t h i s f a c t o r to lengths of stay. The a v a i l a b i l i t y of a l t e r n a t e bed f a c i l i t i e s that came w i t h the implementation of Long Term Care i n January, 1978 and the e a r l i e r a d d i t i o n of Home Care i n 1972, might have had an e f f e c t on average l e n g t h of stay. There i s a temporary decrease i n average length of stay f o r C.O.L.D. i n 1972 and again i n 1979 at Lions Gate H o s p i t a l . I t d i d not occur i n the r e s t of the G.V.R.D. although some C.O.L.D. programs s t a r t e d there i n 1972. 71 P h y s i c i a n Determinants An increase i n the supply of p h y s i c i a n s , p a r t i c u l a r l y I n t e r -n i s t s , might have had an e f f e c t on the number of cases or p a t i e n t days. The number of I n t e r n i s t s remained at: eleven, i n 1970 /, 1971, 1976 / 1977 and 1981 /, 1982. 1 0 There were no increases i n sub-s p e c i a l i t i e s r e l a t i n g to C.O.L.D. Neurology went from one s p e c i a - : l i s t i n 1971 to four i n 1976 and down to two i n 1981. The p h y s i c i a n p o p u l a t i o n on the North Shore appears f a i r l y s t a b l e w i t h major changes i n only A n e s t h e s i o l o g y a n d P s y c h i a t r y . CONCLUSIONS Other f a c t o r s which might a f f e c t u t i l i z a t i o n do not appear to have a n o t i c e a b l e e f f e c t . The program was intended to reduce average l e n g t h of s t a y , decrease the number of cases and p a t i e n t days. L i t t l e or no s i g n i f i c a n t program impact was found. SUMMARY Number of cases and p a t i e n t days d i f f e r g r e a t l y between those i n S.D. #44 and #45 going to Lions Gate and those i n the r e s t of the G.V.R.D. going to other G.V.R.D. h o s p i t a l s . I t appears that average length of stay f a i l s to r i s e i n S.D. #44 and #45 i n "^The i n f o r m a t i o n on numbers of s p e c i a l i s t s i s taken from the Medical D i r e c t o r i e s of the College of P h y s i c i a n s and Surgeons, 1971-72, 1976-77, 1981-82, which l i s t s s p e c i a l i s t s p r a c t i s i n g i n North and West Vancouver. 72 1979/80, as i t does- i n the r e s t of the G.V.R.D. A d j u s t i n g f o r p o p u l a t i o n and age d i f f e r e n c e s hardly changes- the trend. Adding ' s p i l l - o u t ' cases which leave each area seems to po i n t to a program e f f e c t , i n that the trend f a l l s more sharply away from the trend i n the r e s t of the G.V.R.D. A review of other f a c t o r s which might a f f e c t u t i l i z a t i o n does not r e v e a l any major e f f e c t s . There i s a sm a l l drop i n average l e n g t h of stay a f t e r the i n t r o d u c t i o n of the C.O.L.D. program which proved to be not s t a t i s t i c a l l y s i g n i f i c a n t . However, there are small numbers of cases i n S.D. #44 and #45 and only three years of data a f t e r the program began, one year of which may be skewed by the apparent coding problem. A l s o the a d d i t i o n of ' s p i l l - o u t s ' makes the downward trend a f t e r 1976 appear more s t r i k i n g . I f the trend i n S.D. #44 and #45 had continued to f o l l o w that i n the r e s t of the G.V.R.D. i t may have r i s e n . What i s i n t e r e s t i n g and may deserve f u r t h e r study i s that the average length of stay and number of cases increase d r a m a t i c a l l y i n 1979/80 i n the r e s t of the G.V.R.D. and not i n S.D. #44 and #45, and that p o p u l a t i o n and age adjusted cases and p a t i e n t days are much higher i n the r e s t of the G.V.R.D. than i n S.D. #44 and #45. 73 DIABETIC DAY CARE Average Length of Stay Does the data on average l e n g t h of stay f o r D i a b e t i c s show that D i a b e t i c Day Care has an impact on i n p a t i e n t use? As the program began i n S.D. #44 and #45 i n 1966 and i n the r e s t of the G.V.R.D., i n some h o s p i t a l s , i n 1972, one would expect that average length of stay would be lower i n S.D. #44 and #45 i n the e a r l y 1970s and then both trends would converge sometime a f t e r 1972. A graph of the average length of stay of D i a b e t i c s ( F i g . 11) shows that i n 1970 and 1971, although average length of stay was r i s i n g , i t was much lower f o r those i n S.D. #44 and #45 using Lions Gate H o s p i t a l than i n the r e s t of the G.V.R.D. However, average l e n g t h of stay f l u c t u a t e s much more i n S.D. #44 and #45 than i n the r e s t of the G.V.R.D. The trend i s towards increased lengths of stay i n both areas. I f there had been an i n i t i a l impact, from D i a b e t i c Day Care at Lions Gate H o s p i t a l , which kept average lengths of stay below those i n the r e s t of the G.V.R.D., i t disappeared by 1972. 74 Figure 11 Diabetes Average Length of Stay-By Year Geographic Area Cases and P a t i e n t Days As the D i a b e t i c Day Care program was intended to reduce the number of cases e n t e r i n g the h o s p i t a l and the p a t i e n t days the data f o r both were graphed (Fig.12 and F i g . 13). From the data i t appears that the number of cases and p a t i e n t days are much . lower i n S.D. #44 and #45 than i n the r e s t of the G.V.R.D. Although the number of cases remain more or l e s s p a r a l l e l i n both areas, the trend f o r p a t i e n t days i n the r e s t of the G.V.R.D. i s upwards and i n S.D. #44 and #45 r e l a t i v e l y f l a t . Perhaps po p u l a t i o n d i f f e r e n c e s are re s p o n s i b l e f o r the d i f f e r e n c e s . Figure 12 Diabetes Cases By Year & Geographic Area Cases i n Hundreds - 15; — ^ , --•-—4—1—4— •10 J f t »4 . - t • >- • • t 4 - 4 ^ - _ - » T " T ? ; Rest of GVRD •to: r e s t of • -•GVRD IIosps. 'S.D. #44 & 45 to L.G.H. —r.—i i,—~T 1970 71 72 73 74 75 76 Years 77 78 79/80-Conclusions on the Raw Data While there i s a l a r g e d i f f e r e n c e i n the p a t i e n t day trends, the average le n g t h of s t a y , d e s p i t e wide f l u c t u a t i o n s i n S.D. #44 and #45, increases i n both areas. I f the drop i n p a t i e n t days i n the r e s t of the G.V.R.D. a f t e r 1973 i s due to the D i a b e t i c programs i t i s a delayed r e a c t i o n and does not l a s t . The D i a b e t i c Day Care program at Lions Gate H o s p i t a l may be keeping the cases and p a t i e n t days r e l a t i v e l y s t a b l e i n School D i s t r i c t #44 and #45. Figure 13 Diabetes P a t i e n t Days By Year & Geographic Area •Patient Days rin-Thousands- 1-i -;— 4-4 - r T - --t-t-4 4-lilt 4 • 30 H I-4 * + 4 - -4+44 i 4 i i r 4-:4-;-,:r-::-:;v + •!4 11 r r r i J T / 1 • r . v-"7= 4 Rest of GVRD to r e s t . o f •-•GVRD Hosps. A 25-i ±V:\ '•' 20 i i \\\ + 4-/-;-|—i-f ; , y - * -• H — > • • • > • •'• 1 l-^y , -4--5--J -|--+- + + 4 • =• +- + - ; +• 4 i i • . -t--.~ . Years S.D. #44 & 45 to L.G.H . • . I • I . •• I- I - l I • i I • I -• 1970 • 71 72 73 • 74 75 76 77 78 79/80 A d j u s t i n g f o r P o p u l a t i o n D i f f e r e n c e s A d j u s t i n g f o r p o p u l a t i o n d i f f e r e n c e s tends to p u l l the case ra t e s together but does not change the previous trend. The case r a t e i s graphed i n Figure 14. The p a t i e n t day r a t e i n the r e s t of the G.V.R.D. f o l l o w s the same trend w h i l e a d j u s t i n g f o r p o p u l a t i o n i n S.D. #44 and #45 tends to exaggerate the previous trend and show up more f l u c t u a t i o n s . While the p a t i e n t day rat e s are p u l l e d more c l o s e l y together the r a t e i n the r e s t of the G.V.R.D. i s s t i l l more than twice as high i n most years as that i n S.D. #44 and #45, ( F i g . 15). Figure 14 Diabetes Case Rates By Year & Geographic Area Cases per 10,000 Pop T 20 ™ _ U 10 . -J -15---i-4 -S-LI 1.1 - H -;-4--- 4 i j 4 ; - j- -i- i > Rest of GVRD , to r e s t - o f ; - -• GVRD Hosps. . - 4 - H t - H { 7 H T T l l | x i ^ ^ !| • S:D. # 4 4 . & -4-4-1 L J . ! _ ! 1971, 7 2 ; : : ;Z)3T:_ 74. • 75 ' 76 7 7 ; 78 7 9 / 8 0 * - Years -Adjustment f o r Age D i f f e r e n c e s Age adjusted r a t e s were determined, as f o r C.O.L.D., but as the trends are s i m i l a r to the p o p u l a t i o n adjusted r a t e s they are not presented. Figure 15 Diabetes P a t i e n t Day Rates By Year & Geographic Area P a t i e n t Days i n Tens per 10,000 Pop. ; . \ : 35 - h ' r::;. r.; -30-4 4 , 4 -, - I - i --4.-^ • • 25 -i~: • • : 20 H -Hr:i:i"£r 4 i 15 . 10-4-:::: 5.H Rest of GVRD| to r e s t of . GVRD Hosps. ' . . . / . V S.D. #44 & 45 to L.G.H , . I —I .. r 7 i I 1971 72 . 73 74 - 75 76 - • Years 77 78 79/80 ' S p i l l - O u t ' Cases What happens to these trends i f ' s p i l l - o u t cases are added to the case ( F i g . 16). and p a t i e n t day r a t e ( F i g . 17)? While the number of cases i n S.D. #44 and #45 increases only s l i g h t l y , the number of p a t i e n t days increases by up to 43 per cent ( i n 1972). The trends i n the r e s t of the G.V.R.D. remain about the same. 79 Figure 16 Diabetes Case Rates I n c l u d i n g ' S p i l l - O u t s ' By Year & Geographic Area Gases per! 10,000 Pop-. • H W ^ X T J I - J p q : f i 4 4 ^ - i ! ••; t-H t l i: ; f r r H i - 4 - r - l - t - t - t •4-4- + • 4 • - 4— -rt - 10H rtxi -+-+-i-t-+ +-H 4-i.-f -1—j-t 4-+--i 4-t +— > -4- • 4-U xi-tl-^rx-t i Rest of GVRD .i. 4 -j—i. 4---4 !• I- 4 t l ' " -4 !- ,- 14-. 4 4-I ' I I I ' . 1 i -4 4 , - • * 1 .4 -;.4-;-; ; : . ' to a l l GVRD Hosps. Olnc. • -; I- v ' • f 1 . G . II • ) S.D. #44 & 45 to a l l Hosp's. i n province ~ 1971 7-2 73 '• 74 1 75 * 76 : 77 . -(-t+-f r -h - r - l - ! H - f T ^ + ' ' "! 1 r ! " - — ' ^ -4- t -+-4—H-f t ' t f r ; i't T T T T 78 79/80 t -4 L Years When the average length of stay i n c l u d i n g ' s p i l l - o u t s ' i s graphed ( F i g . 18), average length of stay f o r S.D. #44 and #45 shows an increase i n some years but s t i l l f l u c t u a t e s i n the same way as the average length of stay without ' s p i l l - o u t s ' ( F i g . 11). The trend i n the r e s t of the G.V.R.D. remains about the same as without ' s p i l l - o u t s ' . Conclusions The increase i n p a t i e n t days i n S.D. #44 and #45, when the ' s p i l l - o u t ' cases are added, suggests that i n some years cases w i t h high lengths of stay from S.D. #44 and #45 were going to other h o s p i t a l s i n the province. The great f l u c t u a t i o n s from year to year, i n S.D. #44 and #45, and high lengths of stay suggest that 80 the D i a b e t i c Day Care program has not had a s t a b i l i z i n g e f f e c t on the p a t i e n t s on the North Shore. The r e s t of the G.V.R.D. has a much more s t a b l e average length of s t a y , at l e a s t u n t i l 1977. Figure 17 Diabetes P a t i e n t Day Rates I n c l u d i n g ' S p i l l - O u t s ' By Year & Geographic Area P a t i e n t Days i n Tens ;per; 10,000" Pop. :35^ : :: 1-2-5'—1 :-t-1 5-1 / \ V Rest of GVRD • to a l l GVRD Hosps. (Inc. L.G.H.) , A. 20-:'io-i S.D. #44 & 45 to a l l H o s p s . i n province —I ! ..I. 1971- 72 73 74 75 76 Years . ~ ~ r — I - — 1 — 77 78 79/80 81 Figure 18 Diabetes Average Length of Stay I n c l u d i n g ' S p i l l - O u t s ' By Year & Geographic Area Other Factors A f f e c t i n g U t i l i z a t i o n  P a t i e n t - D i s e a s e Determinants As w i t h C.O.L.D. , changes i n the prevalence of Diabetes may have a f f e c t e d the case or p a t i e n t day r a t e s . Oakley, Pyke and Taylor (1973) say that the o v e r a l l prevalence of known cases of Diabetes i s about 1:200, or .5 p e r c e n t of the po p u l a t i o n of B r i t a i n , but that t h i s p r o p o r t i o n i s higher among o l d people. This would mean 50 cases or more per 10,000 po p u l a t i o n which i s much 82 higher than h o s p i t a l admissions i n the t o t a l G.V.R.D. Oakley et a l . a l s o s t a t e that the cause of death f o r D i a b e t i c s i s o f t e n some other c o n d i t i o n . s o Diabetes cases may be admitted to h o s p i t a l f o r other diagnoses. Because severe cases of Diabetes o f t e n have these co m p l i c a t i n g c o n d i t i o n s they may not always be recorded as D i a b e t i c , except i n the secondary diagnosis and these cases would have to be examined to determine the true e f f e c t . H o s p i t a l Determinants The drop i n occupancy r a t e i n 1976 corresponds to a r i s e i n average length of stay f o r D i a b e t i c s and the increase i n occupancy i n 1977 w i t h a decrease i n average l e n g t h of stay. However, the s l i g h t l y d e c l i n i n g occupancy r a t e from 1972 to 1976 i s not r e f l e c t e d i n the Diabetes data. The decrease i n the number of h o s p i t a l beds i n 1978 at Lions Gate does not appear to have had any e f f e c t , i n f a c t , average le n g t h of stay i s an a l l time high of 32 days i n that year f o r S.D. // 44 and #45. CONCLUSION There i s no'apparent impact from the D i a b e t i c Day Care program on i n p a t i e n t use e i t h e r i n the number of cases or p a t i e n t days. There i s a l a r g e d i f f e r e n c e between the two areas i n case rates and p a t i e n t day r a t e s , w i t h the r e s t of the G.V.R.D. being higher but average lengths of stay are s i m i l a r i n both areas. The average l e n g t h of stay f l u c t u a t e s much more i n S.D. #44 and i/45. I f there was an e f f e c t from the program at Lions Gate H o s p i t a l i t was p r i o r 83 to 1972, when average lengths of stay were much lower i n S.D. #44 and #45. The i n t r o d u c t i o n of programs i n some h o s p i t a l s i n the re s t of the G.V.R.D., i n 1972, does not seem to have changed the trend i n the average length of stay i n that area. NEURO PROGRAM The Neuro program f o r p a t i e n t s w i t h cerebrovascular disease, m u l t i p l e s c l e r o s i s and other n e u r o l o g i c a l problems, s t a r t e d i n 1979 so there are not enough data a f t e r the program's i n t r o d u c t i o n to show any e f f e c t s . There are a l s o complications w i t h the 1979/80 data as~mentioned p r e v i o u s l y . In a d d i t i o n , i t appears that data on lengths of stay f o r Extended Care may have been: i n c l u d e d and the l a r g e jump i n 1979/80 i n i n p a t i e n t days may be due to an : . incr e a s e i n Extended Care b e d s . ^ Future research should separate Extended Care data so e f f e c t s could be d i s t i n g u i s h e d . A b r i e f review of f i n d i n g s f o l l o w s . Average Length of Stay ( F i g . 19) The general trend f o r average l e n g t h of stay i n both areas i s upward. Both S.D. #44 and #45 and the r e s t of the G.V.R.D. show marked increases i n 1979/80 but t h i s may be the coding problem, and both areas have f a i r l y s i m i l a r average lengths of stay. This jump a l s o occurred f o r CO.L.D. so the increase i n Extended Care beds may not be re l e v a n t unless., i t a l s o r e l a t e s to the CO.L.D. data. Figure 19 Neuro Diagnoses Average Length of Stay By Year & Geographic Area Days i n Tens 5-^ Rest of GVRD, to r e s t . o f GVRD Hosps. S.D. #44 & 45 to L.G.H. 76 Years 77 78 79/80 Cases and P a t i e n t Days The data f o r cases ( F i g . 20) and p a t i e n t days ( F i g . 21) were graphed. The r e s t of the G.V.R.D. appears to have a much higher number of cases and p a t i e n t days than does S.D. #44 and #45 but when the data were adjusted f o r p o p u l a t i o n case r a t e s ( F i g . 22) and p a t i e n t day r a t e s ( F i g . 23) p a r a l l e l e d each other. Again p a t i e n t day rat e s are much higher i n the r e s t of the G.V.R.D. than i n S.D. #44 and #45, but both increase d r a m a t i c a l l y . The i n t r o -d u c t i o n of the Neuro program i n June, 1979 does not appear to have changed the trend i n S.D. #44 and #45, at l e a s t not before A p r i l , 1980. 85 Figure 20 Neuro Diagnoses Cases By Year & Geographic Area Cases in' Hundreds,-.; :..45 J 4^—• "•40 -| rrr ; ; £ t-t-+4 + +35 H —I—i- - i —»- 4-4 30 ~i 25 H 20-4 -15: i o n 5 4 . - j - i - i t4 ,- . • - , . - • / : ' . , * 4-i.--.Xt X • ' ' : : J : ^ : ; ) v : - ; , 7 r . ; -+ !.. V.I-: r ? , - r T - i - , - H K-+-T - » N Rest of GVRD ; ' \ " . to r e s t of ' , N v G V R D Hosps. i- I v ' + t -4- r -4 . • f-<<t-4-i j } •-{• 4-1 * -:-4 ' 4 *---4 •: -i- • i :~: 4-- r -S.D.. #44 & .45 to L.G.H. •4-1970 71 : • 12 :"73 : 74 - : 75 76 • -77 -78 79/80 [' ' \ * 1.1 '.! V - ; ~ '. , Years - ' . '. . . ' , . 86 Figure 21 Neuro Diagnoses P a t i e n t Days By Year & Geographic Area P a t i e n t Days i n ' Ten -Thousands * 30 H -25 H -20-4 t 10~f 5 H • r-f- H—i—i : Rest of GVRD : t o r e s t of ,*GVRD Hosps. * 7 y S.D. #44 &. 45 to L.G.H. 4-1970- 71 72 73 - 74 75 ' 76 ....... T ,. — ! . , . * . Years --77 78 79/80 Figure 22 Neuro Diagnoses Case Rates By Year & Geographic Area Cases i n Tens per 10, 000 Pop-. • '- Rest of GVRD '' 5._ - -+• - | i to r e s t of GVRD Hosps. - t *S.D. #44 & - — - — • , , i r— • 45 to L.G.H. +_H , t - - . . . .. " 7 - : • ' -- -- ... 1 , , : 1971 - 1 72 i i 73. .74 1 .1 1 , 75 .76 - 77 1 78 79'/80 -Years ' ... ' — -87 Figure 23 Neuro Diagnoses P a t i e n t Day Rates By Year & Geographic Area P a t i e n t Days i n Hundreds per 10,000'. Pop.'. '. . . '.IT ; Rest of GVRD to r e s t of ^'GVRD Hosps. S.D. #44 & 45 to L.G.H, 1971 • 73- 74 75 76 . 77 _ L ; . , . , ! Years! J. X---". f 78 79/-80 ' S p i l l - O u t ' Cases What happens to t h i s data when the ' s p i l l - o u t ' cases are added? There appear to be no changes i n the general trend; • when ' s p i l l - o u t ' cases are added to the case r a t e ( F i g . 24), p a t i e n t day r a t e ( F i g . 25), or average length of stay ( F i g . 26) i n e i t h e r S.D. #44 and #45 or i n the r e s t of the G.V.R.D. 88 Figure 24 Neuro Diagnoses Case Rates I n c l u d i n g ' S p i l l - O u t s ' By Year & Geographic Area Cases j i n T e n s per-10,000 Pop. - 5 H—1—f -+-+-4 4-u 4-U Rest of,GVRD - t o ' a l l GVRD Hosps. (Inc.! ~-.L.G.H.) ; H-TrT^  itj.nitT!.mbiLb-i-tr 1 -p r -t t-+ +-4 4 - - r - i ~ f t i i S.D. .#44-& 44J^5jto; a i i ; * • • Hosps. i n * province 1971 72 73 74 75 76 " 77' 78 79/80 X _ ......I-..,.. L.' -Years Figure 25 Neuro Diagnoses P a t i e n t Day Rates I n c l u d i n g ' S p i l l - O u t s ' By Year & Geographic Area P a t i e n t Days i n Hundreds per. 10,000 Pop. . , ; -40-r ' Rest of GVRDI to a l l GVRD , Hosps. (Inc. / L.G.H.) : : S . D . #44 & • 4 5 . t o a l l ; Hosps. i n province 1 1 1 1971 72 73 74 75 76 Years 77 78 79/80 89 Figure 26 Neuro Diagnoses Average Length of Stay I n c l u d i n g ' S p i l l - O u t s ' By Year & Geographic Area Rest of GVRD to a l l GVRD Hosps'. (Inc. L.G.H.) JJS.D. #44 & sr.kb to a l l Hosps. i n province What i s i n t e r e s t i n g to note i s the very long average lengths of stay f o r the cerebrovascular diseases cate g o r i e s of the Neuro diagnoses (I.C.D. #430 - #438) f o r those coming to Lions Gate H o s p i t a l from the r e s t of the G.V.R.D. ( F i g . 27). I t i s not c l e a r why t h i s i s happening. CONCLUSION There are not enough data to determine whether or not the Neuro Program had an impact on average l e n g t h of st a y , cases or p a t i e n t days. There i s no change i n 1979/80 when the program s t a r t e d except foroa s l i g h t dropuinvcases and ah increase i n p a t i e n t days. No impact from the program can be seen as yet but there may be a problem w i t h the 1979/80 coding. 90 Figure 27 Cerebrovascular Disease Average Length of Stay f o r ' Spill-^Outs' By Year & Geographic Area Days i n Tens / • Rest of•GVRD I to L.G.H. / S.D. #44 & / , 45 to Hosps i n r e s t of province -. . I • • I • • • I • • -.1970 ;71 72 73; 74 75; • ; 76 77 , .*1 . *^_4_*. ' . . .. Y e a r s - — • 78 79/80 GENERAL CONCLUSIONS With the data used in::this t h e s i s i t appears that there i s no impact on i n p a t i e n t use from these programs. Although these r-r e s u l t s are not c o n c l u s i v e they advance our i n f o r m a t i o n and p o i n t to s e v e r a l areas which could be explored f u r t h e r . The methodology proved workable but i t d i d not d e f i n i t e l y answer the question. The methods used i n t h i s t h e s i s , a p p l i e d to s i m i l a r data, w i t h more 91 years of program data and w i t h s t r i c t e r c o n t r o l of extraneous v a r i a b l e s , such as Extended Care i n p a t i e n t use, may s t i l l provide some answers. What should be i n v e s t i g a t e d f u r t h e r are the reasons f o r the b i g d i f f e r e n c e s i n the r a t e s f o r these diagnoses, between S.D. #44 and #45 and the r e s t of the G.V.R.D. .. . As . w e l l with, greater numbers of . : c l i e n t s and more years of the program, the C.O.L.D. program may provide more c o n c l u s i v e answers. The answers, i t seems, have to be determined f o r each program s e p a r a t e l y . 92 CHAPTER VI. IMPLICATIONS FOR POLICY AND PLANNING ". .,. The boundary between the s c i e n t i f i c arid the p o l i t i c a l i s n e i t h e r c l e a r nor immutable." (Langbein,1980, p.5) With complex p o l i c y i s s u e s , such as s u b s t i t u t i o n of a l t e r n a -t i v e s or a l l o c a t i o n of resources, c l e a r i n s i g h t s are not always p o s s i b l e . When research f i n d i n g s are i n c o n c l u s i v e , c l e a r d e c i s i o n s may not be p o s s i b l e . However, the r e s u l t s can be u s e f u l f o r p o l i c y d i s c u s s i o n s and f u r t h e r e v a l u a t i o n and planning. ". . . The i d e n t i f i c a t i o n of trends and the fo r m u l a t i o n of continu i n g p r e d i c t i o n s i s a re l e v a n t aspect of the process of s o c i a l p o l i c y development" ( H a l l , Land, Parker & Webb, 1975, p. 497). This study adds to the development of theory about the impact of ambulatory care on i n p a t i e n t use. The r e s u l t s : i m p l y t h a t . t h e r e i s no impact from these medical day programs on ra t e s of i n p a t i e n t use. This f i n d i n g would be c o n s i s t e n t w i t h the s i m i l a r study of D i a b e t i c Day Care by Gordon and Weldon (1973) and with, the Day Care Surgery st u d i e s by Evans and Robinson (1980). Why have there been no demonstrable e f f e c t s from these day care programs? Are beds being f i l l e d by more s e r i o u s l y i l l p a t i e n t s who remain longer? I f so, why are p a t i e n t s becoming more s e r i o u s l y i l l 2 Do the programs not have any e f f e c t on p a t i e n t s ' h e a l t h status? Are p a t i e n t s put i n t o day care programs a f t e r longer hospitaliza-:: t i o n s ? Are ph y s i c i a n s r e l u c t a n t to make more use of these programs? Perhaps t h e i r , t r a i n i n g s t i l l o r i e n t s them to i n p a t i e n t h o s p i t a l •. 93 care. Do nurses or other h o s p i t a l personnel see day care as t h r e a t e n i n g to the number of jobs i n the h o s p i t a l ? Some of these questions may be answered now that r a t i o n i n g of beds may have to take place and now that other a l t e r n a t i v e s may have to be used i n s t e a d of h o s p i t a l i z a t i o n . More c o o r d i n a t i o n between h o s p i t a l s and community h e a l t h programs would help. I f episodes of i n p a t i e n t use could be s t u d i e d we might o b t a i n a b e t t e r p i c t u r e of what i s happening. In a Canadian College of Health Service E x e c u t i v e s ' Seminar at the G.F. Strong Centre i n Vancouver, i n September, 1981, Stan Dubas, Senior A s s i s t a n t Deputy M i n i s t e r of the p r o v i n c i a l M i n i s r y of H e a l t h , pointed to f i v e areas of government concern: - resources f o r the c h r o n i c a l l y i l l - lower cost a l t e r n a t i v e s to i n s t i t u t i o n a l care - u t i l i z a t i o n of non-physician manpower - geographical imbalances - c o o r d i n a t i o n among a l l concerned w i t h h e a l t h care i n Canada Ambulatory care may address the f i r s t three but these p o l i c y and planning i s s u e s w i l l r e q u i r e more p o l i c y r e l a t e d research. P o l i c y o r i e n t e d a n a l y s i s could "upgrade the general d i s c u s s i o n of . . . cost containment s t r a t e g i e s . . . " and a i d the planning of f u t u r e programs (Raskin,. Coffey & F a r l e y , 1980, p. 11). Whether or not ambulatory programs reduce l e n g t h of stay may not be the r i g h t question. There are l i m i t s to medicine as i s discussed by Lewis Thomas (1978). He p o i n t s out that "no t r e a t -ment e x i s t s f o r preventing the recurrence of s t r o k e " ; that f o r pulmonary disease, "although technologies e x i s t f o r the improvement of a e r a t i o n by the damaged lungs, and thus f o r some pr o l o n g a t i o n of l i f e , there are no measures a v a i l a b l e f o r stopping or r e v e r s i n g the process of the disease"; and that '.' d i s a b i l i t y and death of d i a b e t i c s mostly i n middle-age and l a t e r , are now due to chronic kidney disease and the o c c l u s i o n of a r t e r i e s . . . v i r t u a l l y nothing i s known about the cause of v a s c u l a r l e s i o n s , and there i s no therapy to stop or reverse the process" (p. 343,.344). Perhaps government's concern should be w i t h the improved h e a l t h s t a t u s of i n d i v i d u a l s as the r e s u l t of the programs and ways of measuring that improvement. Perhaps the focus should be on e v a l u a t i n g the e x i s t i n g i n s t i t u t i o n a l i z e d programs ra t h e r than only on new a l t e r n a t i v e s , . M u l t i p l e evaluations studying process-outcome, a l t e r n a t i v e s and the c o s t - e f f e c t i v e n e s s of v a r i o u s p a r t s of the t o t a l system are r e q u i r e d . However, the p r o v i n c i a l government's mandate f o r these pro-grams was a r e d u c t i o n i n length of stay or p a t i e n t days and t h i s r e d u c t i o n cannot be demonstrated. Does t h i s mean that day care programs should not be encouraged.as a l t e r n a t i v e s to h o s p i t a l i z a -t ion? Without any changes to the e x i s t i n g i n s t i t u t i o n s the programs appear to be added on to i n s t i t u t i o n a l care. With present.reductions i n h o s p i t a l beds, f u r t h e r s t u d i e s of day care may produce d i f f e r e n t r e s u l t s . As yet the d e l i v e r y system has not responded to i n n o v a t i o n or cost containment s t r a t e g i e s w i t h any notable success (Evans & Robinson, 1980;.Raskin et a l . ) . Many changes would be needed to a i d the process: monitoring the case flow i n s t i t u t i o n a l l y and r e g i o n a l l y (Evans, Chap. 11, 1980; 95 Weiler & Rathbone-McCuan, 1978), new reimbursement mechanisms which would provide f i n a n c i a l i n c e n t i v e s f o r i n s t i t u t i o n s to move 12 to ambulatory care, a manpower and education p o l i c y w i t h a focus on the ':team' approach. Because h e a l t h care i s an i n t r i c a t e system ". . . change when i t does occur i s most l i k e l y to come i n those areas i n which the for c e s of new knowledge, economics and ideology converge" (Mechanic, 1978). I f 'ideology' i n c l u d e s p o l i t i c a l expediency, Mechanic may w e l l be r i g h t . 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H o s p i t a l s , V o l . 53, No. 5, March 1, 1979, 45-46. 102 Oakley, W. G., Pyke, D. A. and T a y l o r , K. W. Diabetes and I t s Management. Oxford: B l a c k w e l l S c i e n t i f i c P u b l i c a t i o n s , 1973. Oster, C. and K i b a t , W. H. "E v a l u a t i o n of a M u l t i d i s c i p l i n a r y Care Program f o r Stroke P a t i e n t s i n a Day-Care Center." J o u r n a l of the American G e r i a t r i c s S o c i e t y , V o l . X X I I I , No. 2, February, 1975, 63-69. Pegels, C. C. " I n s t i t u t i o n a l vs. N o n i n s t i t u t i o n a l Care f o r the c; E l d e r l y . " J o u r n a l of Health P o l i t i c s , P o l i c y and Law, V o l . 5, No. 3, Summer, 1980, 205-212. P e t t y , T. L., Hudson, L. D. and Neff, T. A. "Methods of Ambulatory Care." The Me d i c a l C l i n i c s of North America, V o l . 57, No. 3, May, 1973, 751-762. Piachaud, D. and Weddell, J . M. "The economics of t r e a t i n g Varicose V e i n s . " I n t e r n a t i o n a l J o u r n a l of Epidemiology, V o l . 1, No. 3, 1972, 287-294. Posner, J . R. and L i n , H. W. " E f f e c t s of Age on Length of H o s p i t a l Stay i n a Low-Income P o p u l a t i o n . " Medical Care, V o l . X I I I , No. 10, October, 1975, 855-875. P r e s c o t t , R. J . , Cuthbertson, C. C , Fenwick, N. , Garraway, W. M. and Ruckley, C. V. "Economic Aspects of day care a f t e r operations f o r h e r n i a or v a r i c o s e v e i n s . " J o u r n a l of Epidemi- ology and Community He a l t h , V o l . 32, 1978, 222-225. Raskin, I . E., Coffey, R. M. and F a r l e y , P. J . " C o n t r o l l i n g Health Care Costs: An E v a l u a t i o n of S t r a t e g i e s . " E v a l u a t i o n and. Program Pl a n n i n g , V o l . 3, 1980, 1-14. Rathbone-McCuan, E. and E l l i o t , M. W. " G e r i a t r i c Day Care i n Theory and P r a c t i c e . " S o c i a l Work i n Health Care, V o l . 2, No. 2, Winter, 1976-77, 153-170. Rathbone-McCuan, E., Lohn, H., Levenson, J . and Hou, J . Cost E f f e c t i v e n e s s E v a l u a t i o n of the Levi n d a l e Adult Day Treatment  Center. Baltimore Md.: Levindale G e r i a t r i c Center, 1975. Re g e n s t r e i f , D. I. "Innovation-•. i n H o s p i t a l Based Ambulatory Care: Some Sources, P a t t e r n s , and I m p l i c a t i o n s of Change." Human  Or g a n i z a t i o n , V o l . 36, No. 1, Spring, 1977, 43-49. Rennie, P. H. "Is Ambulatory Care Worth I t ? " 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, October, 1977, 25-28. Roemer, M. I. "From Poor Beginnings, the Growth of Primary Care." H o s p i t a l s . V o l . 49, March 1, 1975, 38-43. 103 Roemer, M. I. and Shain, M. Hospital U t i l i z a t i o n Under Insurance. American Hospital Association, 1959. Rosengren, W. R. and Lefton, M. Hospitals and.Patients. New York: Atherton Press, 1969. R u s s e l l , I. T., Devlin, H. B., F e l l , M., Glass, N. J . and Newell, D. J. "Day-Case Surgery for Hernias and Haemorrhoids - A C l i n i c a l , S o c i a l and Economic Evaluation." The Lancet, No. 8016, A p r i l 16, 1977, 844-847. Schlenker, R. "The Future Health Care Organization." Health Care  Management Review, Vol. 5, No. 3, Spring, 1980, 69-74. Schuman, J. E., Beattie, E. J . , Steed, D. A., Gibson, J . E., Merry, G. M. , Campbell, W. D. and Kraus, A. S. "The impact of a new g e r i a t r i c program i n a h o s p i t a l for the c h r o n i c a l l y i l l . " Canadian Medical A s s o c i a t i o n Journal, Vol. 118, March 18, 1978, 639-645. Schweitzer, S. 0. "Health Care Cost Containment Programs: An International Perspective." In Hospital Cost Containment:  Selected Notes f o r Future P o l i c y , ed. by Zubkoff et a l . , 1978, 57-75. Shah, C. P., Robinson, G. C , Kinnis, C. and Davenport, H. T. "Day Care Surgery for Children: A Controlled Study of Medical Complications and Parental A t t i t u d e s . " Medical Care, Vol. X, No. 5, September-October, 1972, 437-450. S h o r t e l l , S. M. and Richardson, W. C. Health Program Evaluation. St. Louis: C. V. Mosby Co., 1978. Somers, A. R. "Only the Hospital Can Do I t A l l - Now." Modern  Hos p i t a l , V o l . 119, J u l y , 1972, 95. Somers, A. R. "Rethinking Health P o l i c y for the E l d e r l y : A Six Part Program." Inquiry, Vol. XVII, No. 1, Spring, 1980, 3-17. S t a r f i e l d , B. "Health Services Research: A Working Model." New  England Journal of Medicine, Vol. 289, No. 3, J u l y , 19, 1973, 132-136. Stone, J . R. , Patterson, E. and Felson, L. "The Effectiveness of Home Care for General Hospital Patients." JAMA. The Journal of the American Medical Association, Vol. 205, No. 3, July 15, 1968, 95-98. Thomas, L. "The Limits of Mddern Medicine." i n Health Care P o l i c y  in.a Changing Environment, ed. by B a t t i s t e l l a and Rundall, 1978, 338-351. 104 Timm, M. "Ambulatory Care Program Does More than Contain Costs." H o s p i t a l s , V o l . 53, No. 2, June 16, 19 79, 127. Uni t e d . S t a t e s , Department of Health Education and Welfare. Home  Health Care: Report on the Regional P u b l i c Hearings. DHEW Pub. No. 76-135, September 20 - October 1, 19.76. Warner, K. E. and Hutton, R. C. "Cost-Benefit and. C o s t - E f f e c t i v e -ness A n a l y s i s i n Health Care." Medical Care, V o l . X V I I I , No. 11, November, 1980, 1069-1084. W e i l e r , P. G., Kim, P. and P i c k a r d , L. S. "Health Care f o r E l d e r l y Americans: E v a l u a t i o n of an Adult Day Health Care Model." Medical Care, V o l . XIV, No. 8, August, 1976, 700-708. W e i l e r , P. G. and Rathbone-McCuan, E. Adult Day Care. Community  Work w i t h the E l d e r l y . New York: Springer P u b l i s h i n g Co., 1978. Weissert, W. G. "Costs of Adult Day Care: A Comparison to Nursing Homes." I n q u i r y , V o l . 15, March, 1978, 10-19. Weissert, W. G., Wan, T., L i v i e r a t o s , B. and Katz, S. " E f f e c t s and Costs of Day Care Services f o r the C h r o n i c a l l y 111." A Randomized Experiment. Medical Care, V o l . X V I I I , No. 6, June, 1980, 567-584. Young, V. and R o m i l l y , L. "New models i n ambulatory care." Dimensions i n Health S e r v i c e . V o l . 58, No. 6, June, 1981, 17-19. Zook, C. J . , S a v i c k i s , S. F. and Moore, F. D. "Repeated H o s p i t a l i -z a t i o n f o r the Same Disease: A M u l t i p l i e r of N a t i o n a l Health Costs." Milbank Memorial Fund Q u a r t e r l y , V o l . 58, No. 3, Summer, 1980, 454-471. lions gate hospital FIFTEENTH STREET AT ST. GEORGES. NOR 1 H VANCOUVER, rt.C. V7L 2L7 Dear Dr. Re: T h e s i s on "Impact of Ambulatory M e d i c a l Care on h o s p i t a l i n - p a t i e n t u t i l i z a t i o n " .  Lorna R o m i l l y , a student i n the Health Sciences P l a n n i n g programme at U.B.C, i s working on the above t h e s i s . She has been given p e r m i s s i o n by Lions Gate H o s p i t a l a d m i n i s t r a t i o n to use h o s p i t a l d a t a ' f o r her r e s e a r c h purposes. I t w i l l be necessary f o r her to examine Ambulatory Care and Treatment S e r v i c e (A.C.T.S.) p a t i e n t r e c o r d s t o c o l l e c t the f o l l o w i n g d a t e : Programme Age Sex Diagnosis School D i s t r i c t or M u n i p a l i t y ( f o r geographic l o c a t i o n ) The p a t i e n t s name w i l l not be used and p a t i e n t c o n f i d e n t i a l i t y w i l l be maintained. This i n f o r m a t i o n i s needed t o compare i n - p a t i e n t h o s p i t i l i z a t i o n data i n these c a t e g o r i e s . H o s p i t a l programmes w i l l be s u p p l y i n g the i n - h o s p i t a l data. We r e q u i r e your approval f o r her to examine your p a t i e n t s A.C.T.S. chart. I f t h i s i s not s a t i s f a c t o r y , please contact V a l e r i e Young, A.C.T.S. Co-ordinator, by 6th January,1981. Thank you f o r your help i n t h i s matter. Yours s i n c e r e l y , O r i g i n a l signed by V a l e r i e Young, Coordinator 108 APPENDIX D Diagnoses Back Program CI.CD.' 8th and 9th Revision) L C D . 8th R e v i s i o n Code #. Code # L C D . 9th R e v i s i o n O s t e o a r t h r i t i s & a l l i e d c o n d i t i o n s (713.0 -X.'....' 713.2) 713 DISPLACEMENT OF INTERVERTEBRAL : Spondylosis & a l l i e d ' d i s o r d e r s (721.0 -721 721.9) INTERVERTEBRAL DISC DISORDERS DISC C e r v i c a l 725.0 Lumbar & Lumbosacral 725.1 Un s p e c i f i e d s i t e 725.9 Other i n t e r n a l derange- 724.9 ment of j o i n t A f f e c t i o n of s a c r o - i l i a c 726 j o i n t A nkylosis of j o i n t ,,.,0 (727.0 - 727.9) 727 VERTEBROGENIC PAIN SYNDROME 722.0 Without myelopathy 722.4 • Degeneration of c e r v i c a l d i s c 722.10 Lumbar, without myelopathy 722.3 Schmorl's nodes (722.32 -(722.39) 722.5 Degeneration of t h o r a c i c or lumbar i n t e r v e r t e b r a l d i s c (722.51 - 722.52) 722.2 S i t e u n s p e c i f i e d , without myelopathy 722.6 Degeneration of interver-t t e b r a l d i s c , s i t e unspec. 722.7 I n t e r v e r t e b r a l d i s c d i s o r -der w i t h myelopathy >. .• . (722.70 & 722.73) 722.8 Postlaminectomy syndrome (722.80 & 722.83) 722.9 Other & u n s p e c i f i e d d i s c d i s o r d e r (722.90 & 722.93) OTHER & UNSPECIFIED DISORDERS OF THE BACK 724.0 S p i n a l s t e n o s i s other thar c e r v i c a l (724.00 & 724.02) 724.6 Disorders of sacrum 724.9 Other unspec. back d i s o r d . 724.1 P a i n i n Thoracic Spine -724.2 Lumbago 724.4 Thoracic or lumbosacral n e u r i t i s or r a d i c u l i t i s , u n s p e c i f i e d 724.5 Backache, u n s p e c i f i e d 724.79 Other, Coccygod'yhia c o n t Pain i n Thoracic spine 728.5 Lumbago (Other Non-Arti-c u l a r Rheumatism) 717.0 Lumbalgia 728.7 Ra d i c u l a r syndrome of 728.8 lower limbs Other & u n s p e c i f i e d 728.9 109 APPENDIX I)..(cont.) I.CD. 8th R e v i s i o n Code # Code # L C D . 9th R e v i s i o n 724.8 Other symptoms r e f e r a b l e back S c i a t i c a 353 724.3 S c i a t i c a F r a c t u r e and f r a c t u r e F r a c t u r e of v e r t e b r a l d i s l o c a t i o n of v e r t e b r a l column without mention column without mention of s p i n a l cord i n j u r y of s p i n a l cord l e s i o n (805.4 & 805.5) (N805.4 - N895.9) N805 805 Sprains & s t r a i n s of s a c r o - i l i a c r e gion N 846 846.0 Sprains & s t r a i n s of other and u n s p e c i f i e d p a r t s of back (N847.8 & N847.9) N847 847 (.847.2, 847.4, 847.9) 110 APPENDIX D (cont.) Back Program Diagnoses Average Length of Stay, Gases & P a t i e n t Days By Year & Geographic Area S.D. #44 & 45 to L.G.H. G.V.R.D. to L.G.H. S.D. #44 & 45 to r e s t of Province Rest.of G.V.R.D. to r e s t of G.V.R.D. Hosps. YEARS Pt . AvLOS Cs. Dys. Pt . AvLOS Cs.Dys. Pt . AvLOS Cs. Dys. Pt. AvLOS Cs. Dys. 1970 . AvLOS Cases Pt.Dys. 17.45 242 4222 17.17 23 395 16.18 66 1068 16.93 1943 32892 19 71 AvLOS Cases Pt.Dys. 15.28 260 3972 20.. 58 19 391 13.14 71 933 17.52 2071 36280 19 72 AvLOS Cases Pt.Dys. 14.42 274 3951 35.48 33 1171 16.06 67 1076 16.91 2229 37683 1973 AvLOS Cases Pt.Dys. 20.64 281 5799 22.84 50 1142 13.59 46 625 17.01 2156 36683 1974 AvLOS Cases Pt.Dys. L6.46 244 4016 25.92 24 622 12.54 63 790 16.46 2118 34859 1975 AvLOS Cases Pt.Dys. L9.74 274 5408 54.10 30 1623 25.04 70 1753 18.09 2294 41502 1976 AvLos Cases Pt.Dys. 20.70 229 4741 15.71 42 660 15.58 69 1075 18.25 2222 40544 1977 AvLOS Cases Pt.Dys. 20.07 297 5960 13.85 27 374 12.10 58 702 20.35 2401 48863 1978 AvLOS Cases Pt.Dys. L7.17 397 6817' 38.49 :> 43 1655 14.63 64 936 19.12 2319 44339 19 79/80 AvLOS I Cases Pt.Dys. 16.72 86 ; 1438 L0.42 12 125 , 7.93 14 111 .6.69 619 10331 I l l APPENDIX E MEASURING THE RATE OF POPULATION GROWTH (Barclay, 1958, p. 207) - Assume that the rate of growth Is constant between 1971 and 19 76. - A constant rate of growth produces larger and larger increments because the base of the population becomes 1 larger where P 2 = 1976 T1 = 1971 r = annual rate of growth n = 5 years - using logarithms (1 + r ) n becomes n log (1 + r) ,, ;V- • -;/ -: log ~p log (1 + r) = 5 APPENDIX F POPULATION FIGURES USED IN THIS., STUDY School D i s t r i c t #44 & #45 Po p u l a t i o n By Year & Age YEAR 0 -.14 15 - 44 45 - 64 65+ .. T o t a l s 1971 34,700 55,925 27,820 9,450 :127,895 1972 33,327 57,259 28,436 9,833 128,855 1973 32,008 58,625 29,066 10,231 129,930 1974 30,741 60,023 29,710 10,645 131,119 1975 29,524 61,455 30,368 11,076 132,423 1976 28,355 62,920 31,040 11,525 133,840 1977 27,249 63,238 31,453 12,032 133,972 19 78 26,212 63,217 31,576 12,298 133,303 1979 25,361 64,576 32,063 12,883 134,883 School D i s t r i c t #36 - #41, #43 By Year & Age Pop u l a t i o n Year 0 - 1 4 15 - 44 45 - 64 65+ Tot a l s 1971 223,725 394,465 188,170 94,065 900,425 1972 218,866 404,070 190,565 96,053 909,554 1973 214,112 413,909 192,991 98,083 919,095 1974 209,461 423,988 195,448 100,155 929,052 1975 204,912 434,312 197,936 102,271 939,431 1976 200,460 444,880 200,460 104,430 950,230 1977 194,201 447,091 199,023 106,103 946,418 1978 191,769 454,979 199,569 108,999 955,316 1979 189,660 466,668 200,942 113,542 970,812 113 APPENDIX G ADJUSTED OR STANDARDIZED RATES (.Barclay, 1958, 161-166) I n d i r e c t S t a n d a r d i z a t i o n ("applying a standard set of rat e s to d i f f e r e n t populations by age" (p. 161).) The object i s to c a l c u l a t e the number of expected cases or p a t i e n t days "to be expected i n one po p u l a t i o n on the b a s i s of some in f o r m a t i o n from, another p o p u l a t i o n " (p. 161). In t h i s study the number of 'expected cases' or 'expected p a t i e n t days' i s used to c a l c u l a t e the standardized case r a t e or the standardized p a t i e n t day r a t e . This method r e q u i r e s data: of.the a c t u a l populations by age, the t o t a l number of cases and p a t i e n t days i n both the a c t u a l populations during the year s , 1971 - 1979, the complete schedule of age s p e c i f i c case ra t e s and age s p e c i f i c p a t i e n t day rat e s of the standard p o p u l a t i o n (the t o t a l G.V.R.D. po p u l a t i o n i n 1976), and the crude case r a t e and p a t i e n t day r a t e of the standard po p u l a t i o n . The a c t u a l p o p u l a t i o n f i g u r e f o r each year at each age group i s m u l t i p l i e d by the corresponding age s p e c i f i c case r a t e and p a t i e n t day r a t e which gives the number of expected cases or expected p a t i e n t days i f the a c t u a l p o p u l a t i o n had had the standard case or p a t i e n t day ra t e s at each age group. The a c t u a l number of cases or p a t i e n t days f o r a p a r t i c u l a r year are d i v i d e d by the expected ceases or pa t i e n t : days.for that "year to provide r a t i o s . These r a t i o s are m u l t i p l i e d by the crude case r a t e or p a t i e n t day r a t e of the standard p o p u l a t i o n ( t o t a l G.V.R.D. po p u l a t i o n i n 1976) to o b t a i n standardized case r a t e s and standardized p a t i e n t day rat e s In t h i s way "the probable i n f l u e n c e of a population's age composition on i t s crude . .." case r a t e and crude p a t i e n t day r a t e can be shown "when i t s a c t u a l age s p e c i f i c r a t e s are not known" (p. 166). 

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