Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

The impact of surgical day care on hospital inpatient utilization in a paediatric population Elo, Jyrki A. I. 1987

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1988_A6_7 E46.pdf [ 13.54MB ]
Metadata
JSON: 831-1.0097633.json
JSON-LD: 831-1.0097633-ld.json
RDF/XML (Pretty): 831-1.0097633-rdf.xml
RDF/JSON: 831-1.0097633-rdf.json
Turtle: 831-1.0097633-turtle.txt
N-Triples: 831-1.0097633-rdf-ntriples.txt
Original Record: 831-1.0097633-source.json
Full Text
831-1.0097633-fulltext.txt
Citation
831-1.0097633.ris

Full Text

IMPACT  OF SURGICAL DAY CARE ON HOSPITAL  U T I L I Z A T I O N IN A PAEDIATRIC  INPATIENT  POPULATION  By JYRKI A . I . ELO M.D.,  The U n i v e r s i t y  A THESIS SUBMITTED  o f Kuopio,  1980  IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE HEALTH SERVICES PLANNING  AND  ADMINISTRATION  in THE FACULTY OF GRADUATE STUDIES Department o f H e a l t h Care and  We  accept t h i s to  thesis  required  as  Epidemiology  conforming  standard  THE UNIVERSITY OF B R I T I S H COLUMBIA November ©Jyrki  1987  A . I . E l o , 1987  In presenting  this thesis in partial fulfilment  of the  requirements for an advanced  degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department  or  by  his  or  her  representatives.  It  is  understood  that  copying  or  publication of this thesis for financial gain shall not be allowed without my written permission.  Department of H e a l t h Care  and E p i d e m i o l o g y  The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date November 23 ,  DE-6(3/81)  1987  ii  ABSTRACT  Day c a r e s u r g i c a l saving a l t e r n a t i v e the cost less  services  h a v e b e e n m a r k e t e d as  for inpatient care.  per episode of  day c a r e s u r g e r y  avoiding  for paediatrics, hospital  evidence  50-70  h o s p i t a l i z a t i o n has  because of  the undesirable  be f u l l f i l l e d o n l y i f  care  surgery  each p a t i e n t  significant  rather  relevance of  s a v i n g s and of  the  children  cared f o r i n a  day and  u s e w o u l d n o t be f i l l e d  in  patients.  a previous  total  In  u n i t w o u l d o t h e r w i s e h a v e b e e n an i n p a t i e n t  t h e bed v a c a t e d by day c a r e s u r g e r y  that  percent  effects  need t o d e c r e a s e h o s p i t a l i z a t i o n s  will  by o t h e r  particular  s t a y on c h i l d r e n . However, b o t h c o s t  quality-based  B.C.  s t u d y b a s e d on t h e t o t a l p o p u l a t i o n  component o f  utilization,  d a y c a r e s u r g e r y was  suggesting generation  than s u b s t i t u t i o n .  The p r e s e n t  examine t h e s u b s t i t u t i o n / g e n e r a t i o n (0-14  is  cost  t h a n a c o m p a r a b l e e p i s o d e i n an i n p a t i e n t w a r d .  addition,  In  There i s  a  years)  population,  g e n e r a l i z a b i l i t y of and b e c a u s e of utilization  of  found t o  surgical  augment  activity  s t u d y was d e s i g n e d  issue  i n the  the dramatic  i n Canada d u r i n g  to the p a e d i a t r i c  reduction in  to  paediatric  both because e x p e r t s q u e s t i o n e d  the findings  a  the  population,  paediatric  the p e r i o d s i n c e the  mid-1960s.  iii The  c o n t e n t i o n was t h a t  may  have been an i m p o r t a n t  The  relationship  hospital  inpatient  i n this  between p a e d i a t r i c utilization  series/cross-section  825 d a t a p o i n t s .  analysis,  i t was p o s s i b l e  utilization  d a y c a r e s u r g e r y u s e and i n B.C.  was a n a l y z e d  i n each of  i n each o f t h e study Using a m u l t i v a r i a t e t o e s t i m a t e what  years, regression  hospital  and hence i s o l a t e e s t i m a t e s  impact o f d a y c a r e s u r g e r y on p a e d i a t r i c  Findings  frame c o n s i s t e d o f  p a t t e r n s would have been i n t h e absence o f d a y  care surgery capacity,  and  surgery  downtrend.  s t u d y d e s i g n . The d a t a  B.C. s c h o o l d i s t r i c t s ,  yielding  factor  of day care  1968-1976 a n d 1981/82-1982/83 a n d u s i n g a t i m e  the years  all  the introduction  of the net  inpatient use.  o n t h e r e l a t i o n s h i p between d a y c a r e s u r g e r y u s e  paediatric  utilization  medical/surgical  strongly  support  and s u r g i c a l  t h e view that  inpatient  paediatric  day care  s u r g e r y h a s b e e n l a r g e l y a n add-on t o t h e t o t a l  hospital  system.  Statistically  e f f e c t was  revealed  o n l y f o r t h e most n a r r o w l y  significant substitution  defined inpatient  c a t e g o r y w h i c h more c l o s e l y r e s e m b l e d d a y c a r e cases, age  after controlling for potential  and sex,  paediatric  bed c a p a c i t y ,  characteristics  and t i m e - and d i s t r i c t - s p e c i f i c  here,  10 p e r c e n t o f d a y c a r e s u r g e r y  l e s s than  substitution  for inpatient  s u r g e r y and o v e r  a p p e a r e d t o b e g e n e r a t i o n o f new a c t i v i t y  surgery  surgery-type  confounding different  care  e f f e c t s of  socioeconomic factors.  Even  represented  90 p e r c e n t  to the hospital  iv system as a whole. Furthermore, p a e d i a t r i c "saved"  b y d a y c a r e s u r g e r y u s e were f i l l e d  utilization and  b y non-day  by m e d i c a l  utilization  cases.  i n t h e 0-14  availability  The m a i n d r i v i n g  even a f t e r s t a n d a r d i z a t i o n  district-  and y e a r - s p e c i f i c  been a c o s t  surgical behind  patients hospital  paediatric  bed  status,  and  other  effects.  saving alternative  population.  day c a r e  for inpatient  N e i t h e r has i t r e d u c e d  the p a e d i a t r i c  increased  f o r age, sex,  of socioeconomic  t o t h i s study p a e d i a t r i c  1968-1982/83.  force  y e a r age g r o u p was  s t o c k , measures  According  with  care surgery e l i g i b l e  physician  in  b e d s w h i c h were  overall  s u r g e r y has n o t care  i n B.C. i n  hospitalizations  V  TABLE OF CONTENTS  Page  ABSTRACT  i i  L I S T OF TABLES  ix  L I S T OF FIGURES  xii  ACKNOWLEDGEMENT  xiii  1.  2.  INTRODUCTION  1  1.1.  H e a l t h s e r v i c e s r e s e a r c h and p o l i c y - m a k i n g  1.2.  Background of  1.3.  Purpose of  1.4.  Study o b j e c t i v e s  10  1.5.  U n d e r l y i n g t h e o r i e s and s t u d y h y p o t h e s e s  11  1.6.  Thesis  15  LITERATURE  the study  1 2  the study  9  format REVIEW  17  2.1.  Why n o t i n p a t i e n t c a r e ?  2.2.  Day c a r e s u r g e r y care  2.3.  ...  17  alternative for  inpatient 25  2.2.1.  Definition  25  2.2.2.  A b r i e f h i s t o r y of p a e d i a t r i c day surgery  care 28  2.2.3.  S a f e t y of p a e d i a t r i c day c a r e s u r g e r y  2.2.4.  P a e d i a t r i c day c a r e s u r g e r y l o a d procedures  Estiamtes of p o t e n t i a l cost t o day c a r e s u r g e r y  savings  .  29  and 32  realted 33  vi  page 2.4. 2.5.  Response surgery  of  The r o l e o f  i n p a t i e n t u t i l i z a t i o n t o day  care 39  i n a p t i e n t bed s u p p l y -  Roemer's  Law  2.6.  43  2.5.1.  E v o l u t i o n of Roemer's  2.5.2.  Question of  2.5.3.  The Roemer e f f e c t i n populations  Other f a c t o r s 2.6.1.  Law  43  causality  46 paediatric 51  i n p a e d i a t r i c i n p a t i e n t use  P r e v a l e n c e , i n c i d e n c e and t y p e  ....  of  illness  2.7. 3.  55  56  2.6.2.  Demographic  factors  2.6.3.  Socioeconomic f a c t o r s  59 61  2.6.4. Medical care a v a i l a b i l i t y  63  Summary o f  68  l i t e r a t u r e review  DATA SOURCES AND METHODS  71  3.1. 3.2.  71  3.3.  S t u d y u n i t and r e s e a r c h d e s i g n Dependent v a r i a b l e - p a e d i a t r i c h o s p i t a l use p e r c a p i t a  inpatient 76  3.2.1.  Exclusions  from numerator  76  3.2.2.  Inclusions  i n numerator  81  3.2.3.  Measures of numerator  the dependent v a r i a b l e 85  3.2.4.  Denominator of  3.2.5.  Age-sex adjustment of variable  Independent 3.3.1.  the dependent v a r i a b l e  .  the dependent 93  variables  Day c a r e s u r g e r y  93  95 availability  (DCS)  ...  95  vii  page 3.3.2.  Hospital  bed a v a i l a b i l i t y  3.3.2.1.  Adjustment f o r c r o s s i n g (B")  3.3.2.2. 3.3.3.  3.3.4. 3.4.  3.5. 4.  Number o f  (BEDS)  boundary 98  A d j u s t m e n t f o r non-homogeneous p o p u l a t i o n (P~) physicians  per  4.2.  104  capita  (DOCS)  106  Socioeconomic v a r i a b l e s  112  Data sources 3.4.1. Admission-separation i n p a t i e n t use  database  3.4.2.  database  Admission-separation  116 for 116 for  day c a r e s u r g e r y  117  3.4.3.  Out-of-province u t i l i z a t i o n  118  3.4.4.  P o p u l a t i o n and s o c i o e c o n o m i c d a t a  118  3.4.5.  Hospital  121  Statistical  bed c a p a c i t y d a t a  analysis  121  RESULTS 4.1.  97  D e s c r i p t i v e d a t a - an o v e r v i e w o f u t i l i z a t i o n i n B . C . , 1968-1982/83  127 paediatric  Day c a r e s u r g e r y a v a i l a b i l i t y and p a e d i a t r i c inpatient utilization  127 139  viii  page 4.3. P a e d i a t r i c b e d a v a i l a b i l i t y a n d utilization 4.4. A d j u s t i n g  f o r the e f f e c t  inpatient 149  o f bed s u p p l y  156  4.5. N o n - l i n e a r b e d e f f e c t  167  4.6. C o n f o u n d i n g f a c t o r s  174  4.6.1. P h y s i c i a n - t o - p o p u l a t i o n  ratio  4.6.2. S o c i o e c o n o m i c v a r i a b l e s 4.6.3. Unmeasured c o n f o u n d i n g  175 182  factors  4.7. Roemer's Law a n d d e c r e a s i n g b e d s u p p l y  197 209  5. DISCUSSION  217  6. BIBLIOGRAPHY  231  ix L I S T OF TABLES  Table 1  2  3  4  5  6  7  8  9  10  page I n c i d e n c e o f I n p a t i e n t and Day C a r e S u r g e r y p e r 1,000 P o p u l a t i o n and P e r c e n t a g e o f Day C a r e S u r g e r y o f T o t a l S u r g e r y i n B . C . b y T o t a l and P a e d i a t r i c (0-14 y e a r s ) P o p u l a t i o n b y Y e a r  3  Most Common O p e r a t i v e C a t e g o r i e s i n Day C a r e S u r g e r y i n t h e P a e d i a t r i c (0-14 y e a r s ) Age G r o u p i n B . C . i n 1976 and i n 1982/83  34  T e n M o s t Common Day C a r e S u r g e r y P r o c e d u r e s i n P a e d i a t r i c ( 0 - 1 4 ) Age G r o u p i n B . C . i n 1976 and 1982/83  35  P r o p o r t i o n of Out-of P r o v i n c e U t i l i z a t i o n of t h e T o t a l I n - and O u t - P r o v i n c e U t i l i z a t i o n b y S c h o o l D i s t r i c t i n 1971, 1976 and 1981/82  83  Non-operative Procedures Excluded i n This by D i f f e r e n t R e v i s i o n s of International C l a s s i f i c a t i o n of Diseases  88  Study  M o s t Common S u r g i c a l Day C a r e P r o c e d u r e s i n P e a d i a t r i c Age G r o u p i n B . C . i n 1982/83 and T h e i r M u l t i p l i c a t i o n F a c t o r s f o r SURG C Measure Number o f A c t u a l and S y n t h e t i c P a e d i a t r i c b y S c h o o l D i s t r i c t i n B . C . i n 1971, 1976, 1981/82  90  Beds and 101  A c t u a l and A d j u s t e d P o p u l a t i o n s f o r 0-14 Age G r o u p b y S c h o o l D i s t r i c t i n 1971, 1976, and 1981/82  107  Means and S t a n d a r d D e v i a t i o n s o f D i f f e r e n t Measures of P a e d i a t r i c I n p a t i e n t U t i l i z a t i o n ( p e r 1,000 P o p u l a t i o n ) O v e r S c h o o l D i s t r i c t s by Year . . .  128  Means and S t a n d a r d D e v i a t i o n s o f V a r i a b l e s ( p e r 1,000 P o p u l a t i o n ) D i s t r i c t s by Y e a r  133  DCS and BEDS Over S c h o o l  X  Table 11  12  13 14 15  16 17  18 19  20  page Means and S t a n d a r d D e v i a t i o n s o f D i f f e r e n t Measures o f P h y s i c i a n A v a i l a b i l i t y p e r 10,000 P o p u l a t i o n (0-14 Y e a r s ) O v e r S c h o o l D i s t r i c t s by Year  135  Means and S t a n d a r d D e v i a t i o n s o f D i f f e r e n t Socioeconomic V a r i a b l e s Over S c h o o l D i s t r i c t s by Census Year  137  C o r r e l a t i o n M a t r i x of Main Study V a r i a b l e s P o o l e d 1968-1982/83 D a t a s e t  138  S c h o o l D i s t r i c t MED/SURG and SURG w i t h DCS b y Y e a r  in  Equations 140  School D i s t r i c t Inpatient U t i l i z a t i o n Equations w i t h DCS i n 1 9 7 1 , 1976, and P o o l e d 1 9 6 8 - 1 9 8 2 / 8 3 Dataset  143  S c h o o l D i s t r i c t MED/SURG and SURG w i t h BEDS b y Y e a r  151  Equations  School D i s t r i c t Inpatient Hospital U t i l i z a t i o n E q u a t i o n s w i t h BEDS i n 1 9 7 1 , 1976, and P o o l e d 1968-1982/83 D a t a s e t  154  School D i s t r i c t Inpatient Hospital U t i l i z a t i o n E q u a t i o n s w i t h DCS and BEDS V a r i a b l e s b y Y e a r . .  158  School D i s t r i c t Inpatient Hospital U t i l i z a t i o n E q u a t i o n s w i t h DCS a n d BEDS i n 1 9 7 1 , 1976, 1 9 8 1 / 8 2 , P o o l e d 1 9 6 8 - 1 9 7 6 , and P o o l e d 1968-1982/83 D a t a s e t  162  School D i s t r i c t Inpatient Hospital U t i l i z a t i o n E q u a t i o n s w i t h BEDS a n d BEDSQ i n P o o l e d 1968-82/83 Dataset  169  21  School D i s t r i c t Inpatient Hospital U t i l i z a t i o n E q u a t i o n s w i t h DCS, BEDS and BEDSQ i n 1 9 7 1 , 1976, 1 9 8 1 / 8 2 , P o o l e d 1 9 6 8 - 1 9 7 6 , and P o o l e d 1968-1982/83 D a t a s e t 172  22  School D i s t r i c t Inpatient Hospital U t i l i z a t i o n E q u a t i o n s w i t h DCS, BEDS, BEDSQ and DOCS i n 1976, 1981/82 and P o o l e d 1 9 7 3 - 1 9 8 2 / 8 3 D a t a s e t . .  177  xi Table 23  24  25  26  27  28  page School D i s t r i c t Inpatient H o s p i t a l U t i l i z a t i o n E q u a t i o n s w i t h DCS, BEDS, BEDSQ, GP, PAED, SURGEON, ANA and OTHER V a r i a b l e s i n P o o l e d 1973-1982/83 D a t a s e t  181  School D i s t r i c t Inpatient Hospital U t i l i z a t i o n E q u a t i o n s w i t h S o c i o e c o n o m i c V a r i a b l e s i n 1971, 1981/82 and P o o l e d 1 9 6 8 - 1 9 8 2 / 8 3 D a t a s e t  183  School D i s t r i c t Inpatient Hospital U t i l i z a t i o n E q u a t i o n s w i t h DCS, BEDS, BEDSQ a n d S o c i o e c o n o m i c V a r i a b l e s i n 1 9 7 1 , 1981/82 and P o o l e d 1968-1982/83 D a t a s e t  189  School D i s t r i c t Inpatient Hospital U t i l i z a t i o n E q u a t i o n s w i t h DCS, BEDS, BEDSQ and Time a n d / o r D i s t r i c t Dummies i n P o o l e d 1 9 6 8 - 8 2 / 8 3 D a t a s e t . .  199  School D i s t r i c t Inpatient Hospital U t i l i z a t i o n E q u a t i o n s w i t h DCS, BEDS, BEDSQ, S o c i o e c o n o m i c V a r i a b l e s and Time a n d D i s t r i c t Dummies i n P o o l e d 1 9 6 8 - 1 9 8 2 / 8 3 D a t a s e t  208  School D i s t r i c t inpatient Hospital U t i l i z a t i o n E q u a t i o n s w i t h DCS, BEDS, BEDSQ, BEDSD and BEDSQD i n P o o l e d 1 9 6 8 - 8 2 / 8 3 D a t a s e t  211  xii L I S T OF FIGURES  Figure  page  1  School  2  Hypothetical DCS u s e  3  district  boundaries  plot  of  i n the study  inpatient  use  77  against  S i m p l i f i e d i l l u s t r a t i o n of the d i f f e r e n c e s i n r e g r e s s i o n e q u a t i o n s between i n d i v i d u a l y e a r s and t h e p o o l e d d a t a s e t  123  144  xiii ACKNOWLEDGEMENTS  The p r e s e n t  study  is  examine t h e economics and i t  continues  Robinson  of p a e d i a t r i c h o s p i t a l  counseling unfailing  R o b e r t G.  the process  interest  and t r u s t  wish t o thank Dr.  throughout  skilful  for  the  I  C.  wish to express  my  o f my work and f o r i n my  Morris  the progress  this  are also  assistance  analyses.  of  B.C.,  Geoffrey  and  their  study.  L.  Barer  f o r many  c o n s t r u c t i v e c r i t i c i s m and v a l u a b l e  My s i n c e r e t h a n k s his  Evans.  to  in  t o them f o r t h e i r c o n s t r u c t i v e c r i t i c i s m  during  discussions,  services  t h e work i n i t i a t e d b y P r o f e s s o r  and P r o f e s s o r  deep g r a t i t u d e  I also  a component i n a b r o a d e r a t t e m p t  fruitful  guidance  study.  due t o M r .  P a t r i c Wong-Fung  i n preparing the d i f f e r e n t  for  databases  1  1.  INTRODUCTION  1.1.  Health services  Although process  public policies  of  accepted) studies  r e s e a r c h and  bargaining that  are u s u a l l y  and t i m i n g ,  it  the o b j e c t i v e s  and G a n d y ,  1983).  researchers  that  human and  high expectations  (Robertson of  had o n l y a l i m i t e d  utilization direct  1979;  p o i n t of view r e s e a r c h  p o l i t i c a l demands,  political  process  that  practice  (Robertson  This  is  for  study  rationality  study  as  Weiss  (1977).  facts  i n t u i t i o n and e x p e r i e n c e i n  includes  and Gandy,  decisions  about  policy  a and  1983).  conducted i n a f a i t h  that  in policy-making.  see t h e r o l e of  d e s c r i b e d by t h e  Weiss, is  c o n s i d e r e d a l o n g w i t h e m o t i o n a l and n o n - q u a n t i f i a b l e such as  and  financial  those o b j e c t i v e s  ( R u b i n and R o s e n b l a t t ,  From a p o l i c y - m a k e r s  (and  t o meet,  t h e l i t e r a t u r e on r e s e a r c h  r e s e a r c h has  on p o l i c y - m a k i n g  1980).  of  complex  b o t h more e f f e c t i v e  t h e y were d e s i g n e d  spite  a review of  demonstrates impact  In  a  widely argued  policies  f o r the achievement of  of  from p r o p e r l y - c o n d u c t e d  more e f f i c i e n t i n t h e i r d e p l o y m e n t o f resources  a result  is  the information gained  c a n h e l p t o make s o c i a l  in attaining  policy-making  I  "enlightenment"  The most i m p o r t a n t  role  for  there is  still  room  this  model p r o p o s e d research in  by  policy-  2  making i s t o p r o v i d e an i n t e l l e c t u a l s e t t i n g of  concepts,  p r o p o s i t i o n s , o r i e n t a t i o n s , and e m p i r i c a l g e n e r a l i z a t i o n s t h a t w i l l expand the policy-maker's  frame of r e f e r e n c e and  thus  i n f l u e n c e p o l i c y d e c i s i o n s . T h i s study t r i e s t o shed l i g h t the p o l i c y t o p r o v i d e p a e d i a t r i c s u r g i c a l s e r v i c e s on a care b a s i s .  on  day  The key i s s u e i s r e s o u r c e a v a i l a b i l i t y and i t s  r e l a t i o n s h i p t o h o s p i t a l u t i l i z a t i o n w i t h i n the p a e d i a t r i c population. Potential causal associations that w i l l  be  examined are fundamental i n viewing the o p e r a t i o n s of p a e d i a t r i c s u r g i c a l s e r v i c e s and i n a s s e s s i n g the impact day care surgery and h o s p i t a l bed c a p a c i t y on  of  hospital  u t i l i z a t i o n i n this population.  1.2.  Day  Background of the  study  care s u r g i c a l s e r v i c e s have been p r o v i d e d as a h o s p i t a l  i n s u r a n c e b e n e f i t i n B r i t i s h Columbia s i n c e e a r l y (Province of B r i t i s h Columbia, 1 9 6 8 ) . been a dramatic procedures  expansion  S i n c e then t h e r e  i n the performance of  on a day care b a s i s .  1968 has  surgical  The number of day  care  s u r g i c a l o p e r a t i o n s per 1000 p o p u l a t i o n has i n c r e a s e d from i n 1968  t o 41.8  i n 1982/83 (Table 1 ) .  The expansion  6.7  of t h i s  k i n d of s u r g e r y has a l s o been of s i m i l a r magnitude i n the c h i l d population. c h i l d r e n of 0-14  In 1968  t h e r e were 4.6  o p e r a t i o n s per  years and i n 1982/83 the r a t e was  c h i l d r e n , day care s u r g e r y accounts  1000  2 2 . 8 . /Among  f o r almost h a l f of the  Table  1  3 I n c i d e n c e o f I n p a t i e n t a n d Day C a r e S u r g e r y per 1,000 p o p u l a t i o n a n d P e r c e n t a g e o f Day C a r e S u r g e r y o f T o t a l S u r g e r y i n B.C. by T o t a l and P a e d i a t r i c (0-14 y e a r s ) P o p u l a t i o n b y Y e a r  Total  Year  Population  Inpatient Inc.  Day C a r e Inc. %  Pflftdj flt.ri C P o p u l a t i o n Inpatient Day C a r e Inc. Inc. % 7 .01  60 .98  4 .60  11 .42  53 .17  6 .87  11 .44  15 .16  15 .33  52 .38  10 .59  16 .82  83 .96  18 .12  17 .75  48 .64  11 .85  19 .59  1972  83 .13  19 .68  19 .14  45 .39  12 .47  21 .55  1973  82 .41  21 .69  20 .84  43 .94  13 .89  24 .02  1974  82 .85  23 .51  22 .10  42 .42  13 .95  24 .75  1975  80 .49  25 .30  23 .92  39 .88  14 .69  26 .92  1976  78 .29  26 .62  25 .37  37 .16  15 .21  29 .04  % Change between 1968-76  - 6 .54  295 .54  - 3 9 .06  230 .65  1981/82  77 .32  38 .29  33 .12  30 .11  22 .30  42 .55  1982/83  74 .66  41 .75  35 .86  26 .58  22 .80  46 . 17  % Change between •10 .88 1968-82/83  520 .36  - 5 6 .41  395 .65  6 .73  7 .44  80 .93  10 .43  1970  83 .74  1971  1968  83 .77  1969  S o u r c e s : NUMERATOR DATA: T o t a l p o p u l a t i o n : P r o v i n c e o f B r i t i s h C o l u m b i a : R e p o r t on d a y c a r e s u r g e r y 1 9 8 2 / 8 3 , B r i t i s h Columbia. M i n i s t r y of H e a l t h , Research D i v i s i o n , H o s p i t a l P r o g r a m s , V i c t o r i a , n . d . 1983; and u n p u b l i s h e d d a t a , B . C . M i n i s t r y of H e a l t h , H o s p i t a l Programs. P a e d i a t r i c p o p u l a t i o n : R o b i n s o n CG, C l a r k e HF ( e d s ) : The H o s p i t a l C a r e o f C h i l d r e n . A r e v i e w o f c o n t e m p o r a r y i s s u e s . O x f o r d U n i v e r s i t y P r e s s , New Y o r k 1980; and u n p u b l i s h e d d a t a , B . C . M i n i s t r y o f H e a l t h , H o s p i t a l P r o g r a m s . DENOMINATOR DATA: I n t r a - and e x t r a p o l a t e d f r o m t h e 1 9 6 1 , 1971 and 1981 C e n s u s d a t a .  4 overall third  surgical  load i n  1982/83, i n c o n t r a s t  i n the t o t a l population  There are s e v e r a l p o s s i b l e become so p o p u l a r and i s surgery. surgery  One o f has  reasons  increasing  t h e main arguments  been t h a t  alternative  (Table  it  The d e v e l o p m e n t o f  unnecessary Commission  its  p o r t i o n of  to  support day  controlling (Canada,  one o f  particular  In  a1.,  t h e p r i n c i p a l means o f  1970).  health professionals  saving aspects  the  hospitalization  is  type of 1940s  of  has  ( V e r n o n e_t  t h e s e two r e a s o n s  t h e most i n g e t t i n g  that  their services.  have a l s o emphasized t h e  day c a r e s u r g e r y programs,  t r e a t m e n t may a l s o  ,  the  s t a y s on c h i l d r e n  It  Hall  costs  f o r expanding p a e d i a t r i c day c a r e s u r g i c a l  Although  this  eliminate  lowering or  r e l e v a n c e f o r p a e d i a t r i c s , because of  have a p p e a l e d t o p o l i c y - m a k e r s support  to  recommended b y t h e  addition, avoiding  1965; R o b e r t s o n ,  care  ( E v a n s e t a 1.,  outpatient services  u n d e s i r a b l e e f f e c t s of h o s p i t a l  total  total  h e a l t h c a r e and p a r t i c u l a r l y h o s p i t a l  1964).  cost  their interest  stem f r o m o t h e r g r o u n d s .  and t h e 1950s t h e H o s p i t a l  meant i n c r e a s i n g numbers o f h o s p i t a l  has  expensive  care. Potential  i n p a t i e n t a d m i s s i o n s was as  o v e r one  why d a y c a r e s u r g e r y  s a v i n g s p e r e p i s o d e c o u l d be 50-70 p e r c e n t 1978).  just  1).  represents a less  to inpatient h o s p i t a l  to  in  In  C o n s t r u c t i o n Grant  Scheme  beds  health  i n Canada and  professionals'  p r e f e r e n c e was  for inpatient care.  environment of  a s t a b l e o r d e c r e a s i n g number o f h o s p i t a l  and an i n c r e a s i n g number o f p h y s i c i a n s ,  as  In  an  i n t h e 1970s  beds and,  5  especially, to  i n the  circumvent  1980s, d a y  hospitalizations cared  h a v e b e e n an use  observed. for  the q u a l i t y - b a s e d need t o  o f c h i l d r e n w i l l be  f o r i n a day inpatient  w o u l d n o t be  substitution  and  filled  effect  fullfilled  t h e bed  vacated  o n l y i f each  by d a y  i n by o t h e r p a t i e n t s .  has  decrease  care s u r g e r y u n i t would  otherwise care  surgery  This  b e e n assumed r a t h e r t h a n  actually  There are b a s i c a l l y three t h e o r e t i c a l  t h e r e l a t i o n s h i p between d a y  inpatient  way  perceived f a c i l i t y constraints.  B o t h c o s t s a v i n g s and  patient  care surgery could provide a  possibilities  c a r e s u r g e r y use  and  utilization:  1) case  S t r a i ght  s n h s t i t u t i on.  s u b s t i t u t e s f o r one  vacated  Each day  inpatient  i n p a t i e n t beds a r e not  care  surgery  admission  filled  i n by  and other  patients.  2)  Straight  affect  inpatient  vacated. episode  a d d - o n . Day  Each day o f new  c a r e s u r g e r y use  admissions  a t a l l and  care surgery case  paediatric  surgery.  no  does  not  beds  are  represents  an  6 3)  Substitution with  day care surgery admission,  Each of  third fill  patients  ( e.g.,  surgical  cases).  combinations.  substitutes  Each  beds.  f o r one  new m e d i c a l o r non-DCS  inpatient  c o u l d be s t r a i g h t  could exist  eligible  alone or  F o r e x a m p l e , one t h i r d o f  c o u l d be s t r a i g h t  i n of  i n o f vara tad  b u t v a c a t e d beds a r e f i l l e d i n b y o t h e r  these p o s s i b i l i t i e s  different surgery  case  fill  add-on  (no s u b s t i t u t i o n  substitution  day at  (substitution  v a c a t e d beds w i t h o t h e r p a t i e n t s ) ,  in care  all),  with  and one  no  third  could lead to  substitution with f i l l  two t h i r d s  day c a r e s u r g e r y would r e p r e s e n t g e n e r a t i o n  of  new a c t i v i t y f o r t h e h o s p i t a l  i n of vacated beds.  s y s t e m as  Thus,  a whole and o n l y  t h i r d would reduce i n p a t i e n t u t i l i z a t i o n . Only the  of one  straight  s u b s t i t u t i o n w o u l d f u l l y meet t h e e x p e c t a t i o n s a s s o c i a t e d the  i n t r o d u c t i o n of day c a r e s u r g e r y .  In  the case of  add-on or s u b s t i t u t i o n with f i l l  i n of vacated beds,  no  hospitalizations,  net reduction i n p a e d i a t r i c  total recent  number o f s t u d y has  substitution  is  (Evans e t a l . , s u r g e r y was care,  but  hospital costs.  children's hospital shown t h a t not v a l i d 1983).  contacts w i l l  the assumption  of  60-70 p e r c e n t was s y s t e m as  g e n e r a t i o n of  a whole and, t h u s ,  The g e n e r a t i o n o f  there  but  new h o s p i t a l  is  the  increase.  A  perfect  f o r t y percent of  found t o r e p r e s e n t s u b s t i t u t i o n  with  straight  f o r the o v e r a l l population i n  T h i r t y to  one  for  day  B.C.  care  inpatient  new a c t i v i t y f o r  the  represented add-on u t i l i z a t i o n was  a  result  7 of  fill  i n of  beds,  w h i c h were s a v e d b y d a y c a r e s u r g e r y  b y non-DCS e l i g i b l e causal  positive  determinant of total  of  e f f e c t of  p a r t i c u l a r l y medical cases.  bed a v a i l a b i l i t y  inpatient utilization.  was  inpatient  the  1960s  (Sheps,  1980)  et a l . ,  arrangements  1972),  at  least  to t r a d i t i o n a l  1)  paediatrics  children's  care  that  (Shah  something  Practitioners  that  health care i s  c a r e i n the sense substitute  claim  actively  inpatient  o f f e r the p o s s i b i l i t y  in  consequences  seek  d i f f e r e n t may h a v e b e e n g o i n g on i n p a e d i a t r i c s . i n the f i e l d of  from the  population  and t h e u n d e s i r a b l e to  The  major  A decline  u t i l i z a t i o n i n t h e 0-14 y e a r  h o s p i t a l i z a t i o n w h i c h have l e d p a r e n t s  alternative  the  But do r e s u l t s  p o p u l a t i o n a p p l y t o c h i l d r e n as w e l l ?  hospital since  patients,  use,  d i f f e r e n t from  t h a t day c a r e s u r g e r y  adult  does  f o r i n p a t i e n t c a r e t o a major e x t e n t ,  and  that  2)  hospital  role  in children's  To my k n o w l e d g e , have a d d r e s s e d  bed a v a i l a b i l i t y hospital  does  not p l a y  utilization.  t h e r e have n o t been s t u d i e s  the f i r s t  issue  previously  in a child population.  on t h e s e c o n d a r e s c a r c e and b a s e d on c r o s s - s e c t i o n a l (Connell et al .  f  1981).  a major  that  Reports data  8 From a p o l i c y p e r s p e c t i v e , versus  generation  importance  to  in paediatric  in  is  of  for  paediatric  program.  central  surgery  support  On t h e o t h e r h a n d , is  might have i n t h e absence  surgical  facilities.  day c a r e  surgery  surgery B.C.  than i t  If  it  cannot  is  inpatient  For reasons  of  but mainly  after  the year  population  ratio  has  took  place  of in  inpatient  of  the case,  be m a r k e t e d as  effect. or  day  the  care  paediatric  a cost  saving  simultaneous  i n the t o t a l -  facilities  both adult  a p e r i o d of  o t h e r than day c a r e has  1975, b u t  and p a e d i a t r i c  the e a r l y  1980s.  beds  No p r e v i o u s  day c a r e s u r g e r y  of  day  care  population steady  in  bed the  in  increase  surgery,  taken place  1976. The p a e d i a t r i c  declined since  examined t h e e f f e c t of  than  increased,  (1983) on t h e i m p a c t  1968-1976  downsizing  rationing  other  facilities.  utilization  covered the years  is  accompanied by a  b y Evans e t a l .  on i n p a t i e n t  u s e may h a v e  the l a t t e r  program  unless  i n bed s u p p l y .  decrease  t h a t d e c l i n e may mask a g e n e r a t i o n  less  The s t u d y  paediatric  the  due t o r e a s o n s  declined  of  strong  a  if  hospital  adjustment  decrease  then there are both  The o v e r a l l volume o f  alternative  has  c a r e and c a u s e d a  to  for  concerning  day c a r e  arguments  hospitalization  surgery,  If  inpatient  hospitalization,  surgery  day c a r e  activity  care.  e c o n o m i c and p s y c h o l o g i c a l day c a r e  substitution  on f u t u r e p o l i c i e s  inpatient  substituted  of  hospital  in deciding  alternatives clearly  of  the issue  a B.C.,  to main  i n the  Province  studies  on i n p a t i e n t  have care  9 during  a p e r i o d of  reported studies utilization or  steady  on t h e b e d a v a i l a b i l i t y  have b e e n c o n d u c t e d d u r i n g  bed t o p o p u l a t i o n r a t i o s .  availability utilization hospital  d e c r e a s i n g bed s u p p l y .  and t h e e f f e c t o f  resources?  research into  In  The answer  that  has  of  analyze  this  making  increasing  on  to this  the r e s u l t s  question of  is  hospital  i n B.C.,  decline.  inpatient  there is  of  utmost  utilization  utilization  has  actually this  caused  study  between d a y c a r e s u r g e r y  is  information  study  tries  day  for  t o answer  the  part  and  further  services.  that  to  i n B.C.  i n order to provide health  concerning paediatric hospital this  in  no c l e a r e v i d e n c e  The p u r p o s e o f  and p o l i c y - m a k e r s  questions:  decreasing  with the i n c r e a s e  day c a r e s u r g e r y  and 1 9 8 1 / 8 2 - 1 9 8 2 / 8 3  specifically,  bed  inpatient  u t i l i z a t i o n i n the p a e d i a t r i c p o p u l a t i o n  1968-1976 planners  of  study  the r e l a t i o n s h i p  inpatient  hospital  Would t h e e f f e c t o f  day c a r e s u r g e r y  simultaneously  activity  the i n t r o d u c t i o n of of  periods  the d e c l i n i n g p a e d i a t r i c  taken place  care surgery  or a l l  e f f e c t on  the  policy.  Purpose of the  spite  most o f  be d i f f e r e n t i n a p o l i c y e n v i r o n m e n t o f  importance i n t r a n s l a t i n g  1.3.  Also,  care  decision  More  following  in  10 1)  Is the  increasing  surgery causally paediatric  availability  related  inpatient  2) Does p a e d i a t r i c  3)  inpatient  bed  availability the  utilization  differently  to resource a v a i l a b i l i t y  utilization  of the t o t a l  bed  availability  level  c a r e s u r g e r y and  on p a e d i a t r i c  such  inpatient  hospital  utilization decreasing  i n an e n v i r o n m e n t o f  no  constraints?  1.4.  Study  The  objectives  objectives  of t h i s  1) t o a s s e s s has  than  hospital  population?  o f day  facilities  of  respond  than  be d i f f e r e n t i n a p o l i c y e n v i r o n m e n t o f hospital  play a  utilization?  hospital  4 ) Would t h e i m p a c t  in  utilization?  inpatient  Does p a e d i a t r i c  care  to the decrease  major c a u s a l r o l e i n determining paediatric  of day  an  study  t h e e x t e n t t o which day  independent  paediatric w h i c h may  and  inpatient have an  utilization  are  significant  effect  surgery on  u t i l i z a t i o n when o t h e r  impact  have been  care  on p a e d i a t r i c  controlled.  factors  hospital  11 2)  to assess  availability inpatient  3)  environment  Underlying  Evans e t a l .  has  paediatric  an i n d e p e n d e n t e f f e c t on  inpatient  theories  (1983)  utilization.  of  hospital  surgery is for  In  on h o s p i t a l  two d i f f e r e n t w a y s .  this  bed a v a i l a b i l i t y  the impact  utilization to a  Unless  inpatient  of  overall  should  there are  or other health  principle  "unmet n e e d s "  every increase  model,  care  constraints,  it  Needs  professionals,  due t o  or medical  for  is  inpatient  r u l e d out  care  insufficient  i n day c a r e s u r g e r y  u t i l i z a t i o n exceeding needs,  occur i n t h i s  model  hospital  the h o s p i t a l  be one f o r one s u b s t i t u t i o n  over-utilization,  viewed  needs"  capacity  day  h a v e b e e n an i n p a t i e n t .  the c a p a c i t y of  capacity,  and  of  c a n be  "medical  c a r e a r e i n t e r p r e t e d and c o n v e r t e d i n t o  system.  theoretical  each c h i l d cared f o r by a day  by p h y s i c i a n s  and  hypotheses  framework  According  i n the absence  i n d e p e n d e n t l y of  care  between d a y c a r e s u r g e r y  a c h i l d who w o u l d o t h e r w i s e  utilization  policy  utilization.  inpatient  utilization,  unit,  hospital  equal.  between d a y  have p r e s e n t e d a s i m p l i f i e d  inpatient  in  being  a restraining  and s t u d y  on t h e r e l a t i o n s h i p  surgery  of  on t h e r e l a t i o n s h i p  framework  care  other things  the impact  availability,  paediatric  1.5.  bed  utilization,  to assess  surgery  the extent t o which h o s p i t a l  care.  could  use While  in  in practice  by  12 the assumptions providers  that providers'  decisions  r e s p o n d o n l y t o needs  According to a  "snppTy"  n e e d and d e c i s i o n s  as  c o n t r o l use and  ( Evans,  that  1984).  model, p r o f e s s i o n a l  t o a p p r o p r i a t e use a r e  perceptions  of  themselves  i n f l u e n c e d by the c a p a c i t y a v a i l a b l e .  An i n c r e a s e i n  hospital  bed s u p p l y w i l l  utilization in  the  population (Roemer  -  increase the h o s p i t a l  a phenomenon t h a t  and S h a i n ,  availability  1959; Roemer,  o f t e n c a l l e d Roemer's 1961).  d e t e r m i n e s u t i l i z a t i o n as  the decisions alternative  is  to h o s p i t a l i z e ,  to  inpatient  care  surgery  an e n a b l i n g  for a given  stock  of  and  substitution Unless care  inpatient  surgery  t h e beds  occurs  is  at  inpatient  that  it  facilities  are reduced to  generation  new h o s p i t a l  to  Day  either  some level,  or  both.  effect will  be a c c o m p a n i e d  day  be  at  by  utilization.  d e c r e a s e i n i n p a t i e n t bed s u p p l y w i t h  i n day c a r e s u r g e r y  c a p a c i t y c o u l d l e a d t o more  and l e s s  from day c a r e s u r g e r y  that  an  same e x t e n t as  i n c r e a s e d , any s u b s t i t u t i o n  generation  in  hospital  services,  the i n d i v i d u a l p a t i e n t  and d a y c a r e s u r g e r y w i l l  Simultaneous  as  capacity.  f r e e s up i f  most p a r t i a l , of  variable  therapeutic  w o u l d r e p r e s e n t an i n c r e a s e i n t o t a l  through  resource  care could serve only or p r i m a r i l y  c a p a c i t y c r e a t i n g more demand f o r h o s p i t a l directly,  hospital  then day c a r e s u r g e r y  e x p a n d t h e o v e r a l l volume o f d i a g n o s t i c interventions,  If  Law  substitution  only in  g e n e r a t i o n works t h r o u g h v a c a t e d b e d s .  increase  condition  Substitution  leads  13 to  lower o c c u p a n c y f o r any g i v e n bed s t o c k .  unused bed c a p a c i t y i s  cut o f f  new demand f o r h o s p i t a l  without  services,  u t i l i z a t i o n s h o u l d emerge.  inpatient  bed c a p a c i t y i s  less  is  utilization surgery  is  inpatient care  falls  If  unused c a p a c i t y  vacated  In well  (i.e.,  generation  it  is  beds  faster beds  is  new h o s p i t a l  through  In  Roemer's  situations  decreasing.  increases  is  substitution  Law has  In  care  reduced. If  day  t h e n one w o u l d  directed only to been l e s s  than  u s e may s t i l l  and  care  expect day already  100 result  and s u b s e q u e n t  b e e n assumed  o t h e r words,  when beds  t o work  from  fill  in  affects  to h o s p i t a l i z e .  inpatient utilization  hospital  use,  their hospitalization  t h a n upwards  to a  when b e d  as  supply  utilization  are reduced, a f t e r adapting  hospital  is  are reduced  p r a c t i c e by i n t e r v e n i n g  in revising  when b e d s of  and where  One c a n h y p o t h e s i z e t h a t p h y s i c i a n s  more d i f f i c u l t i e s  level  equally  increasing  are added. A c c o r d i n g t o the  t h e way i n w h i c h p h y s i c i a n s  higher  day  where  than i n absence of  where bed c a p a c i t y i s  model bed a v a i l a b i l i t y  downwards  in  inpatient  e x p e c t e d t o d e c l i n e t h e same amount when beds it  create  an e n v i r o n m e n t  that  role,  o c c u p a n c y has  of  to  beds.  general, in  fall  r e d u c t i o n of  day c a r e s u r g e r y of  Law i m p l i e s  a substitution  u t i l i z a t i o n to  it  r e p r e s e n t i n g more s u b s t i t u t i o n  when s u p p l y o f  playing  surgery.  percent),  Roemer's  allowing  generally decreasing,  not n e c e s s a r i l y  generation.  resultant  then net reduction  inpatient  surgery  If  through decisions will  have  patterns certain capacity  14 is  increased.  decrease to  the  in hospital  decline in  models  -  the  in this  beds  has  is  reduced,  ceiling.  o c c u r r e d so  up  In  seldom  r e s e a r c h r e s u l t s ion R o e m e r ' s  study w i l l  surgery  has  inpatient  is  test  If  found,  substitution  Law  in  'satisfied less,  has  the o v e r a l l  The n u l l  it  Put  of  Roemer's  is  that  the h o s p i t a l  substitution  w o u l d mean t h a t  is  day c a r e s u r g e r y  hospital  substitution).  utilization  The s t u d y  paediatric  causal  e f f e c t on p a e d i a t r i c  that  things  being  equal.  acts  of  If  paediatric  an  hospital day  care  utilization.  m e r e l y as  bed c a p a c i t y h a s  the  care  n e t new  i n respect  inpatient  supported  day  ( s t r a i g h t add-on,  hypothesis  hospital  bed  environment.  with generation  a  care  m o d e l w o u l d be  need'  words,  Law i n  day  in  paediatric  no i n d e p e n d e n t e f f e c t on i n p a t i e n t that  model -  i n other  one t o one  hypothesis  competing  "supply"  e f f e c t on  "medical needs"  also associated  implies  that  14 y e a r s ) .  i r r e s p e c t of  effect is  utilization. surgery  (0.-  an i n d e p e n d e n t , the  t h e two  m o d e l and t h e  the a p p l i c a b i l i t y  utilization  is  to test  The s t u d y h y p o t h e s i s  and t h e r e w o u l d be a  surgery  is  an i n d e p e n d e n t c a u s a l  availability. effect  study  population  child population.  is  of  "medical needs"  a paediatric  This  supply  its  resist  situation.  The e m p h a s i s  this  could t r y to  u t i l i z a t i o n when bed s t o c k  t h e r e a r e v e r y few  this  physicians  l e v e l where o c c u p a n c y r a t e r e a c h e s  practice, that  In t h e o r y ,  add-on  to  no  t o bed  supply  independent  utilization  all  other  15 1.6.  Thesis  Format  C h a p t e r two i n t h i s  thesis  contains  i n t r o d u c i n g a day c a r e s u r g e r y  t h e arguments  p r o g r a m as  inpatient  care. Attention is  inpatient  u t i l i z a t i o n t o day c a r e s u r g e r y  bed s u p p l y  also discussed.  of  confounders surgery  in  paediatric  This discussion  previously published  studies  studying  an a l t e r n a t i v e  a l s o paid to the response  i n determining hospital  other determinants  for  utilization.  and aims t o r e v e a l  are  of  potential  between d a y  u s e and i n p a t i e n t u t i l i z a t i o n i n a  of  Potential  b a s e d on a r e v i e w  the r e l a t i o n s h i p  of  and t o t h e r o l e  inpatient u t i l i z a t i o n is  for  care  paediatric  population.  Chapter three describes used i n  this  study.  c o n s t r u c t i o n of described. analysis,  Chapter  is  of  the data.  method, l i n e a r  and are  also  regression  the r e s u l t s  follows  Impacts of  that  of  of  this  study.  Sequence  the s t a t i s t i c a l  analysis  d i f f e r e n t p o t e n t i a l confounders  between p a e d i a t r i c d a y c a r e s u r g e r y  u t i l i z a t i o n a r e examined g r a d u a l l y . is  sources  presented b r i e f l y .  presentation  relationship  data manipulation  i n d e p e n d e n t and d e p e n d e n t v a r i a b l e s  four describes  this  emphasis  Necessary  Main s t a t i s t i c a l  of  inpatient  t h e r e s e a r c h d e s i g n and d a t a  in revealing potential causal  use  on t h e  and  The m a i n  associations  and  16  testing  t h e two c o m p e t i n g m o d e l s  and t h e  "supply model".  Chapter  f i v e discusses  reference to  the r e s u l t s  the  study.  of  "medical needs"  this  s t u d y o b j e c t i v e s and q u e s t i o n s .  paid to p o l i c y implications. of  - the  Chapter closes  study  model  with  Attention is with  also  conclusions  17  2.  LITERATURE  2.1.  Roth  REVIEW  Why n o t i n p a t i e n t  (1972)  has  care?  d i v i d e d the c r i t i c i s m of  care into three categories. b a s e d m a i n l y on t h e s t u d i e s  hospital  One c a t e g o r y o f and c r i t i c a l  and p u b l i c h e a l t h s p e c i a l i s t s  criticism  and m e d i c a l c a r e  and p s y c h o l o g i s t s .  A third is  i n the f i r s t  category reveal physical  of being h o s p i t a l i z e d .  potential  as w e l l as  i n c r e a s e d p r o b a b i l i t y of acquired infections, errors  (Schimmel  benefits.  iatrogenic  and m i s h a p s  1964; G r o s s ,  surprisingly  countries  scarce,  5 percent  of  it all  is  among t h e w a r d s ,  surgical  wards,  gynecological in  England  paediatric  These r i s k s  of and  has  include  complications,  hospital-  c a u s e d b y human and t e c h n i c a l 1972).  Although  hospital-acquired  assumed t h a t  (Van F u r t h ,  the highest  usually  infections  i n developed  admitted patients  infection during hospitalization varies  Any a d m i s s i o n  1966; R o t h ,  i n f o r m a t i o n on t h e i n c i d e n c e o f is  sociologists  b a s e d m a i n l y on t h e a n a l y s e s  medical hazards risks  medical  investigators.  b a s e d l a r g e l y on t h e work o f  Studies  is  commentary o f  Another category i s  economists.  inpatient  will  acquire  1982).  an  The r a t e  being reported for  f o l l o w e d b y t h e m e d i c a l and o b s t e t r i c a l -  wards.  Large  surveys  and W a l e s showed t h a t  of  infections  22.1 p e r c e n t o f  beds h a d c o m m u n i t y - and 4.1  percent  in  hospitals  patients  hospital-  in  18 acquired infection of  (Meers e t a 1 .  hospital-acquired  i n New Y o r k rate  of  State  infections  than those  complications percent of  all  complications  patients  the  (Welliver  s t a y and t h u s In  accidents  and d i s e a s e s  literature papers al.  f  instances  that  use of  Duff  care.  p a e d i a t r i c wards However,  general  et a1.  Misuse  1984)  (Istre et a 1 .  r  of because  (197 2)  hospitals paediatric of  other drugs accounted care.  and t h e 1 9 8 0 s .  and m y s t e r i o u s  for  Iatrogenic  have a p p e a r e d i n t h e s c i e n t i f i c  et a l . ,  was  portion  o n e - t h i r d of  of questionable  i n f r e q u e n t l y i n t h e 1970s  Solomon  the  go u n n o t i c e d ,  have m a i n l y d e a l t w i t h m e d i c a t i o n e r r o r s  1970;  20  admissions  t h r e e community  than optimal  and q u e s t i o n a b l e  hospital  Major  a great  harm t o t h e p a t i e n t .  and one m a j o r t e a c h i n g h o s p i t a l  79 percent of  treatment  befell  reflects  addition,  i n a u t i l i z a t i o n review of  antibiotics  to  1984).  untoward e p i s o d e  m e d i c a t i o n and t e c h n i c a l e r r o r s  received less  attack  and M c L a u g h l i n ,  f i v e percent of  hospitalization.  hospital  percent  admitted to h o s p i t a l .  length of  study  community.  The p r o b a b i l i t y o f  t h e y do no s e r i o u s  patients  paediatric  t h e t y p e and f r e q u e n c y o f  occurred in  r e l a t e d to  showed  in a large  showed t h a t d e l e t e r i o u s e p i s o d e s  1964).  nursing,  A prospective  t e n d t o be more r e s i s t a n t  study of  (Schimmel,  hazard of  infections  acquired i n the  A prospective  1981).  showed e x a c t l y t h e same 4.1  nosocomial  Hospital  infections  f  medical  Published  (Hynniman e_£ deaths  1985; B u e h l e r e t a l . ,  t h e g e n e r a l news m e d i a a n d , p a r t i c u l a r l y t h e  in 1985). legal  19  arena  seem t o h a v e p i c k e d up t h i s  subject with  increasing  interest.  The of  second  category of s t u d i e s r e v e a l s p s y c h o s o c i a l hazards  hospitalization.  disrupted,  In the h o s p i t a l ,  n o t so much b y one's i l l n e s s  the organization of routines designed o t h e r p e o p l e who a r e n o t i n t e r e s t e d but o n l y i n v e r y l i m i t e d of  control  living)  o v e r one's t r e a t m e n t  a n u i s a n c e t o an a d u l t . can p r e c i p i t a t e  i n one's o v e r a l l w e l f a r e , 1972).  ( a n d many a c t i v i t i e s  environment  But f o r a c h i l d  The m e n t a l  b u t by  f o r the convenience of  The l a c k of d a i l y  c a n be, a t b e s t , a hospital  s h o r t - and l o n g - t e r m e m o t i o n a l  1964).  i s totally  o r treatment,  a s p e c t s o f i t (Roth,  together with a l i e n  (Schimmel,  one's l i f e  just  experience  problems  wellbeing of hospitalized  c h i l d r e n became a m a j o r c o n c e r n when t h e s i g n i f i c a n c e  of the  m o t h e r - c h i l d r e l a t i o n s h i p t o t h e development o f t h e c h i l d r e c o g n i z e d d u r i n g t h e 1940s the  1950s a s e r i e s  despair, 1970).  detachment i n h o s p i t a l i z e d Although  effect  children  1951).  e n t i r e l y on p h y s i c a l  f o rthe social  t h e n , and t h e care with  upsetting  o f h o s p i t a l i z a t i o n has n o t t o t a l l y d i s a p p e a r e d  provide a thorough psychological  after  V e r n o n e t a l . (1965)  review of the l i t e r a t u r e  effects  protest,  and e m o t i o n a l needs o f  and t h e i r p a r e n t s , t h e p s y c h o l o g i c a l l y  the r e c o g n i t i o n of these hazards.  In  ( R o b e r t s o n , 1953,  p a e d i a t r i c wards were d i f f e r e n t  o r no c o n c e r n  children  1945; F r e u d ,  o f s t u d i e s d e s c r i b e d t h e syndrome:  e m p h a s i s was c e n t r e d a l m o s t little  (Spitz,  was  of h o s p i t a l i z a t i o n .  on t h e Several studies  20  showed t h a t p e r i o d of several  the emotional disturbances  hospital  stay but continued  days o r even y e a r s .  setting,  separation  from p a r e n t s  hospital  Findings  setting  as  two d i f f e r e n t t y p e s psychological  that  of  the h o s p i t a l  upset  appear  less  upset  these  seem much l i k e  there  is  findings changes  playroom  care  spite  of  distress  showed t h a t  in well children's f  time  However, the  1965).  The  a major r o l e  in  behavior  children progress. ways, to  to  suggest  others.  In  b e f o r e t e n d t o be more  t h a n t h o s e who a r e (Azarnoff,  from  they  an  On t h e o t h e r h a n d ,  surgery  n o t p r e p a r e one f o r a l l  the  showed  reactions  1965).  of  on  on c h i l d r e n ' s  hospitalization  (Vernon e t a 1 .  f o r the f i r s t  f  c a n be i n t e r p r e t e d v a r i o u s  c h i l d r e n who h a v e had s u r g e r y  surgery  (Vernon e t a 1.  These d a t a  operations  the  came  disturbances.  growing evidence r e l a t e d t o  subsequent  in  experience d i d not reduce  o r h a p p i e r as  one o p e r a t i o n d o e s  about  Controlled t r i a l s  came f r o m s t u d i e s  hospitalization.  unfamiliar  upset  emotional problems  psychological  during  Although  t h e c h i l d were t h e  suggesting that u n f a m i l i a r i t y plays  psychological  hospital  preparation p r i o r to h o s p i t a l i z a t i o n  p r e p a r a t i o n f o r the h o s p i t a l  other data  of  the  the  for  pointed to the u n f a m i l i a r i t y  studies.  decreased posthospital  anxiety during  and age  psychological  a source of of  l i m i t e d to  after discharge  U n f a m i l i a r i t y of  most s u p p o r t e d d e t e r m i n a n t s literature.  were n o t  that fact  anxious  experiencing  1975; C r o c k e r ,  1978).  t h e r e c e n t improvement i n many p a e d i a t r i c w a r d s , w h i c h y o u n g c h i l d r e n e x p e r i e n c e when t h e y  are  In  the  21 admitted to h o s p i t a l siblings,  Data this  and home e n v i r o n m e n t i s  still  r e l e v a n t to the e f f e c t s of  factor  following  contributes  1965).  indicate and  a positive  s e p a r a t i o n and p s y c h o l o g i c a l  c o n t r o l l e d study  that  the  complications  significantly  (1968)  i n c i d e n c e of  that  immediately relationship  upset  (Vernon  h a v e shown i n  a  emotional  l o w e r i n c h i l d r e n who  h o s p i t a l i z e d w i t h t h e i r mother than i t  parents,  there.  separation  There i s  B r a i n and M a c l a y  is  from t h e i r  to upset both during  hospitalization.  between d e g r e e of e t a 1.,  and t h e r e b y s e p a r a t e d  is  with  are  unaccompanied  children.  The i n v e s t i g a t i o n s curvilinear  age  suggested that  r e l a t i o n s h i p between t h i s  psychological months  involving  upset.  and t h r e e t o  variable  four years  of  infants  vulnerable.  age a p p e a r e d t o  reactions  following  a l 1 9 6 5 ) . loss  of  r e l a t i o n s h i p was  less  hospitalization; less  c l e a r , when  children's  h o s p i t a l i z a t i o n were c o n s i d e r e d  ( V e r n o n e_£  O l d e r c h i l d r e n may be p a r t i c u l a r l y c o n c e r n e d w i t h  i n d e p e n d e n c e and c o n t r o l as w e l l as  during hospitalization  The t h i r d c a t e g o r y o f treatment  six  be  and o l d e r c h i l d r e n a p p e a r e d t o be  This  a  and  C h i l d r e n between a p p r o x i m a t e l y  p a r t i c u l a r l y vulnerable to upset during younger  there is  is  (Petrillo  body  and S a n g e r ,  c r i t i c i s m argues t h a t  disfigurement  1972).  hospital  an e x t r e m e l y c o s t l y way t o t r e a t most  ailments  22 (Roth,  1972).  Evans pt. a l .  calculated that percent wards.  less  a paediatric  hospital  the i n d i v i d u a l p a t i e n t , burden to Canadian  dollar  surgery  i n day c a r e s u r g e r y  Although  1946 t o  (1978) h a v e  , for  episode  unit  treatment costs  expenditure. share of  During  f r o m 1.27 percent  a percentage of  Expenditures  the t o t a l ,  in  1971  i n B.C.  (Evans,  (Province  Even a s m a l l  of  showed  1984).  of  In  rapidly,  both  c a r e made up t h e t h e most r a p i d  product i n  t h e mid 1980s,  Columbia,  expenditures  1985).  care to  savings  provincial  level.  that  development of  less  recommended as  a m a j o r means  hospital the  expenditures  1970s  Canadian  (Canada,  lowering 1964  ).  services and In  h e a l t h c a r e s y s t e m and t o  shift  Health Ministers,  1972).  at  the p o l i c y  One o f  of  National  H e a l t h and W e l f a r e  in  of  whole emphasis  centres the  major  b e h i n d t h e community h e a l t h c e n t r e p r o j e c t , s e t  the M i n i s t e r  the  been  the beginning  c a r e t o p r o p o s e d community h e a l t h  (Conference of  has  less  controlling  an a t t e m p t was made t o r e s t r u c t u r e t h e  from h o s p i t a l  reasons  no wonder  expensive outpatient of  3.33  hospital  c o u l d mean c o n s i d e r a b l e is  in  growth:  expensive a l t e r n a t i v e s  It  from  largest  1946 t o  i n u t i l i z a t i o n from h o s p i t a l  or national  to  national  the p u b l i c h e a l t h care  British  shift  inpatient  are not a t h r e a t  total  gross n a t i o n a l  c o s t s make a b o u t h a l f  70  the q u a r t e r century  on h o s p i t a l  and a l s o  percent of  50 -  t h e y a r e i n a g g r e g a t e an e c o n o m i c  tax payers.  and as  costs  t h a n on t h e  1971 h e a l t h c a r e e x p e n d i t u r e s r o s e terms  example,  1971, was  up by a  23 belief  that  some s h i f t  hospital  inpatient  means  slowing  of  spending.  is  to benefits  iatrogenic of  that  it  of  stay.  produces.  The r i s k  o r ambulant  with  in  of  infection  increases  care and  increasing  also expensive r e l a t i v e  on c h i l d r e n a r e a s p e c i a l  These reasons  services  1972).  hospital-acquired  effects  of  concern  in  emphasize t h e need f o r  c a r e from a c t i v e h o s p i t a l  inpatient  health care o f f e r a  Every episode  care. Undesirable psychosocial  paediatrics.  acute  a l w a y s some d i s a d v a n t a g e s  Inpatient care i s  hospitalization  on  increase in health  c a r e has  with r i s k  of  Health Ministers,  complications.  ambulatory  patient  the r a t e of  inpatient  associated  length  c a r e t o o t h e r forms  (Conference of  Hospital addition  from t h e p r e s e n t emphasis  admission  to  f a c i l i t i e s whenever i t  to  shifting  alternate  is  medically  possible.  Hospital  c e n t r e d h e a l t h c a r e system i s  many d e v e l o p e d c o u n t r i e s other arrangements.  because of  The i n t e r n a t i o n a l  emphasized a l t e r n a t i v e approaches problems  of  the p o p u l a t i o n  Lalonde Report but  in  very of  spite  little  its  (Lalonde,  of wide use  (WHO,  1974)  losing  high costs  was  glamour  in  relative  to  community has  in solving 1978,  its  the  1979).  health  In  a move i n t h i s  i n p o l i t i c a l speeches,  it  Canada,  p o p u l a t i o n as  for decreasing  has  had  Despite  inpatient u t i l i z a t i o n in  a w h o l e and i n t h e c h i l d p o p u l a t i o n ,  the  direction,  i m p a c t on C a n a d i a n h e a l t h c a r e p o l i c i e s .  the r a t i o n a l e  also  in  the  24 particular, direction.  there are factors  w h i c h work  for historical  the H o s p i t a l the  1950s,  Canadian provinces  This  Secondly,  universal  functions  the p r o v i s i o n  Crichton  than  just  (1972)  describes  community c a r e .  for  communities  organized,  of  "Hospitals  i n Canada.  close hospitals  to  Canadian  open.  appears  for  systems,  This  t o be  is  less material hard  to  an  politically  once t h e y have been opened  for  1972, p.  (Crichton,  isolated  are  employment and f o c u s e s  towns"  of  find i t  because they are centres of small  As  a r e symbols  They p r o v i d e p o t e n t  d e t e r m i n e d t o keep l o c a l h o s p i t a l s  impossible  Canada  i n the  e m o t i o n a l community g r o u p s who  It  in  1978).  and t h e p o l i t i c i a n s  phenomenon.  in  hospital  health services.  transportation  international  and and  (Taylor,  They p r o v i d e a s e c u r i t y b l a n k e t  p o l i t i c a l controversy  resist  hospitals  of  h a v e a l s o o t h e r , more c o v e r e d  it:  w i t h t h e improvement o f  isolated  1940s  insurance  introduced before the medical insurance  Hospitals  Western  up a c o n s i d e r a b l e  hospital  d e c i s i o n enhanced t h e r o l e of  more  with the help  i n the l a t e  built  h e a l t h care system.  and,  Firstly,  opposite  probably  i n many o t h e r  reasons.  C o n s t r u c t i o n Grants  bed c a p a c i t y . was  to the  The C a n a d i a n h e a l t h c a r e s y s t e m i s  h o s p i t a l - c a r e - o r i e n t e d than that countries  just  5-1).  of  business  25  2.2.  Day c a r e s u r g e r y  2.2.1.  There i s surgery. allows  no g e n e r a l l y  admission  this  (1980)  and i s  outpatient day case  1980).  day c a r e s u r g e r y  surgery  surgery  exceptions  (e.g.,  of  delivering  (Atwell  a hospital,  The to  When d a y c a r e s u r g e r y  offices.  often  housed i n In  ambulatory  hospitals United  (Cloud,  Columbia,  the M i n i s t e r and s h a l l  of  with  few  which  are  1972).  (Province  Health s h a l l  surgery.  for  became an i n s u r e d h o s p i t a l  Insurance Act Regulations  or  States,  have become a n o t h e r m o d e l services  In  called  needed a l s o a j u d i c i a l d e f i n i t i o n .  services  outpatient  and s h o r t - s t a y  to the Hospital 1968)  Robinson  from  1961),  patient  care,  often called surgicenters,  day c a r e s u r g i c a l  it  is  1973)  abortion c l i n i c s ) .  facilities,  1968,  and D u d l e y ,  et a ] . ,  day c a r e surgery  freestanding not p a r t  (Stephens  is  It  elective  treatment with regard  distinguish  which  surgery.  reserved for  l i t e r a t u r e , day c a r e s u r g e r y  Canada,  surgical  service  w h i c h c o u l d be done as w e l l i n d o c t o r s '  the medical  in  on t h e d a y o f  care  a n d m e d i c a l r e c o r d s as w o u l d an i n p a t i e n t .  surgery,  B.C.  to h o s p i t a l  ( R o b i n s o n and C l a r k e ,  t h e same h o s p i t a l  and C l a r k e  In  term r e f e r s  anaesthesia  operative procedures  safety,  a c c e p t e d d e f i n i t i o n f o r day  and d i s c h a r g e  general  receives  care  Definition  Usually  requires  - alternative for inpatient  benefit  in  According of  d e f i n e day  British care  s p e c i f y the b e n e f i t s which are  to  26 be made a v a i l a b l e . provision as  of  this  to the type of  A t t h e t i m e t h e d e c i s i o n was made b e n e f i t , t h e r e was  c a s e t h a t w o u l d be s u i t a b l e  and d i s c u s s i o n  a l s o of  and p r o c e d u r e  (Province  c o n s i d e r a t i o n was list  of  considerable  of  British  Columbia,  it  constant  amendment,  clerical  p e r s o n n e l w o u l d have c o n t i n u i n g  that  was  such a l i s t  admitting  a constantly  therefore decided that  what was  d e a l i n g w i t h the problem  The d e f i n i t i o n o f is  (Province  i n B.C.  services  a r e a compact f o r m o f  therefore  of  procedures  changing  eligible  British  eligible  for  inpatient  list. of  of  Columbia,  1983).  insurance  surgical  c a r e , and as  control considerations  such,  provided  i n the h o s p i t a l s  to  are  expected to p r o v i d e a complete m e d i c a l r e c o r d f o r and t h e s e r e c o r d s a r e s u b j e c t  r e v i e w t a k e n by t h e h o s p i t a l ' s quality  1983).  Medical  Records  c o n t r o l , and a l s o t o a s s i s t  proper u t i l i z a t i o n of Columbia,  of  The a t t e n d i n g p h y s i c i a n s  day c a r e a d m i s s i o n ,  establish  to  hospital  b a s e d an i d e a t h a t d a y c a r e  d e s e r v e t h e same q u a l i t y inpatients.  and  a s u p e r i o r method  day c a r e s u r g e r y  benefits  eligible.  a broad general d e f i n i t i o n  i n t e n d e d f o r c o v e r a g e was  a  difficulties  d i a g n o s e s and t y p e s of  Serious  w o u l d be s u b j e c t  r e v i s i o n and a d d i t i o n s ,  a g a i n s t the background It  1983).  cases  g i v e n t o the development of  However,  interpreting  coverage,  t h e method o f d e f i n i n g a c c e p t a b l e  originally  felt  discussion  for  p r o c e d u r e s and d i a g n o s e s w h i c h w o u l d be was  for  t h e program  (Province  The p r i m a r y g r o u p o f  of  to  the  Committee in  cases are  usual to  assessing  British those  a  27 elective  and n o n e l e c t i v e d i a g n o s t i c  procedures general  r e q u i r i n g t h e use o f  anaesthetic.  and/or  hospital  An a d d i t i o n a l  treatment  facilities  and a  group which a r e  acceptable  a r e t h o s e p r o c e d u r e s w h i c h w o u l d n o r m a l l y be c a r r i e d o u t general  anaesthesia,  e l e c t e d t o use cases  b u t where t h e a t t e n d i n g  l o c a l anaesthesia.  A t h i r d group  of  anaesthesia.  It  is  are required for cystoscopy, gastroscopy,  this  complete h o s p i t a l  that hospital  bronchoscopy,  p r o c e d u r e does  facilities,  o f f i c e or h o s p i t a l  however,  felt  e t c , , and o c c a s i o n a l l y  sigmoidoscopy,  full  services  such cases t h i s A f o u r t h group  acceptable  of  esophagoscopy,  not normally  and i s  usually  require  Occasionally,  may be r e q u i r e d , and  acceptable procedures are those surgical  Simple  as  toenails,  cysts,  removal of warts,  "minor surgery"  or h o s p i t a l  recognized that  outpatient  related  procedures etc.,  , and c a r r i e d o u t as service.  certain plastic  However,  surgical,  it  a  and a t t e n t i o n w h i c h may c a l l facilities  for  (Province of  full  to  are  is  ophthalmological,  operating  British  such  simple  and o t h e r p r o c e d u r e s on t h e f a c e do r e q u i r e a d e g r e e o f  hospital  in  p r o c e d u r e s w h i c h may be  c a r r i e d out under a l o c a l a n a e s t h e t i c .  c o n s i d e r e d as  a  e n d o s c o p i c p r o c e d u r e w o u l d t h e n be a c c e p t a b l e . of  e x c i s i o n of  Regarding  p e r f o r m e d as  service.  the h o s p i t a l  local  facilities  sigmoidoscopy.  outpatient  c e r t a i n c o s m e t i c and p l a s t i c  office  has  are endoscopic procedures c a r r i e d out under e i t h e r  or general  simple  physician  under  care  room and  Columbia,  1983).  other  28  2.2.2.  A b r i e f h i s t o r y of p a e d i a t r i c day c a r e  Day c a r e s u r g e r y has but i t  has  been p r a c t i c e d f o r a l m o s t  been o n l y d u r i n g t h e l a s t  g a i n e d more i m p o r t a n c e . series  of  Hospital  for Sick  a much l a r g e r hospital  James N i c h o l l i n  p e r f o r m e d f r o m 1899 t o Children  share of  1908 a t  (Nicholl,  facilities  b a s i s was  a waste  the Glasgow  1909).  of h o s p i t a l  children.  resources.  children reported a series  economy, and c o n v e n i e n c e .  1,000  as  operative Clatworthy  (1968)  18 months  of  (Lawrie,  of  operations  1909).  Many o f  i n an  these  outpatient safety,  Children's and c h i l d r e n post-  1957, O t h e r s e n and  began p e r f o r m i n g h e r n i o r r a p h i e s on age on a d a y b a s i s  In  indirect  1949, t h e E v e l i n a  In  young  for  f o r reason of  1964).  and  in  Sick  i n order to reduce the i n c i d e n c e of  infections  treated  for  i n L o n d o n s t a r t e d o p e r a t i n g on i n f a n t s  day cases  under  admission In  use  t h e r e more  h e r n i a i n c h i l d r e n ( H e r z f e l d , 1938).  f a c i l i t y without h o s p i t a l  that  easily  (Nicholl,  were o p e r a t e d upon u n d e r g e n e r a l a n e s t h e s i a  Hospital  and t h a t  infants  Edinburgh H o s p i t a l of  Royal  children's  Patients  arms and r e s t  q u i e t l y on t h e w h o l e t h a n anywhere e l s e 19 38, H e r z f e l d a t t h e R o y a l  after  He c o n c l u d e d  He a d d e d t h a t a f t e r o p e r a t i o n t h e y a r e  c a r r i e d home i n t h e i r m o t h e r ' s  has  who c a n be h a n d l e d on a d a y  t h e o u t p a t i e n t d e p a r t m e n t s h o u l d be l a r g e l y  inguinal  outpatients  t h e o p e r a t i v e work i n a  for patients  it  1909 r e p o r t e d a  s h o u l d be done on an o u t p a t i e n t b a s i s  inpatient  a century,  two d e c a d e s t h a t  8,988 p a e d i a t r i c c a s e s t r e a t e d as  operations  surgery  infants  and r e p o r t e d no m a j o r  29 complications or deaths i n over period.  infections  i n V a n c o u v e r has children  capacity  day  2.2.3.  Several  an  1960s, and  1955;  S t e p h e n s and  Clatworthy,  1968; f  Its suitability  1978), ophthalmology (Smith  and  care  Dudley,  this  f  1971).  surgery  of day  1961;  I n n e s e t a 1.  1971;  care  care  hospitalization  Lee,  has  urology  f  1964;  Chiang  Shah e t a l .  Lord,  1974;  et r  Lewis,  been d e m o n s t r a t e d  including dental  (Hadaway e t a 1 .  Lawrie,  1968;  f  1971;  Rudd, 1973;  Young, 1 9 7 6 ) , and  day  i t established  e t a 1.  feasibility  for children  several specialties,  1969  (Davenport  a l t e r n a t i v e to acute  A t w e l l e t a 1 . . 1973;  1975).  Children's Hospital  i n October  care surgery u n i t  Davenport et a 1 .  1968;  1972;  with  and  The  I t began d e v e l o p i n g  S a f e t y o f p a e d i a t r i c day  (Farquharson,  r  late  Columbia.  year  reduction i n post-  been a l e a d e r i n p r o v i d i n g s u r g i c a l  s t u d i e s h a v e shown t h e  s u r g e r y as  Othersen  i n outpatients.  in British  i n the  a nine-bed  •al •  patients during a ten  They a l s o r e p o r t e d a s i g n i f i c a n t  operative  for  350  (Smith  1977),  et a l . .  orthopedics  ( K r o o v a n d and  Perlmutter,  1978).  Shah e t trial  al.  (1972) c o n d u c t e d  on m e d i c a l  to paediatric  day  a quasirandomized  c o m p l i c a t i o n s and  controlled  parental attitudes related  care surgery at Children's H o s p i t a l i n  Vancouver.  F i v e s u r g i c a l procedures  - hernia  cystoscopy,  s q u i n t r e p a i r , m y r i n g o t o m y , and  repair,  dental  restoration  30 -  were s e l e c t e d f o r s t u d y b e c a u s e t h e y c o m p r i s e d a b o u t  percent of  all  s e l e c t e d as  surgical  suitable  procedures at  that  t i m e w h i c h had b e e n  f o r s u r g e r y on a d a y b a s i s .  t h e c o n t r o l g r o u p were a d m i t t e d t o t h e ward f o r after  surgery,  patients  patients  disposition number o f  (e.g.,  patients  the s i t e  of  p o s t o p e r a t i v e day  compared  whereas a s i g n i f i c a n t l y  unhappiness).  A significantly  general larger  o p e r a t i o n a f t e r h e r n i a r e p a i r and p a i n f u l  control  group.  It  was  compared t o t h e p a t i e n t s  suggested that p a r t of  due t o b e t t e r o b s e r v a t i o n o f  home t h a n b y t h e n u r s i n g  staff  in  this  the h o s p i t a l .  parental choice indicated that  78 p e r c e n t o f  difference  The  t h e r e m a i n d e r would have been s a t i s f i e d  authors  (Shah e t a 1 .  c o n c l u d e d t h a t day c a r e s u r g e r y  acceptable,  not only to p h y s i c i a n s ,  a l s o mentioned t h a t  is  f  safe  at  studies  parents  i n v o l v e d i n the day c a r e s u r g e r y group p r e f e r r e d i t ,  n i g h t had been s p e n t i n h o s p i t a l  the  c h i l d r e n by t h e i r p a r e n t s  at  percent of  larger  i n t h e day c a r e s u r g e r y group r e p o r t e d p a i n  a f t e r cystoscopy  of  cough  proportion  i n t h e c o n t r o l g r o u p had a p o o r  voiding  was  not  i n t h e d a y c a r e s u r g e r y g r o u p had a c o u g h on t h e  i n the c o n t r o l group,  number o f  were  and  except f o r greater  in  3 days  The a n a e s t h e t i c  A significantly  o p e r a t i o n and on t h e f i r s t  to those  at  surgery.  d i f f e r e n t i n t h e two g r o u p s ,  and g e n e r a l d i s p o s i t i o n .  day of  1 to  c o m p l i c a t i o n s were few and m i l d i n d e g r e e and  significantly  of  Children  and t h o s e i n t h e d a y c a r e s u r g e r y g r o u p  d i s c h a r g e d home t h e d a y o f general  82  and 75  if  only  1972).  The  one  and  but a l s o to p a r e n t s .  t h e w i d e s p r e a d p u b l i c i t y of. t h e day  They care  31 surgery  unit  physicians  had r e s u l t e d i n p a r e n t s  for this  The r a t e o f surgery  seems  form of  surgical  patients  of  to h o s p i t a l  Davenport e t a l .  approximately 5 percent of B.C.  admission  cough),  have r e p o r t e d lower a d m i s s i o n  In  spite  of  rates:  and 1.7  study r e s u l t s  day c a r e s u r g e r y , medical  1973)  found  care  were  (hoarseness  reasons  or  and v o m i t i n g .  croupy  Others  9 o u t o f more t h a n  percent  care  that  The most f r e q u e n t  were r e s p i r a t o r y p r o b l e m s  (Steward,  (1971)  Children's Hospital  a d d i t i o n a l medical problems,  children  a f t e r day  t h e c h i l d r e n who were d a y  subsequently admitted to h o s p i t a l . for  attending  care.  subsequent admission to vary.  asking t h e i r  (Ahlgren,  8,500  1973).  on t h e s u i t a b i l i t y and s a f e t y  some c o n t r o v e r s y seems t o r e m a i n i n  community i n r e s p e c t t o c e r t a i n s u r g i c a l  of  the  procedures.  T o n s i l l e c t o m y and a d e n o i d e c t o m y , b y f a r t h e most common surgical usually  p r o c e d u r e i n c h i l d r e n (Wennberg and Kimm, considered unsuitable  f o r s u r g e r y on a d a y b a s i s  t h e m e d i c a l community  (Shah and R o b i n s o n ,  Evans e t a 1.  However, C h i a n g e t a 1 .  on 4 0,000 without  f  1983).  1977),  1977; S h e p s , (1968)  t o n s i l l e c t o m i e s p e r f o r m e d on a d a y c a r e  any m a j o r c o m p l i c a t i o n s ,  over twenty years  is by  1980;  reported  basis agol  32 2.2.4.  Paediatric  Paediatric reasons.  day c a r e s u r g e r y  First,  reduces  the  hours.  Second,  it  it  of  p e r f o r m e d on an i n p a t i e n t quality 1960s,  of  care  hospital  care surgery.  in  per  22.8/1,000 comprise 1973),  (1969)  1982/83.  (Atwell,  surgical  l o a d and c o v e r s  day  surgery  care  surgical  In  cases  1976,  paediatric dental,  in  In  that  late  1973),  has  of  surgery  incidence five  fold  to  total  to  (Ahlgren, paediatric  procedures.  46.2 p e r c e n t o f  day  been r e p o r t e d  the t o t a l  of  the  care  the  1968  33 p e r c e n t  1978)  for  inpatient  in  of  required  benefits,  years)  a wide range  comprised  to  when  two-thirds  i n c r e a s e d almost  (0-14  few  the  the  i n c l u d e day  Day c a r e s u r g e r y  (Steward,  and 50 p e r c e n t  to  insurance  population  20 p e r c e n t  compromising  r e f e r r a l centre  has  a  lower than  1980).  estimated  day c a r e s u r g e r y  in  to  it  hospital-acquired  significantly  the d e c i s i o n  hospital  1,000  because  c a r e and 23.2 p e r c e n t q u a l i f i e d  Since  t h e B.C.  paediatric  f r o m 4.6  of  The n e e d f o r a l t e r n a t i v e s  emphasized.  surgery of  et a l .  three  disturbance  b a s i s , without  seen i n a p a e d i a t r i c  conventional  was  is  procedures  c h i l d and p a r e n t  ( R o b i n s o n and C l a r k e ,  Robinson  children  emotional  the r i s k  the cost  l o a d and  been promoted f o r  t h e young  reduces  Third,  has  minimizes  separation  infection.  day c a r e s u r g e r y  In  B.C.  paediatric  1982/83.  t h e most common b r o a d day c a r e s u r g e r y  orthopedics,  procedure categories  i n B.C.  urology,  were  plastic,  in  otorhinolaryngology,  diagnostic  endoscopy,  33 and o p h t h a l m o l o g y the  1982/83 d a t a  surgery  i n B.C.  Programs) (Table  (Robinson  (kept  Myringotomy  2.3.  was,  tooth  of  1982/83  (Table  on i t s  the i n t r o d u c t i o n of  Health,  of  hospitalization,  form of  Evans  (1980)  saving  care should has  aspects practice.  States.  His  1)  it  t h e most  common  cystoscopy  savings r e l a t e d to  day c a r e s u r g e r y  has  been a l s o  lead to s i g n i f i c a n t  lies  day c a r e s u r g e r y Most of  undesirable recognized economic  The e a r l i e r s t u d i e s and e a r l y  1970s)  g e n e r a l l y were  the u n i t s  of  procedures performed, c r i t e r i a  technique.  that  United  (late  descriptions  and c o n t a i n e d l i s t s for  of  types  patient  detailed descriptions  References to costs  hand s t a t e m e n t s  in  follows:  on d a y c a r e s u r g e r y  and more o r l e s s  cost and  were done i n t h e  of  selection,  themselves  that  savings.  both i n p a e d i a t r i c  the studies  day  heavily  c r i t i c a l l y r e v i e w e d t h e l i t e r a t u r e on  of  care  common o p e r a t i v e  f o l l o w e d by  r e v i e w c a n be summarized as  1960s  f o r day  Hospital  t h e most  therapeutic superiority in minimizing  effects  to  3).  Estimates of p o t e n t i a l cost care surgery  Although  According  database  were s t i l l  by f a r ,  1976 and i n  and r e s t o r a t i o n o f  adult  by M i n i s t r y  these seven c a t e g o r i e s  2).  1980).  in admission-separation  procedure both i n  this  and C l a r k e ,  obviously  consisted costs  of  must be  of  offlower.  34  Table 2  Most Common O p e r a t i v e C a t e g o r i e s i n Day Care S u r g e r y i n t h e P a e d i a t r i c (0-14 y e a r s ) Age Group i n B.C. i n 1976 and i n 1982/83 1976 %  OPERATIVE CATEGORY  1  1982/83 %  Otorhinolaryngology  32 .8  34.3  Dental  14 .2  14.2  surgery  Orthopedic  surgery  11 .0  10.3  Urological  surgery  9 .0  8.5  8 .9  8.2  7 .9  6.6  6 .0  6.7  Other  10 .2  11.2  Total Cases  100 .0 9,047  100. 12,638  Plastic  surgery  Diagnostic  endoscopy  Ophthalmology  > S o u r c e : R o b i n s o n GC, C l a r k e H F : The H o s p i t a l C a r e C h i l d r e n . A r e v i e w o f c o n t e m p o r a r y i s s u e s . New Y o r k , O x f o r d U n i v e r s i t y P r e s s , 1980 ( p . 1 1 9 ) . x  of  > S o u r c e : B.C. M i n i s t r y of H e a l t h , H o s p i t a l Programs, A d m i s s i o n - s e p a r a t i o n database f o r day c a r e s u r g e r y . 2  2  35 Table  Op.  code  YEAR  3.  T e n M o s t Common Day C a r e S u r g e r y P r o c e d u r e s i n P a e d i a t r i c ( 0 - 1 4 ) Age G r o u p i n B . C . i n 1976 a n d 1982/83 OPERATIVE PROCEDURE  % of  total  1976 : x  17.0 99.9 A4.6 99.3 92.1  Myringotomy Other d e n t a l surgery operations C y s t o s c o p y and u r e t h r o s c o p y E x t r a c t i o n of t o o t h , forceps L o c a l e x c i s i o n of l e s i o n of s k i n and subcutaneous t i s s u e Circumcision O t h e r o p s . on m u s c l e , t e n d o n f a s c i a , and b u r s a Adenoidectomy without t o n s i l l e c t o m y O t h e r o p e r a t i o n s on m i d d l e e a r Probing of l a c r i m a l duct  61.2 88.9 21.3 17.9 06.5  Total YEAR  number o f  cases  20.0 6.8 6.8 5.7 4.7 4.0 3.2 2.7 2.5 2.2  9,047  1982/83 : 2  32.01 01.34 35.20 76.00 40.50 07.29  Myringotomy w i t h i n s e r t i o n of tube Other nonoperative cystoscopy R e s t o r a t i o n of t o o t h by f i l l i n g Circumcision Adenoidectomy without t o n s i l l e c t o m y Other f o r c i b l e c o r r e c t i o n of deformity Local excision, or destruction o f l e s i o n o r t i s s u e o f s k i n and subcutaneous t i s s u e Other s u r c i c a l e x t r a c t i o n of t o o t h Forceps e x t r a c t i o n of other tooth C l o s e d r e d u c t i o n of f r a c t u r e (without i n t e r n a l f i x a t i o n ) - radius and u l n a  98.12 35.19 35.09 91.01  T o t a l number o f  cases  25.4 6.6 6.2 5.1 3.8 3.5 2.6 2.5 2.5 2.5  12,638  > S o u r c e : R o b i n s o n GC, C l a r k e H F : The H o s p i t a l C a r e o f C h i l d r e n . A R e v i e w o f c o n t e m p o r a r y i s s u e s . New Y o r k , O x f o r d U n i v e r s i t y P r e s s , 1980 ( p . 1 2 0 - 1 2 1 ) . O p e r a t i v e codes r e f e r t o the e i g h t r e v i s i o n of International C l a s s i f i c a t i o n of Diseases. x  > S o u r c e : B.C. M i n i s t r y o f H e a l t h , H o s p i t a l Programs, A d m i s s i o n - s e p a r a t i o n database f o r day c a r e s u r g e r y . O p e r a t i v e codes r e f e r t o t h e Canadian C l a s s i f i c a t i o n of D i a g n o s t i c , T h e r a p e u t i c , and S u r g i c a l P r o c e d u r e s . 2  36 2)  Cost  studies  i n the United States  b a s e d on c h a r g e s . reflected  I n s o f a r as  i n charges  for hospital  economic s a v i n g s r e s u l t i n g a per-case-treated basis running  f r o m 25 t o  costs  are are  mainly accurately  services,  the  from day c a r e s u r g e r y  are very  60 p e r c e n t o f  on  significant, total  inpatient  charges.  3)  Charges  costs.  do n o t ,  in general,  T h e r e seems  t o be a t e n d e n c y t o  day c a r e s u r g e r y  charges  profitable  with p r o f i t s  areas  accurately  reflect  overestimate  and c o v e r d e f i c i t s made on d a y  in  less  care  surgery.  4)  T h e r e a r e o n l y a few s t u d i e s  and d e t a i l e d c o s t hospital  5)  charges  Savings  o r p e r diem  " h o t e l " costs  from r e d u c t i o n of  operative infections diagnostic  i n s t e a d of  testing.  a  relying  serious on  costs.  from day c a r e s u r g e r y  from s a v i n g s of but a l s o  analysis  attempting  do n o t a r i s e  merely  on t h e n u r s i n g  wards  hospital-acquired  post-  and r e d u c t i o n o f  unnecessary  37 6)  The q u e s t i o n o f w h e t h e r d a y c a r e s u r g e r y  r e d u c e s e x p e n s e s on a t o t a l b a s i s merely lowers remains  unit  costs  actually  o r whether  or per-patient  it  costs  unclear.  B e r k and C h a l m e r s  (1981)  r e v i e w e d 109 s t u d i e s  comparing  a m b u l a t o r y and i n p a t i e n t c a r e w i t h r e g a r d t o c l i n i c a l outcome or  cost.  All  but  31 o f  t h e 109 s t u d i e s  o u t c o m e . A l t h o u g h most care,  o n l y two o f  measurements  Evans  of  comparison of using  favored ambulatory care over  the studies  the cost  and R o b i n s o n  mentioned economic  of  (1973)  had u s e d  resources  appropriate used.  c a r r i e d out a d e t a i l e d  from the C h i l d r e n ' s H o s p i t a l  They used step-down c o s t  analysis  allocated  per episode of  long-run  costs  R e p l i c a t i o n of  the r e s u l t ; percent  In  this  potential total  (Evans e t a 1 .  f  care.  with  lower u n i t  fully-  The  study  about h a l f  that  inpatient  1975 d a t a  savings  costs  confirmed 50-70  of day  care  in total health  one must make an a s s u m p t i o n of  the  s a v i n g s p e r e p i s o d e were  s u r g e r y w i l l be t r a n s l a t e d i n t o expenditures,  i n Vancouver.  t r e a t m e n t on t h e  analysis  care  1978).  order to conclude that  substitution  to i s o l a t e  a day c a r e s u r g e r y e p i s o d e c o s t s  of matched p a t i e n t s w i t h s i m i l a r wards.  cost  d a y c a r e s u r g e r y and t r a d i t i o n a l i n p a t i e n t  1970 d a t a  showed t h a t  inpatient  t h a t beds  day c a r e f o r i n p a t i e n t c a r e w i l l  care  f r e e d by  n o t be  filled  38 by o t h e r c a s e s . potential  Yost  savings  the r a t e of  (1976),  f o r example, s t r e s s e s  c a n e a s i l y be d i s s i p a t e d  performance of  surgical  that  i n cost  add-ons  procedures should  with the a v a i l a b i l i t y of  new f a c i l i t i e s .  (1976)  u n n e c e s s a r y i n p a t i e n t beds  p o i n t out t h a t  if  closed or converted, h o s p i t a l rise  if  surgical  makes  only  p o t e n t i a l savings  in  the Canadian context that  potential  a less  savings  a r e t o be r e a l i z e d .  operating  this  specific  a  is care  additional  u n d e r t h o s e c o n d i t i o n s where t h e g o v e r n m e n t  instance,  (Rennie, trade-offs  the through-put  surgery,  writes  constitutes  of  an a d d - o n c o s t  1977, p . 2 6 ) .  is  generated, but  on an a d d i t i o n a l He a r g u e s  Response  of  other things  w i t h no o f f s e t t i n g  use of  these  the  increasing  dollar  i n p a t i e n t c a r e t o day  b e i n g e q u a l , becomes o f  less  inpatient  that unless  a r e acknowledged by government,  patients  is  i n an u n d e r - b e d d e d c o m m u n i t y .  a m b u l a t o r y c a r e p r o g r a m s i m p l y becomes an a d d - o n ,  transfer.  (1977)  a l t e r n a t i v e t o c a p i t a l i n v e s t m e n t and  t h a n w o u l d be t h e c a s e w i t h a d d i n g facility"  Rennie  hospitals  represents  costs  last  shut  Downey  s e r v i c e , o r where i t  p r e p a r e d t o expand f a c i l i t i e s In  where  f o r i n p a t i e n t care with the i n p a t i e n t  a c t u a l l y taken out of  costly  easily  or  justified.  "day c a r e s u r g e r y  not  t o t h e h e a l t h d e l i v e r y s y s t e m where i t  a substitute  facility  marginally  cases  t h e same p o i n t a b o u t t h e n e e d t o  if  either  are  procedures can  o f f i c e o r g e n e r a t e d de n o v o i n intervention is  rise  Donaldson  procedures are s h i f t e d from the p h y s i c i a n ' s  dentist's  (1976)  surgical  Goran and  if  utmost  care  39 i m p o r t a n c e i n making advantages of  2.4.  the f i n a l  day c a r e  Response  of  c o n c l u s i o n on t h e  surgery.  i n p a t i e n t u t i l i z a t i o n t o day c a r e  T h e r e a r e v e r y few p u b l i s h e d s t u d i e s between day c a r e s u r g e r y Robinson  (1973)  the workloads surgical  tried  of  to approach t h i s  care  surgery  proportion  the h o s p i t a l  if  However,  t h e i r study approach i s  many c o n f o u n d i n g  factors,  and as  substitution  the r e g i o n a l  A later  level in  inpatient  they r i g h t l y  u t i l i z a t i o n at f  1978;  inpatient paediatric  day have had  subject  warn,  not to  the and  c a r e c o u l d have t a k e n p l a c e  the r e g i o n a l  G r e a t e r Vancouver Regional T h e r e was  of  day c a r e  hospital  Evans and R o b i n s o n ,  surgical  compared t o c o r r e s p o n d i n g  surgery  the  from o t h e r h o s p i t a l s  examined t h e r e l a t i o n s h i p  (Evans e t a 1.  other regions.  of  at  level.  study  and i n p a t i e n t  for  care  the day c a r e s u r g e r y  g e n e r a t i o n may r e p r e s e n t t r a n s f e r s  and  reviewing  which would not  been a v a i l a b l e .  the  Evans  They c o n c l u d e d  ( a b o u t 24 p e r c e n t )  c a s e s were new g e n e r a t i o n ,  been c a r e d f o r a t  p r o b l e m by  Hospital.  surgery  relationship  surgeons p e r f o r m i n g day  procedures at C h i l d r e n ' s  a significant  on t h e  and i n p a t i e n t u t i l i z a t i o n .  specific  that  economic  trends  surgery  district  1980).  Trends  p r o c e d u r e s o v e r t i m e were i n day c a r e s u r g e r y ,  district  excluding referrals  a marked d e c r e a s e i n  c o i n c i d i n g w i t h an i n c r e a s e  in  i n day c a r e  inpatient surgery.  the from  40 However, larger  the drop i n i n p a t i e n t  The d r o p was  t h a n two t h i r d s  to the increase i n  this  surgical  all  the h o s p i t a l s  tonsillectomies i n p a t i e n t data  all  care),  the r e s i d u a l  an a l m o s t  paediatric  providing  inpatient During  commensurate  surgical  tonsillectomy,  suggested that  for surgical this  relatively  form of  surgery  little)  that  inpatient  care  care.  When  surgical  although  for inpatient  i n t e r p r e t a t i o n , however,  i n the absence of  surgical  the a v a i l a b i l i t y  had b e e n  have  overall  changed.  i n operative procedures  coincident with,  of day c a r e s u r g e r y .  led  though not In  to  (but  day c a r e s u r g e r y ,  p r a c t i c e which c o u l d have  activity  study  d e p e n d e d on t h e  the p o s s i b i l i t y p a t t e r n of  The  care could  There i s  shifts  day  procedures,  some  u t i l i z a t i o n i n t h e r e g i o n would n o t have of  region,  and  day c a r e s u r g e r y  surgery,  when  performance  was v i r t u a l l y u n c h a n g e d .  substitution  This  (inpatient  surgical  the s u r g i c a l  is  t r e n d showed a  increase i n the  t h e main impact of  occurred.  assumption  by,  day  the p e r i o d 1967-71,  procedures  expand t h e t o t a l volume o f  greater  attributed  day c a r e because t h e o p e r a t i o n  but the performance of  excluding  also  The  d a y c a r e was most r a p i d l y i n t r o d u c e d i n t h e  t h e r e was  rate  and a d e n o i d e c t o m i e s were e x c l u d e d f r o m t h e  much l e s s marked d e c l i n e . surgical  more  1978 i n t h e  d e c r e a s e c o u l d n o t be  much  surgical  due t o t h e d e c r e a s e o f  had been judged i n a p p r o p r i a t e  i n almost  in  t o n s i l l e c t o m y and a d e n o i d e c t o m y .  suggested that  one t h a t  largely  o v e r t h e d e c a d e f r o m 1968 t o  performance of  authors  of  i n t h e r e g i o n was  t h a n c o u l d be a c c o u n t e d f o r b y t h e i n c r e a s e  day c a r e .  of  surgery  these  or  to caused  41 circumstances, increased  In  inpatient  sharply  order  to  province-wide surgical to  absence  effect  of  base  and y e a r ,  rates  maternity  of  of  this  the  districts)  design  dependent technology  the  use.  and of  i n the  things  to  effects  impossible  control  care  measure  province  -  of was of  the  of  both  such  as  practice.  the  care  equal.  a number For  p r o v i n c i a l age  day  surgery  day  being  of  in  of  of  care  of  each  and  (net  sex of  u t i l i z a t i o n were beds  reflecting  calculated the  study  extent  (if  for was any)  u t i l i z a t i o n and  combined c r o s s - d i s t r i c t  control  and s u r g i c a l  is  (1968-1976).  hospital  two v a r i a b l e s  The  permitted  confounding  inpatient  care  using  would have been  consisted  (to  et. a l .  affecting  relationship  study  a capacity  day  Evans  it  possible  The p r i n c i p a l f o c u s  between  inpatient  use  and y e a r s  care)  r e l a t i o n s h i p between association  is  age-sex adjusted  district.  available.  population  Although  i t  have  unknown d e t e r m i n a n t s  recent  everywhere  been  factors  u t i l i z a t i o n , other  In addition,  school  study  of  the  hospital  surgery,  long-term  bed use  reduced  of  use.  total  u t i l i z a t i o n of  and  computed.  the  care  for  (75 s c h o o l  district  each  inpatient  and i n p a t i e n t  regions  actual  day  in a total  "model"  or  not  above p o s s i b i l i t y ,  u t i l i z a t i o n and examine  The d a t a  mix)  and a  surgical of  the  u t i l i z a t i o n might  surgery  study  k n o w n a n d some  inpatient surgery  data  care  for  another  and m e d i c a l  know what  the  had day  control  (1983) c o n d u c t e d  hospital  regional shifts  in  The dependent  and  cross-year time-  medical variables  42 were a s e r i e s inpatient  of  increasingly  utilization.  bed c a p a c i t y  Independent  use),  school d i s t r i c t  population,  activity  of  levels  physicians  analysis  the range  30-40 p e r c e n t of  inpatient  of  cases;  socio-economic  but  behind i n p a t i e n t extent ns.  not  day c a r e  "saved"  by day  f i l l e d i n by o t h e r s .  u s e was b e d a v a i l a b i l i t y  (Evans e t a l .  T h e r e a r e no s t u d i e s results  day c a r e  i n the t o t a l  Paediatricians  argue  f  that  and t o a  force  lesser  physicians  per  surgical  a l l o w d i r e c t e x t r a p o l a t i o n of  population to a c h i l d that paediatric  population.  Paediatric  surgical  1983).  and a d u l t  the  population.  care i s  different  i n the p a e d i a t r i c  Also,  took p l a c e i n a p e r i o d of  capacity.  surgery  The d r i v i n g  The number o f  e f f e c t may be h i g h e r  than i n the t o t a l  system  care  care i n r e s p e c t to tendency to h o s p i t a l i z e .  substitution  surgery  f o r the h o s p i t a l of  in  representing  shown t o h a v e any e f f e c t on i n p a t i e n t  utilization  (1983)  the space  socio-economic v a r i a b l e s .  was  adult  new a c t i v i t y  u t i l i z a t i o n , as c a s e s was  each  and  h a d no e f f e c t on o v e r a l l t o t a l m e d i c a l and  surgery-type  of  district.  60-70 p e r c e n t of  the a v a i l a b i l i t y  inpatient  and  status  day c a r e s u r g e r y  as  facilities  use  the data demonstrated s u b s t i t u t i o n  of  Moreover,  of  inpatient  types  i n each s c h o o l  represented generation a whole.  were  and t h e n u m b e r s ,  Multivariate  "saved"  variables  measures  (hypothesized to increase i n p a t i e n t  d e c r e a s e day c a r e s u r g e r y  of  day c a r e e l i g i b l e  from  Net age  group  t h e s t u d y by Evans e t  increasing hospital  or steady  bed c a p a c i t y  a1.  bed in  B.C.  43 fell  i n the second h a l f  of  t h e 1970s  From a p o l i c y p e r s p e c t i v e i t policy  change  relationship inpatient  2.5.  between d a y c a r e s u r g e r y  availability  purchased,  services  hospital  i n the  1930s  1940s  of  income  hospital  utilization  knowledge  of  e t a 1.  f  funds,  1947).  insurance with a coinciding  1950s  is  Roemer and S h a i n  hospital  onto  the supply  arising  (1959)  o f beds all  available  of  to  introduction hospital  factors  summarized  that  the  They  to the  the determinants  from the p a t i e n t ,  care  hospitals.  u t i l i z a t i o n determinants.  t h e most f u n d a m e n t a l o f  utilization  The  for  t h e volume  increase in  s h i f t e d t h e r e s e a r c h emphasis  suggested that  except  received varied in direct proportion  (Hoilingsworth  the l a t e  after  r e c i p i e n t s , whose  seemed t o u n d e r l i e t h e h i g h u t i l i z a t i o n o f  In  Study  showed t h a t ,  s u b s i d i z e d b y p h i l a n t h r o p y and p u b l i c services  c e n t r e d on  low u t i l i z a t i o n .  and t h e e a r l y  Law  privately  u t i l i z a t i o n r e s e a r c h was  t h e v e r y p o o r and f o r p u b l i c a s s i s t a n c e  family  the  Law  were, i n the main,  t h a t were r e l a t e d t o  hospital  this  and  i n p a t i e n t bed s u p p l y - Roemer's  E v o l u t i o n of Roemer's  When h o s p i t a l  was  t o know how  utilization.  2.5.1.  study  important  1980s.  i n r e s p e c t t o bed c a p a c i t y may h a v e a l t e r e d  The r o l e o f  factors  is  and i n t h e e a r l y  of  the h o s p i t a l ,  population hospital or  the  44 doctor.  Their theory, at  cross-sectional  studies.  that  t i m e , was m a i n l y b a s e d  Using  t h o u s a n d p o p u l a t i o n and h o s p i t a l United States and Roemer  1957 d a t a on b e d s u p p l y u t i l i z a t i o n rates  and f o r t h e c o u n t i e s o f  (1959)  on per  for  the  u p s t a t e New Y o r k ,  demonstrated a high  Shain  c o r r e l a t i o n between b e d  s u p p l y and h o s p i t a l u t i l i z a t i o n , s u g g e s t i n g t h a t more t h a n 7 0 percent of  the d i f f e r e n c e s i n h o s p i t a l  u t i l i z a t i o n by  state  and b y c o u n t y were a s s o c i a t e d w i t h d i f f e r e n c e s i n b e d T h e y r a n t h e same a n a l y s e s no boom i n high  i n c o m e s and h o s p i t a l  relationship.  virtually hospital average  with data  Their  f r o m 1940 when t h e r e was  insurance,  study a l s o  finding  showed t h a t  no r e l a t i o n s h i p between t h e s u p p l y o f occupancy.  Only 4 percent of  occupancy r a t e s  from s t a t e  supply.  the  t h e r e was beds  the v a r i a t i o n  to state  a t t r i b u t e d t o d i f f e r e n c e s i n bed s u p p l y .  same  and in  c o u l d be  In  a d d i t i o n to  effect  of  b e d s u p p l y i n p l a c i n g a c e i l i n g on u t i l i z a t i o n  rates,  it  was  set  suggested t h a t t h e bed s u p p l y  a f l o o r on u t i l i z a t i o n  community has admit p a t i e n t s increased, formerly of illness,  (Roemer and S h a i n ,  a r e l a t i v e l y low s u p p l y o f b e d s , who a r e s e r i o u s l y  physicians  will  i l l .  cases  of  If  If  with less  to  a  physicians  t h e bed s u p p l y  will is  who were  serious  an e l e c t i v e n a t u r e , e t c .  (Roemer  1959 ) .  A l r e a d y b e f o r e t h e work b y S h a i n and Roemer (1954)  tends  1959).  tend t o admit p a t i e n t s  lower p r i o r i t y , p a t i e n t s  surgical  and S h a i n ,  likewise  the  i n Saskatchewan  had d e m o n s t r a t e d t h e  (1959),  Myers  relationship  45 between h o s p i t a l that  u t i l i z a t i o n and s u p p l y o f  t h e volume of  supply of level high  of  hospital 7.5  cases  continued to r i s e  beds.  e v e n when t h e  beds was w e l l a b o v e t h e l o c a l l y recommended  p e r 1,000, w h i c h a l r e a d y was an e x c e p t i o n a l l y  bed-to-population ratio.  This  Saskatchewan  r e v e a l e d a d i r e c t r e l a t i o n s h i p between r a t e s  of  operations  A  study  and t h e s u p p l y o f h o s p i t a l b e d s .  i n Saskatchewan  utilization  confirmed that  and h i g h h o s p i t a l  more f r e q u e n t a d m i s s i o n hospital higher  So  stay.  Also,  also  surgical subsequent of  high  bed c a p a c i t y t h e r e t e n d e d t o  t h e r e a d m i s s i o n r a t e s were f o u n d t o be (Roth e t a 1.  1955).  f  studies,  but i n  based  on  1961 Roemer p u b l i s h e d a  longitudinal  s t u d y c o n f i r m i n g what h a d b e e n a l r e a d y f o u n d  the previous  studies.  This  seemed t o e n s u r e a  t h e r e l a t i o n s h i p between b e d s u p p l y and  utilization.  Roemer  changes policies  (1961)  demonstrated t h a t  u t i l i z a t i o n when bed s u p p l y was that of  local physicians.  any e v i d e n c e of  i n c i d e n c e of  the increase  in  i n c r e a s e d was due  to  T h e r e was  illness.  on some s o r t  of  s i m p l y an  i n the given  increased  population,  a corresponding increase i n He s u g g e s t e d t h a t  over the u t i l i z a t i o n r a t e of all  hospital  t h e i n c r e a s e d bed s u p p l y caused i n t h e m e d i c a l  tendency to h o s p i t a l i z e patients without  in  general  acceptance of  hospital  be  which r e q u i r e d s h o r t e r  t h e e v i d e n c e on b e d s u p p l y e f f e c t was  cross-sectional  study  i n the areas  of minor cases  i n t h e s e same a r e a s  far,  He showed  hospitals  the  any e f f e c t i v e c o n t r o l  should r e s t  c o n t r o l over the supply of  first  beds.  of  46 2.5.2.  Although  Question of  there is  related to hospital relationship is  relationship  is  relationship is causally  g e n e r a l agreement t h a t bed s u p p l y  argued.  There are at  interpreting this  causal,  as  spurious  in that  least  ; or  2)  1) the  an a n t e c e d e n t v a r i a b l e  spurious  is  generally  services.  i n c r e a s e i n s u p p l y o f beds and more  u t i l i z a t i o n o n c e beds a r e s u p p l i e d .  Unmet n e e d  hospital  According to  classic  economic t h e o r y of  s u p p l y and demand, s u p p l y d o e s n o t  appear.  as  It  arises  a r e s p o n s e t o a number o f  o f w h i c h c o u l d be t h e demand f o r f a c i l i t i e s . facilities  exists,  the f a c t o r s  compared t o  population ratios  needs.  pressures,  If  (Rosenthal,  i n t o p r o b l e m s , when b e d s u p p l y  illness  just  demand  One has  1964).  levels  one  for  t h a t a f f e c t demand w o u l d  generate pressure to a f f e c t supply runs  claim  u t i l i z a t i o n and b e d c a p a c i t y a r e d e t e r m i n e d  b y unmet demand o r n e e d f o r h o s p i t a l  also This  are  o n l y t o compare b e d - t o -  between d e v e l o p i n g c o u n t r i e s and W e s t e r n  nations  t o be r e m i n d e d o f  illness  n e e d on t h e s u p p l y o f beds  Although  the  r e l a t e d t o b o t h s u p p l y and u t i l i z a t i o n .  that both h o s p i t a l  argument  this  two  relationship:  Roemer s u g g e s t s  T h o s e who s e e t h e r e l a t i o n s h i p as  causes  is  u t i l i z a t i o n , the i n t e r p r e t a t i o n of  still  a l t e r n a t i v e ways o f  causality  the r e l a t i v e l y minor impact (Roemer and S h a i n ,  comparison of d i f f e r e n t areas  countries with respect to  illness  level  within  of 1959).  Western  and b e d s u p p l y may n o t  47 yield  such dramatic  contrasts,  would p r o b a b l y  still  determinant of  bed c a p a c i t y .  increasingly several  little  resources  power"  relationship  communities  If  C o n s t r u c t i o n of  a p o l i t i c a l decisions  "buying  of  the incidence of  which i s  non-health related factors.  demand o f has  outweigh  economic s t a t u s  to i l l n e s s  need.  illness  illness  is  the  decisive,  Economically when  need i s  the impetus  f o r bed s u p p l y  improving health status  However,  this  hospital  sector  has  almost  i n B.C.  not a matter of  i n the l a t e  responding  one  would  the causal  supply  theory,  an i n c r e a s e  supply of  depress  t h e money p r i c e o f  Roemer's  Law i n a  "free  the  and t h e e a r l y  costs.  care"  those and  a time p r i c e mechanism,  and  creates  supply  its  hospital  own demand. beds  services  c a r e demanded a t  this  1980s  and demand  hospital  i n the q u a n t i t y of However,  Downsizing  1970s  theory of  t h o s e who b e l i e v e t h a t  lower p r i c e s .  population.  t h e o r y c a n be d i v i d e d i n t o  r e l y on t h e c l a s s i c  in  the  of  to a decrease i n i n c i d e n c e of  but a d e c i s i o n to c o n t a i n  of  of  never happened.  e x p l a i n t h e Roemer e f f e c t t h r o u g h  increase  well-off  distributed.  with  who s t i l l  this  hospital  hospitals  Supporters  is  and  s e e a d e c r e a s e i n bed c a p a c i t y and c l o s u r e s  diseases,  a  effective  expect to  was  as  i n f l u e n c e d by  h a v e u s u a l l y more p o l i t i c a l w e i g h t  are  area  a hospital  Often i t  f o r beds w h i c h i s  an  serves  In to  resulting the  in  prevailing  c o u l d n o t be t h e e x p l a n a t i o n situation  s u c h as  an  Canada.  of On  48 the o t h e r hand,  it  has  been suggested t h a t  s u p p l y may c a u s e a r e d u c t i o n i n w a i t i n g make p o s s i b l e  times  for  e a r l i e r admissions to h o s p i t a l s ,  r e d u c e t h e amount o f money p r i c e s  an i n c r e a s e  throughout  o n l y the adjustment  t h e economy were h e l d c o n s t a n t  while  (1975)  hospital  b e d s was  o t h e r goods and s e r v i c e s  of  hospital  f o u n d t o be  suggesting that  variables  survey data.  admissions with respect to  .22. T h i s  is  (Ginsburg  less  than i n  and K o r e t z ,  and The  hospital  studies  that  1983)  a t i m e p r i c e mechanism may p l a y a r o l e  in  effect.  The o t h e r s c h o o l o f causal  of  an  t h e r e l a t i o n s h i p between b e d s u p p l y  have o m i t t e d time p r i c e s  Roemer  and  the  in utilization.  u t i l i z a t i o n i n a study using  elasticity  all  and  "price"  c o n t r o l l e d b o t h money and t i m e p r i c e  examining  If  d e s c r i b e d were a l l o w e d t o t a k e p l a c e ,  health care v i s - a - v i s  May  general  care.  r e s u l t w o u l d be a r e l a t i v e d e c r e a s e i n t h e t o t a l  observed increase  bed  treatment,  and i n  time i n v o l v e d i n o b t a i n i n g  in  h e a l t h economists  bed e f f e c t argue  demand p l a y  little  that  who b e l i e v e i n  conventional  laws o f  a  supply  and  r o l e i n h e a l t h care u t i l i z a t i o n because  t h e p e c u l i a r r e l a t i o n s h i p between t h e h e a l t h c a r e consumer h e a l t h care consumption. consumption They argue  The m a j o r d e c i s i o n s  a r e made n o t b y t h e c o n s u m e r , that  the causal  u t i l i z a t i o n works t h r o u g h  e f f e c t of  concerning  but the  bed s u p p l y  t h e way i n w h i c h  on  provider. hospital  physicians  of and  49  practice.  An i n c r e a s e i n t h e g e n e r a l h o s p i t a l b e d  available  to a physician alters  supply  t h e way s h e p r o v i d e s  medical  care, which i n t u r n i n c r e a s e s t h e r a t e a t which t h i s utilized. hospital  In o t h e r words, i n s t e a d o f s h i f t i n g s e r v i c e s a l o n g t h e demand c u r v e ,  supply  o f beds w i l l  itself  ( a l t h o u g h t h e demand s c h e d u l e  interpreted  prompt a s h i f t  supply i s  t h e demand f o r  an i n c r e a s e i n t h e  i n t h e 'demand' cannot,  then,  schedule be  i n t h e c o n v e n t i o n a l manner a s r e p r e s e n t a t i o n o f  consumers' f u l l y - i n f o r m e d responses  to different  hospital  care  prices).  The  s t a n d a r d method o f a s s e s s i n g t h e v a l i d i t y  of  Roemer's  Law h a s b e e n t o u s e m u l t i p l e r e g r e s s i o n a n a l y s i s t o e x a m i n e r e l a t i o n s h i p s between u s e - u s u a l l y d a y s o f h o s p i t a l i z a t i o n per  capita  price  - and demographic v a r i a b l e s ,  of hospital  s e r v i c e s ( n e t o f i n s u r a n c e ) , and v a r i a b l e s  reflecting  the a v a i l a b i l i t y of medical  Feldstein,  1971; A n d e r s o n ,  et  health status, the  resources  1973; H a r r i s ,  (Ro, 1969;  1975a; Van d e r Gaag  a 1 ., 1 9 7 5 ) . The u n d e r l y i n g a s s u m p t i o n i s t h a t i f b e d  availability supply entered  effect  i s spurious, then  the relationship  a n d u s e s h o u l d d i s a p p e a r when c o n f o u n d i n g into  regression  the analysis.  coefficient  m e a s u r e o f t h e Roemer  between  variables are  I f i t does n o t d i s a p p e a r ,  then the  of t h e h o s p i t a l bed v a r i a b l e p r o v i d e s effect.  a  50  Ginsburg in  and K o r e t z  (1983) h a v e n o t e d t h e p r o b l e m s  t h e d a t a u s e d b y many s t u d i e s .  study  They l i s t  the  inherent  following  problems:  a)  T n c o r r e c t measurement of t h e p r i c e of s e r v i c e s .  A p p r o p r i a t e measure o f be -  the marginal that  is.  the p r i c e of  p r i c e minus  insurance  should  reimbursement  the net p r i c e to the p a t i e n t of  d a y o r an e x t r a s t a y i n t h e  b)  services  an e x t r a  hospital.  Tncorreot measurement of the nt.i l i g a t i o n  N u m e r a t o r and d e n o m i n a t o r o f  the u t i l i z a t i o n  rate. rate  s h o u l d r e f e r t o t h e same m a r k e t a r e a .  O f t e n days  hospital  services  care  (the numerator)  d e l i v e r e d by a r e a h o s p i t a l s nonresidents reflects  reflects  to both r e s i d e n t s  a l i k e , but p o p u l a t i o n  only the residents  of  estimates  c)  of  rates  causing  an upward b i a s  in  t h e Roemer e f f e c t .  i n f o r m a t i o n on h e a l t h s t a t u s  tends  The o m i s s i o n  to bias  t h e Roemer e f f e c t upward s i n c e p o o r h e a l t h  in  an a r e a t e n d s  to produce both h i g h e r  supply of  beds.  of  estimates  of  larger  with  overstated  Omission of important v a r i a b l e s .  and"a  and  denominator)  the area. Areas  many beds p e r c a p i t a t e n d t o h a v e utilization  (the  of  status  utilization  51 d)  Simultaneous  equation bias.  W h i l e b e d s u p p l y may  determine u t i l i z a t i o n , theory a l s o  suggests  that  o v e r t h e l o n g r u n , u t i l i z a t i o n s h o u l d d e t e r m i n e bed supply.  Beds p e r c a p i t a i s  the short  run.  could result  f u l l y exogenous  Ordinary least  i n an upward b i a s  squares of  only  in  estimation  the estimate  of  t h e Roemer e f f e c t .  Ginsburg example,  and K o r e t z  (1983)  overcame t h e s e p r o b l e m s ,  by i n c l u d i n g a t h r e e - y e a r lagged v a l u e of  d e p e n d e n t v a r i a b l e as  for  the  a p r o x y f o r unmeasured v a r i a b l e s  that  might  a f f e c t u t i l i z a t i o n and b y e n t e r i n g beds p e r c a p i t a as  first  difference.  unlikely that  Given long  lags  i n bed c o n s t r u c t i o n , i t  t h e change i n beds was  i n f l u e n c e d by t h e  i n u t i l i z a t i o n f o r t h e same t i m e p e r i o d . was v e r y s i m i l a r earlier. highly  t o t h e one t h a t H a r r i s  Both H a r r i s  significant  2.5.3.  and G i n s b u r g  of  hospital  (1975b)  had  was  change design  used  and K o r e t z d e m o n s t r a t e d a  Roemer e f f e c t .  The Roemer e f f e c t i n p a e d i a t r i c  T h e r e a r e v e r y few s t u d i e s paediatric  T h e i r study  a  c a r e , but they a l l  populations  on a b e d a v a i l a b i l i t y  seem t o i n d i c a t e l o w e r  use t o bed s u p p l y t h a n i n t h e a d u l t  (Van d e r Gaag e t a 1 .  f  effect  1975; C o n n e l l e t a l . .  response  population  1981).  in  52 Van d e r Gaag e t general 1,000  al.  (1975)  h o s p i t a l beds  analyzed the  and number o f  general  data  from 44 s e r v i c e  areas  A l t h o u g h b e d a v a i l a b i l i t y was p o s i t i v e l y rates  i n p a e d i a t r i c age  lower than i n the and n e w b o r n s . physician attempt  work:  the  the  Also,  the  related  than f o r the  i n the  groups are not adequately  exogenous v a r i a b l e s used  (bed c a p a c i t y ,  in  number o f  university hospitals, specialists  number o f  per bed,  that  welfare  Connell  of  clearly  infants  centers,  i n the  et  and t h a t  nonsignificant admissions  number o f  school  eight  admissions  nursing personnel covered  sources  physicians)  per  by  and i n d e x o f  of  care  the  (e.g.,  s h o u l d p r o b a b l y be  analysis.  al.  (1981)  compared p o p u l a t i o n - b a s e d  f o r M e d i c a i d c h i l d r e n i n 14 g e o g r a p h i c  Washington S t a t e . u n d e r 21 y e a r s  for  practitioners,  percentage  other  An  and  e x p l a i n e d by the  general  number o f  n u r s i n g home b e d s ,  population density),  included  admission  equation d i d not  c o m p u l s o r y i n s u r a n c e f o r low income f a m i l i e s ,  infant  to  adult population.  regression  stated  using  b e d and  o f most v a r i a b l e s were  The a u t h o r s  per  Netherlands.  were  exception  e x p l a n a t o r y power o f  less  coefficients  l o w e r age  number o f  i n the  include other health care resource v a r i a b l e s  or uninterpretable.  rates  number o f  practitioners  elasticities  a d u l t group w i t h the  c a p a c i t y was  to  groups,  population characteristics  bed,  of  p o p u l a t i o n on h o s p i t a l a d m i s s i o n r a t e b y a g e - g r o u p  cross-sectional  the  effect  of  admission  subdivisions  The s t u d y p o p u l a t i o n c o n s i s t e d age who were M e d i c a i d r e c i p i e n t s  of  of  children  because  of  53 low  i n c o m e and  blindness,  not  chronic  c h i l d r e n made up 21  y e a r s o f age  differences A  i n the  supply  correlations.  The  medical/surgical  The  and  rather  use. the  the  bed  supply  showed t h a t ,  per  showed no  bed  for  supply .25.  higher  capita  significant  total was  .28  and  Occupancy  rates  with o v e r a l l  indicating that  t h a n empty h o s p i t a l s had  high  The  and  subdivisions.  against  significantly associated  rates  areas of  with  surgery.  except f o r s u r g i c a l  a d m i s s i o n r a t e s were n o t  of p h y s i c i a n s .  high  occupancy r a t e s  admission rates,  hospitalization,  well  and  These  dramatic  among g e o g r a p h i c  admission rates  as  a l l c h i l d r e n under  s t u d y showed  a d m i s s i o n r a t e s and  ENT  study a l s o  supply  The  of  correlation coefficient  were p o s i t i v e l y and  full  State.  admission rates  surgical  or mental r e t a r d a t i o n .  approximately 7 percent  a n a l y s i s of  bed  surgical  disease,  s p e c i a l m e d i c a l needs such  i n admission rates  regression  hospital  because of  O v e r a l l , the  r e l a t e d to  study could  not  the explain  inter-area differences in paediatric hospital  authors  s u g g e s t e d as  one  plausible explanation  v a r i a t i o n i n admission rates  reflects  that  differences  in  community p r a c t i c e s t y l e s .  B o t h two al.,  1981)  specific  studies  der  Gaag e-h a 1 ., 1 975;  u s e d a g g r e g a t e bed t o age  substitutable one  (Van  capacity  instead  and  Connell  o f bed  supply  g r o u p . H o s p i t a l b e d s i n a d u l t wards may  f o r p a e d i a t r i c b e d s and  w o u l d e x p e c t c o e f f i c i e n t s on  vice versa.  a g g r e g a t e bed  eJ:  I f so,  capacity  not  be  then to  be  54  downward b i a s e d . age  group  The b i a s  w o u l d be l a r g e r  s i n c e the m a j o r i t y of h o s p i t a l  Wennberg and Kimm (1977) variability  of  have a l s o  paediatric hospital  comparable h o s p i t a l  s e r v i c e areas  rates  b y d i a g n o s i s were as  authors  d i d not  availability use of  use,  injuries.  disease  implying  authors  was  critical use. size is  sixfold.  in  The p r o p o r t i o n o f  conditions  belief  most  beds  admissions found t h a t  judgment  i n the e f f e c t i v e n e s s of  w i t h bed the supply rate.  in diagnosis treatment  position.  Requests  from areas  that  of need,  for additional  are already using  is  hospital  hospital  the itself beds,  in a difficult  facilities hospitals  and  are  When t h e m e d i c a l p r o f e s s i o n  the c e r t i f i e r  of  The  commented on t h e d i f f i c u l t y i n p l a n n i n g  as  to  r o s e m a r k e d l y w i t h i n c r e a s e d bed  The s t u d y a l s o  capacity:"  in  in  beds d e v o t e d  u n c e r t a i n a b o u t t h e p r o p e r , optimum u s e o f  then the s t a t e ,  the  bed  i n e x p l a i n i n g the v a r i a t i o n i n c h i l d r e n ' s  hospital  data  admission  Although  p o s i t i v e l y r e l a t e d to the surgery  They a l s o of  variations  the lowest use a r e a s ,  suggested that p h y s i c i a n s '  physicians'  When t h e  t h e y showed t h a t d i f f e r e n c e s  lowering t h r e s h o l d of  capacity increase. surgeons  In  high  among  beds were a s s o c i a t e d w i t h v a r i a t i o n s  p a e d i a t r i c p a t i e n t mix. were d e v o t e d t o  rates  i n Vermont.  as  adults.  They i d e n t i f i e d  s p e c i f i c a l l y study the e f f e c t of  on h o s p i t a l u s e ,  hospital  infectious  great  beds a r e f o r  admission  were a n a l y z e d b y s p e c i f i c d i a g n o s e s ,  paediatric  pointed out the  use.  twofold differences i n age-adjusted  i n the  commonly come  at greater  than  55  the to  rate  f o r t h e r e g i o n as  such areas  will  between a r e a s . Kimm,  Issuing building  increase the u t i l i z a t i o n d i f f e r e n t i a l  This  dilemma needs  Other f a c t o r s  Although  resolution."  (Wennberg  in paediatric inpatient  harmful e f f e c t s  of h o s p i t a l i z a t i o n  known t h e r e h a v e b e e n few e f f o r t s  determinants level.  and  of  Policies  use  on c h i l d r e n  to assess  paediatric hospitalization  at  the  to control paediatric hospital  population  use  seem t o  of  (Harvard  Child Health Project,  1977).  is  a concern, e s p e c i a l l y i n the United States,  still  subgroups of  they should because of 1984;  The  financial barriers  services (Kozak  f  factors  are r e l a t e d to c h i l d r e n ' s  that  c a n a c t as  absence of  b e t t e r measures.  availability have  some  a s much  as  and  McCarthy,  study.  characteristics  of  proxy f o r a c t u a l health status  in studying  T h e y may a l s o be  the r e l a t i o n s h i p  emphasized the c o m p l e x i t y of  between d a y  utilization.  While  the  several  and  Some o f the in  child the  potential  and i n p a t i e n t u t i l i z a t i o n . Roemer and  affecting hospital  that  health status  importance to t h i s  and s o c i o e c o n o m i c  population  confounders  there  1986).  use bear a s p e c i a l  demographic  care  On t h e o t h e r h a n d ,  P e r r i n et. a l .  hospital  (1959)  a l t e r n a t i v e modes o f  c h i l d r e n do n o t u s e h o s p i t a l  are  the  h a v e c o n c e n t r a t e d on p r o v i s i o n  the  permits  1 9 7 7 , p. 3 9 0 ) .  2.6.  well  a whole.  care  Shain  factors factors  operate  56 directly  and i n d e p e n d e n t l y t o i n f l u e n c e h o s p i t a l  problem i s influence  made more d i f f i c u l t b y t h e f a c t each o t h e r .  characteristics illness in  of  l e v e l of  the processes  2.6.1.  a population  lead to h o s p i t a l  for hospital  sometimes  d e t e r m i n a n t of  i n c i d e n c e and p r e v a l e n c e o f  illness  will  h o s p i t a l i z a t i o n demand, u n l e s s  other  information or the a t t i t u d e s and t h e p o l i c i e s  physicians disease  the c h i l d ,  different  p e r c e p t i o n s of  hospitalization. depends  standards  of  living  concepts  the  us v e r y  of  c h i l d r e n or of  inter-observer variation complex.  and  definable  and t h e p h y s i c i a n may h a v e of  of  normality.  illness  With  (Zola,  i n diagnosing  1975). diseases  rising  techniques  a r e i n c l u d e d i n t h e domain illness  little  their  hospitals  and more r e f i n e d s c i e n t i f i c  m e d i c i n e and l a b e l e d as  e v e n more  tell  this  only  t h e need f o r o r t i m i n g  more and more c o n d i t i o n s  factor  the  Furthermore, the d e f i n i t i o n of  on p r e v a i l i n g  population  Although  Even w i t h a c l e a r l y  the parents  interact  we combine them w i t h  and p r a c t i c e s  i n t h e community.  i n the  e x p e r i e n c e , d a t a on  about  parents  on t h e  illness  utilization.  disease  also  use.  been c o n s i d e r e d almost  hospitalization  the  socioeconomic  but t h e y can a l s o  p r e v a l e n c e and t y p e o f  form the f o u n d a t i o n  they  c a n h a v e an i m p a c t  that population, that  and  P r e v a l e n c e , i n c i d e n c e and t y p e o f  Incidence,  f a c t o r has  Both demographic  that  use,  High  of intra-and  makes  this  57 A study  on n e e d f o r t o n s i l l e c t o m y  how v a g u e t h e i n f l u e n c e o f d i s e a s e utilization  ( D e n z e r and F e l s h i n ,  study  eleven-year-old school  1,000  New Y o r k .  The r e m a i n i n g  (45 p e r c e n t )  for  tonsillectomy. this  first  selected put  t o work.  t h i r d group  of  1943; B a k w i n ,  Out o f  On t h e f i r s t  a n o t h e r 95  in  examination,  (44 p e r c e n t )  h e a l t h y i n t h e two e x a m i n a t i o n s physicians, One o f  53  (46 p e r c e n t )  the conclusions  a child's  the highest  15 y e a r s  respiratory discharges rate  in  healthy  were  physicians  was  had b e e n  were s e n t  to  a  were recommended of  the study  b e i n g recommended f o r  was  operation  r a t h e r t h a n on  the  health.  1978,  under  this  tonsils  119 c h i l d r e n t h a t  d e p e n d e d p r i n c i p a l l y on t h e p h y s i c i a n  In  In  c h i l d r e n were s u r v e y e d  215 c h i l d r e n c o n s i d e r e d a s  When t h e r e m a i n i n g  the chance of  child's  1945).  389 c h i l d r e n were t h e n e x a m i n e d  examination,  of  of  t h e s e h e a l t h y c h i l d r e n were recommended  tonsillectomy.  that  example  hospital  f o r t o n s i l l e c t o m y when a n o t h e r team o f  c o n s i d e r e d as  for  c a n be on  by twenty s c h o o l p h y s i c i a n s .  174  in  a classic  61 p e r c e n t were f o u n d t o have had t h e i r  removed. relays  is  of  age was  system", (Kozak  discharge  rate  f o r Canadian  f o r the category  accounting  and M c C a r t h y ,  for  the  discharge  71 p e r c e n t  higher  t h a n t h e U.S.  likely  c a u s e d by a d i f f e r e n c e i n t h e i n c i d e n c e o r d u r a t i o n  r e s p i r a t o r y diseases  The l a r g e  was  of  all  The C a n a d i a n  for c h i l d r e n with respiratory diseases rate.  "diseases  38 p e r c e n t o f  1984).  children  difference is  between t h e two c o u n t r i e s ;  not  factors  of  other  58  than d i s e a s e  itself  second h i g h e s t poisoning, infective  determine h o s p i t a l  discharge  and p a r a s i t i c  discharges  in  diseases;  accidents,  of  60 p e r c e n t o f (1980)  and v i o l e n c e ;  The f i r s t  62 p e r c e n t o f categories,  all  three diagnostic  cases.  hypertrophy of  all  diseases,  discharge  r a t e i n Canada  common of  1978  for  diagnostic  and a d e n o i d s  in  and  digestive  groups accounted  Of t h e i n d i v i d u a l tonsils  1984).  infective  and  were t h e most  was  reported very  Respiratory  the nervous  anomalies  category  g r o u p s and a c c o u n t e d f o r o v e r 75 p e r c e n t  admissions.  highest  poisoning,  The  and M c C a r t h y ,  Sheps  Columbia.  diseases  and c o n g e n i t a l  diagnostic  (Kozak  accounted f o r  in British  f o l l o w e d by a c c i d e n t s ,  system;  diseases  c h i l d r e n i n Canada.  results  parasitic  f o r c h i l d r e n was  and v i o l e n c e , and t h e t h i r d h i g h e s t  These t h r e e c a t e g o r i e s  similar  rate  u s e as w e l l .  (Kozak  had  the  and  McCarthy,  1984).  Changes i n . i n c i d e n c e o f to  changes  of  the d e c l i n e i n i n c i d e n c e of  (e.g.  of  disease  paediatric hospital  tuberculosis  g e n e r a l l y known. children, of  and p o l i o )  contribute  use over t i m e .  The  infectious on h o s p i t a l  However, w i t h i m p r o v i n g  the r e l a t i v e importance of  hospital  diseases  if  children  health status  disease  hospital  in  impact  u t i l i z a t i o n rates  u t i l i z a t i o n r a t e s may d e c r e a s e ,  become more and more i m p o r t a n t adjust.  i n c h i l d r e n can  as as  a  is  of  determinant  other  factors  bed s u p p l y does  not  59  Because  factors  other than d i s e a s e  determining hospital  use,  hospital  itself  play a part  in  u t i l i z a t i o n d a t a may n o t  v e r y r e l i a b l e f o r i n f e r r i n g t r u e i n c i d e n c e and p r e v a l e n c e , i n o t h e r words,  hospital  care needs,  or  in a population.  P r e v a l e n c e o r i n c i d e n c e ( d e p e n d i n g on t h e t y p e o f d i s e a s e ) be a m a j o r d e t e r m i n a n t o f h o s p i t a l population, available,  b u t f o r most d i s e a s e s  Demographic  shown t h e h i g h e s t hospital  and h o s p i t a l of  age  use.  factors,  association  u s e i n c h i l d r e n shows t h a t have a l m o s t  r a t e and o v e r 5.5  u t i l i z a t i o n rates  age e q u a l t h o s e o f  Race h a s status  of  mortality  infants  have of  under 1 year  a f i v e times  t i m e s h i g h e r number o f  of  hospital  t h a n one y e a r  Boys u s e  rates  1984).  seem t o d i s a p p e a r  health  c h i l d r e n have s u b s t a n t i a l l y  than whites.  of  hospital  b e e n shown t o be r e l a t e d t o m o r t a l i t y and Black  1984).  ( a b o u t 26 p e r c e n t more  (Kozak and M c C a r t h y ,  children.  higher  and M c C a r t h y ,  children less  65-74 y e a r o l d s .  s e r v i c e s more o f t e n t h a n g i r l s discharges).  age and s e x  with the r a t e  d a y s t h a n 10-14 y e a r o l d c h i l d r e n (Kozak Hospital  measures  D a t a on t h e r e l a t i o n s h i p between age  ( e x c l u d i n g newborns)  discharge  t h e r e a r e no  a  factors  Of t h e d i f f e r e n t d e m o g r a p h i c  paediatric  utilization in  may  independent of u t i l i z a t i o n .  2.6.2.  clearly  be  higher  However, t h e r a c i a l d i f f e r e n c e s  i n the highest  income g r o u p s ,  except  among  60 neonates black  (Mare,  1982).  C o l l e and Grossman  c h i l d r e n make more v i s i t s  to physicians  c h i l d r e n e v e n when t h e e f f e c t o f coverage, mother's been c o n t r o l l e d . have v i s i t s hospital  at  schooling, Black  to  -  found  "public sites"  than white  f a m i l y income,  insurance  and p h y s i c i a n a v a i l a b i l i t y  (hospital  emergency  Native  have  than i n p h y s i c i a n s '  not  offices.  In  Indians are h o s p i t a l i z e d about  three  f o u r t i m e s more f r e q u e n t l y t h a n n o n - i n d i a n c h i l d r e n and  longer periods  than others  ( R o b i n s o n and E v a n s ,  1973).  a d d i t i o n t o r a c e , e t h n i c c o m p o s i t i o n and m i g r a t i o n p o p u l a t i o n have been r e l a t e d t o h e a l t h s t a t u s utilization  at  the t o t a l population l e v e l  to  rooms,  o u t p a t i e n t d e p a r t m e n t s , and p u b l i c c l i n i c s  c h i l d r e n of  that  c h i l d r e n were a l s o much more l i k e l y  connected with h o s p i t a l s ) B.C.,  (1978)  and  for  In  status  of  a  hospital  (Anderson,  1973).  U r b a n - r u r a l d i f f e r e n t i a l s i n h o s p i t a l u t i l i z a t i o n have been known f o r a l o n g t i m e hospital is  longer  1973).  admission  (Roemer and S h a i n ,  rates  i n r u r a l areas  Connell's  et a l .  a r e h i g h e r and a v e r a g e  (1981)  et  al.  (1977)  surgical for  rates  a d m i s s i o n s were s i g n i f i c a n t l y  a d m i s s i o n s were s i g n i f i c a n t l y found s i m i l a r  general,  l e n g t h of  f o r u r b a n and of  stay  (Anderson,  study i n Washington S t a t e  f o r M e d i c a i d c h i l d r e n u n d e r 21 y e a r s  surgical  In  compared t o u r b a n a r e a s  n e a r l y i d e n t i c a l t o t a l admission areas  1959).  age.  found  rural  However,  h i g h e r and m e d i c a l  lower i n urban a r e a s .  urban-rural differences  Bombardier for  u t i l i z a t i o n , b u t when u t i l i z a t i o n r a t e s were  income t h e d i f f e r e n t i a l became n o n s i g n i f i c a n t .  adjusted  Long  (1981)  61 has  reported evidence to support  residential  l o c a t i o n serves  relationship,  2.6.3.  Social  as  the hypothesis  a p r o x y f o r m a r i t a l and  o c c u p a t i o n , and h e a l t h  Socioeconomic  that family  status.  factors  and e c o n o m i c f a c t o r s  are important determinants  b o t h c h i l d r e n ' s h e a l t h s t a t u s and t h e i r h e a l t h s e r v i c e s Clinical of  and e p i d e m i o l o g i c s t u d i e s  indicate a higher  h e a l t h p r o b l e m s among p o o r c h i l d r e n ( S t a r f i e l d ,  Egbuoner and S t a r f i e l d , h e a l t h problems children.  1982; D u t t o n ,  c h i l d r e n than nonpoor c h i l d r e n .  1982).  their non-poor  poor  In  average  a d d i t i o n , the is  g r e a t e r among  t h a n among o t h e r c h i l d r e n  u t i l i z a t i o n and f a m i l y income  strongest  class  indicators  of  children's  health  occupational This  accidents,  has  f o r c h i l d r e n (Bombardier e t a l .  Occupational  effects  1985). A l s o ,  children  (Starfield,  On t h e o t h e r h a n d , a p o s i t i v e r e l a t i o n s h i p between  surgical  1-14.  1982^  a r e h i g h e r among  number o f d a y s s p e n t i n t h e h o s p i t a l f r o m low i n c o m e f a m i l i e s  use.  frequency  t e n d t o be more s e v e r e t h a n t h o s e o f  Hospitalization rates  of  of  f a t h e r and m o t h e r ' s  family social (Mare,  class  status,  1982).  1977).  schooling,  have been a l s o  The l o w e r t h e  the higher the m o r t a l i t y of  e f f e c t seems t o be s t r o n g e s t poisoning  of mother's  f  b e e n f o u n d t o be  schooling  related  to  father's c h i l d r e n aged  f o r deaths  and v i o l e n c e . I n d e p e n d e n t  as  from  positive  on b o t h c h i l d r e n ' s h e a l t h  status  62 (Mare,  1982)  and u s e o f  and G r o s s m a n ,  1978)  p o p u l a t i o n has surgical  b e e n f o u n d t o be n e g a t i v e l y  Unemployment has  situation  populations  variables  most s t r o n g l y  overcrowding  socioeconomic utilization.  age,  population. on  to  non-deprived  The d e p r i v a t i o n rates  health status  u s e and v a r i o u s  out t h a t both demographic  Some o f  i n many  the f a c t o r s ,  associations of  associations  demographic  paediatric hospital  and  between  hospital cases,  such  as  to  of  paediatric  i n understanding  this  and s o c i o e c o n o m i c  of  socioeconomic  utilization,  a r e n o t t h e main f o c u s  demographic  and  and p r o b a b l y r e f l e c t some d e g r e e  i n a population are important  c o m p l e x i t y of  were  unemployment.  seem t o be complex a n d ,  care need. Although  inpatient  effects  Effects  the  r a c e , and f a m i l y i n c o m e , a r e c l o s e l y r e l a t e d  children's hospital  but  h a v e an i n f l u e n c e on p a e d i a t r i c  completely understood.  sex,  factors  factors  1984).  and p a r e n t a l  l i t e r a t u r e review points  not yet  1973),  c o r r e l a t e d with admission  i n households  with  i n G l a s g o w were  f o r any r e a s o n t h a n c h i l d r e n i n and S t e w a r t ,  a  hospital  n i n e t i m e s more l i k e l y t o be a d m i t t e d  (Maclure  in  1977)  (Anderson,  in deprived d i s t r i c t s  districts  This  e t a 1..  associated  may be d i f f e r e n t w i t h i n a p a e d i a t r i c  about  hospital  (Bombardier  (Colle  level  had v e r y l i t t l e d i r e c t i m p a c t on  in total  Children living average  services  have been r e p o r t e d . E d u c a t i o n a l  utilization  utilization  ambulatory p e a d i a t r i c  the  these  study.  factors  However,  should  be  63  held constant of  i n order to separate out the net e f f e c t ,  day c a r e s u r g e r y  example,  on p a e d i a t r i c  i n t r o d u c t i o n of  simultaneous  changes  inpatient u t i l i z a t i o n .  d a y c a r e s u r g e r y may  i n demographic  and  characteristics  of  controlled  could lead to biased  for,  association  if  For  coincide  socioeconomic  the p a e d i a t r i c p o p u l a t i o n , which, estimates  between d a y c a r e s u r g e r y  any,  of  if  not  the  and p a e d i a t r i c  inpatient  use.  2.6.4. Medical  care  availability  Before reviewing associations physician look  at  differs  availability  in  Asymmetry o f  health care i s  p e c u l i a r i t y as failures  (Evans,  notion that  a commodity,  1984).  it  is  h e a l t h , as  h e a l t h c a n n o t be b o u g h t  of  utility  of  has  care  of  t h e most  information  r a t h e r than  i n knowing  to himself,  it  much b e t t e r i n f o r m e d a b o u t  is  and  serious  in  this  stems f r o m t h e health  users.  But  (preventive  can. Although  sovereignity  the  fundamental  d i r e c t l y , only services  a health status  p r o v i d e r who i s  most  of v a l u e to i t s  ambulatory or h o s p i t a l )  health services  "commodity"  resource allocators  a status,  which i s  closer  since health  and t h e s o u r c e o f as  or  i n f o r m a t i o n between u s e r  Asymmetry o f  a commodity,  curative,  usefull  probably i t s  of market p r o c e s s e s  as  is  s e v e r a l ways f r o m t h e s t a n d a r d  p r o v i d e r of  care,  and i n p a t i e n t u t i l i z a t i o n , a  the u n d e r l y i n g t h e o r i e s  economic t e x t b o o k s .  field  between m e d i c a l c a r e  the  consumer  the value  the  or  and  expert  the c o n t r i b u t i o n  of  64 health Thus,  services  to the  t h e consumer  interests,  that  own. H i s  are p a r t i a l l y  depends  economic,  congruent  of  and p a r t l y  In  this  both h e a l t h  care  services  direct  Roemer's  the p r o v i d e r  serving  is  a r e f l e c t i o n of  sector.  It  can a p p l y  more c a p a c i t y  leads  1981;  Evans,  In  surgeons  1984).  Roos,  paediatric  surgical  supply  (Vayda  for at  of  the  interests interests those  of  framework  the  consumer/patient's  and h e a l t h c a r e  efficacy  economic,  1984).  Demand c u r v e  sometimes  for give.  r e f e r r e d to  of  addition  to physicians  to o v e r a l l  physicians  and,  supply  (Stoddart  u t i l i z a t i o n rates  Findings  group  s u p p l i e r - i n d u c e d demand  t o more u s e  and A d e r s o n ,  1983). age  the i n t e r e s t  s h i f t e d by t h e a d v i c e p r o v i d e r s  well;  to vary with  cannot,  and p e r s o n a l  circumstances: (Evans,  in  as  riemanrf .  Law i s  care a c t i v i t y ,  which  in c o n f l i c t with  i n f l u e n c e o v e r demand i s  the h o s p i t a l  his  advice,  incomplete agency  status  and p e r s o n a l  K i i p p l i p r - i n r i n r p H  1978;  But  of  1984).  some r e s p o n s i b i l i t y  professional,  on t h e p r o v i d e r ' s  professional,  This  judge  i n f l u e n c e b y t h e p r o v i d e r on t h e  perceptions  health  interest.  (Evans,  and an e c o n o m i c p r i n c i p a l who has  the consumer/patient. direct  the best  be a p e r f e c t a g e n t ,  consumer/patient, his  health  the p r o v i d e r accepts  the consumer's  t h e same t i m e ,  of  no l o n g e r  of  b u t must r e l y on t h e p r o v i d e r ' s  turn implies serving  is  'production'  in  and  levels  Barer, medical found  particularly,  have been s i m i l a r and Kimm,  as  have a l s o been  1975; V a y d a e t a l . ,  (Wennberg  of  in  1977;  in  1976;  Fuchs,  the  Connell  et  al.,  65 1981).  U t i l i z a t i o n studies  relation use;  from the overa11 p h y s i c i a n  stock  to t o t a l  1986).  r  hospital  T h e r e a r e some i n d i c a t i o n s p e r c a p i t a has  u t i l i z a t i o n rates  McCarthy,  that  a negative  (Osgood e t a 1 .  r  interests.  In  their  practice patterns  i n t e r p r e t e d as behavior to  supply,  of p h y s i c i a n s of  "target"  and  physicians care. This  themselves  if  the  "targets",  a new d r u g ,  positive  supply  of  (1977)  argues  s o l v e d by  a d i f f e r e n t treatment.  subject to constraints  to  doing  t h a t m i g h t be done  'doing  prices  are often uncertain  uncertainty is  r e l a t e d t o an e t h i c o f  patients,  c o u l d be  their  income. But  1984). Wildavsky  a l w a y s one more t h i n g  consultation,  closely  (Evans,  change  o n l y p a r t i a l l y and i m p e r f e c t l y r e l a t e d  , thus,  there is  incomes  physicians  income  in  personal  adjusting  f o u n d between a v a i l a b l e  and p r i c e  e f f i c a c y of  another  for  in  i n s u f f i c i e n t to maintain  that medicine i s  more:  and  increase  be i n c r e a s e d as w e l l . T h i s w o u l d e x p l a i n t h e  to  children's  to increase u t i l i z a t i o n . This  some s o r t  correlation usually  is  increases  the r e s u l t  seek  is  or  g e n e r a l , when a v e r a g e w o r k l o a d s  due t o exogenous  h e a l t h and  of  1980; K o z a k  b e h a v i o r i n r e s p o n s e t o exogenous  fall,  physicians  (Roos e_t  t h e number  e f f e c t on  s u p p l y may r e f l e c t e c o n o m i c , p r o f e s s i o n a l ,  will  individual  1984).  Physicians'  expansion  hospital  and t h e i r p e r c e p t i o n s and p r e f e r e n c e s  paediatricians  as  consistent  r a t h e r t h e y have emphasized t h e i n f l u e n c e of  practitioners a1.  have n o t i n d i c a t e d a  everything  This  possible'  on t i m e and e n e r g y ,  so  66 t h a t when a p h y s i c i a n  sees  physician-to-population for  fewer p a t i e n t s  ratio,  e a c h . Whether t h e m o t i v e s  comprehensiveness  of  e.g.), of  (because  he f e e l s  physicians  c a r e , or incomes,  of  rise  in  a b l e t o do more  are to  matters  increase  little  to  the  outcome.  Professional style"  and p r a c t i t i o n e r s '  objectives  pride.  If  consistent  response  practitioners, is  to patients, of  i n d i c a t i v e of  of  the case of  the  and to  his  all  over  in action  North (Evans,  over time i n response Thus a s h i f t  can a l s o  and G i t t e l s o h n ,  1977),  to response  change b e c a u s e  or  1982; R o o s ,  to  standard.  or medical information  tonsillectomies)(Kimm,  The  of  becomes o v e r t i m e t h e new  in training  (Wennberg  e.g.),  w h i c h may i n i t i a l l y be a  S t a n d a r d s and p r a c t i c e p a t t e r n s shifts  trade-off  own and o t h e r s .  recommending more s e r v i c i n g , t o economic f a c t o r s ,  (due  which governs  price levels,  this  bound  provider's  and g e n e r a t e more demand.  p r a c t i c e adapt  current p r a c t i c e , one's  can  shrink  u t i l i z a t i o n t o numbers  regardless  Standards of  The  "practice  between d o l l a r s  ratio,  c o u l d change t h e c r i t e r i a  recommendations  reasons  of  non-economic  income and w o r k l o a d  in physician-to-population  practitioner  America,  process.  T h e r e c o u l d be a t r a d e o f f  professional increase  the demand-generation  i n c l u d e e c o n o m i c as w e l l as  components.  general  concepts  ( v i e w s on how m e d i c i n e o u g h t t o be p r a c t i c e )  and r e g u l a t e  1984).  ethics  (e.g.,  f o r more 1983).  of in  local  67 Physician studying  It  leads and  possible  that high l e v e l  to both high l e v e l s  surgery  a p o t e n t i a l confounding  given use.  to  hypothesize that  specialists generation  A large  paediatric  physician  groups  e.g.).  e f f e c t of  day c a r e  physician  of  supply  inpatient  (Roos,  effects  (i.e.,  Change,  of  net  pressure  A  positive  and i n p a t i e n t bed  use  capacity  use.  a l s o t h e need  for  differences in practice patterns  medical  care  b e e n shown t o  1983).  on b o t h beds  l i t e r a t u r e r e v i e w emphasizes  controlling  for  these  may mask a  c o u l d l e a d t o an i n a p p r o p r i a t e i n f e r e n c e t h a t alone determines  and  surgery.  Bed s u p p l y has  stock  can  f o r day  and a c t i v e p h y s i c i a n p o p u l a t i o n c a n l e a d t o  i n f l u e n c e of  time.  one  both s u b s t i t u t e  High supply  r e l a t i v e to other s p e c i a l i s t s  care  general  c a r e and i n c r e a s e p r e s s u r e  q u a l i t y reasons,  activity,  e f f e c t from day  (e.g.,  and p a e d i a t r i c i a n s )  correlate with physician  standards  and  f o r day  On t h e o t h e r h a n d ,  some s p e c i a l i s t  f o r more b e d a v a i l a b i l i t y .  This  in  availability  inpatient  increased pressure  i n p a t i e n t use.  inpatient  (for  of  c o u l d mask a n e t n e g a t i v e  family practitioners, paediatric  of  bed s t o c k )  This  surgery  surgery  factor  u t i l i z a t i o n a n d , t h e r e f o r e , s h o u l d be c o n t r o l l e d  is  (for  care  is  t h e r e l a t i o n s h i p between d a y c a r e s u r g e r y  inpatient for.  availability  'culture')  across  areas  and  and  over  f o r example,  in hospitalization  patterns,  due  economic o r o t h e r r e a s o n s ,  i n one a r e b u t n o t  i n others  can  to  68  cause b i a s  in  o p e r a t i o n of 'culture' 1970s  cross-area  tonsillectomy  ( E v a n s and R o b i n s o n ,  interpretation that substituted  2.7.  it  Summary o f  i n recommending  been a major s h i f t  1980).  inpatient If  it  is  and o f  Both r i s k  of  compromising  and s a f e t y o f  demonstrated with h a v e shown t h a t percent  less  wards.  However,  several  episode of  there is  substitutes  the q u a l i t y of  use of  things being equal,  of  into  been  analyses is  50 -  unit  savings  T h i s would r e q u i r e t h a t inpatient  w o u l d n o t be f i l l e d b y  i m p o r t a n c e i n making  70  inpatient  lower  c a r e t o day c a r e s u r g e r y ,  utmost  has  cost  t r e a t m e n t on t h e  f o r more e x p e n s i v e  inpatient is  operations.  Detailed  be t r a n s l a t e d  f r e e d by s u b s t i t u t i o n of  group,  on c h i l d r e n c a n be  no c l e a r e v i d e n c e t h a t  health care expenditures.  Response  effects  expensive than s i m i l a r  total  beds  1970s  infections  c a r e i n day c a r e s u r g e r y  day c a r e surgery w i l l  that  for  conventional  hospital-acquired  specialties.  of  surgery  i n the  p a e d i a t r i c day c a r e s u r g e r y  costs  care  the  false  e s p e c i a l l y i n t h e p a e d i a t r i c age  undesirable psychosocial  Feasibility  in  l i t e r a t u r e review  surgery.  minimized without  medical  surgery.  c l e a r q u a l i t y based advantages over the  inpatient  surgery  i n c r e a s e i n day care s u r g e r y inpatient  in  the  not accounted  could lead to a  for paediatric  Day c a r e s u r g e r y , has  has  Change  i n respect to paediatric  in a time-series"study,  has  studies.  in  day  care  and  others. other final  69 conclusions  on t h e e c o n o m i c a d v a n t a g e s o f  a paediatric  There are  inpatient for,  of  use.  Effects  factors  t h a t may d i s t o r t  these  any f i n a l  effect  is  factors  conclusions  a potential  (if  s h o u l d be  is  any)  on t h e  confounder i n  on i n p a t i e n t  hospital  a lack  of  c l e a r evidence t h a t Roemer's  determines  when r e v e a l i n g  between p a e d i a t r i c d a y  e x i s t e n c e s h o u l d be  beds  utilization, potential  effects  lack  false  substitutes  Several  available. of  If  bed s u p p l y  adjustment  demographic  and s o c i o e c o n o m i c  In  care  and i n p a t i e n t u s e ,  of  these  care  only  could  few  inpatient  e f f e c t can l e a d  to  surgery  factors  with paediatric  utilization.  effects  studied  utilization.  on and a s s o c i a t i o n s  surgery  for this  creates  i n t e r p r e t a t i o n t h a t day c a r e  for inpatient  working  P a e d i a t r i c day c a r e s u r g e r y  h a v e b e e n i n t r o d u c e d i n an a r e a b e c a u s e t h e r e i s inpatient  Although,  Law i s  its  and i n p a t i e n t u s e .  studying  utilization.  u t i l i z a t i o n in a population.  associations  and  relationship.  in a paediatric population,  surgery  the  controlled  Law s u g g e s t s t h a t b e d c a p a c i t y a v a i l a b l e  the l e v e l of there  of  bed s u p p l y  day c a r e s u r g e r y Roemer's  confounding  t h e r e l a t i o n s h i p between d a y c a r e s u r g e r y  b e f o r e making  Paediatric  in  population.  several  observations  day c a r e s u r g e r y  have  complex  inpatient  o r d e r t o r e v e a l t h e r e l a t i o n s h i p between day  factors  other t h i n g s  being  s h o u l d be c o n t r o l l e d f o r .  equal  r  Some o f  the  70 demographic  and s o c i o e c o n o m i c  characteristics  p a e d i a t r i c population are associated that  population.  Although,  available  of  the  with the health  health status determines  c a r e n e e d s and t h e r e b y h o s p i t a l few m e a s u r e s  of  status hospital  u t i l i z a t i o n , there are  t h e s e needs  independent  of  very  of  utilization.  Physician regions in  patterns  and s h i f t s  i n medical  'culture'  confounders  t h e r e l a t i o n s h i p between p a e d i a t r i c d a y  and i n p a t i e n t u s e .  However,  c a n n o t be m e a s u r e d b y a  physicians'  'head count'  effects.  care  practice  of  The a d j u s t m e n t w o u l d n e e d a c o n t r o l f o r t i m e - and specific  across  and o v e r t i m e a r e a l s o i m p o r t a n t p o t e n t i a l  studying  surgery  supply  physicians. area-  71  3.  DATA SOURCES AND METHODS  3.1.  Study u n i t  and r e s e a r c h d e s i g n  The p r i n c i p a l i n t e r e s t  in this  between day c a r e s u r g e r y utilization.  "supply"  care)  its  generate  inpatient  care)  its  or,  use,  s t u d y makes i t itself  (i.e.,  population). logical  (inpatient  own demand  if  generation  by o t h e r  patients.  f o r p o t e n t i a l bed s u p p l y e f f e c t  inclusion possible  of  t o examine t h a t  e x i s t e n c e of  Roemer's  Due t o t h e n a t u r e o f  study u n i t  is  potential  Law i n a  questions,  because day c a r e s u r g e r y  may draw p a t i e n t s  population  district"  was  level.  s e l e c t e d as  effect  the  study  availability  one  from o t h e r i n s t i t u t i o n s .  The  effect is  For t h i s  the u n i t  of  only observable  reason the  the  population.  in  substitution/generation  regional,  the  paediatric  people, a  b a s e d a p p r o a c h c o u l d n o t answer  hospital  in  the underlying problem,  an a g g r e g a t e o f  in  and  a bed c a p a c i t y measure  A hospital  overall  for  occurres,  f r e e d beds  day  could  (no s u b s t i t u t i o n  some s u b s t i t u t i o n  the  According  and  t h e r e l a t i o n s h i p between d a y c a r e s u r g e r y  inpatient  inpatient  factor is  own demand. Day c a r e s u r g e r y  addition to c o n t r o l l i n g  studying  relationship  and p a e d i a t r i c  capacity  c o u l d t a k e p l a c e by f i l l - i n of In  i n the  to the p a e d i a t r i c population.  model, h o s p i t a l  generates  directly  availability  is  The m a i n h y p o t h e s i z e d c o n f o u n d i n g  bed c a p a c i t y a v a i l a b l e to a  study  "school  observation  in  this  at  a  72 study.  By u s i n g  homogeneity i s  small  units.  desirable  than l a r g e r  (Joffe,  like  school d i s t r i c t s ,  a c h i e v e d f o r e a c h u n i t as w e l l as  number o f  hospital  areas  For t h i s  districts,  l i k e health regions  comparison of  s e v e r a l areas  (cross-sectional). of  utilization  study.  or populations  knowing  been a  a t one p o i n t for  causal  is  population,  usually  the degrees  of  lacks  statistical  the m u l t i t u d e of  a time s e r i e s  the  s u f f i c i e n t data points freedom n e c e s s a r y t o  effects  time-dependent confounding f a c t o r s , to detect r e a l  A third possible  to  causal  research design,  (1983)  a provide  disentangle affect  However, one c o u l d a d j u s t  for  the  improving  the  associations.  which i s  a combined c r o s s - a r e a / c r o s s - y e a r  Evans e t a l .  of  f o r c e s which might s i m u l t a n e o u s l y  i n p a t i e n t use.  possibility  design,  hazardous  analysis  paediatric of  in  the time-dependent e f f e c t s .  Another research design,  is  has  A l t h o u g h one c a n a d j u s t  c o r r e l a t i o n s as  that  The most commonly u s e d  a r e a - s p e c i f i c confounding f a c t o r s with t h i s  the i n t e r p r e t a t i o n of  study,  regional  three d i f f e r e n t research designs  research design in hospital u t i l i z a t i o n studies  without  a r e more  1979).  c o u l d have been employed i n t h i s  effects  greater  greater  or  when e x a m i n i n g c o r r e l a t e s o f  T h e r e were b a s i c a l l y  time  a  reason school d i s t r i c t s  areas,  a  i n t h e i r study of  used i n  this  approach used  the t o t a l  B.C.  by  73  population over a shorter p e r i o d . This control  f o r both r e g i o n a l  effects  design enables  s u c h as  styles  and t i m e - d e p e n d e n t c o n f o u n d i n g  shifts  i n medical technology or s u r g i c a l  unique  factors  what t h e p a e d i a t r i c the absence of  possible  to  factors but  to a l l  availability  or across  it  e i t h e r over  districts  but  availability.  these other factors  t h e growth o f  for  controlling  simultaneously  varies The  is  ability  crucial  e n s u r e enough f o r t h e many  of  similar  day c a r e s u r g e r y .  design w i l l  of  time  i n f e r e n c e s a b o u t what i n p a t i e n t u t i l i z a t i o n m i g h t  the c r o s s - a r e a / c r o s s - y e a r  in  that  the e f f e c t s  t h e i r i n p a t i e n t use  w i t h day c a r e s u r g e r y  been i n t h e absence of  points  inequivocally  d e s i g n makes  after isolating  t o see i f  c o n t r o l f o r the e f f e c t of  making  No  with d i f f e r e n t levels  u s e and v a r y i n g  districts,  time p e r i o d s ,  systematically to  On t h e o t h e r h a n d , t h i s  affecting hospital  common t o a l l  general  (a h y p o t h e t i c a l s t a t e  compare s c h o o l d i s t r i c t s  day c a r e s u r g e r y  s u c h as  i n p a t i e n t u t i l i z a t i o n might have been  day c a r e s u r g e r y  never o c c u r r e d ) .  practice  practice.  r e t r o s p e c t i v e r e s e a r c h d e s i g n can demonstrate  the  in  have  Also,  data possible  confounders.  The a d o p t e d r e s e a r c h d e s i g n s e t s Because  the impact of  inpatient  day c a r e s u r g e r y  utilization is  and a c r o s s  time,  all  c e r t a i n data  availability  studied both across  changes  in  school d i s t r i c t  and c a p a c i t y v a r i a b l e s .  For t h i s  on  school  o v e r t i m e must be i n c o r p o r a t e d o r r e c o n c i l e d i n utilization  requirements.  districts  boundaries computing  reason a  single  74 set  of  boundaries  other years maintain (1983)  a t one p o i n t  i n t i m e was  were a d j u s t e d t o t h a t  standard.  comparability with the s i m i l a r  on t h e t o t a l  population  c h o s e n and t h e n In  order  i n B.C.,  districts  one. because of v a r y i n g  across  administrative  Ministry  of  hospital  u t i l i z a t i o n data,  t h e same method  H e a l t h , which uses s c h o o l d i s t r i c t s  differently Small  than the M i n i s t r y  Business  of  building partial  Census blocks.  Enumeration Areas,  impossible.  The s m a l l e s t  utilization  records  is  is  d i v i d e d i n t o one t o  districts  municipality  '000'.  of  according  hospital  for  is  Each s c h o o l In  most  is  boundary  district  school that  have a  recorded  as  changes the  data  The p r o b l e m o f  boundary changes  made e v e n more c o m p l i c a t e d b y t h e f a c t  as  only  they o f t e n do,  impossible.  school d i s t r i c t  using  are  u t i l i z a t i o n and c a p a c i t y  t o t h e s e changes  controlling  as  c a n be  hospital  the d i s t r i c t  school d i s t r i c t  and  in  involve  population centers  only p a r t i a l municipalities,  r e a l l o c a t i o n of  in  municipalities.  c o d e and t h e r e s t  involve  unit  the m u n i c i p a l i t y .  municipality  If  areas  p o p u l a t i o n adjustments  t h e r e a r e one o r two  the  Enumeration Areas  boundary changes  geographical  six  used  The p o p u l a t i o n d a t a  i n f o r m a t i o n and Census if  B.C.  E d u c a t i o n , and I n d u s t r y  f o r B.C.  However,  school  somewhat  r e c o n s t r u c t e d q u i t e a c c u r a t e l y by g e o g r a p h i c a l available  was  i n coding  D e v e l o p m e n t , whose d e f i n i t i o n i s  r e p o r t i n g population data  of  The  the borders  of  process  definitions  jurisdictions.  defines  to  s t u d y by Evans e t a l .  b o u n d a r y a d j u s t m e n t was a d o p t e d . The a d j u s t m e n t not a simple  all  that  over time  the M i n i s t r y  of  is  75 H e a l t h does  n o t a l w a y s change t h e s c h o o l d i s t r i c t  used  coding of  in  actual this  its  boundaries  adjustment  hospital  change.  process,  base y e a r i n s t e a d  of  In  discharge  if  the year  1966 was  a more r e c e n t y e a r ,  a school d i s t r i c t  in  later years,  if  the r e a l l o c a t i o n of  d a t a was  this  possible.  (no.  7)  For example,  Ministry 1971.  of  it  was  possible  school d i s t r i c t . population data for  Silverton  10)  and t h e r e s t 1966. it  In was  In  of  of  no.8)  change a s  d a t a was  too  the M i n i s t r y example,  divided  the r u r a l s u b d i v i s i o n  Education  1,  January  7).  This  c a s e s where s c h o o l d i s t r i c t s usually  necessary  of  of  i n the  Cariboo  (no.  27)  data  form C a r i b o o - C h i l c o t i n  (no.  27)  as  (no.  d i v i s i o n was done were c o m b i n e d  district  of  and  discharges  (no.  82)  as  after  of  1966,  discharge  the school d i s t r i c t s  and C h i l c o t i n  and  Slocan  discharge  residence information i n the  H e a l t h had c h a n g e d i t s  1,  Silverton  t o do t h e c o m b i n i n g as  crude f o r separating  The  discharge  b o t h t h e p o p u l a t i o n and  (no.  Nelson  1970.  and New D e n v e r were added t o A r r o w L a k e s to Nelson  1966  population  between  of  to i d e n t i f y residents  comparable,  boundaries.  1966 was  September  o d e r t o make h o s p i t a l  because the p l a c e of  to  as  Health recognized this  New D e n v e r b u t n o t o f  1966  district  10)  population  1966  and  U s i n g t h e m u n i c i p a l i t y code i n h o s p i t a l  records  of  records  in  the  t r i e d t o c a r r y back t o  the M i n i s t r y  (school (no.  and a l l  in existence in  the h o s p i t a l  and A r r o w L a k e s  time  selected for  back t o t h e  d i v i s i o n was  decided to d i v i d e Slocan  each  o r d e r t o minimize the problems  and u t i l i z a t i o n d a t a were b r o u g h t However,  records  definitions  after  coding. were  J a n u a r y 1,  For  combined  1972.  It  76 was  impossible  Chilcotin this  in  to i d e n t i f y residents  the discharge  n e c e s s a r y mergers  of  some d i s t r i c t s  observation  (Figure  1).  t h e number o f  more r e c e n t y e a r s capacity.  1983)  r  s t u d y was  is  after  or  units  reduced to  1968-1976  75  (same as  in  The two  decreasing  the school  presented elsewhere  1966.  the  and 1 9 8 1 / 8 2 - 1 9 8 2 / 8 3 .  The d e t a i l e d d e s c r i p t i o n o f  For  of  1966, b u t  represented a time p e r i o d of  boundary adjustments  1972.  school d i s t r i c t s  covered the years  t h e s t u d y by Evans e t a 1.  in  because of  f o r each y e a r i n t h i s  The s t u d y  for  were c o m b i n e d as  84 s c h o o l d i s t r i c t s  r e a l l o c a t i o n problems,  and  a f t e r J a n u a r y 1,  r e a s o n t h e two s c h o o l d i s t r i c t s  T h e r e were a l t o g e t h e r  of  tapes  for Cariboo  bed  district  (Evans e t  al.,  1983) .  3.2.  Dependent v a r i a b l e use per c a p i t a  3.2.1.  Exclusions  B.C.  in this  study  is  among t h e p a e d i a t r i c  (0-14  years)  Originally,  broadly to  include also  group  hospital  inpatient  population  in  t h e p a e d i a t r i c p o p u l a t i o n was d e f i n e d more 15-19 y e a r o l d c h i l d r e n . However,  most common d e f i n i t i o n o f t h e age  hospital  from numerator  The d e p e n d e n t v a r i a b l e utilization  - paediatric inpatient  0-14.  This  paediatric population includes is  a l s o t h e age r a n g e  that  the  the only  B.C.  BRITISH COLUMBIA School D i s t r i c t s 1. 2. 3. 4. 7. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36.  FIGURE 1. School d i s t r i c t boundaries in the study.  Fernie Cranbrook Klmberley Windermere Nelson Castlegar Arrow Lakes Trail Grand Forks Kettle Valley South Okanagan Pentlcton Keremeos Princeton Golden Revelstoke Saloon Ana Armstrong-Spa Hum Vernon C e n t r a l Okanagan Kamloops North Thompson Cariboo-Chilcotln Ouesnel Llllooet South Cariboo Merrltt Hope Chilliwack Abbotsford Langley Surrey  37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 52. 54. 55. 56. 57. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 75. 76. 77. 78. 80. 81. 84. 85. 86. 87.  Delta Richmond Vancouver New Westminster Burnaby Maple Ridge Coqultlam North Vancouver West Vancouver Sechelt Powell River Howe Sound C e n t r a l Coast Queen C h a r l o t t e P r i n c e Rupert Smithere Burns Lake Nechako P r i n c e George Peace R i v e r South Peace River North Victoria Sooke Saanlch G u l f Islands Cowl Chan Lake Cowlchan Ladysmith Nanalao Qualicum Alba m l Courtenay Campbell R i v e r Mission Aggasslz Summerland Enderby Kltloat F o r t h Nelson Vancouver I s l a n d Vest Vancouver I s l a n d North Terrace Stlklne  78 Ministry  of  H e a l t h uses i n i t s  facilities. paediatric of  age.  beds.  sake  of  bed i s  c o n t i n u i t y of  cared for i n  a chronic i l l n e s s  years  adult  the  bed i s  age".  c a r e e v e n when t h e c h i l d has  c o n d i t i o n of  passed  W i t h 0-14 y e a r o l d c h i l d r e n , c a r e i n  only allowed i n s p e c i a l circumstances,  a paediatric f a c i l i t y is the c h i l d ,  the geographical group  in general,  t h a n 15  t r e a t m e n t may t a k e p l a c e i n a p a e d i a t r i c ward f o r  "paediatric adult  meant o n l y f o r c h i l d r e n l e s s  c a s e s where a c h i l d has  hospital  paediatric  W i t h o n l y few e x c e p t i o n s , a p a e d i a t r i c ward o r a  Older children are,  In  d e f i n i t i o n of  not i n d i c a t e d because of or is  distance.  not e a s i l y  I n c l u s i o n of  bed a v a i l a b i l i t y . the small  s i z e of  and one f o r t h e  t o t a l b e d c a p a c i t y as  the p o p u l a t i o n base i n  Also,  school  a c l o s e r look at  patterns  of  t h e 15-19 y e a r o l d age g r o u p  hospital  u s e more c l o s e l y r e s e m b l e s a d u l t In  1981/82,  for medical separations poisoning  (28 p e r c e n t o f  the  (9 p e r c e n t ) . The most common s u r g i c a l  from  utilization  suggests that utilization  and m e n t a l  procedure  of  hospital  their than  categories  age g r o u p were i n j u r y  (18 p e r c e n t )  15-  districts,  a l l medical separations),  and p r e g n a n c y c o m p l i c a t i o n s  age  a measure  t h e most common d i a g n o s t i c in this  of  p a e d i a t r i c bed  The l a t t e r s t u d y w o u l d h a v e s u f f e r e d  u t i l i z a t i o n measures.  when  studies:  w h i c h w o u l d h a v e i n t r o d u c e d random v a r i a t i o n t o t h e  paediatric.  e.g.  t h e 15-19 y e a r o l d  bed a v a i l a b i l i t y ,  19 y e a r o l d age g r o u p u s i n g  an  i n reach because  one f o r t h e 0-14 y e a r o l d age g r o u p u s i n g a measure o f  the  the medical  i n t h e s t u d y w o u l d have meant c o n d u c t i n g two  c a p a c i t y as  the  and  delivery disorders  categories  79 were o b s t e t r i c a l p r o c e d u r e s separations), percent)  and o p e r a t i o n s  percent). the  operations  the  all  on m u s c u l o s k e l e t a l on n o s e ,  T h i r t y two p e r c e n t o f  15-19 y e a r o l d age  reasons,  (27 p e r c e n t o f  surgical  system  (25  mouth and p h a r y n x  (13  t h e day c a r e s u r g e r y  g r o u p was  for abortions.  15-19 y e a r o l d age g r o u p was  use  in  For a l l  e x c l u d e d from  these this  study.  In  addition,  since  this  group  paediatric of  hospital is  c h i l d r e n from 0 t o  was  assumed  is  that  is  dealt with  14 y e a r s  of  that  chronic, convalescent  computerized h o s p i t a l  Thus,  only those  hospitals  discharged  Maternity surgery  'E'-code  In  in  the from  separation  Rehabilitation  order to  cared  excluding  cases  remained i n the  a l s o assumed t o be i n d e p e n d e n t o f  availability.  care  rehabilitation  were e x c l u d e d b y  from acute c a r e h o s p i t a l s  It  all  r e h a b i l i t a t i o n c a s e s who were  from the study.  use i s  Thus,  r e c o r d s , were e x c l u d e d  U n l i k e extended care p a t i e n t s ,  in rehabilitation hospitals  those  availability.  d e t e r m i n e d b y an  discharge  the  consists  and r e h a b i l i t a t i o n  c o u l d n o t be i d e n t i f i e d i n t h e h o s p i t a l  records. for  study  r e s t r i c t e d only to acute care u t i l i z a t i o n .  extended care s e p a r a t i o n s ,  patients  in this  Thus,  age.  a r e independent of day c a r e s u r g e r y  the study.  excluded  not s u b j e c t t o day c a r e s u r g e r y .  age g r o u p  The s t u d y  u t i l i z a t i o n b y newborns was  sharpen the focus  study.  day of  care the  80 study  all  maternity cases  pregnancy, study. age  In  (delivery,  c h i l d b i r t h , and p u e r p e r i u m ) 1981/82  of  were e x c l u d e d f r o m t h e  t h e r e were 19 s u c h c a s e s  i n the  paediatric  group.  Terminations  of  day c a r e s u r g e r y  pregnancies  (abortions)  and on an i n p a t i e n t  implementation of  The l e g a l i z a t i o n  a r e done b o t h on a  care basis.  of  done i n B r i t i s h  abortion coincided with the  day care s u r g e r y .  After legalization,  basis.  that  abortions  the i n c r e a s e of  day c a r e s u r g e r y  represent a substitution of  impediments. surgery  for inpatient  new s u r g e r y It  i n B.C.  is  a f t e r a b o l i t i o n of  l i k e l y that  hospitals  of  abortions  In  order to  substitution/generation the e f f e c t of  subsequent study  is  it  was  felt  not  a  day  of  care  abortions  the  special  the increase that  argued  legal  the  in  relationship  and i n p a t i e n t u t i l i z a t i o n r e l a t e d  c o u l d be q u i t e d i f f e r e n t f r o m t h a t w i t h  procedures.  place,  and t i m i n g  pregnancies,  between day c a r e s u r g e r y  does  t h e i n c r e a s e d demand f o r  circumstances  surrounding  have been  c a n be  i n the absence of  Because  focus  other  t h e s t u d y on t h e  effects  t h a t would n o r m a l l y  legalization  of  a b o r t i o n and  take  the  i n c r e a s e i n demand were a l s o e x c l u d e d f r o m t h e  by e x c l u d i n g a l l  abortions  26,  introduction  It  care but  would have i n d u c e d a b o r t i o n c l i n i c s .  t e r m i n a t i o n of  the  Columbia.  abortions  f r e q u e n t l y done on a d a y c a r e s u r g e r y  generation  Before  amended a b o r t i o n - l a w i n Canada on A u g u s t  1969 t h e r e were v e r y few a b o r t i o n s  of  complications  both from the  inpatient  to  81 utilization  and f r o m t h e d a y c a r e s u r g e r y  Operative procedures  in this  category  p l a y a major r o l e i n the h o s p i t a l paediatric population.  In  use  in this  i n any c a s e ,  u t i l i z a t i o n of  study.  did  the  1981/82 t h e r e were o n l y  25  abortions  done on an i n p a t i e n t b a s i s and 76 i n d a y c a r e s u r g e r y for  the p a e d i a t r i c  3.2.2.  p r o v i n c e are not records hospital  u t i l i z a t i o n of  However,  this  u t i l i z a t i o n i n B.C.  B.C.  i n B.C.,  by n o n - r e s i d e n t  t h e main d a t a b a s e  only  and d a y s o f  that  stay  derived  of  surgical  subcategories  from these data  of  In  children separate  out-of-province  E x t r a c t i o n of  by s c h o o l d i s t r i c t  would have been a l e n g t h y p r o c e s s . measures  children.  the o u t - o f - p r o v i n c e data  i n a hard copy form.  includes  combined t o a  Adding  was were admissions  r e s i d e n c e , age  Moreover,  f o r the study purposes  because  o r d e r t o overcome  problems,  out-of-province  different  and d a y s were s i m i l a r l y measures  of  d i s t r i b u t e d by age,  the dependent v a r i a b l e  sex  been  p r o c e d u r e c o d e s were n o t r e c o r d e d . In  admissions  and  accurate  c o u l d n o t have  an a s s u m p t i o n was made t h a t  the  discharge  to the u t i l i z a t i o n w i t h i n the province  h i n d e r e d by the f a c t available  outside  u t i l i z a t i o n of  was  o u t - o f - p r o v i n c e u t i l i z a t i o n database. utilization  residents  computerized database  order to determine the t o t a l h o s p i t a l residing  B.C.,  numerator  i n c l u d e d i n t h e main h o s p i t a l  database.  in  population.  Inclusions i n  D a t a on h o s p i t a l  not  as  within  these  sex  and  82 province u t i l i z a t i o n . days by s c h o o l extracted. school  Only t o t a l  district  Age,  district  of  number o f  residence  i n age  s e x and d e p e n d e n t v a r i a b l e of  u t i l i z a t i o n before adding  handling.  the years  by s c h o o l  district  years  and 1 9 8 2 / 8 3 .  district  two n e i g h b o u r i n g 1968-1969  years  was  Table  in  1971,  out-  1976 and 1 9 8 1 / 8 2 .  In  their  out-of-province  i n A l b e r t a , have a h i g h e r  province u t i l i z a t i o n . in  In  Golden)  results  1981/82  reflect  one o r two l o n g  (and t o  school  of  For  (e.g.,  stay admissions outside  and the  the  total 1982/83  in  it  1981/82.  utilization  of  district  districts  near  or  out-of-  Windermere  some e x t e n t  for  out-of-  n e a r Edmonton  p r o p o r t i o n of  some c a s e s  all  the average  t h e same as  in particularly,  manual  admissions  1971 and 1973.  general,  the  and  at  and i n - p r o v i n c e u t i l i z a t i o n b y s c h o o l  the A l b e r t a border and, Galgary  of  exist  1970 and f o r t h e y e a r  t h e p r o p o r t i o n was  to  1971  process  The number o f  was made t h a t  4 shows t h e p r o p o r t i o n o f  the t o t a l in  that  figures  f o r m e d t h e same p r o p o r t i o n o f  u t i l i z a t i o n as  assumed  within  out-of-province  f o r the years  f o r the years  by  out-of-province  were c a l c u l a t e d as  an a s s u m p t i o n  province u t i l i z a t i o n inpatient  0-14  distributions  Furthermore, such data d i d not  1968-1969  days by s c h o o l  were  the o u t - o f - p r o v i n c e  1973 w o u l d h a v e r e q u i r e d an e v e n l e n g t h i e r data  group  to the  province u t i l i z a t i o n . Accessing  u t i l i z a t i o n data  and  r e s i d e n c e were d e r i v e d f r o m t h e  p r o v i n c e u t i l i z a t i o n and t h e n a p p l i e d  within  admissions  in  and  197 6)  the  province.  Table 4  P r o p o r t i o n of O u t - o f - P r o v i n c e U t i l i z a t i o n of t h e T o t a l I n - and Out-  P r o v i n c e U t i l i z a t i o n by School D i s t r i c t  1n 1971, 1976, and 1981/82  Admissions School  1.  District  1971  Days  1976  1981/82  1971  1976  1981/82  12.35  Fernie  6.28  10.94  4.08  10.65  16.94  2. Cranbrook  5.83  9.66  5.79  9.02  18.26  12.39  3. Kimberley  4.74  5.34  4.47  7.22  11.26  21.93 44.22  4 . Windermere  9.61  5.88  14.09  14.93  27.78  7.  Nelson  1.35  2.39  0.84  1.15  6.34  2.25  9.  Castlegar  0.80  0.58  0.00  0.75  0.34  0.00  10. Arrow Lakes  0.46  0.91  0.00  0.36  0.38  0.00  11.  0.96  1.32  0.89  0.80  3.63  2.22  12. Grand F o r k s  0.58  1.70  0.69  0.39  1.19  0.33  13. K e t t l e  Trail  '  0.00  0.00  1.85  0.00  0.00  0.48  14. Shouthern Okanagan  0.97  1.32  0.46  0.99  1.05  0.21  15.  0.64  2.19  0.95  0.32  2.92  0.64  16. Keremos  1.10  0.00  0.00  1.97  0.00  0.00  17.  0.42  0.00  0.00  0.34  0.00  0.00  9.31  14.68  14.19  20.65  43.02  40.14  Valley  Penticton Princeton  18. Golden Revelstoke  1.98  3.62  0.41  2.08  4.20  1.98  2 0 . Salmon Arm  0.51  1.15  1.09  0.33  0.58  1.54  2 1 . Armstrong S p a l l u m  0.00  0.72  2.24  0.00  1.12  1.66  2 2 . Vernon  1.54  0.60  1.74  3.75  0.75  1.37  2 3 . C e n t r a l Okanagan  0.84  1.92  1.94  0.96  1.94  1.06  2 4 . Kamloops  1.24  1.25  0.81  1.20  1.14  1.13  2 6 . N o r t h Thompson  2.67  3.95  0.61  2.09  9.63  0.52  27.  19.  0.73  0.49  0.40  0.35  0.35  0.51  28. Quesnel  1.18  0.83  0.41  0.68  0.55  0.21  29.  Lillooet  0.08  0.00  0.31  0.04  0.00  0.17  3 0 . South C a r i b o o  0.28  0.73  0.71 .  0.12  0.72  0.16  31.  0.90  0.25  0.24  0.84  0.05  0.05  3 2 . Hope  0.93  0.43  0.00  0.46  0.13  0.00  33.  Chilliwack  1.01  1.05  0.97  1.12  1.18  1.42  34.  Abbotsford  1.24  0.86  0.20  1.04  0.93  0.87  35.  Langley  Cariboo-Chilcotin  Merritt  0.86  0.88  0.60  0.67  0.53  0.48  36. Surrey  0.74  1.15  0.79  0.60  1.28  0.84  37.  1.10  1.67  1.24  1.16  1.57  0.53  1.47  0.32  1.49  0.88  1.38  1.05  1.22  0.92  1.03  0.77  0.54  0.48  0.53  0.19  0.51 0.37  Delta  3 8 . Richmond 3 9 . Vancouver 4 0 . New W e s t m i n i s t e r 4 1 . Burnaby  0.43 0.84 0.82 0.84  1.51 1.49 1.00 0.49  0.70  4 2 . Maple R i d g e  0.40  0.74  0.66  0.86  0.62  43.  Couquitlam  0.92  1.63  1.03  0.93  1.36  0.76  4 4 . N o r t h Vancouver  1.07  0.76  0.97  1.21  0.60  0.63 0.81 0.07  4 5 . West Vancouver  1.15  1.07  1.53  1.24  0.84  46.  0.75  0.95  0.27  0.28  0.78  Sechelt  84  Table 4  . . .Continued  P r o p o r t i o n of 0 u t - o f - P r o v 1 n c e U t i l i z a t i o n of t h e T o t a l I n - and Out-  P r o v i n c e U t i l i z a t i o n by School D i s t r i c t  1n 1971, 1976, and 1981/82  Admissions School  District  47. P o w e l l  River  1971  1976  Days 1981/82  1971  1976  1981/82  0.49  0.54  0.26  0.24  0.24  0.38  4 8 . Howe Sound  0.89  1.10  0.00  0.83  1.10  0.00  49. C e n t r a l  0.13  0.45  0.00 •  0.05  3.29  0.00  5 0 . Queen C h a r l o t t e  1.33  1.53  1.33  1.24  1.24  0.70  5 2 . P r i n c e Rupert  0.55  0.29  0.42  0.55  0.13  0.31  Coast  54. S m i t h e r s  0.46  2.77  0.00  0.53  3.83  0.00  5 5 . Burns Lake  1.26  0.36  1.16  0.59  0.11  0.70  56. Nechako  0.94  0.35  0.10  0.63  0.07  0.07  5 7 . P r i n c e George  2.32  2.86  1.58  2.18  3.16  2.00  19.75  10.16  3.96  24.25  15.40  4.02  6 0 . Peace R i v e r N o r t h  5.52  4.89  2.20  5.81  8.61  1.92  61. V i c t o r i a  0.94  1.60  0.92  1.02  2.47  0.67  59. Peace R i v e r South  6 2 . Sooke  1.56  1.97  0.87  1.54  1.22  0.59  63. Saanich  0.52  0.30  1.21  0.29  1.05  0.89  64. Gulf  Islands  0.95  0.83  1.12  0.48  2.34  1.16  6 5 . Cowichan  0.24  0.08  0.55  0.27  0.11  0.74  6 6 . Lake Cowichan  0.19  0.00  0.00  0.06  0.00  0.00  67. Ladysmith  0.38  0.72  0.24  0.30  0.94  0.05  6 8 . Nanaimo  0.59  0.41  1.22  0.78  0.14  1.32  6 9 . Qualicum  0.00  1.99  0.99  0.00  1.00  0.21  70. A l b e r n i  0.72  0.65  0.60  0.63  1.25  0.33  71. Courtenay  0.76  1.33  1.18  0.85  1.75  0.76  72. Campbell R i v e r  0.55  1.01  0.74  0.23  0.76  0.75  75. M i s s i o n  0.21  1.71  0.65  0.15  1.28  0.45  76. A g a s s i z  0.32  0.75  0.00  0.34  1.27  0.00  7 7 . Summerland  0.72  0.00  0.00  0.66  0.00  0.00  78. Enderby  0.82  0.41  0.00  0.79  0.28  0.00  80. K i t i m a t  0.65  2.21  0.62  0.69  1.64  0.26  81. Fort  Nelson  1.81  2.54  1.88  1.86  5.44  3.90  8 4 . Vancouver I s l a n d West  0.40  1.55  0.00  0.54  0.40  0.00  8 5 . Vancouver I s l a n d N o r t h  1.16  1.12  0.57  0.56  0.91  0.20  86. Terrace  1.24  2.83  0.39  1.05  5.17  0.20  8 7 . S t i k i n e (+ 8 8 . Skeena)  2.56  2.73  0.60  2.02  2.05  0.23  1.45  1.73  1.10  1.61  2.24  1.26  Total  B.C.  3.2.3.  In  this  Measures o f t h e dependent v a r i a b l e numerator  study,  the o v e r a l l impact of day c a r e s u r g e r y  assessed  on b o t h p a e d i a t r i c a d m i s s i o n s  hospital  days.  (or  separations)  The i m p a c t o f d a y c a r e s u r g e r y on  straight  s u b s t i t u t i o n w i t h o u t any f i l l - i n o f  one w o u l d e x p e c t a d m i s s i o n s care  surgery  Robinson,  In  In  vacated  the case of  straight  4 (Evans  generation  care  S i t u a t i o n where d a y c a r e s u r g e r y w o u l d show no  e f f e c t on a d m i s s i o n s  hospital  d a y s w o u l d i m p l y f i l l - i n o f v a c a t e d beds b y  w i t h s h o r t e r l e n g t h of other things  but s u b s t i t u t i o n  being equal.  If  e f f e c t on  lengths  Only a concurrent examination of stay  of  admissions,  or generation.  per thousand p o p u l a t i o n i n t h i s  admissions  study.  of and  information which,  Thus d e p e n d e n t v a r i a b l e , h o s p i t a l  was m e a s u r e d b o t h as  stay  with  admissions  u s e f u l i n assessing the p l a u s i b i l i t y of  utilization,  patients,  b e i n g e q u a l , t h e r e w o u l d be s u b s t i t u t i o n  h o s p i t a l days can r e v e a l l e n g t h of is  patients  d a y c a r e s u r g e r y w o u l d show no  o f v a c a t e d beds b y i n c r e a s i n g  inpatients.  e f f e c t on  s t a y t h a n among s u b s t i t u t e d  on h o s p i t a l d a y s b u t a n e g a t i v e  other things  turn,  and  neither  negative  fill-in  beds,  n o r h o s p i t a l d a y s w o u l d show any e f f e c t f r o m d a y  surgery.  effect  case  or  s u b s t i t u t i o n with complete f i l l - i n of vacated beds, admissions  the  t o d e c r e a s e b y one f o r e a c h d a y  c a s e and h o s p i t a l d a y s b y 2 t o  1973).  and  admissions  may be d i f f e r e n t f r o m t h e i m p a c t on h o s p i t a l d a y s . of  is  in  substitution inpatient  and p a t i e n t  days  86  Inpatient u t i l i z a t i o n subcategories  was,  furthermore,  t o a s s e s s whether day  divided into  care surgery might  been s u b s t i t u t i n g  f o r a t i g h t e r day  care e l i g i b l e  cases,  e v e n i f no  detectable effect  on  found.  Without examining subcategories  of  by d a y  surgery,  generation  c o u l d not  from s u b s t i t u t i o n w i t h  o t h e r p a t i e n t s , i f no utilization.  effect  Thus, t h e  v a r i a b l e were c o n s t r u c t e d f o r t h e both  as  admissions  and  fill-in  following  of  on  straight  of vacated overall  by  dependent  each being  h o s p i t a l d a y s i n 0-14  beds  inpatient  measures of the study,  is  t o be s u b s t i t u t e d  differentiate  i s found  subset  inpatient  w h i c h have a h i g h e r p o s s i b i l i t y one  have  overall utilization  utilization care  several  year  measured  old  age-  group :  Total m p r l i r a l  1) MKn/RTTRGi utilization cases).  (net  and  of m a t e r n i t y ,  From t h e m e d i c a l  surgical  a b o r t i o n and  t o day  measure, such overall  as  care  surgery a v a i l a b i l i t y  surgical utilization,  utilization  n e e d , an  i n c r e a s e i n day utilization  are determined  by  use.  care  as  the  this  similar  a more  restricted  after adjusting for forms  independently  care surgery  should  of  by  medical  cause a f a l l  same amount. However, t h e  medical/surgical utilization may  show a  capacity constraints. Since a l l other  hospital  overall  extended  needs model's p o i n t o f v i e w  measure of t h e dependent v a r i a b l e s h o u l d response  inpatient  in  total  measure o f t h e dependent v a r i a b l e  d i s p l a y a d d i t i o n a l v a r i a n c e u n r e l a t e d t o day  care  surgery  87 According to the generation hypothesis, new h o s p i t a l  u s e may o c c u r e v e r y w h e r e . Day c a r e s u r g e r y  p r o c e d u r e s may f a l l ,  but other s u r g i c a l  occupy the r e l e a s e d space. may c o n t r a c t somewhat, overall  the generation of  hospital  use i s  Or, o v e r a l l s u r g i c a l  increase to  i n p a t i e n t use  b u t m e d i c a l u s e may e x p a n d , s u c h unchanged.  For this  one m e a s u r e o f t h e d e p e n d e n t v a r i a b l e i s substitution/generation  admissions  type  that  r e a s o n more  than  needed t o c a p t u r e the  e f f e c t s of the day care  surgery  availability.  2)  iSTJRG:  Total  surgical  includes only surgical of  an TCP o p e r a t i o n  non-surgical of  inpatient  discharges  r  nt.il i 7 a t . i n n  f  which  determined b y t h e presence  code on the d i s c h a r g e form.  Cases  o p e r a t i o n c o d e s were e x c l u d e d f r o m t h i s  the dependent v a r i a b l e  substitution hypothesis  (Table 5 ) .  with  measure  A c c o r d i n g t o the  t h i s measure s h o u l d show  u n e x p l a i n e d v a r i a t i o n i n response t o day c a r e  less  surgery  availability.  3)  SlJRG-TftA:  tonsillectomies  Total  (Tonsillectomies  Adenoidectomies). the  focus  surgical  surgical  utilization  n e t of  and T o n s i l l e c t o m i e s  This variable i s ,  again,  used t o  o f t h e s t u d y by removing from t o t a l  sharpen  surgical  u t i l i z a t i o n t h a t has been d e c l i n i n g f o r  m a i n l y u n r e l a t e d t o day care surgery  with  use,  reasons  availability.  88  Table 5  Non-operative Procedures Excluded i n T h i s Studyby D i f f e r e n t R e v i s i o n s o f 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 o f Diseases  Code  Procedure  C a n a d i a n C l a s s i f j r a t i on o f Di agnnsr.i o T h e r a p e n t i c a n d S n r g i ca1 P r o c e d u r e s ( i n f o r c e 1979 - ) r  r  02.00-02.99 03.00-03.99 04.00-04.99 05.00-05.99 06.00-06.99  D i a g n o s t i c R a d i o l o g y and r e l a t e d techniques C l i n i c a l e v a l u a t i o n and examination M i c r o s c o p i c examination Other m i c r o s c o p i c examination N u c l e a r medicine  07.00-07.25 07.30-07.52 07.54-07.99  P h y s i c a l medicine, r e h a b i l i t a t i o n , and r e l a t e d procedures  08.00-08.99  D i a g n o s t i c and t h e r a p e u t i c and p s y c h i a t r y  09.00-09.03 09.05-09.49  O p h t h a l m o l o g i c a l and o t o l o g i c a l d i a g n o s i s and treatment  10.00-10.99  Non-operative i n t u b a t i o n , i r r i g a t i o n , and m a n i p u l a t i o n procedures  11.00-11.04 11.14-11.87  Replacement and removal therapeutic appliances  13.00-13.99  Other n o n - o p e r a t i v e procedures  Eight  (in  revision  of International  psychology  Classification  of Diseases  f o r c e i n 1969-1978)  R1.0-R1.9  Radiotherapy and r e l a t e d  R4.0-R4.9  P h y s i c a l medicine and r e h a b i l i t a t i o n  R9.0-R9.9  Other n o n s u r g i c a l procedures  Seventh r e v i s i o n  of International  therapies  Classification  ( i n f o r c e i n 1958-1968) 95.0-95.9  R a d i a t i o n therapy  99.0-99.9  M i s c e l l a n e o u s n o n s u r g i c a l procedures  of Diseases  89 4)  SURfi A:  I n p a t i e n t , u t i 1 i s a t i on of s u r g i c a l  have u n d e r g o n e one o f t h e p r o c e d u r e s t h a t  care surgery.  pa1-.ient.Fi t h a t  a r e common  i n day  In order t o d e r i v e t h i s measure a l i s t  t h i r t y most common o p e r a t i v e procedure  of the  c a t e g o r i e s of  p a e d i a t r i c day care surgery i n 1982/1983 were e x t r a c t e d from the day care s u r g e r y u t i l i z a t i o n d a t a .  A l l procedures  within  these c a t e g o r i e s t h a t appeared f o r a t l e a s t 40 day care s u r g e r y p a t i e n t s i n the 0-14 to  year o l d age group were s e l e c t e d  r e p r e s e n t t h e most common day care s u r g e r y  (Table 6 ) .  procedures  T h i s l i s t was a p p l i e d t o every study year  making necessary t r a n s l a t i o n s from one r u b r i c of codes t o another,  to identify a l l surgical  d i s c h a r g e s t h a t had one of the procedures  after  procedure  inpatient i n the l i s t .  These  i n p a t i e n t d i s c h a r g e s formed the b a s i s f o r u t i l i z a t i o n measures which r e f l e c t p o t e n t i a l day care surgery e l i g i b l e  inpatient  utilization.  5)  SURG B:  Inpatient  utilisation  by s u r g i c a l  patients  who  had undergone, one of the, p r o c e d u r e s common i n day care surgery, whose length of. s t a y was 5 days or l e s s ,  and whose  combination  procedure  r o d e was  of p r i m a r y d i a g n o s i s on d i s c h a r g e  also  found  i n t h e day c a r e  surgery  and  records f o r  19 82/83.  i n order t o c o n s t r u c t t h i s v a r i a b l e a l l the primary  diagnoses  were l i s t e d by the most common day care  procedures  surgery  from the 1982/83 day care surgery u t i l i z a t i o n  T h i s combination  of d i a g n o s i s and l e n g t h of s t a y c r i t e r i a  data. was  then a p p l i e d t o i n p a t i e n t s i n c l u d e d i n the SURG A measure, t o  Table 6 Most Common Surgical Day Care Procedures i n Paediatric Age Group i n B.C. i n 1982/83 and Their M u l t i p l i c a t i o n Factors f o r SURG C Measure  90  1  Code ICD 8  CLD  2  Procedure  ICD  Myringotomy w i t h i n s e r t i o n of O t h e r myringotomy (1.00)  (1.00)  20.4 20.4 20.4  17.0 17.0 17.0  32.01 32.09 32.10  F o r c e p s e x t r a c t i o n o f d e c i d u o u s t o o t h (0) F o r c e p s e x t r a c t i o n o f o t h e r t o o t h (0) O t h e r s u r g i c a l e x t r a c t i o n o f t o o t h (0) R e s t o r a t i o n o f t o o t h b y f i l l i n g (0) (1.00)  24.1 24.1 24.2 24.6  99.3 99.3 99.4 99.9  35.01 35.09 35.19 35.20 35.49  Other non-operative cystoscopy  90.6  A4.6  1.34  69.2  61.2  76.00  92.0  98.04  Circumcision  tube  7  (0.86)  (1.00)  I n c i s i o n w i t h removal of f o r e i g n body 89.0 o f s c i n and s u b c u t a n e o u s t i s s u e (0) L o c a l e x c i s i o n pr d e s t r u c t i o n of l e s i o n 89.1 o r t i s s u e o f s k i n and s u c u t i s (0.20) S u t u r e o f s k i n and s u b c u t a n e o u s t i s s u e ( e x c l u d e s l i p and e x t e r n a l mouth) (0) 89-4 89.2 Removal o f n a i l b e d ( 1 . 0 0 )  92.1  98.12  92.5 92.4  98.22 98.96  Repair of Bilateral Repair of  38.2 38.2 38.8  65.01 65.21 65.49  27.2 27.3  21.2 21.3  40.20 40.50  82.0 82.3  84.0 84.4  91.01  82.6  83.3  91.02  i n g u i n a l h e r n i a (0.40) r e p a i r of i n g u i n a l h e r n i a u m b i l i c a l h e r n i a (1.00)  40.0 (0.49) 40.0 40.6  T o n s i l l e c t o m y w i t h a d e n o i d e c t o m y (0) Adenoidectomy w i t h o u t t o n s i l l e c t o m y (0.43) Closed r e d u c t i o n of f r a c t u r e (without i n t e r n a l f i x a t i o n ) - humerus (0) C l o s e d r e d u c t i o n of f r a c t u r e s (without i n t e r n a l f i x a t i o n ) - c a r p a l s and metacarpals (1.00) Other f o r c i p l e c o r r e c t i o n of d e f o r m i t y (1.00) E x c i s i o n of l e s i o n o r t i s s u e of o c u l a r muscles o r tendons Advancement o r r e c e s s i o n of o c u l a r muscles (1.00) Probing of l a c r i m a l t r a c t (1.00) (1.00)  (1.00)  7.29 11.0 11.2  10.5  23.10  11.3 18.5 18.5  10.6 6.5 6.5  23.20 21.32 21.33  Table  91 (continued) H o s t Common S u r g i c a l Day C a r e P r o c e d u r e s i n P a e d i a t r i c Age G r o u p i n B . C . i n 1982/83 a n d T h e i r M u l t i p l i c a t i o n F a c t o r s f o r SURG C Measure 6  1  Code ICD 8  CLD  2  Procedure  ICD  Meatotomy (1.00) R e p a i r and p l a s t i c o p e r a t i o n s on u r e t h r a ( 1 . 0 0 )  64 .1  57 .1  70. 10  64 .4  57.4  70. 36  7  O t h e r o p e r a t i o n s on n o s e ( 1 . 0 0 ) Reduction (closed) of n a s a l f r a c t u r e (1.00)  21 .9  19.5  33. 03  21 .5  19.4  33. 61  E x c i s i o n of l e s i o n of muscle, and f a s c i a ( 1 . 0 0 )  85 .2  88.2  94. 21  20 .2 20 .3  16.5  12. 21  12 .1 12 .2  7.1 7.2  22. 11  26 .0  96.1  37. 91  20 .2  94.0  30. 40  -  -  92. 85  67 .7  59.7  74. 40  93 .2  A9.1  67. 86  21 .6  19.7  34. 00  20 .4  17.6 17 .9  3 1 . 40  30 .4  30.2  4 9 . 95  -  -  C o r r e c t i o n of Removal o f Lingual  prominent ear  chalazion  frenotomy  tendon (1.00)  (1.00)  (1.00)  S u r g i c a l c o r r e c t i o n of of prominent e a r (1.00) Arthroscopy Orchiopexy  (0.66) (0.75)  Retrograde pyelogram Other  sinusotomy  Myringoplasty Right  (0)  (1.00)  (1.00)  cardiac catheterization  (0)  Eye e x a m i n a t i o n u n d e r a n e s t h e s i a  1  >  Multiplication  2  >  Codes:  ICD  factors  (1.00)  are i n  9. 04  brackets.  7 = I n t e r n a t i o n a l C l a s s i f i a c t i o n of Diseases, 7th r e v i s i o n ; ICD 8 = 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 o f Diseases, 8th r e v i s i o n ; CLD = Canadian C l a s s i f i c a t i o n of D i a g n o s t i c , T h e r a p e u t i c , and S u r g i c a l P r o c e d u r e s .  92 select  the u t i l i z a t i o n  eligible  6)  SURG  C.i  T h i s was  .inpatient  d e r i v e d by a s k i n g procedures  the  t o the f i r s t  measure.  surgeons s p e c i a l i z i n g  of stay of 5  three  this  utilization  care  surgery  digits.  day c a r e  surgery  T h i s m e a s u r e was i n performing  i n c l u d e d i n t h e SURG A m e a s u r e s t o l o o k  SURG B a n d t o g i v e t h e i r  the  at the  of stay combinations of cases i n judgements a s t o what p r o p o r t i o n o f  c o u l d e q u a l l y w e l l h a v e b e e n done on a d a y  basis. This  judgement was o b t a i n e d  surgeons i n t e r v i e w e d  i n 1983. A l l  were w o r k i n g a t t h e B.C. C h i l d r e n ' s  i n V a n c o u v e r , a n d were s e l e c t e d on a b a s i s o f t h e i r  s p e c i a l t y t o cover  a l l t h e p r o c e d u r e s i n c l u d e d i n t h e SURG A  measure. M u l t i p l i c a t i o n applied  lengths  most r e s t r i c t i v e  utilization  procedure/diagnosis/length  Hospital  surgery  The t r a n s l a t i o n o f d i a g n o s t i c c o d e s f r o m one  t o a n o t h e r was r e s t r i c t e d  eligible  the  day care  d i a g n o s e s and p r o c e d u r e s w i t h  days o r l e s s . rubric  that reflected  t o a l l study  f a c t o r s d e r i v e d t h i s way were  years  t o d e r i v e t h e SURG C  then  utilization  m e a s u r e f r o m SURG B f i g u r e s ( T a b l e 6 ) .  T h e s e s i x m e a s u r e s o f t h e d e p e n d e n t v a r i a b l e were u s e d t o test has  t h e same h y p o t h e s i s ,  t h a t day care  an i n d e p e n d e n t a n d s i g n i f i c a n t  inpatient regardless  hospital utilization  surgery  negative  availability  e f f e c t on  among a p a e d i a t r i c p o p u l a t i o n ,  o f t h e h o s p i t a l bed c a p a c i t y a v a i l a b l e .  93  3.2.4.  All  D e n o m i n a t o r of  measures  of  t h e dependent  the dependent v a r i a b l e  independent v a r i a b l e s  excluding  e x p r e s s e d i n p e r c a p i t a terms of  as w e l l as  all  socioeconomic v a r i a b l e s  were  f o r the school d i s t r i c t s .  The  denominator of  all  number o f  year o l d c h i l d r e n i n the school d i s t r i c t .  0-14  measures  variable  t h e d e p e n d e n t v a r i a b l e was  t h e n u m e r a t o r and t h e d e n o m i n a t o r o f both r e f e r biases area  t o t h e same s c h o o l d i s t r i c t  that  studies  were a v o i d e d  Age-sex  (Diehr,  residence,  distribution  t h e dependent  differences in  i n t h e 0-14 y e a r o l d age  and o v e r t i m e , a l l  distribution.  S i n c e age  t h e measures  of  source of  c r e a t e d measures its  and sex a r e s t r o n g l y  u t i l i z a t i o n , age-sex adjustment  important  of  systematic  bias.  1-4,  admissions  school  the dependent age-sex related  controls  for  of  was:  one  process  school d i s t r i c t ' s  the province  and 1 0 - 1 4 .  The a d j u s t m e n t  as  if  in  age/sex-specific  e x p e r i e n c e . The a g e - g r o u p s u s e d f o r t h e 5-9  to  u t i l i z a t i o n f o r each s c h o o l d i s t r i c t  1981, b u t i n c u r r e d t h a t  were 0,  age-sex  The a d j u s t m e n t  p o p u l a t i o n a g e / s e x mix had b e e n t h a t  utilization  small  variable  group a c r o s s  v a r i a b l e were a d j u s t e d t o t h e 1981 p r o v i n c i a l  hospital  the  1984).  a d j u s t m e n t of  order to control for possible  districts  of  Since  variable  have been o f t e n r e l a t e d t o t h e s e k i n d o f  3.2.5.  In  the dependent  the  procedure  adjustment for  94  u<«o  and f o r t h e h o s p i t a l  13  Pl3  —  D  «*>  district group the  i;  P  f o r the is  in district  3  *  Pij  3  P.-  a r e a d m i s s i o n s and d a y s o f  i 3  i 3  P.  i 3  =  i  respectively,  P. .  days:  u  where C i j and D  P. 3  = 2_  j t h age-sex group r e s i d e n t s  t h e number o f i;  stay,  P.  3  is  c h i l d r e n i n the  t h e number o f  of jth  age-sex  c h i l d r e n i n B.C.  j t h a g e - s e x g r o u p a c c o r d i n g t o t h e 1981 C e n s u s ,  total  school  in  and P..  p r o v i n c i a l p o p u l a t i o n i n t h e 0-14 y e a r o l d age g r o u p  is in  1981.  In  smaller  school d i s t r i c t s  the adjustment  process  e n c o u n t e r e d some p r o b l e m s , b e c a u s e t h e age b y s e x  population  d a t a t h a t were a v a i l a b l e h a d b e e n r a n d o m l y r o u n d e d t o For  small  group rates,  school d i s t r i c t s ,  0, t h i s  with very small  can have a l a r g e  numbers  e f f e c t on a p p a r e n t  in  can s h i f t  utilization  rate.  district/age/sex c h i l d r e n was  In cell  significantly  the e n t i r e  order to minimize t h i s  consolidated with i t s  immediate  age-  for  district  effect  v a l u e which c o n t a i n e d l e s s  10.  utilization  w h i c h , when w e i g h t e d b y p r o v i n c i a l p r o p o r t i o n s  summation,  5 or  any  than  25  neighbour.  95 3.3.  Independent  3.3.1.  variables  Day c a r e s u r g e r y a v a i l a b i l i t y  The m a i n i n d e p e n d e n t v a r i a b l e availability  total  the day c a r e  f o r the p a e d i a t r i c population,  p o l i c y v a r i a b l e whose measured.  is  Day c a r e s u r g e r y  availability  p e r 1,000  appears  measure o f  t o be no s a t i s f a c t o r y  as  age-sex for  inpatient  1968-1970  admissions.  s e x and s c h o o l d i s t r i c t o n l y by h o s p i t a l group.  This  residence  of  the  surgery  procedures  measures  categories  the  measure  procedure data  from  and no d a t a  r e s i d e n c e . The d a t a were  s e r v i c e f o r the t o t a l  of  utilization  The d a y c a r e s u r g e r y  p o s e d two p r o b l e m s :  listed  0-14 y e a r o l d  age d i s a g g r e g a t i o n ,  on  age  and  determination.  An a s s u m p t i o n surgery  of  be  u t i l i z a t i o n t h e same  t h e same a d j u s t m e n t  i n c l u d e d o n l y b r o a d age  to  There  the day c a r e  The d a y c a r e s u r g e r y  standardized using  or  of  population.  t h e y were e x c l u d e d f r o m t h e s u r g i c a l  dependent v a r i a b l e . was  (net  opposed t o u t i l i z a t i o n . N o n - o p e r a t i v e  were e x c l u d e d f r o m t h e d a y c a r e s u r g e r y way as  an e x o g e n o u s  was m e a s u r e d as  utilization  m a t e r n i t y and a b o r t i o n c a s e s )  as  as  surgery  i m p a c t on i n p a t i e n t u t i l i z a t i o n i s  p a e d i a t r i c day c a r e s u r g e r y  capacity,  (DCS)  patient  was made t h a t  flows  origin-destination  across  matrix)  the p a t t e r n of  school d i s t r i c t  was  t h e same i n  day  care  boundaries  1968-1970  as  (an it  was  observed for  in  1971.  the year  The o r i g i n - d e s t i n a t i o n  1971 and i t  took  the  m a t r i x was  derived  form:  Six . .• • S 1 j • .• .Sin S i l . . . .Si j . . . . Siri. Srxl • •••SnJ••  where S i  is  3  t h e number o f  district  i  district  j , and n i s  who r e c e i v e d c a r e i n h o s p i t a l s  the province. school  day c a r e s u r g e r y  the t o t a l  number o f  The d a y c a r e s u r g e r y  district  c a l c u l a t e d as  i n the  follows  0-14  DCS 70,  7  patients school care  is  7  district  surgery  cases  summed a c r o s s care  surgery  j in  all  patient  district  j .  1968 and  1969.  7  in  is  for  in  in  each then  , .3  .3  day c a r e  the t o t a l  school  and S?o,.j i s cared for  school  surgery  c a r e d f o r by h o s p i t a l s  1971; S i , . j  cared for i),  i ,  school  districts  * S 70  -  district  in  g r o u p was  S i, i  t h e o b s e r v e d number o f  from s c h o o l  school  from  1970:  171,  where S i , i 3  located  utilization  y e a r o l d age  f o r the year  cases  district  in  number o f j (=  day  S i,ij 7  t h e o b s e r v e d number o f  1970 b y h o s p i t a l s  The same c a l c u l a t i o n was  used a l s o  in  f o r the  day  school years  97 The age  and s e x d i s a g g r e g a t i o n o f  utilization  f o r each s c h o o l d i s t r i c t  assuming t h a t same as for  in  the day c a r e  the age-sex d i s t r i b u t i o n  1971. A g e - s e x  other years  3.3.2.  The s u p p l y m o d e l o f of  of  the dependent  as  an e x p a n s i o n  c a p a c i t y would i n c r e a s e t h e o v e r a l l  hospital  use  lower i n p a t i e n t substitution effect  use,  without  in  but  f i l l - i n generation.  This  including hospital The b e d  t h e r e l a t i o n s h i p between d a y c a r e s u r g e r y  inpatient  utilization,  this  hospital measure  study beds  of  since i t  may be c a u s a l l y  u t i l i z a t i o n and t o i n p a t i e n t  t h e number o f  p e r 1,000  hospital  in adult  or  perhaps  p o p u l a t i o n was  bed a v a i l a b i l i t y .  system  factor  in  and  related  both  utilization.  selected for It  is  children that  the type of  bed  the  impossible have  beds b e c a u s e a d m i s s i o n - s e p a r a t i o n  c o n t a i n no i n d i c a t i o n o f  any  officially-reported paediatric  determine the a c t u a l p r o p o r t i o n of cared for  overall  availability  analyzing  In  the  generation  h y p o t h e s i z e d t o be t h e m a i n c o n f o u n d i n g  t o day c a r e surgery  as  d e p e n d i n g on w h e t h e r o r n o t t h e r e i s  c a p a c i t y i n the u t i l i z a t i o n equation. is  that  surgical  day c a r e s u r g e r y ) ,  c a n n o t be s t u d i e d w i t h o u t  variable  the  (BEDS)  hospital  (inpatient plus  was  by  variable.  u t i l i z a t i o n implies  day c a r e s u r g e r y  done  then c a r r i e d out  bed a v a i l a b i l i t y  hospital  1968-1970 was  i n those years  a d j u s t m e n t was  and m e a s u r e s  Hospital  availability  for  surgery  (paediatric  to been  records or  98 adult). Sheps  However,  (1980)  children  has  10-14  r a t e d beds.  In  this  estimated that  studied  order to estimate  separately  hospitals  t h a n 0.5  beds.  small.  percent  r a t h e r than  t h e number o f  for hospitals  beds  that  paediatric utilization t h a t d i d n o t have  days  were c a l c u l a t e d i n e a c h o f  these  acute  u s e d b y t h e p a e d i a t r i c g r o u p was d e t e r m i n e d .  These  official and 2.9  and t h e n a p r o p o r t i o n o f  p a e d i a t r i c beds  amounted t o  p a e d i a t r i c bed c a p a c i t y i n percent i n  1981/82  i n B.C.  0.9  1971,  percent of  2.3  Because  was  approved  total  "unofficial"  non-  capacity  B o t h t o t a l d a y s and t h e number o f  i n B.C.,  of  paediatric  c o n t r i b u t e t o t h e o v e r a l l bed  consumed b y 0-14 y e a r o l d s  beds  less  f o r t h e 0-14 y e a r o l d s ,  paediatric  b e l i e v e d t o be  are admitted to adult  paediatric hospitals available  proportion is  care  the  percent i n  t h e s e beds  1976  play  o n l y a minor r o l e i n the o v e r a l l p a e d i a t r i c bed c a p a c i t y , d e c i s i o n was made n o t t o i n c l u d e d t h e s e  3.3.2.1.  Hospital  Adjustment  beds  district  "synthetic" district. residents located.  to which r e s i d e n t s  have a c c e s s .  In  bed c o u n t was  residents,  of  c o n s t r u c t e d f o r each  the school d i s t r i c t ,  First,  a patient  nor  any p a r t i c u l a r  o r d e r t o overcome t h i s  T h i s measure r e f l e c t s t h e beds of  (B~)  located i n a school d i s t r i c t  not e x c l u s i v e l y used by s c h o o l d i s t r i c t t h e y t h e o n l y beds  i n t h e BEDS v a r i a b l e .  f o r boundary c r o s s i n g  physically  a  are are school  problem a school  a c t u a l l y u s e d by  w h e r e v e r t h e y m i g h t be  origin-destination  matrix  was  the  99 derived  from the i n p a t i e n t u t i l i z a t i o n d a t a b a s e .  shows t h e number o f  p a t i e n t days  m a t e r n i t y and a b o r t i o n s ) district,  It  care,  takes the  matrix  excluding  used by the r e s i d e n t s  i n t h e i r own d i s t r i c t  the p r o v i n c e .  (acute  This  of  a  school  and i n e a c h o t h e r d i s t r i c t  in  form:  D n • • . . D i j . • • .Din D i i . . . .Di j . . . .Din Dnl....DnJ••••Dnn  where D of  is  A J  t h e number o f  school d i s t r i c t  district the  i  j , and n i s  days of  in hospital the t o t a l  beds  located in  number o f  residents  school  school d i s t r i c t s  in  c a l c u l a t e d f o r each year  in  province.  The o r i g i n - d e s t i n a t i o n the study,  was  matrix,  then a p p l i e d to the v e c t o r of  l o c a t e d i n each s c h o o l d i s t r i c t . was  c a r e r e c e i v e d by  u s e d t o d e r i v e t h e number o f  district  The f o l l o w i n g "synthetic"  actually  calculation  beds  in  school  i:  '13  D,  Where Bj i s school  beds  t h e number o f  district  j and D  r e c e i v e d by r e s i d e n t s located in  i 3  beds is  x B-  t h e number o f  j.  (0.8)(365)  (approved p a e d i a t r i c beds)  i n school d i s t r i c t  school d i s t r i c t  Di.  The s y m b o l  i  patient  days  in hospital D.j i s  in  beds  t h e sum o f  100 the  (Du  + D  + D  2 J  3 3  ...  + D s,j)  values  7  districts  i n the province,  residents  who h a v e r e c e i v e d c a r e i n  Utilization  of  district  Since  f o r B.C.  The s y m b o l  out-of-province  available  capacity.  to  B.C.  was made t h a t equals  Thus,  assumed  is  assumed  general,  in  not  this  in way  from the  days of of  care  in  school  not  as  easily  by s c h o o l  available  B.C.  adjusting  for transfers  in  outside as  In  used, that  care  is  other  words,  always taken selected  facilities  1971,  had a n e t g a i n o f of  bed.  u s e has  place  occupancy  i n B.C.  because  the province are,  within  between a c t u a l  district  and 1976,  beds  capacity  80 p e r c e n t i n  The a r b i t r a r i l y  hospital  bed  out-of-province  than i n p a e d i a t r i c  an  been a c t u a l l y  out-of-province  facility.  that  has  out-of-province  capacity  the province,  occupancy r a t e of  7 shows t h e d i f f e r e n c e s counts  anywhere  the o u t - o f - p r o v i n c e  the c a p a c i t y that  that  higher  outside  e a c h 292 d a y s o f  in a paediatric  it  In  a r e removed  t h e number o f  is  7  r e c e i v e d by r e s i d e n t s  residents  c o n s i d e r e d one a v a i l a b l e  is  j.  D s,a,  no way t o d e f i n e t h e e x a c t b e d  a s s u m i n g an a v e r a g e  rate  district  residents,  residents  DA,-7 6 i s  hospitals  there is  assumption  is  out-of-province  school  residents  school  i.  available  it  for  75  3  available  province.  7  all  the p r o p o r t i o n m u l t i p l i e d by B .  used by o u t - o f - p r o v i n c e  capacity  D s,3  by t h e o u t - o f - p r o v i n c e  the numerator beds  plus  across  the province.  and s y n t h e t i c  1976 and 1 9 8 1 / 8 2 .  paediatric  bed a v a i l a b i l i t y  beds  Table  bed In  after  across  in  the  1971  Table 7  Number of Actual and Synthetic Paediatric Beds by School District in B.C. in 1971. 1976. and 1981/82  1971 Actual School District  1. Fernie 2. Cranbrook 3. Kimberley 4. Windermere 7. Nelson 9. Castlegar 10. Arrow Lakes 11. Trail 12. Grand Forks 13. Kettle Valley 14. Shouthern Okanagan 15. Penticton 16. Keremos 17. Princeton 18. Golden 19. Revelstoke 20. Salmon Arm 21. Armstrong Spa Hum 22. Vernon 23. Central Okanagan 24. Kamloops 26. North Thompson 27. Cariboo-Chilcotin 28. 29. 30. 31. 32.  Quesnel Lillooet South Cariboo Herritt Hope  beds  4 12 5 5 11 10 5 28 4 0 4 20 0 4 3 6 5 0 20 28 50 0 23 18 12 19 12 4  1976 Synthetic beds  6.08 12.98 7.52 6.04 12.46 12.68 6.01 19.89 3.17 1.74 6.41 14.18 2.97 4.02 4.15 8.32 9.65 2.44 17.92 30.16 39.73 5.20 33.71 21.48 12.05 22.24 13.86 8.18  1981/82  Actual beds  Synthetic beds  Actual  6  10.77  12 5 5 11 10 5 18 4 0 6 15 0 0 5 6 7 0 22 28  12.32 6.13 5.95 14.33  11 12 5 5  50 0 31 18 12 16 12 8  11.99 7.17 11.66 4.28 3.29 8.74 12.99 0.80 1.45 7.04 7.60 11.83  beds  11 4 4 15 4 0 6 15 0 0 5 6  28.38 41.94  7 0 22 23 48  2.37 42.07 21.45  0 31 14  12.99 18.29  12 8  14.74 10.08  12 8  2.21 19.00  Synthetic beds  13.10 9.23 5.14 5.03 12.78 5.73 6.18 11.17 4.84 1.35 8.53 10.70 0.82 1.00 4.87 7.85 10.28 2.99 18.00 24.41 35.99 3.05 42.74 19.02 13.31 11.64 15.61 9.61  .Continued  Table 7  Number of Actual and Synthetic Paediatric Beds by School District in B.C. in 1971. 1976. and 1981/82  1971 Actual School District  33. 34. 35. 36. 37. 38. 39. 40.  Chilliwack Abbotsford Langley Surrey Delta Richmond Vancouver New Westminister  41. Burnaby 42. Maple Ridge 43. Couquitlam 44. North Vancouver 45. West Vancouver 46. Sechelt 47. Powell River 48. Howe Sound 49. Central Coast 50. Queen Charlotte 52. Prince Rupert 54. 55. 56. 57. 59. 60.  Smithers Burns Lake Nechako Prince George Peace River South Peace River North  61. 62. 63. 64. 65.  Victoria Sooke Saanich Gulf Islands Cowichan  beds  19 14 16 31 0 26  1976 Synthetic beds  18.15  21 0 44 0 6 19 2 19 7 24  18.82 18.97 61.71 24.12 40.76 181.10 18.50 61.93 23.67 50.09 41.65 9.45 8.13 22.36 7.63 17.25 9.50 26.15  25 14 9 70 20  17.06 13.42 15.22 73.64 25.28  21 106 0 6 3 29  27.59 67.67 17.90 14.40 3.97 30.55  371 96 37  Actual beds  Synthetic  Actual  1981/82 Synthetic  beds  beds  beds  19 14 24 53 0 26  21.1b 19.24 35.24 73.39 35.04 37.84 123.22 17.02 54.25 31.70 48.86 36.11  19 16 24 53 0 26 278 45 37 24 0 24 0 6  20.63 21.39 34.77 69.02 26.37 36.07  322 94 37 23 0 44 0 6 19 4 5 7 31 23 20 13 71 21 21 131 0 6 3 32  8.96 8.35 22.13 10.88 7.08 10.03 26.51 17.99 24.51 16.65 72.96 23.99 26.63 74.96 21.71 17.88 4.39 39.05  12 3 3 3 31 23 20 13 67  96.92 8.41 38.22 30.43 25.14 24.15 5.88 9.12 14.64 7.70 3.49 5.46 27.10 20.33  21  24.91 19.17 61.32 21.94  21 129 0 6 3 32  26.29 78.38 17.91 14.93 4.11 35.68  .Continued  ' Table 7  Number of Actual and Synthetic Paediatric Beds by School District in B.C. in 1971, 1976. and 1981/82  1971 Actual  Synthetic  beds  beds  School District  66. Lake Cowichan 67. Ladysmith 68. Nanaimo 69. Qualicum 70. Alberni 71. 72. 75. 76. 77. 78. 80. 81. 84. 85. 86. 87.  Courtenay Campbell River Mission Agassiz Sumnerland Enderby Kitimat Fort Nelson Vancouver Island West Vancouver Island North Terrace Stikine (+ 88. Skeena) Total B.C.  0 13 27 0 25 15 10 10 0 3 6 18 12 0 21 6 44 1577  Net gain (loss) of paediatric beds outside the province  6.34 14.57 21.55 3.55 32.67 20.54 13.29 10.50 4.60 3.89 4.75 21.41 13.41  Actual beds  0 13 27 0 30 11 12 10 0 3 6  1976 Synthetic beds  4.85 14.87 24.08 3.65 39.75 13.27 17.20  4.22 28.99 10.27 59.17  17 9 0 16 4 30  14.63 3.90 3.51 6.68 22.44 10.21 3.95 21.86 6.75 45.30  1585.59  1569  1576.46  8.59  7.46  Actual beds  0 4  1981/82 Synthetic beds  3.58  32  9.48 19.53 4.13 27.92 16.12 12.76 14.73 3.18 5.13 2.07 18.65 12.64 3.68 19.94 7.76 42.79  1379  1368.92  22 0 16 11 12 10 0 3 0 14 11 0 13 4  (10.08)  104 provincial  border.  p a e d i a t r i c beds,  B u t i n 1981/82 t h e r e was a n e t l o s s  although  decreased markedly. available  o f 10  a c t u a l bed count i n B.C. had  T o t a l number o f p a e d i a t r i c beds  f o r o u t - o f - p r o v i n c e users  made  d i d n o t v a r y much  from  (15-17 p a e d i a t r i c b e d s ) , b u t b e t w e e n 1976 a n d  year to year 1981  t h e r e was a marked d e c r e a s e i n t h e number o f p a e d i a t r i c  beds  used by B.C. r e s i d e n t s  t o around district basis  5 beds). transfers  out-of-province  T a b l e 7 shows a l s o t h e e f f e c t s  i n Vancouver.  p a e d i a t r i c beds district  F o r example,  i n the d i s t r i c t ,  residents.  of  o f p a e d i a t r i c bed a v a i l a b i l i t y ,  o f a c t u a l u s e . These t r a n s f e r s  effect  23-24 beds  (from  on t h e  have e s p e c i a l l y  in  inter-  striking  1981/82, o f 278 96.92 a r e a l l o c a t e d t o  only  Table 7 indicates  that,  Vancouver beds have been i n c r e a s i n g l y  over  time,  used by o u t - o f - d i s t r i c t  patients.  3.3.2.2.  Populations structure.  Adjustment  f o r non-homogeneous  a r e non-homogeneous  population  i n respect to age-sex  A school d i s t r i c t with a r e l a t i v e l y  elderly  p o p u l a t i o n w o u l d be e x p e c t e d t o n e e d a n d u s e more capacity.  In such s c h o o l d i s t r i c t s  population  r a t i o might s t i l l  effect  is  the higher  The same a p p l i e s  just  represent tight  needs  since  it  of the  b u t t h e age  the paediatric  t h e r e l a t i v e need f o r beds,  bed-to-  capacity i f  t o p a e d i a t r i c beds,  r e v e r s e d . The younger  hospital  an a p p a r e n t l y h i g h  were n o t h i g h enough t o meet t h e a b o v e a v e r a g e population.  (P*)  infants  population a n d 1-4  105 years  o l d c h i l d r e n have h i g h e r h o s p i t a l  older  children.  the  p a e d i a t r i c p o p u l a t i o n between s c h o o l d i s t r i c t s  availability  In o r d e r  t o minimize t h i s  coefficients  i m p l i e d by an a s s u m p t i o n  and i n t e r - t e m p o r a l a g e - s e x - s p e c i f i c  u s e f o r t h e a c t u a l a g e - s e x mix i n e a c h d i s t r i c t and I n o t h e r words, i f a c t u a l p a e d i a t r i c p o p u l a t i o n  d o e s n o t c h a n g e , b u t t h e r e i s a mix s h i f t c a p i t a use c h i l d r e n ,  given the  on t h e p a e d i a t r i c b e d  age g r o u p was d i v i d e d b y an  the population  inter-district  time p e r i o d .  bigger  over  s c h o o l d i s t r i c t p a e d i a t r i c p o p u l a t i o n . The a d j u s t e d  constant  per  and  p o s s i b l e b i a s , t h e s y n t h e t i c bed  f o r t h e 0-14 y e a r  population estimates  hospital  than  measure.  count d e r i v e d adjusted  rates  D i f f e r e n c e s i n demographic s t r u c t u r e w i t h i n  t i m e may b i a s t h e e s t i m a t e d  of  utilization  than  the adjusted  actual to reflect  higher  t o younger,  population w i l l expected  unchanged a g e - s e x - s p e c i f i c u t i l i z a t i o n  adjusted  p o p u l a t i o n accounts  higher be  h o s p i t a l use, p e r c a p i t a . Thus,  not only f o r actual  p o p u l a t i o n c h a n g e s , b u t a l s o f o r c h a n g e s i n t h e a g e - s e x mix as they would a f f e c t  hospital utilization.  This  adjusted  p o p u l a t i o n d e n o m i n a t o r f o r t h e s y n t h e t i c BEDS v a r i a b l e (B") was c a l c u l a t e d f o r e a c h s c h o o l d i s t r i c t b y summing a c r o s s t h e number o f c h i l d r e n i n e a c h a g e - s e x c a t e g o r y , province-wide  relative utilization  year  s e l e c t e d f o r t h e base year.  1981 was  weighted by  r a t e s i n a base year. The c a l c u l a t i o n  P x  "(81)  D. .  their The was:  106 Where P A J i s  t h e number o f  age-sex  class  j. P.j  age-sex  group  j in a l l  D.j Bi)  is  (  the t o t a l  by c h i l d r e n i n  B.C.  received.  P..<ei>  population  by the  that  population  8  of  B.C.,  and D . . < B I J 1981 C e n s u s ,  in  1981/82.  school  the t o t a l  number o f  hospital  1981/82  between t h e  1981 C e n s u s  is  j in  are t o t a l  of  paediatric  c a r e r e c e i v e d by  in and  1971,  population  (as  of  year population  and  1976  and  adjusted difference  beginning  of  June)  (extrapolated  to  October).  The f i n a l m e a s u r e o f s t u d y was  received  8 shows t h e a c t u a l  district  in  wherever  provincial  and d a y s o f  and  and  care  1981/82,  caused by t h e s l i g h t  1981/82 m i d f i s c a l  the beginning  days of  i,  children  1981 C e n s u s ,  The d i f f e r e n c e between a c t u a l in  district  number o f  by t h e  Table  by s c h o o l  populations  and t h e  is  i)  i n age-sex group  adjusted populations 1981/82.  (  children in  t h e p a e d i a t r i c bed a v a i l a b i l i t y  B*/P*, w h i c h i s ,  f o r now o n ,  in  this  c a l l e d t h e BEDS  measure.  3.3.3.  Number o f  A physicians controlling physician paediatric the  per capita  for potential  availability.  per capita  r a t i o was  included i n the study  confounding  Number o f  (DOCS)  effects  physicians  associated available  for with  to  p o p u l a t i o n may have an i n d e p e n d e n t e f f e c t , b o t h  l e v e l of  inpatient  physicians  day c a r e s u r g e r y  utilization rate.  In  u t i l i z a t i o n , and on this,  it  may a c t  as  the a  the on  Table 8  Actual and Adjusted Populations for 0-14 Age Group by School district in 1971. 1976. and 1981/82  1971 Actual  Adjusted  1976 Actual  1981/82  Adjusted  Actua1  Adjusted  1. Fernie  3.550  3.658  4.445  4.412  4.765  5,010  2. Cranbrook 3. Kimberley 4. Windermere  4.805 2.595 1.610 5.200  4.716 2.406  5.290  4.951 2.101 1.473  5.759  5.721 2.066 1.770  3.250 1.155 6.330 1.555 775 2.465 5.265 650 995 2.265  3.011 1.114 5,966 1.418 680 2,183 4,636 559 905 2.211 2.730 4.012 981 6.848 13.165  7. Nelson 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.  Castlegar Arrow Lakes Trail Grand Forks Kettle Valley Shouthern Okanagan Penticton Keremos Princeton Golden  19. Revelstoke 20. Salmon Arm 21. Armstrong Spallum 22. Vernon 23. 24. 26. 27. 28. 29. 30. 31. 32.  Central Okanagan Kamloops North Thompson Cariboo-Chilcotin Quesnel Lillcoet South Cariboo Merritt Hope  33. Chilliwack 34. Abbotsford 35. 36. 37. 38. 39. 40. 41.  Langley Surrey Delta Richmond Vancouver New Westminister Burnaby  42. 43. 44. 45. 46.  Maple Ridge Couquitlam North Vancouver West Vancouver Sechelt  2.820 4.435 1.190 7.555 14.155 17.575 1.220 7.960 5.945 1.445 2.860 3.120 1.980 10.045 9.475 8,340 33.545 16.515 19.860 84.300 8.340 32.105 8,220 29.045 25.730 8.930 2.590  1.559 4.852  16.302 1.240 7,859 5.734 1.436 2.716 3.028 1.814 8.981 8.878 7.967 30.894 16,113 18.100 81.123 8.430 30.453 7.774 27.470 24.311 7.458 2.514  2,200 1.535 5,100  4.885  2.167 1.584 4.866  3,105 1,195 5.200 1.505 825 2.280 5,425 690 1.255 1.860  2.794 1.139 4,829 1.337 789 2.133 5.041 593 1.210 1.742  2.982 1.217 4,800 1.489 717 2.664 5,056 728 1.041 1,608  2.645 5.075 1,520  2.577 4.750 1.404  2.527 5,358 1.760  9.330 17.255 20.105 1.515 9.710 6,515 1.340 2,390 2.935 1.950  8.855 15,830 18.967 1.561 9.528 6.223 1.340 2.288 2.718 1.827  9.850 10,775 13.605 33,305 20.860 20,615 68,185 5.650 26,070 9,225  9.180 10.316  9,773 17.362 19.593 1.472 10.308 6,372 1,248 2,266 2,686 1,860 9.649 13,601 15,899 38.228 20.462 21.180 59.999 4.599 22.255 9.684  25,950 21,505 6.960 2,920  13.373 32.474 19.554 19.917 65.149 5.615 24.695 8.916 24.061 19.873 5.796 2.800  24.392 18.086 5.905 3.497  4.825 2.979 1.191 4.754 1.544 651 2.708 4,941 750 984 1,662 2.585 5.378 1.731 9.638 16.580 19.115 1.398 10.645 6,440 1,346 2,251 2.647 1,883 9.486 14.148 15,458 39,666 18.921 20.988 61,371 5.001 22,648 9.898 24.142 17.617 5.407 3.661  .Continued  Table 8  Actual and Adjusted Populations for 0-14 Age Group by School district in 1971. 1976. and 1981/82  1971 Actual  47. Powell River 48. Howe Sound 49. Central Coast 50. Queen Charlotte 52. Prince Rupert  86. 87.  5.696  Actual  Adjusted  5,153  Actua 1 Adjusted  4.361 3.908  4.068  1.495 1.595 5.870  5,485 3,380 1.390 1.775 5,080  3.346 1,366 1,800 5,006  3.895 2,180 4.245 23.730 7.615 7,380  3.949 2.097 4.043 23,274 7.133 7.013  3.665 2,480 4.620 25,690 6.375 6,920  3.609 2,376 4.646 25.302 5,899 6.685  8.153  8.637  34.565 8,085 5.915 890 7.400 1.935 2.840 11,145 1.895 10.405 7,805 6,105 Campbell River Mission 3.710 1,280 Agassiz Sunmerland 1.290 1.045 Enderby 5.120 Kitimat 1.410 Fort Nelson Vancouver Island West 1.505 3.565 Vancouver Island North 3.345 Terrace 9.815 Stikine (+ 88. Skeena)  31.581 7.725 5.428 845 6.709 1,860 2.675 10.135 1.630 10.189 6.909 5.787 3.405 1.208 1.175 925 5.042 1.485 1.634 3,597 3.015 9,829  28.760 9.185 6.780  26.652 8.729 6.172 1.043 7.579 1.656 2.555 10.881 2,503 9.058 6.903 6.340 5,175 1,103 1.235 1.239 4.413 1.505 1.396  25.405 9.115 7.128 1.268 7.899 1.472 2,881 12,534 3.859 8.246 8.100 7.315 6.299 1.086 1,410 1.218 4,489 1.501 1.444  3.985 2.663 9.206  4.342 2.661 9.083  25.431 8.805 6.957 1.178 7.664 1.500 2.861 12.672 3.931 7.940 7,881 7.434 6.247 1.089 1.254 1.159 4.544 1.586 1.416 4.720 2.621 9.169  57. Prince George 59. Peace River South 60. Peace River North  72. 75. 76. 77. 78. 80. 81. 84. 85.  Adjusted  1981/82  3,169 1.376 1.618 6.045  54. Smithers 55. Burns Lake 56. Nechako  61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71.  5.945 3.185  1976  Victoria Sooke Saanich Gulf Islands Cowichan Lake Cowichan Ladysmith Nanaimo Qualicum Alberni Courtenay  Total B.C.  610.010 576.398  1.125 7,905 1.675 2.785 11.665 2.590 9.350 7.550 6.515 5.040 1.180 1.415 1.260 4.490 1.560 1.365 3.925 2.890 9.455  594.970 566.067  852 1.584 4,953  4.095 953 1.624 5,000  4.294 2.479 5.062  4.386 2.574 5,159  25.493 6.284  25.718 6.455  587.638 588.342  109 confounding  f a c t o r when s t u d y i n g  t h e r e l a t i o n s h i p between t h e  two.  The p h y s i c i a n - t o - p o p u l a t i o n total  f u l l - t i m e equivalent  paediatric population physicians  in  either  as  the  Then t h i s  Services  Services  information for  on p a t i e n t s  this  was  considered essential,  10,000  p r i o r to  for this  since  it  f o r a 0-14  undertaking  l i n k e d to the the  1976 t h e l i s t  r e c o r d s on a  i n f o r m a t i o n was  d i f f e r e n c e was  of  ( E v a n s et. a 1 .  based  (Barer  it  does  1983).  and Wong F u n g ,  m e t h o d , e a c h p h y s i c i a n r e c e i v i n g payments than one-half  f  others  a r e c o u n t e d as  the  not  FTE Health  1985).  equal to  t h e payment mean f o r h i s / h e r  p r a c t i c e = 1 FTE; a l l  on  not  were c a l c u l a t e d u s i n g a method d e v e l o p e d b y t h e  greater  Medical  of  values  this  in  specialty  had b e e n shown t h a t  significantly  i n B.C.  oral  their  the figures  Research Unit  year  age were i n c l u d e d  change  Manpower  all  and t o c a l c u l a t e a F T E v a l u e  but the b i l l i n g  Adjustment  of  records,  (or a c t u a l l y  was d e r i v e d f r o m t h e d i s c h a r g e  years.  per  discharge  data i n order to get  For years  calendar year basis, fiscal  of  of p h y s i c i a n s  f o r each p h y s i c i a n  each d o c t o r .  physicians  categories  dentists  C o m m i s s i o n numbers)  Plan b i l l i n g  10,000  or operating physician  list  the  o r d e r to d e r i v e these measures,  were i d e n t i f i e d . A l s o ,  in hospitals  Medical  In  per  F T E - a d j u s t e d number  five different specialty  the admitting  list.  physicians  who a p p e a r e d on t h e h o s p i t a l  old child, surgery  (FTE)  (DOCS) and as  paediatric population. physicians  r a t i o was m e a s u r e d b o t h as  peer  By  or type  proportion  110 of  their receipts  of  practice peers.  was  t o t h e mean r e c e i p t s o f If  a physician's  a s s i g n e d an F T E v a l u e o f  one,  their full-time  s p e c i a l t y was  since his  type  unknown he  r e f e r e n c e peers  c o u l d n o t be d e t e r m i n e d .  The F T E v a l u e "partitioned" r e s i d e n c e of allocation  c a l c u l a t e d f o r each p h y s i c i a n  among s c h o o l d i s t r i c t s his  of  0-14  paediatric hospital  database  then that  physician  district  split  half  were r e s i d e n t s c o u n t e d as  for physicians'  process.  a physician  admitting  physician  weight of  0.25.  p a t i e n t was  If  If  of  if  FTE v a l u e  on t h e  hospital district,  in that  school  inpatients  the p h y s i c i a n ' s  he a p p e a r e d as  given a weight of  0.75  t h e p a t i e n t was operating and i f  data  physician,  the p h y s i c i a n  c o u n t e d as  one. T h i s weighting  was done  allocating  physicians  physician's residents  of  was  to  across  of  patients  school d i s t r i c t s .  as  the had was  in  The p u r p o s e  i n d i c a t e the p r o p o r t i o n of  hospital-based  this  given a  the p a t i e n t  weighting  However,  t i m e and e f f o r t was done i n  b o t h a d m i t t e d and o p e r a t e d on t h e p a t i e n t ,  this  were  F T E was  and so o n .  a p p e a r e d on t h e d i s c h a r g e  The  of  each  t i m e and e f f o r t made a v a i l a b l e  each s c h o o l d i s t r i c t .  of  all  t h e same s c h o o l  paediatric  a patient,  or  was done on b a s i s  between t h e d i s t r i c t s ,  a weighting If  his  of  the  partitioning  a physician appearing  f r o m two d i s t r i c t s ,  and h a l f  to  For a given year,  and z e r o e l s e w h e r e .  drawn e q u a l l y  This  across d i s t r i c t s  records.  h o s p i t a l i z e d c h i l d r e n of discharge  according  year old patients.  FTE v a l u e s  was  admitting/visiting  to  Ill process  may n o t r e p r e s e n t as much e f f o r t o r  commitment as  the operation i t s e l f .  to d i f f e r e n t i a t e the chosen, 1983).  but  his  seemed p l a u s i b l e  availability,  FTE i n t o t a l .  districts  is  operations  c a p a c i t y were  to physicians  differs  significantly  Finally,  school d i s t r i c t population of  of  because each p h y s i c i a n  t h e i r r a t i o of  used  arbitrarily  (Evans e t a 1.  Only t h e i r p a r t i t i o n i n g  altered i f  the p a t i e n t .  for  The w e i g h t s t h a t were  T h e s e w e i g h t s do n o t a f f e c t o v e r a l l m e a s u r e s  physician as  available  capacity  of  still  among  admissions  f  counts  school to  according to the residence  t h e a l l o c a t e d F T E s were summed i n  p a t i e n t and d i v i d e d b y t h e  the school d i s t r i c t .  each  paediatric  No p o p u l a t i o n  c h a n g e s i n a g e - s e x mix a c r o s s d i s t r i c t s  of  adjustment  and o v e r t i m e  was  used.  The same a p p r o a c h was s p e c i f i c measures calculations Physicians  of  used to c a l c u l a t e the  physician a v a i l a b i l i t y ,  were done s e p a r a t e l y  were c l a s s i f i e d  into  specialtybut  the  f o r each s p e c i a l t y  the f o l l o w i n g  category.  specialty  categories:  1)  general  and f a m i l y p r a c t i t i o n e r s  2)  paediatricians  3)  surgical  (PAED);  specialties  surgery,  neurosurgery,  thoracic  surgery,  gynaecology,  (GP);  (SURGEON), w h i c h i n c l u d e s orthopaedic surgery,  urology,  opthalmology,  dental surgery, and e a r ,  general  plastic  surgery,  obstetrics  n o s e and  throat;  and  112 4)  anaesthesiologists  (ANA);  5)  other specialties  (OTHER).  If  a physician's  category  s p e c i a l t y was unknown he was  into  i n f o r m a t i o n was n o t  d a t a was  f o u n d t o be i n c o m p l e t e . I t  was  1972/73  thus  decided  c a l c u l a t e the FTE-adjusted p h y s i c i a n - t o - p o p u l a t i o n  (DOCS) and d i f f e r e n t p h y s i c i a n b y s p e c i a l t y m e a s u r e s PAED,  SURGEON, ANA,  and n o t years  and OTHER)  only f o r the years  measure (GP,  1973 and o n ,  t o i n c l u d e any p h y s i c i a n a v a i l a b i l i t y m e a s u r e s  1968-1972  i n the  The a d j u s t m e n t school  the  available  t o t h e y e a r 1972. The s p e c i a l t y i n f o r m a t i o n i n  billing to  put  OTHER.  The s p e c i a l t y and b i l l i n g prior  and  districts  procedure i n a l l o c a t i n g physicians was done o n l y f o r t h e y e a r s  i n the e a r l i e r years.  was made t h a t  3.3.4.  rationale  and e a c h p a t i e n t was  Socioeconomic  These v a r i a b l e s hospital  For the year  across  1974 and o n , discharge  1973 an  assumption  t h e a d m i t t i n g p h y s i c i a n would have been t h e  operating physician,  c o u n t e d as  one.  variables  were i n c l u d e d i n t h e s t u d y as  proxies  c a r e n e e d i n t h e p a e d i a t r i c p o p u l a t i o n , on t h e that  the  study.  because o n l y a d m i t t i n g p h y s i c i a n appeared i n the records  for  inter-district variation in  hospital  for  113 u t i l i z a t i o n may be a r e f l e c t i o n o f demographic, district  social  factor,  population,  is  of  The e f f e c t o f  of  characteristics  of  utilization  socioeconomic v a r i a b l e  This  by Census  in  change v e r y q u i c k l y o v e r t i m e ;  t h e same s e t  i n c l u d e d i n t h e s t u d y as (1983).  The v a r i a b l e s  the value of  of  this  that of  each  Values  of  the  were  and 1972-1976  analysis  and e c o n o m i c c h a r a c t e r i s t i c s  Areas.  to  were e x t e n d e d a l s o t o t h e  d e c i s i o n was b a s e d on an a s s u m p t i o n  Basically  Enumeration  1968-1970  i n the cross-area/cross-year  data of  in  were d e r i v e d  d e r i v e d f r o m t h e 1971 C e n s u s  1981 Census  the only a v a i l a b l e  other  rates.  to construct  school d i s t r i c t s  from the  demographic not  to  population  several  i n each s c h o o l d i s t r i c t .  socioeconomic v a r i a b l e s  1982/83  However,  adjustment  and  E n u m e r a t i o n A r e a s were t h e n a l l o c a t e d school d i s t r i c t s  school  paediatric  f o r the school d i s t r i c t s  f r o m t h e 1971 and 1981 C e n s u s e s  values  the  t h e p o p u l a t i o n may a l s o p l a y a r o l e  The s o c i o e c o n o m i c d a t a  also  the  influential  and t h e DCS v a r i a b l e ,  t h e BEDS v a r i a b l e .  determining hospital  given  of  of  a l r e a d y been i n c o r p o r a t e d by a g e - s e x  mix a d j u s t m e n t  appropriate  t h e most  age-sex d i s t r i b u t i o n  the dependent v a r i a b l e  These Census  in  and e c o n o m i c c h a r a c t e r i s t i c s  populations.  demographic  the v a r i a t i o n  of  the  and  year data.  social,  a population  i n any e v e n t ,  do  t h e s e were  sort.  socioeconomic v a r i a b l e s  was  i n t h e e a r l i e r s t u d y by Evans e t  i n c l u d e d were:  al.  114 1)  P e r c e n t a g e o f p o p u l a t i o n b o r n i n Canada  (CAN).  2)  P e r c e n t a g e o f p o p u l a t i o n whose m o t h e r t o n g u e was  English  (MTENG). 3)  Percentage of  ethnicity 4)  p o p u l a t i o n who were o f  population l i v i n g  where r u r a l was d e f i n e d a s : municipalities  education  less  than  5 education (in  tapes,  (in  1981 C e n s u s )  less  that  15 y e a r s  reserves  square  and v i l l a g e s  with a  and o l d e r , who had  1971 C e n s u s ) (EDUC).  or less  classification 1981  not e x a c t l y comparable  r e a s o n t h e EDUC v a r i a b l e was  year cross  less  than grade 9  Because the  t h e EDUC v a r i a b l e i s  only i n the s i n g l e  analysis  in  omitted  and i n c l u d e d  s e c t i o n a l analyses  for  years  1981/82.  6) A v e r a g e number o f  rooms p e r d w e l l i n g  c a l c u l a t e d by c a l c u l a t i n g  in private dwellings  total  400 p e r  towns  from the p o o l e d c r o s s - a r e a / c r o s s - y e a r  was  incorporated rural  somewhat d i f f e r e n t i n t h e 1971 and  1971 and 1981. F o r t h i s  1971 and  of  1000.  population,  e d u c a t i o n was  Census  parts  (RURAL),  and u n o r g a n i z e d t e r r i t o r i e s , I n d i a n  Percentage of  than grade  i n r u r a l areas  and i n c o r p o r a t e d c i t i e s ,  p o p u l a t i o n of  of  all  a p o p u l a t i o n d e n s i t y of  kilometer,  5)  Eskimo  (IND).  Percentage of  having  Indian or  first  (ROOMS). T h i s  t h e t o t a l number o f  i n each enumeration area  rooms(i)= average  number o f  dwellings(i)  variable  rooms(i)  rooms  i:  * number o f  private  115 The a v e r a g e was  rooms p e r d w e l l i n g  t h e n c a l c u l a t e d b y summing t o t a l  areas of  number o f  in  school d i s t r i c t  dwellings  7) A v e r a g e  in  total  (INC).  In  capita  income of  income o f  persons  all  enumeration  t h a t by t o t a l  15 y e a r s  variable,  and  the average  a g e d 15 and o v e r i n e a c h  enumeration a r e a . These e s t i m a t e s  of  total  e n u m e r a t i o n a r e a were t h e n added a c r o s s a l l i n the school d i s t r i c t . district  area /cross-year adjusted  F i n a l l y the t o t a l  was d i v i d e d b y t h e p o p u l a t i o n ,  the school d i s t r i c t .  For the a n a l y s i s  data the average  t o t h e 1981 l e v e l  number  older  of  age  income i n  enumeration  income of  15 y e a r s  of  per  enumeration  a r e a was m u l t i p l i e d b y t h e p o p u l a t i o n o v e r 14 y e a r s that  j  j.  population  order to derive this  school d i s t r i c t  rooms o f  j and d i v i d i n g  school d i s t r i c t  in  pooled  the  in each  areas school  and o v e r ,  in  cross-  income i n t h e 1971 C e n s u s  u s i n g t h e V a n c o u v e r consumer  was  price  index. 8)  Percentage  9)  Percentage of  collar  of  teaching  clerical  10)  (UNEM). f o r c e who had  (WHITE), where w h i t e c o l l a r  managerial  occupations;  technological,  f o r c e unemployed  the experienced labor  occupations  were d e f i n e d a s :  related  labor  social,  occupations;  and a d m i n i s t r a t i v e  occupations religious sales  white  occupations occupations;  i n m e d i c i n e and h e a l t h ; and a r t i s t i c  occupations;  and s e r v i c e o c c u p a t i o n s ;  and  occupations.  Percentage of  industries  experienced labor  force involved in  (PRIM), where p r i m a r y i n d u s t r y was  defined  primary as:  116 agriculture; and o i l  3.4.  forestry;  fishing  quarries  sources  The a n a l y t i c v a r i a b l e s sources.  Each of  in this  s t u d y were drawn f r o m  t h e main d a t a b a s e s  involved is  several  described  below.  3.4.1. Admission-separation  Until  mines,  wells.  Data  briefly  and t r a p p i n g ;  1982/83 H o s p i t a l  database  for inpatient  Programs i n t h e B . C .  Ministry  Health r e c e i v e d a completed a d m i s s i o n - s e p a r a t i o n each p a t i e n t  cared for i n a hospital  s t o r e d on  magnetic  d a t a were c h e c k e d a t  tapes.  The l o g i c  of  record  i n the province.  r e c o r d s were k e y p u n c h e d c e n t r a l l y b y H o s p i t a l  use  for  These  Programs  and  and u n i f o r m i t y o f  the  the time of keypunching.  For example,  u n i f o r m i t y i n c o d i n g t h e p r i n c i p a l and s e c o n d a r y d i a g n o s e s  the or  p r o c e d u r e s were e x a m i n e d . T h i s method o f d a t a c o l l e c t i o n and storing measures  decreased the p o s s i b i l i t y of  independent v a r i a b l e s  due t o v a r i a t i o n maintenance of  that v a r i a t i o n of across  i n r e c o r d i n g and c o d i n g .  different  school d i s t r i c t s After  1982/83 t h e .  d a t a i n t e g r i t y was d e c e n t r a l i z e d . T h u s ,  may be t h e l a s t y e a r o f d a t a s u i t a b l e area comparison, without c o m p a r a b i l i t y of  the data  for this  type of  running i n t o d i f f i c u l t i e s (Sauter  and Hughes,  is  with  1983).  1982/83 cross-  117 Information  on p a t i e n t s '  and m u n i c i p a l i t y ) , diagnosis this  age,  and t y p e o f  database  sex,  Since also  The M e d i c a l  of  stay,  Admission-separation  Services  was  database  f o r day c a r e  records.  cases by h o s p i t a l 69,  and  p r i o r to  The d a t a  Information  70+).  for  the  was  the  1971 i n t h e f o r m o f  and b y b r o a d age  B.C.  t h e same inpatients,  main  availability,  The d a y c a r e s u r g e r y  only available  in  has  t a p e i n t h e same  The n u m e r a t o r o f  f o r the years  surgery  Health  case  record for  the day c a r e s u r g e r y  database.  data d i d not e x i s t  limited.  of  each day c a r e s u r g e r y  the i n p a t i e n t data.  d e r i v e d from t h i s  number  extracted for  Programs i n t h e M i n i s t r y  the admission-separation  independent v a r i a b l e ,  from  the  Commission  were a l s o k e y p u n c h e d and s t o r e d on m a g n e t i c  patient  principal  These r e c o r d s , which c o n t a i n e s s e n t i a l l y  i n f o r m a t i o n as  district  variable.  r e c e i v e d a r e c o r d of  manner a s  (school  e a c h measure o f  and o p e r a t i n g p h y s i c i a n s  1971, H o s p i t a l  hospitals.  residence  p r i n c i p a l o p e r a t i o n were d e r i v e d  physician-to-population  3.4.2.  length  f o r the numerator of  dependent v a r i a b l e . the admitting  p l a c e of  was  utilization individual  1968-1970 were more on t o t a l  category  number  (0-14,  of  15-44,  45-  118 3.4.3.  Hospital inpatient earlier 1970,  Out-of-province  Programs k e e p s  utilization  records of  u t i l i z a t i o n b y B.C.  residents.  the data are a v a i l a b l e  1972,  1974-1976  of  service.  of  1971 and 1973  l i s t e d by h o s p i t a l  of  there  is  1982/83,  p r o v i n c e day c a r e s u r g e r y the nature of utilization  is  this  type of  use by B.C. surgery,  assumed t o be v e r y  Out-of-prOvince  B.C.  of  p r i o r to  Programs, out-of-  residents.  Because  the  small.  t h e measures  of  of  the  to  dependent  bed c a p a c i t y  available  residents.  3.4.4.  P o p u l a t i o n and s o c i o e c o n o m i c  The p o p u l a t i o n d a t a b y s c h o o l d i s t r i c t available  by the M i n i s t r y  of  of  out-of-province  i n p a t i e n t u t i l i z a t i o n d a t a were u s e d  and t o a d j u s t  197 0  on t h e  c o m p l e t e t h e numerator f o r t h e measures  to  and  Out-of-province  e i t h e r . According to Hospital  no i n f o r m a t i o n r e a d i l y a v a i l a b l e  variable  the  service,  u t i l i z a t i o n d a t a were n o t a v a i l a b l e  in  For  discharges  u t i l i z a t i o n i n f o r m a t i o n by s c h o o l d i s t r i c t  inpatient  noted  r e s i d e n c e and t h e n b y  r e s i d e n c e w o u l d have b e e n a l e n g t h y p r o c e s s .  and n o t  as  hospital  o n l y i n a hard copy form.  For the years  d i s c h a r g e s were f i r s t obtaining  However,  and 1981/82 o u t - o f - p r o v i n c e  were l i s t e d b y s c h o o l d i s t r i c t hospital  out-of-province  data  i n B.C.  I n d u s t r y and S m a l l  a r e made Business  119 Development,  but the boundaries  the M i n i s t r y  of  of  Health but the M i n i s t r y  the confusion that  caused,  the M i n i s t r y  districts  used a r e not t h o s e d e f i n e d by of  t h e two d e f i n i t i o n s of  H e a l t h has  Local Health Areas.  figures  Evans  for Ministry  of  school  et a l .  of  (1983)  t h e same w o r k ,  1968-1976.  procedure  for allocating  1966 b o u n d a r i e s previous  For t h i s  the population  reason,  1982/83.  In  Development.  by M i n i s t r y  and  avoid  were for  the  adjustment  it  was  study.  into  the  done i n  the  Because  of  done b y c o m p a r i n g  to the l i s t s  district,  of  this  1981/82  and  of  Census  1981  districts  I n d u s t r y and S m a l l in this  boundaries  school d i s t r i c t  t h e same i n  a list  used i n  Education school  The e n u m e r a t i o n a r e a s  were s t i l l was  f o r the years  of  nested i n t o the school d i s t r i c t  Areas  the  that study  f o r the school d i s t r i c t s  o b t a i n e d from the M i n i s t r y  nesting  derive  order to  u t i l i z a t i o n data  order to derive these data,  Enumeration Areas  1976  a  study.  s t u d y were n o t r e a d i l y a v a i l a b l e  this  in this  was done t h e same way as  The p o p u l a t i o n d a t a  was  In  figures  also,  hospital  did  school  Health school d i s t r i c t s  p r o v i d e d b y t h e i r s t u d y were u s e d a l s o years  districts  i n order to  t o m o d i f y t h e s e d a t a t o t h e 1966 b o u n d a r i e s . repeating  Because  r e c e n t l y renamed i t s  c o n s i d e r a b l e amount o f d a t a m a n i p u l a t i o n population  Education.  list  were  Business then  t h a t were u s e d  boundaries  in effect  1981/82 and 1 9 8 2 / 8 3 , most t h e 1981 Census  1976 e n u m e r a t i o n a r e a s  p r o v i d e d by t h e p r e v i o u s  study  in in  of  the  Enumeration i n each  study  (Evans e t a l .  f  1983).  120 However, census  the enumeration area boundaries  to another.  n o t match t h e was  In  change  f r o m one  c a s e s where a 1981 e n u m e r a t i o n a r e a  1976 e n u m e r a t i o n a r e a b o u n d a r i e s ,  done b y l o o k i n g  at  the a c t u a l  l o c a t i o n of  the  the  did  nesting  enumeration  a r e a on a map and d e t e r m i n i n g t h e s c h o o l d i s t r i c t  t o which  it  belonged.  The 1981 C e n s u s used i n t h i s b y age  s t u d y was  and s e x  districts.  Enumeration Area l i s t i n g  the h o s p i t a l  1982/83 were b a s e d on f i s c a l reporting but  f o r each  of  of  u t i l i z a t i o n data years,  of  in  June  O c t o b e r . The p o p u l a t i o n  1981 C e n s u s  1981 C e n s u s e s . using  using  population  Data  for  Columbia Data  Canada.  tapes  tapes  Library,  at  figures  figures  the Day)  for  forward  from both  1976  from and  were d e r i v e d  were e x t r a c t e d f r o m t h e  the U n i v e r s i t y of  b y Census  used i n t h i s  of  and  extrapolation.  socioeconomic v a r i a b l e s  1971 and 1981 Census  Census  figures  The 1982/83 p o p u l a t i o n  t h e same method o f  1981/82  (Census  1981/82 were e x t r a p o l a t e d l i n e a r i l y f o u r months the  figures  these  the mid-point  p e r i o d was n o t t h e b e g i n n i n g  the beginning  districts  used t o e x t r a c t the p o p u l a t i o n  f r o m t h e 1981 Census  Since  by s c h o o l  British  Enumeration A r e a . A l l  s t u d y were p r o v i d e d b y  the  Statistics  121 3.4.5.  Hospital  Hospital  Programs,  unpublished data Hospital  B.C.  on B . C .  year i n during  at  the year,  Programs.  of  In  surgery  of  approved p a e d i a t r i c  1966-1983/84  for  this  (at  t h e end o f  These dates  capacity during  at  year,  figures  were  variable also  constructing  matrixes.  analysis  examines  availability,  the r e l a t i o n s h i p s  between d a y  p a e d i a t r i c bed c a p a c i t y and  u t i l i z a t i o n with special  associations.  were  t h e bed  b e d c a p a c i t y d a t a was  l o c a t i o n i n f o r m a t i o n used i n  the  Hospital  change  the  t h e p a e d i a t r i c bed a v a i l a b i l i t y  Statistical  place  were a d j u s t e d u s i n g  were a v a i l a b l e  in  fiscal  c a p a c i t y changes had t a k e n  Hospital  bed  represented the s i t u a t i o n  the year  r e f l e c t e d average  bed c o u n t ) .  study  type.  were u s e d . A f t e r t h e s e a d j u s t m e n t s  for hospital  inpatient causal  bed c a p a c i t y b y  the year-end figures  the o r i g i n - d e s t i n a t i o n  This  maintains  t h a n y e a r end. These a d j u s t e d bed c a p a c i t y  (synthetic  3.5.  If  Health,  t h e c a s e s where o n l y month o r y e a r o f  used t o c o n s t r u c t  source  t h e end o f  changes.  known, m i d - p o i n t s capacity data  of  f o r the years  1981/82-1982/83).  exact dates  rather  hospital  The bed c o u n t i n t h e l i s t  each h o s p i t a l  data  Ministry  programs p r o v i d e d a l i s t  c a p a c i t y by h o s p i t a l study.  bed c a p a c i t y  interest  F o r an a s s o c i a t i o n  in  care  paediatric  revealing  t o be c a u s a l  h a v e t h e e x p e c t e d t e m p o r a l r e l a t i o n s h i p between c a u s e  it  should  and  122 effect.  C a u s e must p r e c e d e e f f e c t .  o r magnitude putative  of  causal  effect.  factor  should  and no o t h e r v a r i a b l e  association.  Control  this  for other,  existence the  statistical  should e x p l a i n  possible  in  this  confounding, effects  is  crucial  in  study.  in this  procedure i s (inpatient  analysis. equivalent  utilization)  day c a r e s u r g e r y scatter  of  deviation  all  variables  least  squares  simplest  form t h i s  statistical  to the p l o t t i n g  dependent  variable  a g a i n s t an i n d e p e n d e n t v a r i a b l e  observations,  the observed data  and f i t t i n g  of  a l i n e through to minimize  the squares  (Figure  2).  from a s i n g l e  (e.g.,  of  their  the  the  vertical  Each p o i n t  plotted  school d i s t r i c t  in  year.  e n t e r e d as  analyzed using  were e n t e r e d i n t o  were done u s i n g  regression,  dataset.  with  Then p o t e n t i a l  the r e g r e s s i o n  b o t h i n d i v i d u a l y e a r d a t a and  pooled cross-area/cross-year the regression  simple  an e x p l a n a t o r y v a r i a b l e .  confounding v a r i a b l e s  study:  t h e method o f  p l o t t e d , i n s u c h a way as  The d a t a were f i r s t  Analyses  its  from the f i t t e d l i n e  represents  o n l y DCS  In  availability)  points  across  a single  between d e p e n d e n t and i n d e p e n d e n t  s t u d y were e x a m i n e d u s i n g  or regression  of  in  l e a d t o a change  in revealing potential causal  The a s s o c i a t i o n s  sum,  a change  Cause and e f f e c t must show a  association,  variables  Also  The f o l l o w i n g  model a r e p r e s e n t e d i n t h e r e s u l t s  model. the  parameters of  this  123  DCS cases per 1000 population FIGURE 2. Hypothetical plot of inpatient use against DCS use.  124 Point  est:-i ma-he h o f  the regression  t h e amount and d i r e c t i o n o f associated  w i t h a one u n i t  independent v a r i a b l e . coefficient,  It  is  coefficient  describes  coefficient  association  In  (partial  error  district  data  universe  of  estimate error.  If  regression  of  all  this  The  the  regression  an e s t i m a t e and t h e  and  of  in  independent  districts  and p o s s i b l e  regression  the are  random  f r o m some  coefficient is this  c o e f f i c i e n t estimate  is  greater  is  its  b a s e d on a t  b a s e d on a t  least  Thus,  an  parameter i n  than  i n i n d i v i d u a l year sample),  when t h e e s t i m a t e  infinite  itself  f a i t h t o be p l a c e d i n  is  school  observations.  size r e l a t i v e to  (t-ratio)  the  variables.  t h e amount o f  random d r a w i n g s  own  1.99 least  a  this standard  when t h e 75  or greater 825  the  independent  of - b c o e f f i c i e n t s  describes  The d e g r e e o f  ratio  (as  Figure 2  l i n e or  other variables  Values  depends on i t s  observations 1.96  is  a t r u e b u t unknown v a l u e o f  of  In  between dependent  coefficient)  a r e v i e w e d as  universe.  population  w i t h t h e c o e f f i c i e n t when t h e o b s e r v e d  similar  of  the  the case of m u l t i p l e r e g r e s s i o n  (SE)  the measured v a l u e of  larger  the regression  u n d e r t h e names o f  e r r o r of b  associated  estimate  sample.  e q u a t i o n Y = a + bX.  equation are held constant. presented i n tables  variable  the true  between t h e d e p e n d e n t v a r i a b l e  v a r i a b l e when t h e e f f e c t s  Standard  of  p a r t i c u l a r data  the a s s o c i a t i o n  independent v a r i a b l e s . beta  i n the dependent  an e s t i m a t e  the slope of  value b i n the regression  reflects  i n c r e a s e i n the v a l u e of  b a s e d on t h i s  the c o e f f i c i e n t i s  change  coefficient S  than  observations  125 (as  i n pooled c r o s s - d i s t r i c t / c r o s s - y e a r  random c h a n c e o f observed,  obtaining  o r even l a r g e r ,  a c o e f f i c i e n t as  less  set  is  than f i v e percent. A r a t i o  d e p e n d i n g on t h e s a m p l e  size,  then  large  when t h e t r u e v a l u e  from which the observed data is  sample),  (in  as  indicates  2.58 less  or  what  the  a random s a m p l e ) above  the was  universe is  2.65  zero,  ,  t h a n one p e r c e n t  chance.  (CONST) r e f e r s t o t h e p o i n t  Intercept regression  l i n e crosses  p r e d i c t e d v a l u e of  the Y axis  independent v a r i a b l e  The  intercept is Intercept  sample,  of  and r e p r e s e n t s  (or v a r i a b l e s )  the constant a is  also a point  around i t s  'explained by'  mean  regression 2  (adjusted  the  estimate,  R ) 2  It  model  of  describes  b a s e d on  of  the  the extent  this  refer  t h e same t i m e .  Symbol R  2  to the adjusted c o e f f i c i e n t of  is  to  c a n be in  measure  adjustment  used i n t h i s  determination.  the  fit  of has  has  r e l e v a n c e when t h e r e a r e s e v e r a l i n d e p e n d e n t v a r i a b l e s equation at  study  dependent  t h e goodness of  freedom. T h i s  2).  universe.  measures  of  of  equation Y =  (or the v a r i a t i o n  e q u a t i o n . The a d j u s t m e n t  f o r degrees  (Figure  i n the dependent v a r i a b l e  the regression  independent v a r i a b l e s ) .  corrected R  zero  the true i n t e r c e p t a i n a l a r g e r  which o v e r a l l v a r i a t i o n  the  is  a i n the regression  Adjusted c o e f f i c i e n t of determination variable  sample  t h e d e p e n d e n t v a r i a b l e when t h e v a l u e  the  a + bX.  at which the  in  study  the to  126 Standard  p r r n r o f p r e d i nt.fid v a l n f i B  predictive  r e l i a b i l i t y of  applied  specific  of  to  'predict'  observations.  the r e g r e s s i o n  its  e r r o r of  variable  , arising  Knowing a ,  of  model  school  prediction. of  the f i t t e d r e l a t i o n ,  from  the degree  SE Y i n d i c a t e s the  value  district,  the dependent v a r i a b l e  the p r e d i c t e d values out of  the  6 , and t h e  The SE Y w o u l d i n d i c a t e  uncertainty attached to that standard  reflects  for a particular  value  equation.  Y)  the observed r e g r e s s i o n  the independent v a r i a b l e  one c o u l d  (SE  the  dependent Y = a + bX.  of  127  4.  RESULTS  4.1.  All  D e s c r i p t i v e d a t a - an o v e r v i e w o f p a e d i a t r i c u t i l i z a t i o n i n B.C., 1968-1982/83  t h e measures  declining  means  the dependent v a r i a b l e  trend during the study p e r i o d  independent of Hospital  of  days  that  any age-sex  distribution  of  school  district  stay.  The g r e a t e s t hospital  surgery-type  1976 t h e mean o f  days.  However,  w h i c h was  admissions).  This  not  average of day  SURG A and  During  the  showed no  (30 p e r c e n t than the  l i k e l y caused by  p a t t e r n of  period change respect this  decrease  decrease  13 p e r c e n t d e c r e a s e  coding  that  utilization  a major drop i n  1981/82  (only  i n p r o c e d u r e and d i a g n o s i s because a s i m i l a r  variable  clearly larger  drop i s  in  inpatient u t i l i z a t i o n  t h e r e was  the preceding f i v e years  which  rates  and o n l y a s l i g h t d e c r e a s e i n  u t i l i z a t i o n f r o m 1976 t o  i n admissions)  1979),  this  is  time.  occurred with  (measures  showed r e l a t i v e l y l i t t l e d e c l i n e .  to h o s p i t a l  shift  u t i l i z a t i o n rates  the s u r g i c a l  i n respect to admissions  during  over  a decrease i n  c l o s e l y resemble day c a r e s u r g e r y  f r o m 1968 t o  type of  changes  which  d e c r e a s e i n mean v a l u e s  inpatient u t i l i z a t i o n  Surprisingly,  s h o u l d most (SURG C)  9),  i n a d d i t i o n to the d e c l i n e i n admission  length  SURG B ) .  (Table  general  showed a g r e a t e r d e c r e a s e t h a n a d m i s s i o n s ,  t h e p a e d i a t r i c p o p u l a t i o n t h e r e was a l s o  care  showed a  in  coinciding  (which took p l a c e  d e c l i n e over the  in  study  Table 9  Means and Standard D e v i a t i o n s o f D i f f e r e n t Measures o f P a e d i a t r i c  I n p a t i e n t U t i l i z a t i o n ( P e r 1,000 P o p u l a t i o n ) Over S c h o o l D i s t r i c t s by Year  MED/SURG Year  SURG  SURG A  SURG-T&A  SURG B  SURG C  SD  Mean  SD  Mean  SD  Mean  SD  Mean  SD  158.00  63.65  61.19  63.91 68.50  52.10 52.00 49.15 46.32 44.65 43.10 40.30 37.39  14.89 13.18 12.30  34.42 31.64 30.44 30.74 29.72 29.95 29.07 28.19 26.78  9.06 8.18 6.83  45.43  152.44 151.73 150.02 152.58 145.09 141.20 130.80 126.80  12.95 10.83 10.38  38.69 31.90 32.57 30.48 28.19 26.20 24.62 22.60 20.82  11.96 9.74 9.78 8.25  Mean  Mean  SD  ADMISSIONS: 1968 1969 1970 1971 1972 1973 1974 1975 1976 % Change between 1968-1976 1981 1982  63.52 65.86 65.78 56.50 52.13 52.37  -38.90  -19.75  103.69 95.11  % Change between 1968-1982/83  -39.80  Pooled 1968-1982/83  137.04  9.44 10.79 11.61 9.52 9.37 8.57  41.74 42.44  32.20 28.53  7.76 8.46  44.27  25.01 22.88  5.98 7.27  28.99  9.92 7.63 7.79 7.09  16.11 13.56  7.45  29.55  9.02 9.76 7.24 7.19 6.78  -46.19  5.33 5.45  -70.15  -33.53  13.98  8.71 9.34  -48.05  -22.20  -53.38  61.55  6.81 6.22 6.38 5.66 6.50 5.47  37.17 37.47 34.82 32.32 29.92 28.46 26.19 23.60  14.79 12.56  25.77  8.28 7.87 8.24 7.68 7.61 7.21  2.46 2.81 2.69 2.88 2.71 3.07 2.53 3.02 2.31  0.84  4.99 4.97  -67.54  12.67  7.15 7.68 7.50  5.05 4.52  2.36 2.42  -36.78  11.20  7.16  2.90  .Continued  Table 9 Means and Standard Deviations of Different Measures of Paediatric Inpatient Utilization (Per 1,000 Population) Over School Districts by Year  MED/SURG Year  DAYS: 1968 1969 1970 1971 1972 1973 1974 1975 1976 % Change between 1968-1976 1981 1982  SURG  Mean  SD  Mean  1,044.46 1.019.65 987.76 941.67 934.33 834.64 802.64 732.67 693.58  510.66 538.69 563.07 498.47 505.50 444.65 424.14 366.95 381.63  323.30  222.32 218.79 199.75 182.75  SD  79.68 73.05 78.84 66.97 69.88 72.66 72.21 53.15 47.89  -43.47  -33.59  470.97 431.39  278.26 262.70 246.30 235.18  SURG-T&A  200.01 200.86  144.00 135.05 -58.23  -58.70  SURG B  SURG C  Mean  SD  Mean  SD  Mean  SD  Mean  SD  258.90 231.43 212.80 205.74 199.27 190.41 187.98 173.19 159.60  70.32 67.56 70.36 66.68 64.13 66.64 70.71 49.00  151.74 121.78  48.27 43.64  26.77  17.42 18.48  119.10 107.57 100.08 92.27 89.28 80.28 68.98  38.83 29.77  84.83 71.22 72.07 65.76  34.62 41.06 33.91 29.41 25.18  59.85 55.59 53.38 48.44 44.43  6.12 7.63 6.61 6.30 5.55  45.79  -54.54  -38.35  43.87 53.46  SURG A  128.99 123.41  42.46 52.58  38.70 32.21  -47.62  15.30 16.47  -78.77  -52.33  23.99 22.60 17.80 17.73 19.93 15.94 15.95 15.19  28.90 24.08  17.72 18.68 17.16 18.07 17.19 16.50 15.57  6.26 5.71 6.99 5.08  -10.62  9.72 10.57  -71.61  10.15 9.10  4.63 5.04  -47.76  1968-1982/83 Pooled 1968-1982/83  802.52  479.30  222.58  84.56  188.34  72.47  91.09  47.78  55.32  25.43  16.00  6.78  130 p e r i o d was although surgery data  not associated  t h e y were a l s o  b a s e d on t h e most  p r o c e d u r e s and d i a g n o s i s ,  and t r a n s l a t e d  these  w i t h SURG A and SURG B m e a s u r e s ,  d e r i v e d from the  t h e d e c l i n e seems  p a t t e r n o v e r t h e whole s t u d y p e r i o d .  f r o m 1971 t o the  is  five  generally  hospital  follow a  The d r o p i n SURG A and  known t h a t much o f  the d e c l i n e i n  caused by a d e c l i n e i n  r a t e . According to the data  approximately  65 p e r c e n t o f  1976,  9,  the d e c l i n e i n per c a p i t a  with adenoidectomies  adenoidectomies.  measures.  but not  of  the  include tonsillectomies  showed t h e l o w e s t  utilization  d e c l i n e of  p e r c e n t of  at all  Between t h e f i v e y e a r p e r i o d f r o m 1971  the t o t a l  district/cross-year  surgical  admissions  sample w h i l e  67 p e r c e n t and SURG B 58 p e r c e n t .  represented only i n the pooled  SURG A a d m i s s i o n s  to  SURG C  played o n l y a minor r o l e i n the o v e r a l l drop  u t i l i z a t i o n . SURG C a d m i s s i o n s  the  tonsillectomies  b o t h showed a 13 p e r c e n t d e c l i n e i n a d m i s s i o n s .  surgical  surgical  contained  The o n l y two m e a s u r e s  t h a t d i d not  SURG C and SURG-T&A,  surgical  paediatric  the  i n Table  B o t h t h e SURG A and SURG B measure  dependent v a r i a b l e all,  during  o v e r t h e s t u d y p e r i o d was due t o t h e d e c l i n e i n  tonsillectomies without  period  years.  tonsillectomy  T&A r a t e .  With  steady  32 p e r c e n t d u r i n g t h e f i v e y e a r  u t i l i z a t i o n was  admissions  ICD.  1976, and 32 and 29 p e r c e n t , r e s p e c t i v e l y ,  following  It  was  to  care  1982/83  t o t h e 8 t h and 7 t h r e v i s i o n o f  two m e a s u r e s ,  SURG B a d m i s s i o n s  common d a y  in 16  cross-  represented  131 The p e c u l i a r shifts based  t i m e t r e n d f o r t h e SURG C m e a s u r e may be due  i n medical p r a c t i c e over time. on d a y c a r e s u r g e r y  experts  in  suitable  1983.  If  eligibility  substitution  really  occurs,  as  in  1981 b u t n o t  day c a r e  surgery  a high variation  varied  to  variation of  than  paediatric school  admission  in  1975 t o  districts.  7.7  or converging  f o r admissions  of  in  The h i g h e s t  admissions varied  (around days),  in respect  The r a t i o  1973.  show a n y c l e a r  f r o m 2.4  e x c e p t an i n c r e a s e ,  1982/83 was  also  of pattern over  for medical/surgical  u t i l i z a t i o n rates  than the t o t a l  to in  lowest  ratio  1971 t o  o f v a r i a t i o n was q u i t e  Similar  showed  of  variation  days  4.8  stable  increase  especially  less  paediatric for in  surgical 1982/83.  The  from y e a r t o  for hospital  o t h e r measures  of  year  hospital  days,  in inter-district variation  found w i t h a l l  42  showed  24 p e r c e n t f o r a d m i s s i o n s and 29 p e r c e n t f o r  1982/83.  to  districts  Coefficients  inter-district  Surgical  marked i n t e r - a r e a v a r i a t i o n  coefficient  SURG C  ( a v e r a g e s were a r o u n d 51 p e r c e n t and  respectively).  utilization.  in  care  utilization  r a t e between s c h o o l  The c o e f f i c i e n t s were h i g h e r  percent,  changes  inpatient  f o r each study year d i d not  diverging  time.  across  lowest  f r o m 5.1  inpatient  1976,  suitability.  The a g e - s e x a d j u s t e d  highest  1968 o r  see a d e c r e a s e  u t i l i z a t i o n o n l y when m e d i c a l t h i n k i n g  of  considered in  f o r day c a r e s u r g e r y - t y p e  one w o u l d e x p e c t t o  was  judged by a group  an o p e r a t i v e p r o c e d u r e was  f o r day c a r e s u r g e r y  and i f  The SURG C v a r i a b l e  to  in  in  surgical  132 utilization. surgical of  In  general,  of  the d i f f e r e n t subcategories  u t i l i z a t i o n , SURG-T&A  variation  showed t h e l o w e s t  i n d i f f e r e n t study  day c a r e s u r g e r y  showed a marked i n c r e a s e d u r i n g t h e s t u d y p e r i o d t h e f i v e y e a r p e r i o d f r o m 1971 t o  over the school d i s t r i c t s subsequent of  f i v e years  day c a r e surgery  much h i g h e r  t h e i n c r e a s e was  at  0-14 y e a r s .  During  in a l l  102.1  to  of  percent)  increase u n t i l the year  change  9.5.  10).  The f a l l  f r o m 1975 t o  1975, when i t  i n mean v a l u e o f 1982/83,  toward bed r e d u c t i o n .  school  1,000 years,  presence i n  the  the highest  to  The c o e f f i c i e n t s  of  u s e between 1968 and  measure  and  not  some  in inter-district variation  The p a e d i a t r i c b e d a v a i l a b i l i t y  percent  its  the  was  1969  f o r e a c h s t u d y y e a r showed a s t e a d y d e c r e a s e 36.4  rate  Variation  two s t u d y  school d i s t r i c t s ,  d a y c a r e s u r g e r y was  p a e d i a t r i c day c a r e s u r g e r y  (Table  1968,  cases per  the l a s t  paediatric population  variation  In  a l l , while  37 d a y c a r e s u r g e r y  had e s t a b l i s h e d  ratio  10).  school d i s t r i c t s  surgery.  when d a y c a r e s u r g e r y  lowest  1976 t h e mean  a s c h o o l d i s t r i c t whose p o p u l a t i o n d i d  h a d 19 t o  population of  (Table  45 p e r c e n t .  u t i l i z a t i o n across  r e c e i v e p a e d i a t r i c day c a r e s u r g e r y districts  utilization,  i n c r e a s e d 21 p e r c e n t and d u r i n g  than with i n p a t i e n t  197 3 t h e r e was  coefficient  years.  The m a i n i n d e p e n d e n t v a r i a b l e ,  During  of  this  of  1982/83.  showed a  started to  (from  slight  decline  v a r i a b l e was  25  r e f l e c t i n g a general  policy  Although  districts  some s c h o o l  133 Table 1 0  Means a n d S t a n d a r d D e v i a t i o n s o f DCS a n d BEDS V a r i a b l e s (per 1 , 0 0 0 Population) over School D i s t r i c t s by Year DCS  Year  BEDS  Mean  SD  Mean  1968  4.27  4.36  3.17  1.47  1969  6.38  6.13  3.34  1.60  1970  9.44  7.53  3.38  1.67  1971  11.35  8.22  3.64  1.94  1972  11.64  6.76  3.64  2.06  1973  12.86  7.47  3.58  1.88  1974  13.06  7.13  3.57  1.81  1975  13.57  7.03  3.59  1.82  1976  13.69  7.06  3.55  1.80  % Change between 1968-76  220.61  SD  11.99  1981/82  19.85  7.28  2.97  1.73  1982/83  19.83  7.22  2.70  1.50  % Change between 1968-82/83 Pooled 1968-82/83  -14.83  364.40  12.36  8.30  3.37  1.78  134 d i d n o t h a v e t h e i r own p a e d i a t r i c beds period,  all  u t i l i z e d p a e d i a t r i c beds  districts.  The h i g h e s t  population year.  adjusted  However,  a steady  bed a v a i l a b i l i t y  off  in  50.7  In  lowest  during  in other  school  ratio  BEDS v a r i a b l e was  f r o m 1968 t o  1972  In  1974-1976  availability  period  ( f r o m 46.4  supply  the f a i l u r e of  physicians  whose  latter  in paediatric  of  years,  was  showed  58.2 p e r c e n t  the  shows a  because of  unknown.  clear  p r o c e d u r e has  has  obviously  for physicians  with  data.  reflect  a c e n t r a l i z a t i o n of  1973  were  specialty. led to  n o t c a u s e d so much b i a s  an  to  in  the  physicians'  The p e c u l i a r t r e n d w i t h ANA i n T a b l e anaesthesiologists  for  unknown  improved i n f o r m a t i o n i n  billing  in  (and,  These p h y s i c i a n s  one and a l l o c a t e d t o OTHER  FTE v a l u e this  in  study  study t o c a l c u l a t e FTE v a l u e s  s p e c i a l t y was  However,  leveled  bed  The DOCS and OTHER v a r i a b l e  A c c o r d i n g t o T a b l e 11 t h i s overestimation  and  1982/83).  this  a s s i g n e d a FTE v a l u e of  specialty.  56.6  t r e n d i n r e s p e c t t o DOCS and OTHER  some e x t e n d , t o A N A ) .  reflect  to  i n the study  The y e a r 1973, h o w e v e r ,  from t h i s  showed  paediatric  increased dramatically during  11).  to  of  ( t h e c o e f f i c i e n t o f v a r i a t i o n was  (Table  deviation  f o r each year  the c o e f f i c i e n t of v a r i a t i o n  and 55.6 p e r c e n t i n  study  synthetic,  1973 t h e v a r i a t i o n d e c r e a s e d s l i g h t l y  1974.  Physician  the  the  a r o u n d 10 f r o m y e a r  p e r c e n t . The two more r e c e n t y e a r s  1981/82  of  in inter-district variation  increased i n t e r - d i s t r i c t variation  to  all  c o e f f i c i e n t s of v a r i a t i o n  increase  percent).  to  at  11 may fewer  and  Table 11  Means and Standard Deviations of Different Measures of Physician Availability per 10,000 Population (0-14 Years) Over School Districts by Year  DOCS Year  Mean  1973  44.70  1974  GP SD  PAED  Mean  SD  10.78  24.45  6.39  40.24  10.89  26.05  1975  41.15  9.97  1976  42.99  10.87  % Change between -3.83 1973-1976  ANA  OTHER  SD  Mean  SD  Mean  SD  Mean  SD  0.81  0.66  7.60  3.71  0.59  1.80  11.24  8.93  6.83  0.96  0.65  8.58  3.86  6.47  1.55  4.17  3.12  26.99  7.52  1.10  0.91  8.39  3.62  0.23  0.60  4.44  3.48  26.68  8.11  1.19  0.90  8.47  3.31  0.22  0.50  6.43  6.07  9.12  Mean  SURGEON  46.91  11.45  -62.71  -42.79  1981  53.62  14.86  31.66  8.65  1.48  0.84  10.02  3.19  0.70  1.96  9.77  9.98  1982  54.67  18.16  32.59  10.16  1.49  1.17  10.60  5.99  0.64  1.60  9.36  11.12  h Change between 22.30 1973-1982/83 Pooled 1973-1982/83  46.23  33.29  14.10  28.07  83.95  8.54  1.17  39.47  0.90  8.94  8.48  4.16  0.48  -16.73  1.46  7.57  8.18  136 bigger  (in  (since  these a r e s c h o o l d i s t r i c t means).  is  respect to population)  s u p p o r t e d by a s i m u l t a n e o u s  variation  of  t h e ANA  surgical  (GP)  paediatricians the highest increase),  This  interpretation  categories,  general  group  (SURGEON). However,  and  by  t h e mean v a l u e  per population over the school d i s t r i c t s  increase  of  family  followed  f r o m 1973 t o  but t h e i r p r o p o r t i o n of  1982/83 all  (84  of showed  percent  physicians  the p a e d i a t r i c p o p u l a t i o n remained q u i t e s m a l l three  197 0s  decrease i n the c o e f f i c i e n t  formed t h e l a r g e s t  specialties  i n the  variable.  Of t h e d i f f e r e n t s p e c i a l t y practitioners  districts  available  (less  to  than  percent).  Means o f d i d not  the socioeconomic v a r i a b l e s  across  change much f r o m t h e 1971 Census  to  school  districts  1981 C e n s u s  (Table  12) .  Table  13 shows t h e c o r r e l a t i o n m a t r i x o f  t h e main  variables  i n the pooled c r o s s - a r e a / c r o s s - y e a r  to  correlations,  simple  negatively  day c a r e s u r g e r y  r e l a t e d t o a l l measures  of  data.  the dependent  t h e BEDS v a r i a b l e was n e g a t i v e l y  variable  but p o s i t i v e l y with the i n p a t i e n t use, of  I n p a t i e n t use  a spurious (i.e.,  was  variable.  correlated with suggesting  r e l a t i o n s h i p between DCS  BEDS i s  According  availability  However,  possibility  study  a f f e c t i n g both of  and  them).  DCS the  137 Table  12  Means a n d S t a n d a r d D e v i a t i o n s o f D i f f e r e n t Socioeconomic V a r i a b l e s Over S c h o o l D i s t r i c t s b y Census Y e a r  Variable  1971 Mean  SD  1981  SD  Mean  CAN  81.33  4.59  80.98  5.74  MTENG  83.32  6.95  85.18  5.25  4.94  6.56  4.56  6.57  RURAL  46.10  26.81  44.70  28.60  EDUC  4.67  2.78  15.21  4.71  5.14  0.38  5.75  0.38  IND  1  ROOMS INC  2  3,916.08  600.39  11/ 814.29  1,750.14  INC  3  9,839.39  1,508.51  11/ 814.29  1, 7 5 0 . 1 4  8.11  1.91  7.72  2.14  WHITE  45.01  9.67  40.06  10.11  PRIM  16.04  10.18  14.34  9.65  UNEM  > C l a s s i f i c a t i o n o f e d u c a t i o n was d i f e r e n t 1981; f i g u r e s a r e n o t c o m p a r a b l e . x  2 ) 1971  in  i n c o m e s a r e n o t a d j u s t e d t o t h e 1981 l e v e l .  > 1971 i n c o m e s a r e a d j u s t e d t o t h e 1981 l e v e l V a n c o u v e r Consumer P r i c e I n d e x . 3  1971 a n d  using the  Table 13  Correlation Matrix of Main Study Variables in Pooled 1968-1982/83 Dataset  MED/SURG  SURG  SURG-T&A SURG A  SURG B  SURG C  DCS  BEDS  _  _  _  -  -  Admissions: MED/SURG SURG SURG-T&A SURG A SURG B SURG C DCS BEDS  1.00 0.51 0.54 0.50 0.42 0.25 -0.25 0.74  _  1.00 0.79  -  0.97 0.96 0.58 -0.40 0.23  1.00 0.69 0.64 0.70 -0.27 0.39  _  _  1.00 0.97 0.83 0.66 0.41 -0.38 0.43  1.00 0.73 0.49 0.37 -0.31 0.47  -  -  1.00 0.98 0.57 -0.44 0.20  -  1.00 0.59 -0.40 0.12  1.00 -0.20 0.16  _  _  -  -  -  1.00 -0.20  -  -  -  1.00  Days: MED/SURG SURG SURG-T&A SURG A SURG B SURG C DCS BEDS  1.00 0.67 0.66 0.64 0.41 0.25 -0.29 0.75  -  -  1.00 0.80 0.48 -0.46 0.35  1.00 0.63 -0.45 0.16  1.00 -0.26 0.22  _  -  1.00 -0.20  -  1.00  139 4.2  A  Day c a r e s u r g e r y a v a i l a b i l i t y a n d p a e d i a t r i c inpatient utilization  regression  measures  analysis  on s u r g i c a l  admissions u n t i l  a d m i s s i o n s was  1981/82 and 1982/83 the regression also  (Table  if was  1976, and t h e significant  14).  1970,  In  1969,  effect only  1974 and  in  1975  c o e f f i c i e n t on DCS was a l s o r e l a t i v e l y h i g h  its  standard e r r o r , i n d i c a t i n g high the estimate.  was d e t e r m i n e d w h o l l y o u t s i d e  the a v a i l a b i l i t y  random  If  hospital  the h o s p i t a l  system,  care and  district  u n c o r r e l a t e d e i t h e r w i t h need o r w i t h i n p a t i e n t  capacity  and i f  inpatient  all  of day c a r e s u r g e r y  but  i n a school  levels,  districts  had t h e same d e g r e e o f  and d a y c a r e s u r g e r y  s h o u l d be - 1 . 0 0  capacity,  and t h e a s s u m p t i o n  of  hold.  However,  simple  surgery  the r e s u l t s  causal  suggest that  to d e s c r i b e the r e a l i t y .  availability  explains  (less  than twelve p e r c e n t , at b e s t ) ,  there are other factors the v a r i a t i o n of districts. suggest that  F i r s t of  the r e s u l t s  100 d a y c a r e s u r g e r y  in  should  scenario is all, the  day  care  utilization  which i n d i c a t e s  that  determining  u t i l i z a t i o n across  cases  much  total  and s u r g i c a l  1976,  DCS  relationship  t h a t a r e more i m p o r t a n t i n  paediatric hospital  Secondly,  this  v e r y l i t t l e of  variation in overall medical/surgical  surplus  t h e n t h e s l o p e on  between d a y c a r e s u r g e r y and i n p a t i e n t u t i l i z a t i o n  too  for  e f f e c t on  statistically  f l u c t u a t i o n and u n c e r t a i n t y o f "need"  performed  DCS d i d n o t have any s i g n i f i c a n t  medical/surgical  s o was  t h e MED/SURG and SURG u t i l i z a t i o n  on d a y c a r e s u r g e r y a v a i l a b i l i t y was  each study y e a r . total  of  1981/82 and  substitute  for  school 1982/83  Table 14  School District MED/SURG and SURG Equations with DCS by Year Admissions  Measure & Year  MEO/SURG: 1968 1969 1970 1971 1972 1973 1974 1975 1976 1981 1982  DAYS: 1968 1969 1970 1971 1972 1973 1974 1975 1976 1981 1982  1  2  p < 0.05 p < 0.01  DCS  SE  -0.28 -0.87  1.71  -0.88 -0.13 0.28 -0.17 -1.20 -1.58 -1.88  SE Y  OCS  64.07 64.12 68.64 63.94 66.28 66.21 56.23 51.28 51.02  -8.90 -10.40 -2.08  1.03 0.92 0.85 0.84  159.19 -0.0133 158.01 -0.0066 160.02 -0.0042 151.44 -0.0134 149.38 -0.0129 147.25 -0.0133 156.85 0.0095 152.25 0.0324 152.46 0.0510  0.65 0.66  134.09 126.57  0.0586 0.0602  40.50 41.14  -3.33 -3.83  3.22  61.16 -0.0100 53.40 -0.0047 53.98 0.0031 52.09 0.0379 43.64 0.0074 42.05 0.0034  14.99 13.21 12.28 9.26 10.75  -0.63  2.14  -1.11 -0.11 -0.41 0.45 -0.19  1.39 1.23 0.95 1.21 1.14  -0.89 -0.30 -1.94  1.18 0.89  1.22 1.06 0.90 1.14  1  -1.53  1  -1.59  1  0.40  0.01 -0.20 -0.21 -0.26 0.23 0.20 -0.04  0.25 0.19 0.13 0.19 0.18 0.16 0.16 0.14  -0.11 -0.15 -0.32 -0.43  2  2  0.12 0.13  CONST  Days R  2  43.62 -0.0128 41.81 -0.0066 39.44 0.0017 38.62 36.96  0.0796 0.1197  11.59 9.96 9.40 8.57 7.45 7.94  SE  -1.22 -4.45 -4.53 -9.51 -9.22 -12.81  -0.72 -1.16  1  13.68 1.082.42 10.22 1.085.94 8.75 1.007.39 7.09 955.46 8.74 986.13 6.95 892.90 6.87 936.74 6.02 857.69 6.15 868.93 3.19  1  CONST  R  2  -0.0079 0.0005 -0.0129 -0.0133 -0.0101 -0.0078  SE Y  0.0122 0.0179 0.0432  512.66 538.57 566.69 501.77 508.05 446.39 421.55 363.65 373.31  537.06 507.29  0.0012 0.0055  199.90 200.30  325.98 285.33 263.74 250.90 229.98  -0.0125 -0.0049  80.18 73.23 79.37 67.34 70.29  0.76  -0.0136 -0.0112 -0.0118 224.78 -0.0133 230.37 -0.0059 303.75 -0.0122 209.34 0.0693  0.70 0.86  158.36 158.04  0.0009 0.0112  73.15 72.42 53.47 46.20 43.85 53.17  141 a p p r o x i m a t e l y 150 m e d i c a l / s u r g i c a l 30-40  surgical  cases.  Or,  i n o t h e r words,  surgery  cases  would s u b s t i t u t e  cases.  This,  of  course,  something  else  is  inpatient  utilization.  i n p a t i e n t cases  is  for  100 d a y  110 m e d i c a l  n o n s e n s e and s u g g e s t s  1976.  years  that  inpatients  The r e s u l t s  i n T a b l e 14 a l s o  or s u r g i c a l  the admission  the average  length of  c a r e would have been l e s s 1982/83 b u t n e a r l y  1974,  show  13 d a y s i n  surgical  the  the year  equations  surgical  f o r by s u r g i c a l  1976 w h i c h i s  cases  that  p a t i e n t d a y s when  than t h r e e days i n  The v a r i a t i o n i n m e d i c a l / s u r g i c a l  1968 t o  stay of  and  significant  and h o s p i t a l d a y  t h a t may h a v e b e e n s u b s t i t u t e d  variation in  that  are concerned, with the exception of  Comparison of  suggests  care  a f f e c t i n g t h e r e l a t i o n s h i p b e t w e e n DCS  on t o t a l m e d i c a l / s u r g i c a l  individual  only  inpatient  day c a r e s u r g e r y a v a i l a b i l i t y does not have any effect  but  1981/82  day  and  unreasonable  e x p l a i n e d by  d a y c a r e u s e was p r a c t i c a l l y z e r o  and t h e n i n c r e a s e d f r o m t h r e e p e r c e n t t o  high.  the from six  p e r c e n t between 1975 and 1 9 8 2 / 8 3 . Day c a r e s u r g e r y u s e d i d explain variation in and 1 9 8 2 / 8 3 . was year  also  surgical  The g o o d n e s s o f  cases fit  t h e o n l y y e a r when DCS  the v a r i a t i o n i n i n p a t i e n t  1971,  the regression  v e r y poor f o r m e d i c a l / s u r g i c a l  1976 was  1981/82 equations  and s u r g i c a l  days.  The  seemed t o e x p l a i n some o f  days.  The n e x t s t e p i n t h e a n a l y s i s equations  of  except i n  not  was t o e x a m i n e  s e p a r a t e l y f o r each measure o f  regression  the dependent  142 variable  i n o r d e r t o see whether t h e r e i s  p r e d i c t i o n when more r e s t r i c t e d s u r g i c a l Results  1981/82,  and f o r t h e p o o l e d c r o s s - a r e a / c r o s s - y e a r  The r e g r e s s i o n  highly in  significant  significance a greater  of  pooled data  dependent process  R ) 2  is  that  This  This  capture also  affects  suggests  that  difference  some k i n d o f  individual  for  in  between fit  equations  the  DCS  surgical and data.  simply  increase  in the  i n i n d i v i d u a l year data  and  data.  to  the  illustrate  u t i l i z a t i o n i n a c l u s t e r of However,  3 tries  in  (adjusted  (SURG, SURG A ,  with the simultaneous  between d a y c a r e s u r g e r y  year.  school  time-  t h e c a p t u r e d t i m e - e f f e c t m i g h t be  pooled c r o s s - d i s t r i c t / c r o s s - y e a r  inpatient  (75  suggesting that  The improvement o f  u t i l i z a t i o n . Figure  to  (825  from i n d i v i d u a l y e a r d a t a t o p o o l e d  in regression  association  p a r t l y due  greater  the r e l a t i o n s h i p  w h i c h i n c l u d e T&As  t h e d e c r e a s e i n T&A r a t e s day c a r e s u r g e r y  the  is  is  e s p e c i a l l y marked w i t h t h e e q u a t i o n s  when m o v i n g  variable  c o e f f i c i e n t s are also,  individual years,  utilization.  u t i l i z a t i o n measures SURG B)  the dependent  and t h e e x p l a i n e d v a r i a n c e  data  (Table  statistically  i n the pooled data  the regression  cross-area/cross-year  and data  than i n the i n d i v i d u a l year data  compared t o  and i n p a t i e n t  of  is  in  are  1976  i n the i n d i v i d u a l years  observations  However,  higher  measures  1971,  the c o e f f i c i e n t v a r i e s .  school d i s t r i c t s )  general,  but  number o f  districts).  c o e f f i c i e n t on DCS  with a l l  the pooled data,  for  categories  studied.  15).  are presented only  any improvement  There i s  o n l y weak  u t i l i z a t i o n and observations  day c a r e s u r g e r y  surgical  of  utilization  any is  T a b l e 15  School O i s t r i c t  I n p a t i e n t H o s p i t a l U t i l i z a t i o n E q u a t i o n s w i t h DCS  in 1971, 1976, 1981/82 and P o o l e d 1968-1982/83 D a t a s e t Admissions  Days  Year & Measure  DCS  1971 MEDS/SURG  -0.13  SURG  -0.26  SURG-T&A  -0.07  SURG A  -0.31  SURG B  -0.27  SURG C  -0.05  1  1  1  SE  CONST  R  SE  CONST  R  0.90  151.44  -0.0134  63.94  0.13  52.09  0.0379  9.26  -1.22  7.09  955.46  -0.0133  501.77  -0.41  0.95  250.90  -0.0112  0.10  31.54  -0.0065  67.34  6.83  0.12  0.95  204.35  -0.0135  0.12  38.34  67.13  0.0729  8.39  -0.91  0.41  117.90  0.0503  0.11  29.01  33.53  0.0593  8.00  -0.61  0.24  72.64  0.0658  17.20  0.04  8.87  0.0086  2.87  -0.07  0.09  19.52  -0.0042  6.32  0.84  152.46  0.0510  51.02  -12.81  1  6.15  868.93  0.0432  373.31  1  0.76  209.34  0.0693  46.20  0.74  180.55  0.0427  44.81  2  SE Y  DCS  1  1  2  SE Y  1976 MEDS/SURG  -1.88  SURG  -0.15  0.14  39.44  0.0017  8.57  -1.94  SURG-T&A  -0.07  0.09  27.76  -0.0051  5.48  -1.53  SURG A  -0.13  0.12  25.38  0.0032  7.08  -0.67  0.41  78.16  0.0222  24.90  SURG B  -0.09  0.11  22.04  -0.0050  6.80  -0.43  0.25  50.27  0.0261  14.99  SURG C  -0.01  0.04  7.40  -0.0120  2.32  -0.07  0.08  16.57  -0.0034  5.09  0.65  134.09  0.0586  40.50  -3.33  3.19  537.06  0.0012  199.90  0.12  38.62  0.0796  7.45  -0.72  0.70  158.36  0.0009  43.85  0.09  29.60  0.0668  5.78  -0.43  0.68  137.46  -0.0083  42.64  0.08  20.09  0.0620  5.17  -0.61  1  0.24  50.75  0.0707  14.75  0.08  18.08  0.0457  4.87  -0.44  2  0.15  37.54  0.0938  9.26  0.04  6.50  0.0384  2.31  -0.17  1  0.07  13.42  0.0539  4.51  3  0.25  159.70  0.0601  59.67  -16.67  459.15  3  0.05  52.49  0.1551  12.85  -3.90  0.03  32.00  0.0727  7.17  -2.72  0.05  37.87  0.1934  11.37  -2.62  0.04  32.50  0.1624  10.25  -1.38  0.01  8.02  0.0383  2.85  -0.21  1981/82 MEDS/SURG  -1.53  SURG  -0.32  SURG-T&A  -0.23  SURG A  -0.20  SURG B  -0.17  SURG C  -0.07  Pooled MEDS/SURG  -1.83  SURG  -0.67  SURG-T&A  -0.24  SURG A  -0.67  SURG B  -0.55  SURG C  -0.07  1  p < 0.05  2  p < 0.01  3  p < 0.001  1  1  2  1  1  1  3  3  3  3  '  1  1.93  1014.50  0.0823  3  0.33  270.74  0.1454  78.17  3  0.29  221.94  0.0961  68.86  0.18  123.40  0.2056  42.58  0.10  72.31  0.2006  22.73  0.03  18.58  0.0640  6.56  3  3  3  3  • o T A +  Observation Observation Observation Observation Observation  in year 1 in year 2 in year 3 in year 4 in year 5  Regression line in pooled (years 1-5) dataset Regression line in individual year dataset  c o 3  a. o o.  o o o  CL  «/>  <u l/l ca  u  c <v ro  CL  C  DCS cases per 1000 population FIGURE 3- Simplified i l l u s t r a t i o n of the differences in regression equations between individual years and the pooled dataset.  145 i n c r e a s i n g over time while s u r g i c a l decreasing,  inpatient utilization  and t h e s e two t r e n d s a r e p r o b a b l y  largely  independent of  each o t h e r , s i n c e the decrease i n  utilization  largely  surgery  is  eligible  observations level care  of  in  one y e a r w i l l  Thus a c l u s t e r  use than the c l u s t e r of  at  in  p r e v i o u s y e a r . When a r e g r e s s i o n  equation i s  pooled c r o s s - d i s t r i c t / c r o s s - y e a r  data,  t r e n d and show a h i g h r e g r e s s i o n  c o e f f i c i e n t on DCS,  there  is  a  lower  l e v e l of  observations  it  care  of  b e , on t h e a v e r a g e ,  i n p a t i e n t u t i l i z a t i o n and a t a h i g h e r  surgery  inpatient  caused by d e c r e a s e i n non-day  tonsillectomies.  is  the  f i t t e d to  will  capture  no n e c e s s a r y c a u s a t i o n between DCS and  day  the this  although  surgical  inpatient u t i l i z a t i o n .  None o f  t h e d i f f e r e n t measures  of  surgical  a f f e c t e d by t h e day c a r e s u r g e r y a v a i l a b i l i t y 1971 and 1981/82 DCS had a s t a t i s t i c a l l y association  , causal  utilization. quite  low,  implying  and l e s s  The e f f e c t o f  1976, b u t  significant  s u b s t i t u t i o n of was  less  less  negative  than e i g h t  percent with  t h a n 10 p e r c e n t w i t h h o s p i t a l  less  days.  on SURG-T&A a d m i s s i o n s  1971 b u t i n  results  still  t h a n one t h i r d . The  t h a n on  1981/82 t h e e f f e c t s were  t h e same m a g n i t u d e and e q u a l l y s i g n i f i c a n t .  cross-sectional  in  o r n o n - c a u s a l , w i t h SURG A and SURG B  DCS was  SURG A and SURG B i n roughly  in  However, t h e a c t u a l c o e f f i c i e n t s were  explained variation admissions  a d m i s s i o n s were  all  These  p r o b a b l y r e f l e c t h i g h e r T&A r a t e s  in  146 school d i s t r i c t s  with less  raises  DCS a c t i v i t y  1981/82.  This  h i g h DCS  r a t e i n a s c h o o l d i s t r i c t were  progressivity' 'progressive'  in that d i s t r i c t physicians  T&As and s t a r t both of  that  1971, b u t n o t  'markers'  i n the e a r l y  A low r e g r e s s i o n  'medical In  to  1971,  reduce  Ten y e a r s  had become commonplace. i n Table  of  1970s.  were p r o b a b l y t h e f i r s t  with the findings  in  a l o w T&A r a t e and a  p e r f o r m i n g day c a r e s u r g e r y .  these practices  consistent  R  a possibility  in  This  later, would  15.  c o e f f i c i e n t on DCS and p a r t i c u l a r l y a  low  i n t h e e q u a t i o n f o r SURG C b o t h i n i n d i v i d u a l y e a r d a t a  2  i n t h e p o o l e d d a t a was  a surprise,  already  d a y c a r e s u r g e r y may n o t h a v e much  effect  suggested that on t h i s  admissions  still  measures  Although  'explained by'  availability was  measure.  was  higher  in  the v a r i a t i o n  results  of  paediatric hospital  of  surgical  1976 o r  More o f  15 p e r c e n t )  was  use  in total  use  the v a r i a t i o n was  (6-8  to less  t h e SURG C  surgical  a c c o u n t e d f o r by day c a r e s u r g e r y  (SURG A)  it  other  i n p a t i e n t u t i l i z a t i o n show more o r  than i n o v e r a l l m e d i c a l / s u r g i c a l  inpatient  1971,  i n T a b l e 15 w i t h r e s p e c t  the v a r i a t i o n  F u r t h e r m o r e , more o f  surgery  use.  what one w o u l d e x p e c t , w i t h t h e e x c e p t i o n o f equation.  i n Table 9  i n day c a r e  than i n  and  i n SURG C  lower than the e x p l a i n e d v a r i a t i o n with  Results with the pooled data measures  although  the v a r i a t i o n  1981/82  be  use  (around  availability  percent).  i n day c a r e s u r g e r y - t y p e  e x p l a i n e d by v a r i a t i o n  i n day  of  care  147 surgery  availability  regression  than i n t o t a l  admissions  more m e d i c a l t h a n  by 67.  cases  length of  ( E v a n s and R o b i n s o n ,  The n e x t e q u a t i o n i m p l i e s  of  stay  admissions,  which i s  equations  that  A comparison of  implies  that  unrealistically  6 days,  found i n the  stay  are not  the  suitable  for  and h o s p i t a l  day  "non-T&A"  length of  inpatient  low number g i v e n  admission  the saved  surgical  stay of  day  admissions  11.3 d a y s ,  which  high.  a v a i l a b i l i t y was h i g h e s t  admissions  is  earlier  "non-T&A"  a c c o u n t e d f o r by t h e v a r i a t i o n i n day c a r e  SURG A t y p e  for  which  The p r o p o r t i o n o f v a r i a t i o n i n i n p a t i e n t u t i l i z a t i o n  regression  the  100 c h i l d r e n o p e r a t e d on i n a  a suspiciously  w o u l d h a v e h a d an a v e r a g e  "saved"  100  1973).  f e e l i n g that tonsillectomies  care surgery.  a l e n g t h of  about  d a y c a r e s u r g e r y u n i t w o u l d s a v e o n l y 24  was  day  surgical  A comparison of  and d a y s i m p l i e s  inpatient surgery  above t h e average  research  is  the  The c o e f f i c i e n t s i m p l y t h a t  admissions  f o r admissions  "saved"  general  But  c a r e d f o r i n a day c a r e s u r g e r y u n i t would d e c r e a s e  equations  well  "saves"  and p a t i e n t d a y s .  the o v e r a l l s u r g i c a l  the  use.  c o e f f i c i e n t s with the pooled data suggest that  care surgery a v a i l a b i l i t y  children  surgical  that  surgery  w i t h SURG A i n t h e p o o l e d d a t a .  c o e f f i c i e n t s imply that a l l (100 d a y c a r e s u r g e r y  cases  SURG " s a v i n g s " will  of  SURG A t y p e )  and t h e a v e r a g e  cases  w o u l d be 3.9  days,  which i s  save  67  length of reasonable.  The  w o u l d be inpatient stay The  of  148 plausibility however,  represents r e a l  substitution i s ,  l e s s e n e d by t h e l a c k o f s i m i l a r  equation with surgical both  that this  strength i n the  i n d i v i d u a l year data. A t h i r d  p r a c t i c e over time,  factor,  f o r example, may h a v e i n f l u e n c e  on DCS u s e a n d SURG A t y p e u t i l i z a t i o n  observed  correlation  (statistically  because o f a m i s s i n g v a r i a b l e ) .  and cause t h e  significant  The n e x t  does n o t i n c r e a s e t h e p l a u s i b i l i t y When c a s e s  of causal  combinations  among d a y c a r e s u r g e r y p a t i e n t s a r e e x c l u d e d , see a t l e a s t  t h e same k i n d o f improvement  goodness o f f i t o f t h e r e g r e s s i o n e q u a t i o n m o d e l was t r u e .  Instead, the adjusted R  The r e g r e s s i o n c o e f f i c i e n t respect the  t o admissions  falls  when m o v i n g f r o m  SURG B e q u a t i o n . The a v e r a g e  admissions  Given  the unexplained  one i s l e d t o c o n c l u d e s u r g e r y and i n p a t i e n t stage, while  five  days o r  t h a t c a n be one w o u l d  found expect  i n the overall  i fa  substitution  isa little  lower.  -0.67 t o -0.55 i n t h e SURG A e q u a t i o n t o  length of stay of  "saved" days.  findings with these equations  and a  t h a t have n o t been a c c o u n t e d f o r ,  t h a t t h e a s s o c i a t i o n between d a y c a r e u s e , which has been e s t i m a t e d  statistically highly significant  i s not a basis f o ri n f e r r i n g  presented  (SURG B)  association.  i m p l i e d b y t h e SURG B e q u a t i o n s was 2.5  number o f m i s s i n g v a r i a b l e s  data,  from  2  but not causal  equation  t h a t have l o n g e r l e n g t h o f s t a y t h a n  do n o t h a v e d i a g n o s i s / p r o c e d u r e  to  a shift i n  s o f a r do n o t e x c l u d e  causality.  at this  i n the pooled The r e s u l t s  the p o s s i b i l i t y  that the  r e l a t i o n s h i p between d a y c a r e s u r g e r y a n d i n p a t i e n t u s e i s  149 actually  g o i n g i n t h e o t h e r d i r e c t i o n , o r more p l a u s i b l y ,  both v a r i a b l e s factor or  might  be i n f l u e n c e d j o i n t l y b y some  P a e d i a t r i c bed a v a i l a b i l i t y utilization  The most  obvious  variable  availability available  and  inpatient  t o check f o r a  i n f l u e n c e on t h e r e l a t i o n s h i p  confounding  between s u r g i c a l  and p a e d i a t r i c i n p a t i e n t u s e i s ,  supply  of  p a e d i a t r i c beds.  i n T a b l e 13 showed,  supply of  c o r r e l a t e d w i t h day c a r e s u r g e r y correlation is less  small.  More beds  day c a r e s u r g e r y  had been b u i l t  surgery,  it  is  that  If  inpatient  is  negatively  the a v a i l a b i l i t y a high  l e v e l of  low l e v e l of be  causal.  of  with  somewhat  day  is  from  introduced in  is  causally  t h e bed s u p p l y  activity,  also  areas  is  that  simple as  high  related  to  determines  t h e n one w o u l d  activity  beds  Law s u g g e s t s  13 was  in  care  i n p a t i e n t u t i l i z a t i o n . The  day c a r e s u r g e r y  the  t h e bed c a p a c i t y ,  Roemer's  day c a r e s u r g e r y ,  inpatient  although  t h e r e l a t i o n s h i p works  p a e d i a t r i c bed a v a i l a b i l i t y  u t i l i z a t i o n and i f  the  beds  c o r r e l a t i o n between BEDS and MED/SURG i n T a b l e .74.  course,  correlation  are associated  day c a r e s u r g e r y  determines  care  the  availability,  where t h e r e a r e few i n p a t i e n t b e d s . bed a v a i l a b i l i t y  of  before the i n t r o d u c t i o n of  plausible  t o day c a r e s u r g e r y :  day  As  u t i l i z a t i o n . Since  general,  as  third  factors.  4.3  matrix  that  find  associated  but the a s s o c i a t i o n  that  with  would  a  not  150 Regressions  of  total medical/surgical  on b e d a v a i l a b i l i t y another  (Table  relationship  showed a c o n s t a n t  16).  in hospital  the v a r i a t i o n admissions. 1968-1976  1968 t o  but i n  once p a t i e n t s  day e q u a t i o n s  percent  in  coefficient of  its  29.6  d a y s and i n  9.5  in  association  fit  of  1982/83  in  admissions  21.4 a d d i t i o n a l  These f i g u r e s 1968 and 4.6  had f a l l e n i n Table  additional  admissions  i m p l y an a v e r a g e days i n  1982/83  and  to  almost  16 have  patient  99.1  length  and an  with  regression  p a e d i a t r i c bed would  and 280.4  80.1  between BEDS and  1976 t h e  1976. The r e s u l t s  the  1970 t o  b u t more marked f a l l w i t h r e s p e c t  in  than  availability  The g o o d n e s s o f  1968 one a d d i t i o n a l  additional  days. days  level  in  of  t o bed  E s p e c i a l l y a f t e r the year  by  t o bed s u p p l y  on BEDS i n p a t i e n t d a y e q u a t i o n s  suggest that  of  that  u t i l i z a t i o n showed a s l i g h t d e c r e a s e o v e r t i m e  p a t i e n t days.  patient  of  The  in  f r o m 55.2 p e r c e n t i n  The s t r e n g t h  respect to admissions  meant  ranged  varied  better  implies  the pattern  not v e r y s e n s i t i v e  were h o s p i t a l i z e d .  1974.  2  s t a y was more s e n s i t i v e  patient  1976.  than v a r i a t i o n  adjusted R  1981/82-1982/83  h o s p i t a l i z a t i o n was  into half  days.  medical/surgical  d a y s was e x p l a i n e d s l i g h t l y  The c o m p a r i s o n o f  length of  admissions  inpatient  and p a t i e n t  68.7 p e r c e n t i n  i n bed a v a i l a b i l i t y  to  strong  a c c o u n t e d f o r by p a e d i a t r i c bed a v a i l a b i l i t y  f r o m 45.8 p e r c e n t i n variation  had a v e r y  to both i n p a t i e n t admissions in total  utilization  p a t t e r n f r o m one y e a r  Bed a v a i l a b i l i t y  The p r o p o r t i o n o f v a r i a t i o n admissions  inpatient  of  stay  average  151  Table 16  School District MED/SURG and SURG Equations with BEDS by Year  Admissions Measure & Year  BEDS  SE  CONST  Days R  2  SE Y  BEDS  SE  CONST  R  2  SE Y  0.6441 0.6292 0.5516 0.6674 0.7016 0.7247 0.8014  304.67 328.05 377.07 287.46 276.15 233.32 189.06  0.7821 0.7311  171.30 197.89  •  MED/SURG: 1968 1969 1970 1971 1972 1973 1974 1975 1976  29.59 30.14 28.17 25.96 24.52 25.53 25.67 23.30 24.26  1981/82 1882/83  SURG: 1968 1969 1970 1971 1972 1973 1974 1975 1976 1981/82 1982/83  1  2  3  p < 0.05 p < 0.01 p < 0.001  280.43 268.04 252.25 210.38 206.31 202.04 210.34 178.64  24.15 23.83 26.30 17.21 15.60 14.44 12.15 10.94  0.6874  46.88 42.21 50.21 38.89 42.59 45.33 32.44 30.53 29.28  182.18  12.81  155.13 124.35 136.51 175.28 183.79 112.29 51.56 91.30 47.34  0.6789 0.5986  23.65 26.89  95.46 99.05  7.65 9.86  187.65 164.38  0.6766 0.5745  113.74 131.02  14.95 13.18 12.22 9.44  27.60 23.00 17.98 18.16 19.33 20.74 24.03 17.67  5.48 4.62 5.12 3.43 3.27 3.82 3.73 2.72  235.76 201.45 202.03 180.16  0.2481 0.2436 0.1328 0.2673  0.52  58.87 -0.0085 48.92 -0.0001 47.92 0.0134 47.03 0.0008 41.79 0.0436 41.77 0.0035 37.50 0.0761 31.36 0.2236 31.10 0.1258  13.09  2.72  164.86 148.15 132.98 136.33 136.34  0.3149 0.2778 0.3534 0.3573 0.2303  69.09 63.53 73.42 57.32 57.84 61.75 58.06 42.61 42.01  0.44 0.53  25.02 20.13  2.57 3.58  106.27 91.56  0.2408 0.2066  38.22 47.62  2.81 2.09 1.95 1.90  64.18 51.76 56.66 55.46 63.37 53.81 49.55 47.15 40.76  0.4575 0.5638 0.4627 0.6250 0.5817 0.5251 0.6703 0.6571  19.95 21.35  1.59 2.02  44.47 37.56  0.73 0.95 1.21 0.58 1.25  1.19 0.96 0.85 0.57 0.60 0.72 0.59 0.53  3  3  3  3  3  3  3  3  3  3  3  1  0.81 1.57 2.49 1.77  2  3  2  2.42° 3.12 3  3.72 3.07 3.50 2.33 2.41  0.2801 0.3147  10.55 11.59 9.15 8.26 8.02 6.59 7.01  3  3  3  3  3  3  3  3  3  3  3  3  3  3  3  3  3  3  3  3  12.71° 16.14 3  152 occupancy r a t e percent  an  a d d i t i o n a l bed  surgical  bed  availability  inpatient  explained  by  the  use,  percent).  and  31.5  use  days suggested t h a t t o bed  the  (the  less strongly  also  highest  s u p p l y and  association  between bed  regression  s u p p l y and the  improved a t  capacity  i n the  Table  suggest that  the  one  additional  0.7  additional  s u r g i c a l d a y s i n 1968.  the  except  availability  and  in  association  decreasing  to decline.  f i t of  The  In  showed t h e  would  in have  27.6  1982/83 t h e s e  16.1,  and  bed  results bed  It  the  paediatric  s u r g i c a l a d m i s s i o n s and  f i g u r e s w o u l d h a v e b e e n 3.1  a l l the  i s more  between BEDS  additional paediatric  meant o n l y  SURG-T&A o f  the  same t i m e when t h e  province started  patient  c o e f f i c i e n t s from  association  equation  bed  35.7  stay rate  the  s u r g i c a l days over time.  a d m i s s i o n s became s t r o n g e r and  1971,  days  of  for  with  2  strengthening  surgical  16  l e s s than  with patient  than admission  to  variation  s u r g i c a l admissions but  i n t e r e s t i n g to note that  with  27  related  adjusted R  i n surgery length  availability  b e t w e e n bed  of  s u p p l y was  y e a r t o a n o t h e r showed s l i g h t l y  In  p e r c e n t and  e q u a t i o n s f o r a d m i s s i o n s and  1981/82-1982/83. C o m p a r i s o n o f  is  77  proportion  p e r c e n t and  Comparison of  sensitive  was  v a r i a t i o n i n bed  medical/surgical  a d m i s s i o n s was  one  of  respectively.  Paediatric  total  of  same  respectively.  strongest  association  s u r g i c a l u t i l i z a t i o n measures whereas  SURG m e a s u r e showed t h e  strongest  r e l a t i o n s h i p i n 1976  and  153 1981/82  (Table  a n d SURG A ,  measures of  of  percent) in  paediatric  measures  1981/82  availability  1971.  association,  was  (38.5  and i n  significant  highest  1981/82  these  bed  relationship  w i t h SURG-T&A  to  in  1981/82  day measures  statistically  in  of  highly  low i n t h e  SURG A ,  (35.4  the  beta  significant  the a s s o c i a t i o n s  1976 and 1 9 8 1 / 8 2 .  did  in not  The e x p l a i n e d  B and C  equations. almost  the  same f o r t o t a l m e d i c a l / s u r g i c a l  u t i l i z a t i o n i n the pooled  as  but  the i n d i v i d u a l year data,  i n the pooled set  The s t a b i l i t y availability  of  hypothesis  the adjusted R  admissions,  bed s u p p l y  but the evidence of  equation for  p a e d i a t r i c be  will  increases  give  is  total  supports  inpatient not  t o about  26  the  the  utilization,  conclusive.  w i t h p o o l e d d a t a one  rise  less  bed  and t h e h i g h p r o p o r t i o n o f  the c a u s a l i t y  According to the equations  was  data  years.  a c c o u n t e d f o r b y t h e BEDS v a r i a b l e that  2  t h e b e t a c o e f f i c i e n t on p a e d i a t r i c  i n the regression  medical/surgical variation  than i n i n d i v i d u a l  of  w i t h SURG A  The b e t a c o e f f i c i e n t on p a e d i a t r i c bed s u p p l y was  in  all  surgical  p e r c e n t ) . With the pooled data  but the strength  fairly  1976 a n d 1981/82  equation for d i f f e r e n t  much f r o m t h o s e  v a r i a t i o n was  In  and  i n p a t i e n t u t i l i z a t i o n . The g o o d n e s s  on BEDS was  equations,  differ  between bed  and f o r d i f f e r e n t s u r g i c a l  coefficient all  in  had s t a t i s t i c a l l y  the regression  admission  also  insignificant  showed s t r o n g e r  availability  fit  The a s s o c i a t i o n  SURG B and SURG C a d m i s s i o n s were weak  statistically measures  17).  additional  additional  Table 17  School District inpatient Hospital Utilization Equations with BEDS in 1971. 1976. 1981/82 and Pooled 1968-1982/83 Dataset Admissions  Year & Measure  BEDS  SE  1971 MED/SURG SURG SURG-T&A SURG A SURG B SURG C  25.96° 0.58 1.75 0.28 -0.35 0.08  2.33 0.57 0.36 0.52 0.50 0.17  1976 MED/SURG SURG SURG-T&A SURG A SURG B SURG C  24.26° 1.7/2  1981/82 MED/SURG SURG SURG-T&A SURG A SURG B SURG C Pooled MED/SURG SURG SURG-T&A SURG A SURG B SURG C 1  2  3  p < 0.05 p < 0.01 D < 0.001  SE Y  BEDS  55.46 0.6250 47.03 0.0008 24.36 0.2393 33.82 -0.0099 31.75 -0.0068 7.99 -0.0108  38.89 9.44 5.94 8.76 8.28 2.90  210.38° 18.16 19.38  1.90 0.52 0.33 0.43 0.43 0.15  40.76 31.10 22.86 18.45 17.28 6.25  0.6874 0.1258 0.1199 0.1234 0.0571 0.0320  29.28 8.02 5.13 6.64 6.58 2.27  182.18 13.09 11.17 7.59 2.72 0.89  19.95° 2.42 2.08 1.22 0.79 0.43  1.59 0.44 0.32 0.33 0.33 0.15  44.47 25.02 18.82 12.50 12.44 3.78  0.6789 0.2801 0.3541 0.1444 0.0628 0.0855  23.65 6.59 4.81 4.93 4.83 2.26  25.74 1.79 1.65 1.41 0.76  0.81 0.27 0.13 0.24 0.22  50.20 38.21 23.41 24.80 23.19  0.5521 0.0509 0.1544 0.0378 0.0135  41.19 13.62 6.85 12.42 11.12  0.27  0.06  6.26  0.0257  2.87  3  l.ll  2  1.45 1.00 0.27  2  1  3  3  3  1  2  3  3  3  3  3  3  CONST  Days R  2  SE  R  2  SE Y  175.29 0.6674 180.16 0.2673 135.16 0.3092 87.52 0.1171 66.17 -0.0135 17.19 0.0024  287.46 57.32 55.43 27.97 17.92 6.30  12.81 2.72 2.68 1.38 0.94 0.31  47.34 136.34 119.99 42.07 34.79 12.40  0.7311 0.2303 0.1807 0.2831 0.0910 0.0873  197.89 42.01 41.45 21.32 14.49 4.86  95.46° 12.71 11.99 5.55 1.58 0.83  7.65 2.57 2.51 0.81 0.63 0.30  187.65 106.27 93.41 22.23 24.22 7.69  0.6766 0.2408 0.2279 0.3852 0.0662 0.0834  113.74 38.22 37.31 12.00 9.40 4.44  202.90 20.31 18.97 9.27 2.31 0.82  6.19 1.50 1.26 0.88 0.49 0.13  123.94 154.07 124.33 59.81 47.53 13.23  0.5658 0.1813 0.2159 0.1180 0.0249 0.0453  315.84 76.51 64.13 44.87 25.11 6.63  3  3  5.51 -0.11 0.41  3  17.21 3.43 3.32 1.67 1.07  CONST  0.38 3  3  3  3  2  2  3  3  3  1  2  3  3  3  3  3  3  155 admissions  (20-30  admissions  according to the equations  individual  years)  and t o a b o u t  203 a d d i t i o n a l p a t i e n t  (96-280  days a c c o r d i n g to the i n d i v i d u a l y e a r d a t a ) .  implies  an a v e r a g e  admission  length of  stay of  7.8  bed  (203/365).  i n T a b l e 9 and 10 was  higher,  66 p e r c e n t .  In  be o n l y  17 p e r c e n t l e s s  level  of  56 p e r c e n t f o r  o t h e r words,  only  in general, quite  26 a d d i t i o n a l a d m i s s i o n s  less  beds,  admissions  the estimated increase i n s u r g i c a l increase  i n beds  is  o n l y about  overall medical/surgical admissions  of  although  low.  that out  t r i g g e r e d b y an a d d i t i o n a l  t h a n two w o u l d be s u r g i c a l  from  an a d d i t i o n a l b e d w o u l d  occupied than e x i s t i n g  occupancy i s ,  the  slightly  The s e c o n d e q u a t i o n i n t h e p o o l e d d a t a i m p l i e s the  This  The o c c u p a n c y r a t e c a l c u l a t e d  the d e s c r i p t i v e data  the  days  f o r each a d d i t i o n a l  and an a v e r a g e o c c u p a n c y r a t e o f  additional  in  (Table  admissions  7 percent of  Since  an  the response  use but the p r o p o r t i o n of  the t o t a l m e d i c a l / s u r g i c a l  bed  17).  due t o  of  of  surgical  admissions  is  about  33 p e r c e n t , one c a n c o n c l u d e t h a t t h e s t r e n g t h o f  the e f f e c t  from beds  for  as  it  is  t o use i s  o n l y a b o u t o n e - f i f t h as  f o r o v e r a l l use.  coefficients  By c o m p a r i n g t h e  the e f f e c t of  p a e d i a t r i c bed a v a i l a b i l i t y  on s u r g i c a l  admissions coefficient  admissions  admissions  equations  one c a n f i n d  to that  relatively  e x c l u d i n g T&As and on SURG A  t h a n on o v e r a l l s u r g i c a l f o r SURG-T&A i s  is  surgery  regression  on BEDS i n more r e s t r i c t e d s u r g e r y  the equation f o r o v e r a l l s u r g i c a l  stronger  great  admissions.  92 p e r c e n t o f  The  the c o e f f i c i e n t  for  156 overall of  surgery,  the t o t a l  implying  b u t SURG-T&A  surgical  nearly  suggests  to the n e c e s s i t y  (as  9)  of  to c o n t r o l f o r the e f f e c t of the r e l a t i o n s h i p  availability  surgery  coefficients  This bed  day  care  of  Also  correlations  the v a r i a t i o n  (Roemer's  availability  of  variation surgery.  supply  to explain  p a e d i a t r i c bed  Law),  would  s u g g e s t t h e need  i n day c a r e s u r g e r y  f i n d a decrease i n the strength day c a r e s u r g e r y  bed  bed  l o a d when b e t a  than f o r t o t a l  i n attempting If  t h a n one  the unexplained  and t h e o r y ,  i n p a t i e n t use.  utilization  less  surgical  higher  equation  The e f f e c t o f  f o r the e f f e c t of  i n c l u d e b o t h BEDS and DCS in paediatric  the t o t a l  s u r g e r y was  Adjusting  simple  equation.  were c o m p a r e d .  these type of  inpatient  effect  coefficient  i n t h e SURG A  on SURG B and SURG C was  e x p e c t by t h e i r s h a r e of  explains  of  t o t h e s e more r e s t r i c t e d m e a s u r e s  t h e r e l a t i v e l y h i g h e r bed e f f e c t  than i n the o v e r a l l  4.4  surgery.  SURG-  utilization.  spite  Both  d e r i v e d from T a b l e  than f o r o v e r a l l  t h e r e was more u n e x p l a i n e d v a r i a t i o n  for  66 p e r c e n t  F o r SURG A t h e r e l a t i v e  e v e n when e x a m i n i n g  availability  surgical  In  surgery.  20 p e r c e n t g r e a t e r  availability surgery  admissions  form o n l y  n e a r l y 40 p e r c e n t g r e a t e r bed s u p p l y e f f e c t f o r  T&A t h a n f o r o v e r a l l is  admissions  to  variation  availability  availability  and  t h e n one w o u l d e x p e c t  the r e l a t i o n s h i p  between  and i n p a t i e n t u t i l i z a t i o n when  to  157 t h e bed v a r i a b l e that  this  is  b e t w e e n DCS for  is  i n c l u d e d i n the equation.  e x a c t l y what h a p p e n s .  and t o t a l m e d i c a l / s u r g i c a l  bed a v a i l a b i l i t y ,  utilization positive 1981/82  is  virtually  and 1 9 8 2 / 8 3 .  of  In  highly  medical/surgical  the equations  significant  fit  of  analysis  BEDS was  has  is  t o t h e DCS  the years  1976,  a powerful  two and  the  controlled.  The  were v i r t u a l l y  to the p r o p o r t i o n of  the  DCS variation  variables.  surgical  inpatient  care  i n b e t a c o e f f i c i e n t on DCS when t h e  standardized  (Table  18)  f o r bed a v a i l a b i l i t y coefficients in  compared t o  the (Table  r e s u l t e d i n almost  1970-1973.  1981/82 and 1982/83 t h e  d e c r e a s e d i n v a l u e and s i g n i f i c a n c e negative.  the  total  t h e c o e f f i c i e n t on DCS t u r n e d f r o m n e g a t i v e in  except  i n t h e e q u a t i o n w i t h o n l y t h e DCS v a r i a b l e  The a d j u s t m e n t  changes  years  shows a  even i n t h e s e  i m p a c t on  f o r the t o t a l  showed l e s s marked c h a n g e s  coefficient  DCS  i n T a b l e 16 and 18.  a c c o u n t e d f o r b y t h e BEDS and DCS  14).  inpatient  fact,  positive  the o v e r a l l equations  contributed v i r t u a l l y nothing  of  adjusted  f o r p a t i e n t days  availability  corresponding equations  Regression  is  a d m i s s i o n s and p a t i e n t d a y s e v e n when  day c a r e s u r g e r y  goodness of  effect  In  P a e d i a t r i c bed a v a i l a b i l i t y  statistically  same i n  admissions  DCS on  eliminated.  c o e f f i c i e n t on DCS was  years.  effect  any e f f e c t of  18 shows  relationship  e f f e c t on MED/SURG a d m i s s i o n s i n a l l  regression later  When t h e  Table  In  1974 and  to p o s i t i v e  1975  and  coefficient  although  remained  The b e t a c o e f f i c i e n t on DCS d i f f e r e d f r o m z e r o  no  at  Table 18  School District Inpatient Hospital Utilization Equations with DCS and BEDS Variables by Year  Admissions Measure & Year  DCS  SE  BEDS  1968 1969 1970 1971 1972 1973 1974 1975 1976  0.73 0.52 0.10 0.45 1.23 0.90 0.11 0.10 0.11  1.26 0.82 0.79  0.53 0.51  28.24 26.14 25.03 26.ll 25.76 23.40 24.39  1981/82 1982/83  -0.29 -0.33  0.39 0.45  0.03 -0.01 -0.17 -0.25 0.28 0.24  Days SE  CONST  R  2  SE Y  DCS  SE  BEDS  0.61 1.90  280.61  6.79 3.44 3.47 3.82 1.27 3.89 2.24  8.23 6.36 5.88 4.09 4.81 3.68 3.16 2.93 3.46  269.32 257.03 211.73 207.74 204.50 211.34 182.79 184.99  2  SE Y  17.32 15.77 14.63 12.48 11.33 13.57  151.97 107.97 56.28 131.31 138.27 54.40 31.44 23.65 6.71  0.6391 0.6245 0.5536 0.6661 0.6996 0.7250 0.7991 0.7843 0.7290  306.76 330.12 376.21 288.04  SE  CONST  R  MED/SURG:  SURG: 1968 1969 1970 1971 1972 1973 1974 1975 1976 1981/82 1982/83  -0.18 -0.26  p < 0.05 p < 0.01 p < 0.001  3.75 3.13 3.57 2.34 2.39 2.83 2.14 2.04 2.01  60.36 47.29 55.54 49.71 47.23 40.19 47.74 45.47 38.76  0.4526 0.5602 0.4553 0.6233 0.5920 0.5289 0.6659 0.6525 0.6833  47.09 42.38 50.55 38.98 42.07 45.15 32.65 30.73 29.47  19.63 20.92  1.66 2.12  51.16 45.21  0.6769 0.5960  23.73 26.97  2.92 2.32  1.87 2.20  98.74 102.10  7.86 10.27  119.92 110.24  0.6829 0.5752  112.63 130.92  0.40 0.26  0.74 0.84  1.20  3  5.54 4.72 5.21 3.47  234.14 201.97 195.85  3.28 3.89 3.83  180.25 149.07 137.95 127.38  1.05 -0.98  0.73 0.73  19.82 21.18 24.31 18.79  0.2379 0.2331 0.1232 0.2572 0.3191  69.56  1.23 1.15 0.82 1.00 0.98 0.97  27.70 22.95 18.35 18.15  0.72 0.60  0.31 -0.06 0.52 -0.01 1.20 0.67 0.35  3  1.09 0.48 1.36 0.96 1.60  15.05 13.24 12.24 9.28 10.45  1.87  0.19 0.13 0.18  58.71 -0.0224 50.34 -0.0082 49.96 0.0109 50.20 0.0347 38.09 0.0619 38.12 0.0137 36.85 0.0642  2.81 2.86  118.02 154.07  0.09 -0.20  0.64 0.80  2.68 3.76  104.24  0.55 0.73 0.71 0.54  0.18 0.15 0.14 0.14  0.04 0.07 -0.01  1  29.80 30.49  0.11 0.11  3  3  3  3  3  3  3  3  s  3  3  1  2  0.98 0.86 0.56 0.59  0.55  30.09  2  0.55  31.22  0.2156 0.1137  2.21 2.78  0.45 0.53  29.28 26.15  0.2983 0.3509  2.57 1.76  3  3  3  11.53 9.20 8.30 8.07 6.50 6.82  3  3  3  3  3  3  3  3  3  3  3  3  3  3  3  3  3  11.86  3  12.81  3  15.87  3  24.44 24.35 26.56  96.33  277.06 233.19 190.11 170.42 198.68  0.2725 0.3457 0.3667  63.97 73.82 57.72 57.66 61.98 58.41 42.29  0.2388  41.78  0.2305 0.1963  38.48 47.93  159 the  f i v e percent  admissions percent  The  equation,  and  d a y s was  almost  entered  into  of the  16  much more marked t h a n  the equation on  DCS  study  on  1 8 ) . The  bed  c o e f f i c i e n t on  1972,  in surgical  effect  significance  on  and  The  positive  regression  significance  almost  in  18  same  days r e g a r d l e s s of  statistically  The  for surgical 1982/83 i n t h e  p r o p o r t i o n of  utilization  variable  support  the  accounted  expected  f o r by  the hypothesis  inpatient  given  the  alone.  c a r e s u r g e r y d o e s n o t h a v e any  t o t a l or s u r g i c a l  the  i d e n t i c a l to the p r o p o r t i o n  o f t h e DCS  i n Table  almost  1974-1976, 1981/82 and  f o r by BEDS a l o n e , as w o u l d be  day  18).  i n the equation  inpatient  t h e DCS/BEDS model was  paediatric  for  a v a i l a b i l i t y was  and  BEDS was  i n a l l study years  results  for  care surgery a v a i l a b i l i t y (Tables  f o r s u r g i c a l admissions.  The  bed  s u r g i c a l admissions  equation  l a c k of  year.  a v a i l a b i l i t y measure had  i n years  accounted  i n that  i n the equation  d i d not have s t a t i s t i c a l  d a y s and  variation  26  years.  overall  significant  e f f e c t of  from n e g a t i v e t o  ( T a b l e s 14  s t a n d a r d i z a t i o n f o r day and  1982/83  i n the equation  c o e f f i c i e n t turned  paediatric  effect the  The  DCS  a l l y e a r s when p a e d i a t r i c  coefficient  The  implying a substitution  a g e n e r a t i o n e f f e c t o f 74 p e r c e n t  admissions.  any  l e v e l only i n the  c h a n g e i n c o e f f i c i e n t on  surgical  in  significance  that  independent  utilization.  The  only  160 meaningful for  t r a c e of  inpatient  the equation different to  c a r e was  in  substitution  1982/83.  study years  provides  day c a r e s u r g e r y  respect the  to o v e r a l l  same as  on s u r g i c a l  years.  The y e a r  the negative  1982/83  that  Since  n e v e r be l e s s  is  The r e s u l t s  average  than one,  length of  this  consistent as  implying  length stay  that  of  of  study  even here admissions  "saves" stay  of  inpatients  0.26 less can  substitution  year.  support has  to the  hypothesis  an i n d e p e n d e n t i m p a c t  on  The b e t a c o e f f i c i e n t s on BEDS show a  p a t t e r n from y e a r t o y e a r ,  medical/surgical admissions  use.  case  c a s t s d o u b t on a  i n T a b l e 18 do g i v e  inpatient  v e r y much  significant  f o r both s u r g i c a l  w i t h an a v e r a g e  with  surgery  t h e o n l y e x c e p t i o n . But  p a e d i a t r i c bed a v a i l a b i l i t y  hospital  T a b l e 18  Day c a r e  one d a y c a r e s u r g e r y  i n t e r p r e t a t i o n even i n t h a t  that  use.  in  1968-1976  inpatient u t i l i z a t i o n in different  admissions  than a day.  had no  inpatient u t i l i z a t i o n is  c o e f f i c i e n t on DCS  implies  inpatient  over the p e r i o d  in  in  inpatient u t i l i z a t i o n  d o e s n o t a p p e a r t o have h a d a n y  effect  and d a y s  surgical  surgery  from which  has  The i n t e r p r e t a t i o n o f  for overall hospital  availability  basis  availability  on o v e r a l l m e d i c a l / s u r g i c a l  1981/82-1982/83.  day c a r e  utilization  a reasonable  t h e p a e d i a t r i c p o p u l a t i o n i n B.C. and i n  of  The c o e f f i c i e n t on DCS  for total medical/surgical  conclude that  effect  possible  the a d d i t i o n of admissions  e a c h bed  by about  accounted f o r about  and may be i n t e r p r e t e d  1-2.  increased  25-30, These  of which  additional  surgical  161 admissions  involved  l e n g t h s o f s t a y f a l l i n g from about  days o v e r time, w i t h t h e s u r g i c a l longer  In  Table  19, r e g r e s s i o n c o e f f i c i e n t s  f o rpaediatric  a n d 19 shows t h a t  affected  bed a v a i l a b i l i t y .  by t h e adjustment  markedly the a s s o c i a t i o n  bed  adjustment.  the  first  the  same i n s p i t e  19).  Also  inpatient  f o r the e f f e c t  the  Tables  b u t i n 1976  o f BEDS r e d u c e d  between DCS a n d t h e d i f f e r e n t The n a r r o w e s t  (SURG C) showed t h e l e a s t  However, t h a t  association  p l a c e . The c o e f f i c i e n t s  surgical c h a n g e due t o  was v e r y weak i n  on BEDS v a r i a b l e  of t h e adjustment  f o r DCS  (Tables  were  almost  17 a n d  i n 1976 a n d 1981/82 t h e v a r i a n c e o f d i f f e r e n t u t i l i z a t i o n m e a s u r e s a c c o u n t e d f o r b y t h e DCS/BEDS  m o d e l was a l m o s t t h e same a s b y t h e s o l e surgery a v a i l a b i l i t y goodness  Comparing  f o r bed a v a i l a b i l i t y ,  u t i l i z a t i o n measures.  u t i l i z a t i o n measure  incorporating  i n 1971 t h e DCS e f f e c t was n o t much  1981/82 t h e s t a n d a r d i z a t i o n  surgical  on DCS f o r d i f f e r e n t  u t i l i z a t i o n measures a r e r e p o r t e d ,  adjustment  and  l e n g t h s o f s t a y b e i n g much  (25 down t o u n d e r 6 d a y s i n 1 9 8 2 / 8 3 ) .  surgical  15  10 t o 5  BEDS m o d e l . Day c a r e  seems t o c o n t r i b u t e t o t h e o v e r a l l  o f f i t o f t h e r e g r e s s i o n e q u a t i o n o n l y w i t h SURG B  d a y s i n 1981/82. I n 1971, t h e g o o d n e s s o f f i t o f t h e o v e r a l l e q u a t i o n s w i t h SURG A a n d SURG B m e a s u r e s days) i s improved by t h e i n c l u s i o n  The  results  substitution  i n 1971 i n T a b l e effect  ( a d m i s s i o n s and  o f t h e DCS  19 r a i s e  variable.  the p o s s i b i l i t y  of a  of day care surgery w i t h i n t h e narrower  Table 19  School District Inpatient Hospital Utilization Equations with DCS and BEDS in 1971. 1976, 1981/82, Pooled 1968-1976 and Pooled 1968-1982/83 Dataset  Admissions Year & Measure  DCS  1971 MED/SURG SURG SURG-TSA SURG A SURG B SURG C  0.45 -0.25 -0.03 -0.31 -0.28 -0.05  1976 MEO/SURG SURG SURG-T&A SURG A SURG B SURG C  0.11 -0.01  1981/82 MED/SURG SURG SURG-T&A  -0.29 -0.18 -0.11 -0.13 -0.13 -0.05  SURG A SURG B SURG C  0.02 -0.01 -0.01 0.01  1  1  SE  BEDS  0.55 0.13 0.09 0.12 0.11 0.04  26.14 0.48 1.74 0.15 -0.46 0.06  0.51 0.14 0.09 0.12 0.12 0.04  24.39 1.76 1.13 1.44 0.99 0.29  0.39 0.11 0.08 0.08  19.63 2.21 1.96 1.07 0.65 0.37  0.08 0.04  3  3  3  3  2  2  1  3  3  3  2  1  Days  SE  CONST  R  SE Y  DCS  SE  BEOS  2.34  49.71 50.20 34.77 37.74  0.6233 0.0347  38.98 9.28  3.44 -0.01  4.09 0.82  211.73 18.15  5.97 8.44 8.01 2.89  0.55 -0.80 -0.61 -0.07  0.79 0.39 0.25 0.09  19.59 5.19 -0.36 0.38  2  SE  3  0.56 0.36 0.51 0.48 0.17  35.32 8.64  0.2302 0.0613 0.0582 -0.0036  2.01 0.55 0.35 0.46 0.45 0.16  38.76 31.22 22.48 18.69 17.45 6.07  0.6833 0.1137 0.1084 0.1113 0.0441 0.0194  29.47 8.07 5.16 6.68 6.63 2.28  2.24 -0.98 -0.69 -0.06 -0.23 0.00  3.46 0.73 0.72 0.37 0.25 0.09  184.99  1.66 0.45 0.33 0.34 0.33 0.16  51.16 29.28 21.31 15.57 15.32 4.94  0.6769 0.2983 0.3614 0.1637  23.73 6.50 4.78 4.88 4.78  2.92 0.09 0.36 -0.22 -0.36  1.87 0.64  98.74 12.81 12.39  2.24  -0.12  0.0813 0.0955  1  1  1  0.62 0.20 0.15 0.07  3  3  2  3  11.86 10.30 7.51 2.43 0.89  3  3  3  1  2  3  3  3  5.24 1.17 0.69  3  1  17.32 3.47 3.34  CONST  R  2  SE Y  131.31 180.25 128.09 97.69 74.02  0.6661  288.04  0.2572 0.3043 0.1540 0.0544 18.03 -0.0040  57.72 55.62 27.38 17.30 6.32  6.71 154.07 132.55 43.15 38.94 12.40  0.7290 0.2388 0.1798 0.2734 0.0888 0.0746  198.68 41.78 41.47 21.46 14.50 4.89  2.62 0.83 0.64  119.92 104.24 85.12 28.59 32.58  112.63 38.48 37.48 11.92 9.11  0.31  10.48  0.6829 0.2305 0.2207 0.3929 0.1229 0.1049  1.65 1.04 0.38 13.57 2.86 2.83 1.47 0.99 0.33 7.86 2.68  4.38  Table 19  .Continued  School District Inpatient Hospital Utilization Equations with OCS and BEDS in 1971. 1976. 1981/82. Pooled 1968-1976 and Pooled 1968-1982/83 Dataset  Admissions  Days  Year & DCS  Measure  Pooled  MED/SURG  1968-76 SURG SURG-T&A SURG A SURG B SURG C Pooled  MED/SURG  1968-83 SURG SURG-T&A SURG A SURG B SURG C  1  2  3  p < 0.05 p < 0.01 p < 0.001  -0.26 -0.38 -0.08 -0.40  3  -0.33 0.01 -0.77 -0.61  2  3  3  3  3  -0.18 -0.64 -0.53 -0.06  3  3  3  3  SE  BEDS  0.22 0.06 0.03 0.06 0.05 0.01  25.44  0.17 0.05 0.03 0.05 0.04 0.01  25.02 1.23 1.48 0.82 0.27 0.21  3  0.80 1.27 0.52  2  3  1  -0.03 0.11 3  3  3  3  3  SE  CONST  R  SE Y  DCS  0.91 0.Z8 0.15 0.24  59.32  0.5417  32.08 7.23  10.95 10.10 2.74  -1.53 -0.87 -0.02  3  0.22 0.06  0.0648 0.1133 0.0805 0.0544 0.0025  -4.69 -2.07 -1.14  2  48.67 26.57 35.31  42.02 12.65 6.72  0.81 0.25 0.13 0.23 0.21 0.06  62.16 47.71  40.73 12.68 6.69 11.29 10.24 2.83  -8.39 -3.16 -1.99 -2.31 -1.33 -0.18  26.21 34.69 31.45 7.19  2  0.5620 0.1775 0.1925 0.2056 0.1632 0.0534  3  3  3  3  3  3  3  3  3  SE  BEDS  1.57 0.37  208.54 16.94  0.32 0.20 0.11 0.03  16.96 6.80 0.55 0.47  1.32 0.31 0.27 0.17 0.10 0.03  195.13 17.38 17.13 7.13 1.08 0.66  SE  CONST  R  3  6.67  3  1.55 1.34  209.31 203.92 155.09 96.00 69.09 16.03  0.6033 0.2003 0.2159 0.1659 0.0825 0.0166  306.77 71.18 61.73  253.83 202.98 155.17 95.60 68.11 16.03  0.5856 0.2730 0.2652 0.2724 0.2051  308.54 72.10 62.08 40.75 22.67 6.47  3  3  3  3  3  3  3  1  3  0.86 0.48 0.14 6.17 1.44 1.24 0.82 0.45 0.13  2  0.0913  SE Y  39.71 22.27 6.27  164 paediatric  surgical  indication that The r e s u l t s year  of  1971 i s  t h e SURG e q u a t i o n s  Table  on  association  T a b l e 19 i m p l i e s  that this  "non-T&A"  surgical  association  utilization in  1971 surgical  is  mainly  1971.  In  substituted  coinciding  It  seems t h a t  f o r i n p a t i e n t T&As i n  i n c r e a s e i n day c a r e s u r g e r y r a t e i n t h i s  The y e a r 1971 c a n a l s o r e f l e c t a  progressivity'  effect;  'progressive'  Although  study years,  it  a d m i s s i o n s was p o s i t i v e  data  19).  overall  to and  took  substitution  of  for  doing  shifts  in  the eleven  highly  cross-area/cross-year  On t h e o t h e r h a n d , d a y c a r e  surgery  added v e r y l i t t l e t o t h e goodness of  e q u a t i o n . The p o o l e d e q u a t i o n  overall  i n nine of  was n e g a t i v e and s t a t i s t i c a l l y  i n t h e p o o l e d 1968-1982/83  availability  year  were  a result  c o e f f i c i e n t on DCS  significant (Table  1971  technology.  the regression  medical/surgical  either  'medical  physicians  T&As and more d a y c a r e s u r g e r y as  m e d i c a l k n o w l e d g e and  in  t h e d e c l i n e i n T&A r a t e  c o n c u r r e n t l y b u t i n d e p e n d e n t l y , and no r e a l  occurred.  no  addition,  9 r e v e a l e d a g r e a t e r d r o p i n t h e i n p a t i e n t T&A r a t e  a m a j o r e x t e n t o r , more p l a u s i b l y ,  that  The y e a r  the  " e f f e c t " on T&A u t i l i z a t i o n . DCS had a l m o s t  d a y c a r e s u r g e r y has  less  results.  between DCS a n d o v e r a l l  1970-1971 t h a n i n t h e s u r r o u n d i n g y e a r s .  place  some  i n T a b l e 18 s u g g e s t t h a t  d i f f e r e n t from the o t h e r y e a r s .  due t o t h e DCS effect  However, t h e r e i s  s o m e t h i n g e l s e may l i e b e h i n d t h e s e  showed a n e g a t i v e admissions.  categories.  fit  (1968-1982/83)  100 c h i l d r e n a d m i t t e d t o a d a y c a r e s u r g e r y  unit  of  the  implies would  165 have  saved  s t a y of far  i n p a t i e n t admissions.  77  "saved"  inpatients  The a v e r a g e  w o u l d have b e e n 10.9  t o o h i g h t o be c o n s i d e r e d p l a u s i b l e .  difference  that  is  also  which  decreasing  and o b v i o u s l y  surgical  (T&A)  availability.  least  day  availability  was  causally  If  i n p a t i e n t u t i l i z a t i o n , one w o u l d e x p e c t t o regression this  points  day c a r e  r e l a t e d to o v e r a l l  see  negative  to the n e c e s s i t y to c o n t r o l f o r e f f e c t s  the pooled  The a s s o c i a t i o n stronger  of  DCS w i t h o v e r a l l  surgical  utilization  b e t w e e n p o o l e d d a t a and i n d i v i d u a l y e a r d a t a was  imply that surgical (Table  100  3.  The c o e f f i c i e n t s  day care surgery  admissions with average 19).  factors  dataset.  f o r t h e above m e n t i o n e d r e a s o n .  i n Figure  All  of  i n the pooled data than i n the i n d i v i d u a l  obviously  illustrated  surgery  c o e f f i c i e n t s also i n i n d i v i d u a l year equations.  when a n a l y z i n g  data,  the  paediatric  m e a s u r e d and unmeasured t i m e - d e p e n d e n t c o n f o u n d i n g  also  care  hospital  u t i l i z a t i o n may have f a l l e n o v e r t i m e i r r e s p e c t i v e o f capacity.  by  of  u t i l i z a t i o n and i n c r e a s i n g  i n c r e a s e i n day c a r e s u r g e r y  and  of  partly,  independent trends  The o v e r a l l p a e d i a t r i c  is  striking  seen w i t h o t h e r measures  u t i l i z a t i o n c a n be e x p l a i n e d , a t  the simultaneous  surgery  days,  of  i n t h e c o e f f i c i e n t between i n d i v i d u a l y e a r d a t a  the pooled data inpatient  The  length  year  The d i f f e r e n c e already  from the pooled  c a s e s would have saved length of  was  stay of  5.2  data  61 days  166 The b e t a  coefficient  significance  also  on DCS  showed i n c r e a s e i n v a l u e and  f o r o t h e r measures o f s u r g i c a l  inpatient  u t i l i z a t i o n when m o v i n g f r o m i n d i v i d u a l y e a r d a t a t o p o o l e d data  (Table 19).  equations.  The r e g r e s s i o n c o e f f i c i e n t s  SURG C a d m i s s i o n s admissions. expect  The i n c r e a s e i n v a l u e was  were c l e a r l y  to find  stronger negative  SURG-T&A o r SURG C b o t h  missing variables  f o r other  study years.  i n both  on DCS f o r  there are s t i l l  potential  sets of the data a n a l y s i s .  1976 a n d 1981/82) pooled  The  data  However,  only i n s i x of the eleven  I n 1969-1971 t h e d i f f e r e n c e was  (equations are presented  than  d a t a and i n t h e  clear,  1981/82 - 1982/83 t h e c o e f f i c i e n t s were o n l y  stronger  surgical  t h a t i n c l u d e T&As  i n the pooled  s t r o n g e r c o e f f i c i e n t s were f o u n d  i n 1976  slightly  only f o r the years  ( T a b l e 19). Thus, t h e c o e f f i c i e n t s  1971, i n the  s h o u l d be i n t e r p r e t e d w i t h c a u t i o n .  s t r e n g t h o f t h e a s s o c i a t i o n between p a e d i a t r i c b e d  availability both  than  f o r SURG-T&A and  coefficients  utilization  i n d i v i d u a l year data, although  and  on DCS  SURG C  I f DCS was c a u s i n g t h e d e c l i n e i n T&As one w o u l d  t h o s e measures o f s u r g i c a l for  lower  lowest with  a n d i n p a t i e n t u t i l i z a t i o n was  i n t h e same r a n g e  i n t h e i n d i v i d u a l y e a r d a t a and i n t h e p o o l e d d a t a  19). A l s o , t h e r e g r e s s i o n c o e f f i c i e n t s medical/surgical utilization the pooled (Tables  (Table  on BEDS f o r t h e o v e r a l l  e q u a t i o n s were a l m o s t  d a t a s e t b e f o r e and a f t e r t h e a d j u s t m e n t  17 a n d 1 9 ) . However, t h e a d j u s t m e n t  f o r DCS  t h e same i n f o r DCS decreased  167 slightly  the strength  d i f f e r e n t measures  Table  of  19 p r e s e n t s  of  the a s s o c i a t i o n  surgical  also  year data.  This  utilization in this  the r e s u l t s  the shorter pooled dataset,  al.  f  1983).  t i m e r a n g e was  regression  in results  surgery  much t h a t  results  to the  r e v e a l e d t h e same s o r t s  from the s i n g l e  (Evans  On t h e b a s i s  of  results  to  s±  of  year equations,  a steeper  l i n e than with the dataset  on  previous  but  1982/83  had i n c r e a s e d and T&A u t i l i z a t i o n d e c r e a s e d  one w o u l d e x p e c t t o g e t  regression  analyses  studied separately in order  d i f f e r e n c e s were n o t s o p r o m i n e n t . By t h e end o f care  dataset.  cross-area/cross-  c a r r i e d o u t on t h e t o t a l p o p u l a t i o n  This dataset  differences  of  t h e 1968-1976  be a b l e t o compare t h e r e g r e s s i o n s t u d y t h a t was  between BEDS and  the  day so  downward  t h a t ends  in  1976.  i n each i n d i v i d u a l y e a r i n T a b l e 19,  one c o u l d c o n c l u d e t h a t d a y c a r e s u r g e r y a v a i l a b i l i t y has  not  h a d a n y e f f e c t on t o t a l p a e d i a t r i c i n p a t i e n t u t i l i z a t i o n and very  little  surgical data  any,  i n p a t i e n t use.  on more n a r r o w l y d e f i n e d  But t h e e q u a t i o n s w i t h t h e  pooled  s u g g e s t some e f f e c t .  4.5  It  effect, if  N o n - l i n e a r bed e f f e c t  has  b e e n s u g g e s t e d t h a t t h e r e l a t i o n s h i p between  hospital  utilization  and b e d a v a i l a b i l i t y may n o t be l i n e a r  but  curvilinear  (Evans e t a l .  when b e d  f  1983).  In  o t h e r words,  168 availability  is  low,  one a d d i t i o n a l bed l e a d s  i n c r e a s e i n u t i l i z a t i o n t h a n one a d d i t i o n a l where beds and a t stand  In of  a r e numerous.  h i g h enough c a p a c i t y  levels  greater  bed i n a  situation  s a t u r a t i o n might set  f u r t h e r beds w o u l d  this  bed a v a i l a b i l i t y ,  inpatient BEDSQ)  regression  i n the pooled data  through  the data zero,  hypothesis,  and t o r e f i n e t h e  equations  u t i l i z a t i o n were e s t i m a t e d u s i n g  bed a v a i l a b i l i t y  just  forces  If  20).  a quadratic  the s c a t t e r  set.  (Table  of  BEDS and B E D S  utilization/beds  t h e s q u a r e d t e r m has  combinations  in  a c o e f f i c i e n t equal  to  and  b e s t d e s c r i b e d by a s t r a i g h t  But  has  c o e f f i c i e n t , as  relationship  a negative is  i n Table  line.  2 0 , then  b e s t d e s c r i b e d by a concave c u r v e d l i n e .  coefficient  on B E D S  significant  in a l l  2  was  six  negative  equations.  and s t a t i s t i c a l l y However,  the  The improvement i n R  w i t h o n l y BEDS was  greater  than f o r m e d i c a l / s u r g i c a l relatively t e r m was  utilization.  r e l a t i v e to  spite  measures the  l o w i n f l u e n c e on t h e e x p l a i n e d v a r i a n c e ,  the  suggesting that of  linearity.  not  equations  of  t o an a s s u m p t i o n  In  The  contribution  for different surgical  always s i g n i f i c a n t ,  superior  2  the  highly  t o t h e p r o p o r t i o n o f v a r i a n c e e x p l a i n e d b y t h e m o d e l was very dramatic.  of  f u n c t i o n r a t h e r than a  t h e n t h e r e l a t i o n s h i p between bed a v a i l a b i l i t y  it  of  (or  2  The s q u a r e d m e a s u r e  utilization is  if  measure  f o r each measure  inpatient  is  in,  empty.  order to test  line  Eventually  to a  BEDS  a curvilinear  2  fit  169  Table 20  School District Inpatient Hospital Utilization Equations with BEDS and BEDSQ in Pooled 1968-82/83 Dataset  Measure  BEDS  SE  BEDSQ  25.74 39.65  0.81 2.66  -1.41  1.79 6.27  0.27 0.88  0.45  0.13 0.44  -0.21  0.24 0.81  -0.33  0.22 0.73  -0.28  0.06 0.19  -0.07  6.19 20.65  -6.78  1.50 4.95  -2.58  18.97 37.99  1.26 4.16  -1.92  9.27 21.60  0.88 2.92  -1.25  2.31 8.51  0.49 1.64  -0.63  0.13 0.43  -0.12  SE  CONST  R  SE Y  0.26  50.20 23.70  0.5521 0.5673  41.19 40.49  0.09  38.21 1.89  0.0509 0.0814  13.62 13.40  0.04  23.41 19.46  0.1544 0.1774  6.85 6.75  0.08  24.80 18.50  0.0378 0.0577  12.42 12.29  0.07  23.19 17.87  0.0135 0.0315  11.12 11.02  0.02  6.26 4.95  0.0257 0.0417  2.87 2.84  1.99  123.94 -3.89  0.5658 0.5713  315.84 313.82  0.48  154.07 105.47  0.1813 0.2083  76.51 75.24  0.40  124.33 99.09  0.2159 0.2362  64.13 63.29  0.28  59.81 36.32  0.1180 0.1374  44.87 44.37  0.16  47.53 35.73  0.0249 0.0420  25.11 24.89  0.04  13.23 10.99  0.0453 0.0535  6.63 6.60  2  Admissions: MED/SURG  3  3  SURG  SURG-T&A  SURG A  SURG B  SURG C  3  1.65 3.73  3  3  3  1.41 4.72  3  0.76 3.56  3  3  3  0.27 0.95  3  3  3  3  3  3  3  3  Days: MED/SURG  202.90 269.99  3  3  SURG  20.31 45.81  3  3  SURG-T&A  3  3  SURG A  3  3  SURG B  SURG C  3  3  0.82 2.00  3  3  1  p < 0.05  2  p < 0.01 p < 0.001  3  3  3  3  3  3  2  170 A c c o r d i n g t o t h e l i n e a r m o d e l i n T a b l e 20 one a d d i t i o n a l would  increase total medical/surgical  cases of  and h o s p i t a l  existing  d a y s b y 202.90  bed c a p a c i t y .  one a d d i t i o n a l c a p a c i t y of  p e r 1,000  (39.65  p o p u l a t i o n b y 242.87 marginal of  7.1  1,000 only  But  population 28.37  length  percent.  Thus,  population  of  of  beds w i l l  zero,  level  2(1.41)BEDS) -  per  of  bed would  1,000  and d a y s p e r  2(6.78)BEDS)  implying  66.5 p e r c e n t and a l e n g t h capacity  one a d d i t i o n a l  level  7.6  of  1,000  a of  stay  4 beds  bed w o u l d l e a d implying  but i t  d a y s and o c c u p a n c y r a t e o f  bed c a p a c i t y .  remains  in  The l e v e l  f o r c e up t o v e r y of  and s o l v i n g  f o r beds,  of  to  59.1 as  high  c a p a c i t y a t w h i c h more  i n d u c e no f u r t h e r a d m i s s i o n s the d e r i v a t i v e s  per  a  t h e Roemer e f f e c t w o u l d a p p e a r t o weaken  found by s e t t i n g to  (BEDS = 2)  and 215.75 p a t i e n t d a y s ,  stay  25.74 the  existing  admissions  the e x i s t i n g  (BEDS = 4)  c a p a c i t y expands, levels  at  admissions  marginal  -  (269.99  occupancy r a t e of  days.  i r r e s p e c t i v e l y of  population at  increase t o t a l medical/surgical p o p u l a t i o n b y 34.01  by  A c c o r d i n g t o t h e c u r v i l i n e a r model  bed p e r 1,000  2 beds  admissions  bed  or patient  d a y s c a n be  the c u r v i l i n e a r  equations  thus:  39.65 - 2 ( 1 . 4 1 ) BEDS = 0 269.99 - 2 ( 6 . 7 8 ) BEDS = 0  t o y i e l d BEDS = 14.06 respectively. less  and 19.91  These s a t u r a t i o n  theoretical since  (per  1,000  levels  are,  population) of  c o u r s e , more  t h e y a r e beyond t h e range  of  or  171 observations. data  was  The also  of  When bed  stay increases,  hypothesized of  stay,  cases are  that  physicians  and  as  although not  one  t r y i n g to hold  b e e n low  i n a l l school  b o t h by  rates  implies  t h a t new  stay.  a basis  other  and  p a e d i a t r i c i n p a t i e n t use  in  Table  19  measures of  lengths  shortening  on  showed t h a t t h e  But have  province explanations.  a Roemer also low  effect: by  occupancy  (Table  DCS  the 21).  in this  impact of  inpatient utilization  d i d not  influence  r e l a t i o n s h i p of Comparison  table to DCS  on  had  needs.  to study the  c a p a c i t y m e a s u r e on  of  lengths  constant.  environment of  a n a l y s i s was  with  hand,  alternative  than medical  If  severe  demand f o r h o s p i t a l s e r v i c e s  improved bed  coefficients  other  throughout the  I n an  the  regression  less  i n c r e a s i n g admissions but  of  next phase i n the  the  association reflects  lengths  b e e n g e n e r a t e d on  correlated  scarce,  admission rates  suggesting  increasing this  On  marginal  dramatically.  s c a r c i t y by  districts  study period,  filled  very  stay i s  o c c u p a n c y r a t e s h a v e known t o  i s possible that this  The  these  of  the  might a n t i c i p a t e t h a t  capacity rises.  p a e d i a t r i c bed  beds a r e  in  length  capacity increases,  t h a t when b e d s a r e  hospital  the  c a p a c i t y and  m i g h t r e s p o n d t o bed  stay while  during  ratio  s e v e r i t y o f i l l n e s s was  r a t i o n e d out,  s t a y would f a l l  It  bed-to-population  13/1,000.  interesting.  length  of  highest  r e l a t i o n s h i p between bed  length one  The  DCS  of  coefficients  different  change a f t e r  of  Table 21  School District Inpatient Hospital Utilization Equations with DCS, BEDS and BEDSQ in 1971. 1976. 1981/82. Pooled 1968-1976 and Pooled 1968-1982/83 Dataset  Admissions Year & Measure  1971 MED/SURG SURG SURG-T&A SURG A SURG B SURG C 1976 MED/SURG SURG SURG-T&A SURG A SURG B SURG C 1981/82 MED/SURG SURG SURG-T&A SURG A SURG B SURG C Pooled 1968-76  Pooled 1968-83  SE  BEDS  0.42 -0.25 -0.04 -0.31  0.55 0.13 0.09  -0.28 -0.05  1  1  36.90 2.09 3.04 -0.11  7.87 1.89 1.21 1.73  0.67 0.16 0.10 0.15  -0.60 0.04  1.64 0.59  -0.96 -0.14 -0.12 0.02 0.01 0.00  3  1  0.15 0.15 0.05  11.69 3.98  0.1384 0.0795 0.0615  1  0.54 0.15 0.11 0.12 0.11 0.05  20.75 25.77 19.00 12.76 11.75 3.70  0.7015 0.2997 0.3605 0.1672 0.0966 0.0980  22.80 6.50 4.78 4.87 4.74 2.24  3  0.29 0.09  0.5534  41.48  0.0752 0.1220 0.0837  0.02  33.82 43.42 23.93 32.45 29.99 6.67  0.0559 0.0041  12.58 6.69 10.93 10.09 2.73  0.26 0.08 0.04 0.07 0.07 0.02  36.30 40.75 22.60 30.26 27.69 6.00  0.5744 0.1946 0.2088 0.2137 0.1704 0.0645  40.15 12.55 6.62 11.23 10.20 2.81  4.08 3.80 1.31  1.53  1  1.52 0.52  -0.27 -0.29 -0.10  0.03 -0.15 -0.08 -0.10 -0.09  0.40 0.11 0.08 0.09 0.08 0.04  33.40 3.80 3.01 2.34 2.27 0.93  5.46 1.56 1.15 1.17 1.14 0.54  -1.43 -0.16 -0.11 -0.13 -0.17 -0.06  0.21 0.06 0.03 0.06  38.18 3.43  3.09 0.94 0.50  -1.26 -0.26 -0.13 -0.14  -0.04  MED/SURG SURG SURG-T&A SURG A SURG B SURG C  -0.67 -0.58 -0.17 -0.62 -0.52 -0.06  3  1  3  3  3  3  3  3  3  3  3  1  1  1  1  3  3  2.59 1.95 1.01  3  1  0.05 0.01  0.39  0.17 0.05 0.03 0.05 0.04 0.01  37.82 4.67 3.27 3.01 2.13 0.80  3  3  3  3  2  3  0.82 0.75  SE Y  29.58 7.88 5.02 6.58  0.12 0.11 0.04  1  2  29.42 23.49 17.23 13.28  0.14 0.05  2  2  R  38.70  -0.47 -0.38 -0.26  1  2  CONST  27.07 0.6287 46.83 0.0319 22.03 0.2331 38.29 0.0484 35.61 0.0450 8.68 -0.0177  6.90 1.84 1.17  -0.33 0.01  p < 0.05  SE  28.97 5.55 3.70  SURG B SURG C  p < 0.01 p < 0.001  BEDSQ  0.52 0.14 0.09  -0.24 -0.38 -0.08 -0.40  1  0.12 0.12 0.04  SE  0.14 0.02 0.04 0.01 0.01 0.02  MED/SURG SURG SURG-T&A SURG A  2  3  DCS  1  1  1  2  2  0.20  -0.10 -0.03  2.68 0.84 0.44 0.75 0.68 0.19  -1.28 -0.35 -0.18 -0.22 -0.19 -0.06  3  3  3  2  2  2  0.67 0.18 0.11  0.05 0.08 0.07  0.6810 0.1565 0.1584  9.29 5.96 8.50 8.06 2.91  6.51 2.23  .Continued  Table 21  School District Inpatient Hospital Utilization Equations with DCS. BEDS and BEDSQ in 1971, 1976. 1981/82. Pooled 1968-1976 and Pooled 1968-1982/83 Dataset  Days Year & Measure  DCS  SE  BEDS  1971 MED/SURG  3.04  SURG SURG-T&A  -0.09 0.48  3.88 0.77 0.74  386.22 52.96 52.15  SURG A SURG B  -0.80 -0.62  SURG C  3  3  3  0.39 0.25  7.31 0.30  -0.06  0.09  -0.51  1976 MED/SURG  1.63  SURG SURG-T&A SURG A SURG B SURG C  -0.78 -0.52 -0.03 -0.20 0.01  3.40 0.69 0.69 0.38 0.25 0.09  97.77 40.32 35.61  1981/82 MED/SURG SURG SURG-T&A SURG A SURG B SURG C  4.28 0.14 0.38 -0.32 -0.33 -0.11  1.90 0.67 0.66 0.21  157.35 15.20 13.46 3.10 2.65 1.38  Pooled 1968-76  1  1  1  1  MED/SURG SURG SURG-T&A SURG A SURG B SURG C  -4.56 -2.03 -l.ll -1.51 -0.86 -0.02  Pooled MED/SURG 1968-83 SURG SURG-T&A SURG A SURG B SURG C  -7.95 -2.99 -1.86 -2.24 -1.30 -0.17  1  2  3  p < 0.05 p < 0.01 p < 0.001  2  3  3  3  3  0.16 0.08 1.56 0.36 0.31 0.20 0.11 0.03  3  3  3  3  3  3  1.33 0.31 0.27 0.18 0.10 0.03  SE  BEDSQ  54.88 11.01 10.65 5.60  -15.53 -3.10 -2.90  3.54 1.29  SE  -0.19 -0.06  4.67 0.94 0.91 0.48 0.30  0.08  2  2  2  184.82 95.94 80.87 34.98 29.45 10.84  0.7400 0.3282 0.2549 0.2703 0.1024 0.0680  194.61 39.25 39.53 21.51 14.39 4.91  1  2.59 0.92 0.90 0.28 0.22 0.10  -9.57 98.97 82.76 33.33 29.33 8.97  0.7015 0.2205 0.2099 0.3896 0.1167 0.0981  109.28 38.73 37.74 11.96 9.14 4.40  2  2.14 0.49 0.43 0.28 0.16 0.04  79.81 163.54 123.22 80.25 64.22 15.65  0.6079 0.2180 0.2300 0.1742 0.0844 0.0154  304.97 70.39 61.17 39.51 22.24 6.27  1.97 0.46 0.39 0.26 0.14 0.04  146.73 162.16 123.36 78.84 60.31 14.27  0.5888 0.2892 0.2785 0.2806 0.2111 0.0951  307.37 71.29 61.52 40.52 22.58 6.45  273.31 37.14 32.90 14.68 2.99 0.66  22.73 5.25 4.56 2.94 1.66 0.47  -6.38 -1.99 -1.57 -0.78 -0.24 -0.02  248.13 37.59 32.87 15.43 4.94  20.55 4.77 4.11 2.71 1.51 0.43  -5.31 -2.03 -1.58 -0.83 -0.39 -0.09  3  3  3  3  3  3  3  2  1.52  3  52.36 27.54  4.41 0.89 0.90 0.49 0.33 0.11  -6.06 -0.25 -0.11 0.22 -0.15 -0.07  3  269.78 54.10  17.42 6.34  26.17 9.27 9.04 2.86 2.19 1.05  1  0.7071 0.3474 0.3834 0.1440 0.0415  SE Y  -0.0107  3  11.51 7.08 1.66  1  2  0.11  -S.86 -2.89 -2.57 -0.41 -0.47 -0.08  3  -235.88 107.00 59.58  R  93.22 72.65 19.91  45.38 9.15 9.22 5.02 3.36 1.14  1  3  CONST  1  2  2  3  3  2  2  3  3  2  2  1  174 inclusion  of BEDS  coefficient equations.  i n t h e model i n 1971.  2  remained  statistically  insignificant  I n 1981/82, t h e a d j u s t m e n t  value of the p o s i t i v e MED/SURG d a y s and  regression  f o r BEDS  coefficient  DCS  The  did  not  for  surgical  overall  surgical  use  variation  According was  expected  n e g a t i v e and  be  equations clearly  In the p o o l e d d a t a use  be  on DCS  of  the  accounted  s l i g h t l y as e x p e c t e d .  for  In  decreased  slightly  significant.  factors  a v a i l a b i l i t y of p a e d i a t r i c  t o be a m a j o r c o n f o u n d i n g between DCS  and  factor  paediatric  years suggested  that  beds  when s t u d y i n g  inpatient this  use.  r e a l l y could  t h e c a s e . However, t h e p r o p o r t i o n o f v a r i a n c e e x p l a i n e d by  t h e m o d e l s u s e d was, at  in  t h e shape o f t h e r e s p o n s e  statistically  t o Roemer's Law  i n individual  coefficient  t h e r e might  measures of i n p a t i e n t  model improved  the r e l a t i o n s h i p Results  that a l t e r  The  and  insignificant  implying that  availability.  Confounding  i n value  1981/82, b u t i m p r o v e d  the regression c o e f f i c i e n t s  but remained  4.6  factors  of d i f f e r e n t  by t h e o v e r a l l general,  and  e q u a t i o n s i n 1976  t o bed  for  goodness o f f i t f o r d i f f e r e n t  c h a n g e much i n 1971  time-dependent  i n c r e a s e d the  2  regression  i n a l l admission equations remained  1981/82.  ina l l  significant.  f o r SURG B d a y s d e c r e a s e d  became s t a t i s t i c a l l y a i n s i g n i f i c a n t . The  the  on DCS  changed i t t o s t a t i s t i c a l l y  negative c o e f f i c i e n t  on  I n 1976,  i n g e n e r a l , lower than i n s i m i l a r  an a d u l t p o p u l a t i o n (Evans  et a 1.  f  1983),  suggesting  studies that  175 t h e r e m i g h t be o t h e r i m p o r t a n t hospital  use.  variables,  to  thus this  for  The e x p l o r a t i o n o f t h e e f f e c t s  bed a v a i l a b i l i t y ,  p o i n t , was t h e n e x t  of additional  and p a e d i a t r i c  i n p a t i e n t use,  step i n t h i s  paediatric  a day care  that physician a v a i l a b i l i t y snhstituted  inpatient  care  ( f o r a n y g i v e n b e d s t o c k ) and  surgery b a s i s , then  i n inpatient  day care  into  surgery.  the equation,  availability  time has o c c u r r e d  that this  the pooled  data.  effect,  a net negative  i n physician increase i n  conceivable  leads t o both  effect  high  and ( f o r a g i v e n bed s t o c k )  f o r day care s u r g e r y a c t i v i t y .  i f present  i n B.C.,  c o u l d be r e l e v a n t i n a n a l y z i n g  of physician a v a i l a b i l i t y  increased pressure  surgery  inpatient utilization  On t h e o t h e r hand, i t i s q u i t e  level  an i n c r e a s e  disappear  concurrently with  hypothesis  of inpatient a c t i v i t y ,  positive  should  i n strength. Increase  i n paediatric  suggesting  levels  with  t h e a s s o c i a t i o n between d a y c a r e  supply  a high  t o see a  B u t , when p h y s i c i a n c a p a c i t y i s e n t e r e d  o r be r e d u c e d  that  concurrent  and i n p a t i e n t u t i l i z a t i o n  DCS a n d d e c r e a s e  i s p e r f o r m e d on  one w o u l d e x p e c t  utilization  completely over  observed  study.  t h a t when p h y s i c i a n s a r e a b u n d a n t more s u r g e r y  in  surgery  Physician-to-population ratio  one h y p o t h e s i z e d  decline  paediatric  cause systematic b i a s i n t h e r e l a t i o n s h i p ,  4.6.1  If  affecting  w h i c h may h a v e i n f l u e n c e on d a y c a r e  availability, and  factors  and n o t a c c o u n t e d  from day c a r e s u r g e r y  This  dual  f o r , c o u l d mask  t o i n p a t i e n t use.  176 In  o t h e r words,  paediatric 'true'  of  physician  c o u l d cause b i a s if  not  substitution  Further, a large  lead to pressure  influence  stock  on b o t h beds  for,  availability  of  entered into  the r e g r e s s i o n  A  availability  DOCS v a r i a b l e availability  effect,  as  a  was  possible  and p a e d i a t r i c h o s p i t a l  s i n c e t h e m a i n f o c u s was  and d i f f e r e n t s p e c i a l t y measures  elsewhere.  were o n l y i n t r o d u c e d f o r  adjusting  inpatient  day use. not  1973, t h e i n d i v i d u a l y e a r e q u a t i o n s  are  the years  measures  1976 and 1981/82  1973-1976  and  and t h e  f o r the e f f e c t of  pooled  1981/82-1982/83.  22 shows t h e c o e f f i c i e n t s on DCS and BEDS  standardizing  The  the e f f e c t of  on p a e d i a t r i c  in  could  f o r the years  covers  utilization  physician  FTE-adjusted physician a v a i l a b i l i t y  presented only  between  specific  and bed a v a i l a b i l i t y  be c a l c u l a t e d p r i o r t o  analysis  and  the  to the p a e d i a t r i c population equations  use  inappropriate  Thus,  c o n f o u n d i n g e f f e c t s when a n a l y z i n g  surgery  Because  positive  factor.  any s p e c i f i c d e t a i l  possible  been  and i n p a t i e n t  could lead to  f r o m beds a l o n e .  physicians  the  population  study d i d not t r y to e x p l o r e the r e l a t i o n s h i p  physician  Table  and  e f f e c t would have  i n t h e o b s e r v e d bed a v a i l a b i l i t y  causality  care  faster  growth,  f o r more bed a v a i l a b i l i t y .  e x p l i c i t l y adjusted  confounding  supply  and a c t i v e p h y s i c i a n  i n f e r e n c e of  This  physician  i n p a t i e n t use might have f a l l e n  day c a r e s u r g e r y  observed. could  i n the absence of  DOCS v a r i a b l e .  after  Since  DCS/BEDS  Table 22 School District Inpatient Hospital Utilization Equations with DCS. BEDS. BEDSQ and DOCS in 1976. 1981/82 and Pooled 1973-1982/83 Dataset  Admissions Year & Measure  1976  DCS  MEDS/SURG SURG SURG-T&A  0.22 -0.03 0.00  SURG A SURG B SURG C  -0.02 -0.02 0.00  1981/82 MEDS/SURG SURG SURG-T&A SURG A SURG B SURG C Pooled MED/SURG 1973-83 SURG SURG-T&A SURG A SURG B SURG C  1  2  3  p < 0.05 p < 0.01 p < 0.001  0.53 0.14 0.09 0.12  29.75  0.40 0.12 0.09 0.09 0.09 0.04  -0.03  -0.09 -0.24 -0.21  BEDS  0.11 0.04  -0.20 -0.19 -0.12 -0.11 -0.09  -0.17 -0.19 -0.18 -0.18 -0.06  SE  2  3  1  3  3  -0.19 -0.16  3  -0.06 -0.06  2  2  2  0.22 0.22 0.06 0.07 0.04 0.04 0.06 0.06 0.05 0.05 0.02 0.02  3  5.12 3.30 3.88 3.47 1.14  2  2  1  1  1  30.52 3.28 2.60 2.31 2.28 1.05  3  1  1  1  33.94 33.87 6.04 6.04  3  3  3  3  3.82 3.66 4.37  3  3  3  4.56 3.76 3.89  3  3  3  1.30 1.29  3  3  SE  BEDSQ  6.99 1.84 1.14 1.55 1.52 0.51  -0.52 -0.35 -0.23 -0.25 -0.26 -0.09  5.44 1.59 1.16  -1.20 -0.12 -0.08 -0.13 -0.17 -0.07  1.21 1.17 0.55 3.15 3.16 0.91 0.91 0.54 0.53 0.81 0.80 0.75 0.75 0.26 0.26  1  1  1  -1.01 -1.01 -0.40 -0.40 -0.22  2  2  3  3  3  -0.21 -0.29 -0.30 -0.28  3  -0.29 -0.10 -0.10  3  3  3  3  SE  DOCS  SE  CONST  R  0.68 0.18  -0.25 0.14 0.13  0.33 0.09 0.05 0.07 0.07 0.02  37.15  0.6791 0.1747 0.2117 0.1365 0.0963 0.1161  29.67 7.79 4.86 6.59 6.44 2.17  0.18 0.05 0.04  8.42 23.56 17.27 12.63  0.7192 0.3102 0.3725 0.1554 0.0837 0.0956  22.12 6.45 4.74 4.90  0.6386 0.6378 0.2219 0.2202 0.2758 0.2945  33.28 33.31 9.61 9.62 5.67 5.60  0.2018 0.2138 0.1377  8.53 8.47 7.97 7.94  0.11 0.15 0.15 0.05 0.53 0.16 0.11 0.12 0.11 0.05 0.31 0.31 0.09 0.09 0.05 0.05 0.08 0.08 0.07 0.07  0.07 0.11 0.06  1  0.42 0.08 0.06 0.01 0.00  1  0.04 0.04 0.02  -0.02 _  _  0.03  0.12  -  -  0.00  0.03  0.07  3  -0.08  2  0.03  1  0.03  -0.06  0.02  -  3  0.03  -  -  3  0.03  0.00  0.01  19.24 13.26 11.22 8.36 2.27  11.77 4.18 28.04 27.00 26.00 25.96 18.24 15.93 16.32 19.05 14.67 16.60 4.72 4.68  2  0.1443 0.1305 0.1286  SE Y  4.77 2.24  2.77 2.78  .Continued  Table 22  School District Inpatient Hospital Utilization Equations with DCS,  BEDS. BEDSQ and DOCS in 1976, 1981/82 and Pooled 1973-1982/83 Dataset Days Year & Measure  1976  MEDS/SURG SURG SURG-T&A SURG A SURG B SURG C  1981/82  MEDS/SURG SURG SURG-T&A SURG A SURG B SURG C MED/SURG  DCS  SE  BEDS  3.43 -0.51 -0.28 0.09  3.33 0.69 0.70 0.38  -0.23 -0.03  0.26 0.09  6.79 1.36  3.60  1.95 0.66 0.65  148.81 9.31 7.84 2.60 2.55  -0.32 -0.06 -0.36 -0.33 -0.10  1  0.08  SURG-T&A  -2.23 -1.14 -0.85 -0.76 -0.44  SURG A  -0.41 -1.00  SURG B  -0.80 -0.59  3  3  SURG C  -0.52 -0.16  1973-83 SURG  1  1  3  3  3  -0.16 1  2  3  p < 0.05 p < 0.01 p < 0.001  0.22 0.17  3  SE  BEDSQ  114.70  44.05  42.81 37.88 12.65  9.09 9.20  7.68 -3.06 -2.73  5.02 3.41 1.14  -0.49 -0.45 -0.06  26.68 9.07 8.86 2.95 2.26 1.09  -5.40 0.21 0.33 0.26 -0.15 -0.08  0.22 0.11  20.46  2.88 2.57  2.01 1.99 0.52  1  3  3  1  3  1.46  1.41 1.44 0.36 0.37  145.27 150.87 30.85 31.33  0.34 0.35 0.20  25.52 25.64 13.63  0.20 0.11 0.12 0.04  14.69 7.86  0.04  2.53  3  3  3  3  3  3  3  3  3  8.25 2.53  3  3  3  20.31 5.27 5.29 4.86 4.88 2.91 2.87 1.63 1.62 0.58 0.58  3  -1.22 -1.24  2  1  1  SE  DOCS  4.25 0.88 0.88  -5.44 -0.80 -0.73  0.48 0.33 0.11  -0.37 0.09 0.10  2.61 0.89 0.87 0.29  1.26 0.87  -0.80 -0.81  0.52 0.48 0.48  -0.49 -0.55  0.29 0.28  -0.56 -0.58 -0.16 -0.16  1  SE  1  2  0.7602 0.3514 0.2740 0.2846  0.16  26.57 7.87  0.0940 0.0970  -46.15 73.76 58.73 31.19 28.92 9.30  0.7056 0.2925 0.2793 0.3859 0.1045  171.46 252.61  0.6794 0.6863 0.3126 0.3129  0.30 0.30 0.10 0.08  _ 2  0.74  -  -  -0.21  0.19  -  -  -0.05  -  -0.46  0.18  -  0.06  39.11  -  10.74 10.73  0.10  0.16 0.16  -0.17  2  0.06  -  2  0.06  0.00  1.02  3  3  2  111.78 118.73 93.96 95.73 44.07 59.38 33.49  3  186.89 38.57  120.59 103.35 46.24  0.04  _  -2.43  SE Y  2  352.73  0.89  0.83 0.07 0.01 -0.01  R  2.06 0.42 0.43 0.23 0.05  2  CONST  0.0866  0.2968 0.2954 0.2991 0.3268 0.1837 0.1966 0.1608 0.1590  39.02 21.29 14.46 4.83 108.52 36.90 36.05 11.99 9.20 4.43 216.31 213.97 55.73 55.72 51.34 51.39 30.80 30.18 17.23 17.10 6.08 6.09  179 model had n o t been p r e s e n t e d p r e v i o u s l y w i t h t h e p o o l e d 1982/83 d a t a ,  these regression  comparison i n Table  I n c l u s i o n of  1973-  e q u a t i o n s were c a l c u l a t e d  22.  a single  p h y s i c i a n a v a i l a b i l i t y measure  improved t h e goodness of  fit  of  the o v e r a l l  (DOCS)  regression  e q u a t i o n f o r SURG-T&A and SURG-C t y p e s  of  admissions  b u t d i d n o t h a v e a n y e f f e c t on t h e f i t  in  1981/82 and i n  pooled  1973-1982/83 d a t a s e t  coefficients  (Tables  on BEDS and B E D S  2  21 and 2 2 ) .  slightly  a f t e r adjustment  i n p a t i e n t day e q u a t i o n s  of for  suggests  that  This  1976, the  r e m a i n e d p r a c t i c a l l y t h e same equations  physician availability.  in  The  i n d i f f e r e n t i n p a t i e n t admission  effect  for  and c h a n g e d  c o n s i s t e n c y i n bed  Roemer e f f e c t i s  the o v e r a l l physician supply.  only  for  availability  r e l a t i v e l y independent  Also  the e f f e c t of  adjustment  p h y s i c i a n a v a i l a b i l i t y on t h e r e l a t i o n s h i p b e t w e e n d a y  care surgery  a v a i l a b i l i t y and i n p a t i e n t u t i l i z a t i o n was  marginal  in a l l  surgical  admissions  insignificant association  equations.  in  r e m a i n e d low and  1976 and 1 9 8 1 / 8 2 .  DCS on t o t a l  and s t a t i s t i c a l l y  physician availability  In  the pooled dataset  the  utilization  significant.  Thus,  overall  t o t h e p a e d i a t r i c p o p u l a t i o n was n o t  confounding v a r i a b l e i n examining the  between day c a r e s u r g e r y paediatric  and  statistically  between DCS and o v e r a l l s u r g i c a l  remained negative  critical  The i m p a c t o f  only  availability,  inpatient utilization.  relationships  bed s u p p l y  and  a  180 The  next  physician  s t e p was t o i n c l u d e t h e more r e f i n e d m e a s u r e s o f stock i n the regression equations  1973-1982/83 d a t a s e t availability effects  ( T a b l e 2 3 ) . One c a n h y p o t h e s i z e  of different  on p a e d i a t r i c  population  physician specialties  inpatient utilization.  c o u l d l e a d t o more i n p a t i e n t  g i v e n bed stock) t o i n c r e a s e d p r e s s u r e activity, unless  i n the pooled  availability  specialties  important  than  different  A large  f o r day care  i s accounted  surgeon  surgery  effect  from  DCS  f o r . Other p h y s i c i a n  s p e c i a l t i e s may n o t h a v e s i m i l a r e f f e c t s , different  have  s u r g e r y and ( f o r a  obscuring the "true" substitution  surgeon  that  and thus  t h e mix o f  i n a s c h o o l d i s t r i c t c o u l d be more  overall  physician availability  i n confounding  t h e r e l a t i o n s h i p between d a y c a r e s u r g e r y a n d p a e d i a t r i c i n p a t i e n t use.  The  simultaneous  adjustment  f o r GP, PAED, SURGEON, ANA and  OTHER m e a s u r e s o f p h y s i c i a n a v a i l a b i l i t y fit  of a l l inpatient u t i l i z a t i o n  and  p a t i e n t days  also  equations  the overall  f o r both  admissions  ( T a b l e s 22 a n d 2 3 ) . T h i s a d j u s t m e n t  affected  t h e a s s o c i a t i o n s between DCS, BEDS a n d i n p a t i e n t  utilization.  Compared t o t h e c o e f f i c i e n t s  model i n T a b l e  22, t h e c o r r e s p o n d i n g  were g e n e r a l l y s m a l l e r especially coefficient day  improved  coefficients  ( a n d i n many c a s e s ,  less  f o r m e d i c a l / s u r g i c a l admissions. i n the overall  surgical  equation  c a r e s u r g e r y c a s e s would have saved  admissions  on DCS i n DCS/BEDS  w i t h average  i n T a b l e 23  significant),  The r e g r e s s i o n i m p l i e d t h a t 100  15 s u r g i c a l  l e n g t h o f s t a y o f 3.4 d a y s .  inpatient The  Table 23  Admissions  Variables MED/SURG  SURG A  -0.07 0.04  -0.19 0.06  -0.04  -0.15 0.07  BEDS SE  33.69 3.12  BEDSQ SE  -1.07 0.31  GP SE  -0.38 0.20  -0.07 0.06  PAED  -2.84 1.88  -1.58 0.55  -0.16 0.41  0.30 0.12  0.23 3  SE SURGEON SE  3  SE  2.30 1.10  OTHER SE  0.56 0.21  CONST  37.69 0.6527 32.62  ANA  1  2  3  p < 0.05 p < 0.01 p < 0.001  1  2  Days  SURG SURG-T&A  DCS SE  RSQ SE Y  School District Inpatient Hospital Utilization Equations with DCS, BEDS, BEDSQ, GP. PAED, SURGEON, ANA and OTHER Variables in Pooled 1973-1982/83 Dataset  1  6.24 0.91  3.79 0.51  -0.42 0.09  -0.22 0.05  3  3  3  3  2  3  -0.31 0.08  3  -0.10 0.05  -0.04 0.03 2  4.73 0.80  SURG B  -0.77 0.31  1  0.43 0.07  3  -1.47 0.48  2  MED/SURG  SURG C  -0.15 0.05  2  4.06 0.75  3  -0.05 0.02  2  1.40 0.26  3  3  0.03  2.16 1.97  -0.05 0.05  -0.02 0.02  -4.64 1.31  2  3  -0.49 0.16  2  3  0.08 0.10  0.16 0.03  0.13 0.28  0.07 0.27  -0.17  0.32  -0.08 0.18  0.02 0.06  0.07 0.04  -0.08 0.06  26.04 0.2417 9.49  16.18 0.3555 5.35  0.10  151.21 20.10  -0.10  -1.29 0.46  -0.51 0.38  2.67  0.09 0.11  1  -2.31  -O.30 0.07  3  SURG SURG-T&A  3  -26.89 12.13  -0.18 0.35  32.29  SURG B  -0.68  -0.48 0.12  2  0.21  SURG C  3  -0.14 0.04  3  3  2.80 0.56  3  3  26.40 4.79  15.26 2.86  3  8.68 1.62  -1.36 0.51  2  -0.90 0.47  -0.63 0.28  1  -0.62 0.16  -1.00  2  -0.97 0.31  -0.59 0.19  2  -0.14 0.11  -4.71 1.73  2  5.22  0.34 1  SURG A  -6.56 3.15  1  3  2  -4.50 2.89  -3.19 0.98  3  -0.18 0.06  2  -0.05 0.04 2  -1.20 0.34  3  -2.31 2.67  1.72 0.69  2.05 0.64  -0.14 0.38  0.12 0.22  0.38 0.07  3  -1.54  -2.07 1.68  -0.38 1.01  0.06  -0.46  1  0.09  10.37 7.06  0.57  0.20  -0.06 0.05  -0.02 0.02  0.39 1.37  0.36  0.28 0.33  -0.21 0.20  -0.16 0.11  -0.03 0.04  18.84  16.08  0.2265 8.40  0.1531 7.89  4.14 0.1858 2.68  305.85 0.6968 210.35  0.3391 54.64  101.61 0.3303 50.11  60.72 0.3367 29.96  37.60 0.2085 16.97  9.56 0.2279 5.84  1  1.84 0.16  123.79  2  182 adjustment strength  f o r d i f f e r e n t s p e c i a l t y measures  of  association  utilization, equations  increased the  between b e d a v a i l a b i l i t y  and  inpatient  w i t h t h e e x c e p t i o n o f MED/SURG, SURG and  f o r admissions.  some p h y s i c i a n  specialties  It  is  possible  (e.g.,  that  SURG-T&A  availability  paediatricians)  leads  to  more a m b u l a t o r y c a r e and l e s s p a e d i a t r i c i n p a t i e n t c a r e particularly, are  still  day c a r e s u r g e r y - t y p e ) ,  but these  i n a school d i s t r i c t . Adjustment  specialties,  as  i n T a b l e 23, i s  supply e f f e c t .  specialties  radically  of  for  these  expected to r e v e a l higher  A l t h o u g h t h e changes  availability  earlier,  (in  p o s i t i v e l y a s s o c i a t e d w i t h p a e d i a t r i c bed  availability  for  caused by t h e  different physician  a l t e r the a s s o c i a t i o n s  bed  adjustment  specialties  did  not  t h a t had b e e n r e v e a l e d  t h e y support the p l a u s i b i l i t y of  a causal  association  b e t w e e n b e d s u p p l y and p a e d i a t r i c i n p a t i e n t u t i l i z a t i o n . results  of  also  support  the previous  findings  t h a t DCS has  The not  h a d a n y i n d e p e n d e n t i m p a c t on o v e r a l l i n p a t i e n t u t i l i z a t i o n , but a s i g n i f i c a n t  e f f e c t on c e r t a i n c a t e g o r i e s  of  surgical  utilization.  4.6.2  Socioeconomic  These v a r i a b l e s hospital  24).  were i n c l u d e d i n t h e s t u d y as  care need.  paediatric  variables  The e f f e c t o f  variation  these v a r i a b l e s  i n p a t i e n t u t i l i z a t i o n was  Altogether these v a r i a b l e s in medical/surgical  a proxy  analyzed f i r s t  explained half  admission  rates  in  of  for  alone  on  (Table the  1971,  1981  Table 24  School District Inpatient Hospital Utilization Equations with  Socioeconomic Variables in 1971, 1981/82 and Pooled 1968-1982/83 Dataset  Year & Measure  CAN  SE  MTENG  SE  IND  0.13  1.51 0.31 0.23 0.29 0.27 0.09  2.47 0.52 0.25 0.38 0.37 0.02  1.54 0.31 0.23  0.98 0.13 0.17 0.16 0.16 0.08  0.55 -0.39 -0.27 -0.14 -0.16 0.03  1.08 0.23 0.18 0.18 0.17 0.08  3.10 0.46 0.33 0.28 0.20 0.05  0.38 0.11 0.06 0.10 0.09  0.18 0.12 O.U 0.05 0.07 0.04  0.25 0.07 0.04 0.07 0.06 0.02  4.19 0.18 0.28 0.10 0.01 0.06  SE  RURAL  1.11 0.22 0.16  -0.14 -0.12 -0.06 -0.10 -0.09 -0.03  SE  EDUC  SE  ROOMS  SE  0.27 0.05 0.04 0.05  6.02 1.40 0.55 1.15 0.97  4.13 0.84  -48.20 1.98 -0.51 1.29 2.82 0.92  1  18.53 3.75 2.76 3.53  -26.53 -5.98 -4.89 -3.17 -2.75 -1.06  1  Admissions: 1971 MED/SURG SURG SURG-T&A SURG A SURG B SURG C  -0.39 -0.16 -0.17 -0.28 -0.03  1981/82 MED/SURG SURG SURG-T&A SURG A SURG B SURG C  2.04 0.46 0.38 0.20 0.13 0.01  MED/SURG SURG SURG-T&A SURG A SURG B  1.43 0.06 -0.01 0.13 0.07 -0.01  Pooled 1968-83  SURG C  1  1  1  3  0.02  0.29 0.28 0.10  2  2  4.51  3  -0.08 0.23 -0.03 -0.12  0.21 0.20 0.07  0.04 3  2  2  2  1  3  1  3  3  1  0.05 0.02  0.62 0.13 0.10 0.10 0.10 0.05  0.03 -0.01 0.01 -0.02 -0.02 -0.02  0.29 0.08 0.05 0.08 0.07 0.02  -0.07 -0.07 -O.03 -0.07 -0.07 -0.02  0.20 0.04 0.03 0.03 0.03 0.02  2  1  3  3  3  0.08 0.02 0.01 0.02 0.02 0.00  -0.02 2.32 -0.30 -0.34 -0.12 -0.16 -0.05  0.62 0.79 0.74 0.26 1.74 0.38 0.29 0.28 0.28 0.13 _  -  -  -  -  -  -  3.32 1.15  1  2  1.72 1.67 0.81  -53.01 -9.31 -3.76  3  3  3  -9.84 -7.57 -0.80  10.57 2.28 1.79  3  3  2  4.36 1.29 0.69 1.14 1.03 0.27  CO  Continued  Year & Measure  Table 24 School District Inpatient Hospital Utilization Equations with Socioeconomic Variables in 1971. 1981/82 and Pooled 1968-1982/83 Dataset  INC  SE  UNEM  SE  WHITE  1971 MED/SURG SURG SURG-T&A SURG A SURG B SURG C  -0.01 -0.00 -0.00 -0.00 -0.00 -0.00  0.01 0.00 0.00 0.00 0.00 0.00  -4.34 0.19 -0.60 0.28 0.25 -0.36  3.61 0.73 0.54 0.69 0.65 0.22  -1.36 -0.51 -0.08 -0.36 -0.38 0.08  1981/82 MED/SURG SURG SURG-T&A SURG A SURG B SURG C  0.00 0.00 0.00 0.00 0.00 0.00  0.00 0.00 0.00 0.00 0.00 0.00  -2.51 0.16 0.31 0.21 0.24 0.24  2.40 0.52 0.41 0.39 0.38 0.18  0.00 0.00 0.00 0.00 0.00  -4.09 0.13 0.07 -0.12  SE  PRIM  SE  CONST  R  0.15 0.19 0.18 0.06  -0.16 -0.09 -0.17 -0.14 0.00  0.75 0.15 0.11 0.14 0.13 0.05  279.92 56.14 49.13 30.60 30.66 15.54  0.4836 0.0450 0.0012 0.0021 0.0179 0.0423  45.64 9.23 6.80 8.71 8.17 2.82  -0.63 -0.17 -0.14 -0.11 -0.14 -0.09  0.64 0.14 0.11 0.10 0.10 0.05  -0.70 -0.14 -0.20 -0.09 -0.06 -0.07  0.57 0.12 0.10 0.09 0.09 0.04  -23.05 59.42 47.32 26.10 31.90 7.50  0.5034 0.3334 0.3102 0.1968 0.1316 0.0773  29.41 6.34 4.97 4.78 4.65 2.27  0.90 0.27 0.14 0.24 0.21  -0.14 0.19 0.06 0.27 O.20  0.23 0.07  -0.66 -0.05 -0.07  357.44 90.33 47.44  0.5017 0.1534  -0.03 -0.03  0.21 0.06 0.03 0.06 0.05  43.45 12.86 6.91 11.40  0.06  0.06  -0.02  0.01  2  SE Y  Admissions:  Pooled  MED/SURG  1968-83 SURG SURG-T&A SURG A SURG B SURG C 1  2  3  p < 0.05 p < 0.01 p < 0.001  2  0.00 -0.00 -0.00 -0.00 -0.00 -0.00  2  3  3  3  3  3  0.00  0.09 -0.01  3  1  1  2  3  3  3  0.99 0.20  0.04 0.06 0.05 0.01  -1.46  1  2  1  74.92 62.55 11.80  0.1380 0.1895 0.1569 0.1361  10.28 2.70  .Continued  Table 24  School District Inpatient Hospital Utilization Equations with  Socioeconomic Variables in 1971. 1981/82 and Pooled 1968-1982/83 Dataset  Year & Measure  CAN  SE  MTENG  SE  IND  2.08 -0.04 0.31 0.97 -0.39 -0.03  10.63 1.96 1.93 0.94 0.60 0.20  5.29 0.88 0.39 0.13 0.45 -0.03  10.82 1.99 1.96 0.96 0.61 0.21  39.43 1.82 2.34  1981/82 MED/SURG SURG SURG-T&A SURG A SURG B SURG C  4.74 1.54 1.32 1.07 0.38 0.07  5.06 1.27 1.28 0.43 0.30 0.15  4.33 -0.83 -0.49 -0.51 -0.46 -0.03  5.55 1.39 1.40 0.47 0.33 0.17  16.80 2.14 1.87 0.99 0.31 0.07  Pooled MED/SURG 1968-83 SURG SURG-T&A SURG A SURG B SURG C  7.02 0.76 0.65 0.89 0.15 -0.01  2.81 0.64 0.55 0.36 0.20  -5.39 -0.22 -0.17  1.88 0.43 0.37 0.24  34.41 2.75  SE  RURAL  SE  7.75 1.43 1.41 0.69 0.44 0.15  0.68 -0.31 -0.21 -0.19 -0.18 -0.06  1.88  3.19 0.80 0.81 0.27 0.19 0.10  -0.14 0.19 0.20  2.13 0.48 0.41  0.22 -0.17  EDUC  SE  ROOMS  SE  Days: 1971 MED/SURG SURG SURG-T&A SURG A SURG B SURG C  1  1  1  0.05  -0.12 0.11 0.10  2  2  0.13 0.04  3  0.73 -0.02 0.29 3  2  1  3  3  3  2.97 1.02 0.01 0.18  3  3  3  0.27 0.15 0.04  0.02 -0.03 -0.04  -0.13 -0.15 -0.11 -0.04  1  2  3  0.35 0.34 0.17 0.11 0.04  27.17 3.14 1.76 1.44 1.04 -0.28  28.98 5.33 5.26 2.56 1.63 0.56  -428.28 -41.69 -42.97  1.02 0.26 0.26 0.09 0.06 0.03  11.03 0.21 0.25 -0.33 -0.47 -0.24  8.97 2.25 2.27 0.76 0.53 0.27  -104.12 -37.03 -33.80 -10.79 -6.50 -2.01  0.57 0.13 0.11  _  _  -  -  0.07 0.04 0.01  2  -15.02 5.66 2.92  -424.02 -70.09  2  1  1  1  23.92 23.59 11.50 7.31 2.50 54.37 13.66 13.74 4.59 3.20 1.63  3  -53.92 -45.41 -19.71 -2.45  130.00  3  3  3  3  3  32.38 7.36 6.31 4.11 2.33 0.62  CO  . . .Continued  Table 24  School District Inpatient Hospital Utilization Equations with  Socioeconomic Variables in 1971. 1981/82 and Pooled 1968-1982/83 Dataset  Year & Measure  INC  SE  UNEM  0.02 0.01 0.00 0.00  0.10 0.02 0.02 0.01 0.00 0.00  -39.07 -8.47 -10.92 -0.66 1.03 -0.69  0.02 0.01 0.01 0.00 0.00 0.00  -12.94 2.19 2.62 0.29 0.45 0.67  0.01 0.00  -41.37 -4.19 -4.04 -2.98 -0.21 -0.19  SE  WHITE  SE  PRIM  SE  CONST  R  25.35 4.66 4.60 2.24  6.94 1.28 1.26 0.61 0.39 0.13  -7.73 -0.40  1.43 0.49  -4.16 -1.59 -0.57 -0.63 -0.83 0.17  5.28 0.97 0.96 0.47 0.30 0.10  2750.58 490.45 468.24 127.75 72.64 31.81  0.2408 0.0943 -0.0234 0.0473  12.35 3.10 3.12 1.04 0.73 0.37  -3.84 -0.03 0.06 0.12 -0.22 -0.14  3.27 0.82 0.83 0.28 0.19 0.10  -4.37 -0.60 -0.76 -0.16 0.01 -0.09  2.91 0.73 0.74 0.25 0.17 0.09  107.65 196.73 160.29 36.12 70.62 20.44  0.4280 0.2500 0.1892 0.3022 0.1634 0.0371  151.27 37.99 38.24  6.70 1.52 1.30 0.85 0.48  4.62 1.29 0.98 1.07 0.47 0.17  1.70 0.39 0.33 0.22  -2.15 0.15 0.01 -0.06 -0.02 -0.06  1.59 0.36 0.31 0.20 0.11 0.03  3187.74  0.5457 0.2450 0.2453 0.2623 0.1657 0.1607  323.07 73.47  2  SE Y  Days: 1971 MED/SURG SURG SURG-T&A SURG A SURG B SURG C 1981/82 MEO/SURG SURG SURG-T&A SURG A SURG B SURG C Pooled  MED/SURG  1968-83 SURG SURG-T&A SURG A SURG B SURG C 1  2  3  p < 0.05 p < 0.01 p < 0.001  -0.00 -0.01  2  0.02 0.01 0.01 0.00 0.00 0.00 -0.03 -O.Ol -O.Ol -O.Ol -0.00 -0.00  2  2  2  3  3  3  0.00 0.00 0.00 0.00  1  3  2  2  3  0.13  1  2  3  2  3  3  3  0.12 0.03  -0.31 -0.65 -0.17 -0.04  583.87 467.12 294.66 153.80 30.46  0.5873 0.2261  320.22 58.91 58.10 28.33 18.00 6.15  12.78 8.90 4.55  62.91 41.03 23.22 6.22  187 and i n t h e p o o l e d d a t a p r o p o r t i o n of  set.  v a r i a n c e was  For h o s p i t a l 59 p e r c e n t i n  1981 and 56 p e r c e n t i n t h e p o o l e d d a t a . population that average  number o f  determinants higher  of  of  I n d i a n o r Eskimo  1971,  the  explained  43 p e r c e n t  The p e r c e n t a g e e t h n i c i t y and  in  of  the  rooms p e r d w e l l i n g were t h e most p o w e r f u l  p a e d i a t r i c a d m i s s i o n s and h o s p i t a l  the p r o p o r t i o n of  the higher rooms  is  days,  I n d i a n s o r Eskimos i n t h e  the p a e d i a t r i c h o s p i t a l  p e r d w e l l i n g was  negatively  utilization. r e l a t e d to  days.  The  population  The number  of  hospital  utilization.  The p r o p o r t i o n o f v a r i a n c e  in total  surgical  a c c o u n t e d f o r by t h e s o c i o e c o n o m i c v a r i a b l e s percent, five  except f o r admissions i n  percent.  highest  socioeconomic  with  i n T a b l e 24  surgical  raise  characteristics,  as  hospital  capacity.  If  15 -  was  use  30  less  t h e ROOMS v a r i a b l e  than had  the  utilization.  the p o s s i b i l i t y  that  a proxy f o r h o s p i t a l  m i g h t be p r i m a r y d e t e r m i n a n t s  thereby of  was  1971 when i t  the pooled dataset  association  The r e s u l t s  needs,  In  inpatient  of  care  d i f f e r e n c e s i n use  p a e d i a t r i c bed  and  availability  was m a i n l y d e t e r m i n e d b y n e e d s , w h i c h a l s o t h e n d e t e r m i n e d use,  t h e n one may a n t i c i p a t e t h a t  measures effect for  of  inclusion  i n the equation with v a r i a b l e s n e e d w o u l d n o t add a n y t h i n g  the o v e r a l l equation,  significant  regression  that  of  t h e bed  capture  supply  the  t o t h e goodness of  and t h e BED v a r i a b l e w o u l d n o t  coefficient.  fit have  188 Table  25 shows t h a t  availability  adding  to the socioeconomic v a r i a b l e  substantially  improves  the goodness o f  a d m i s s i o n and h o s p i t a l the pooled equations, utilization has  in  day e q u a t i o n s  data  set  is  1 9 8 1 / 8 2 . As p r e v i o u s  i n T a b l e 25,  of  all  of  days i s  socioeconomic v a r i a b l e s  alone  and  SURG B shown,  DCS  these equations;  the  alone.  variance  accounted f o r ,  the  1971 and 1981/82  a n a l y s e s have  fit  67 p e r c e n t o f  In  the  in  compared t o  (Table  pooled  24).  55 p e r c e n t  On t h e  other  c o m p a r i n g T a b l e 25 t o T a b l e 2 0 , t h e n e t c o n t r i b u t i o n  socioeconomic v a r i a b l e s containing  BEDS i s  percentage points, i n Table  (7/43)  medical/surgical capacity,  so much  f r o m 57 p e r c e n t i n T a b l e 20 t o  of  that  left  p e r c e n t f o r beds  and 23.3 p e r c e n t  These r e s u l t s  p a e d i a t r i c bed a v a i l a b i l i t y  i n f l u e n c e on p a e d i a t r i c  exerts  i n p a t i e n t use  characteristics.  support a  in  f o r BEDS. , Bed  u n e x p l a i n e d by s o c i o e c o n o m i c  socioeconomic v a r i a b l e s ) .  socioeconomic  explained  the remaining unexplained variance  f o r p a t i e n t days the net c o n t r i b u t i o n s (26.7  7  64 p e r c e n t  socioeconomic v a r i a b l e s  admissions a f t e r adjustment  of  already  An i m p r o v e m e n t o f  on t h e o t h e r h a n d , e x p l a i n e d 28 p e r c e n t  the variance However,  when a d d e d t o an e q u a t i o n  much s m a l l e r .  25 i n d i c a t e s  16 p e r c e n t  that  in  due t o t h e BEDS v a r i a b l e  medical/surgical  hand,  fit  surgery  equations  the only exception being  no e f f e c t on t h e g o o d n e s s o f  improvement  for  bed c a p a c i t y and d a y c a r e  (14/50)  of  variables. d i d not  differ  for the  hypothesis  significant  independent  of  Table 25  Year & Measure  School District Inpatient Hospital Utilization Equations with DCS. BEDS. BEDSQ and Socioeconomic Variables in 1971. 1981/82 and Pooled 1968-1982/83 Dataset  DCS  SE  BEDS  0.21 -0.25  0.58 0.13 0.09 0.12 0.12 0.04  28.84 3.10 5.25 0.08 -0.35 1.28  0.41 0.13 0.09 0.10 0.10 0.04  24.86 2.22 1.91 1.38 1.49 0.82  0.17  26.89 5.17 3.89 3.28 2.64  SE  BEDSQ  SE  CAN  SE  MTENG  SE  9.89 2.26 1.46 2.13 2.03 0.70  -0.62 -0.11 -0.18 0.07 0.05 -0.06  0.77 0.18 0.11 0.17 0.16 0.05  0.04 -0.35 -0.17 -0.13 -0.24 -0.03  1.29 0.30 0.19 0.28 0.27 0.09  0.97 0.44 0.04 0.39 0.41 -0.02  1.35 0.31 0.20 0.29  5.19 1.62 1.20 1.26 1.24 0.57  -1.04 -0.08 -0.04 -0.08 -0.12 -0.05  1  1.37 0.35 0.26 0.12 0.08 -0.06  0.71 0.22 0.16 0.17 0.17 0.08  0.20 -0.36 -0.25 -0.08 -0.12 0.09  0.78 0.24 0.18 0.19 0.19  2.70 0.87  -0.87  3  0.32 0.10 0.06 0.09  0.36 0.28 0.17  0.22 0.07 0.04  Admissions: 1971 MED/SURG SURG SURG-T&A SURG A SURG B SURG C 1981/82 MED/SURG SURG SURG-T&A SURG A SURG B SURG C Pooled  KED/SURG  1968-83 SURG SURG-T&A SURG A SURG B SURG C  -0.02 -0.33 -0.29 -0.04  1  1  0.45 -0.03 -0.03 -0.07 -0.05 -0.08 -0.35 -0.56 -0.18 -0.58  1  3  3  -0.49 -0.06  3  3  3  0.05 0.03 0.05 0.04 0.01  2  3  3  3  3  3  3  3  1.32  3  0.46 0.76 0.70 0.19  0.49 0.15 0.11 0.12 0.12 0.05  -0.35 -0.21 -0.22 -0.19 -0.09  3  3  2  2  3  0.25 0.08 0.04 0.07 0.06 0.02  0.87 -0.03 -0.08 0.06 0.02  2  -0.03  0.08 0.02  0.21 0.21 0.06  0.28 0.10  0.09  3  3  3  3  0.06 0.06 0.02  Table 25  .Continued  Year & Measure  School District Inpatient Hospital Utilization Equations with DCS. BEDS, BEDSQ and Socioeconomic Variables in 1971. 1981/82 and Pooled 1968-1982/83 Dataset  IND  SE  RURAL  SE  EDUC  SE  ROOMS  -0.19 -0.10 -0.06 -0.08  0.23 0.05 0.03 0.05 0.05 0.02  2.19 1.10 -0.02 1.09 1.00 -0.13  3.59 0.82 0.53 0.77 0.74 0.25  -23.86 3.81 3.36  1.43 -0.37 -0.41 -0.13 -0.17 -0.06  1.17 0.36 0.27 0.28 0.28 0.13  -10.11 -4.30  SE  Admissions: 1971 MED/SURG SURG SURG-T&A SURG A SURG B SURG C  0.70  1.23  -0.42 -0.31 -0.24 -0.19 -0.06  0.28 0.18 0.27 0.25  1981/82 MED/SURG SURG SURG-T&A SURG A SURG B SURG C  1.69 0.32 0.19 0.22 0.17 0.01  Pooled  MED/SURG  1968-83 SURG SURG-T&A SURG A SURG B SURG C  3  1  1.44 -0.08 0.01 -0.08 -0.11 0.00  1  3  0.09  -0.07 -0.03  0.44 0.14 0.10 0.11 0.11 0.05  -0.05 -0.02 -0.01 -0.04 -0.04 -0.04  0.29 0.09 0.05 0.08 0.07  -0.10 -0.08 -0.03 -0.07 -0.07  0.02  -0.02  0.14 0.04 0.10 0.03 1  3  2  3  3  3  0.03 0.02 0.06 0.02 0.01  _  _  -  0.02 0.02  -  -  0.00  -  -  16.68 3.81 2.46 3.59 3.43 1.18  1.22 2.25 1.69  7.30 2.28 0.17 1.78 1.74 0.80  -3.12 -2.35 -2.29 -0.47 -35.31 -4.60 -1.07 -5.84 -4.29 0.02  3  3  3  3  3.88 1.24 0.66 1.09 1.00 0.27  O  . .Continued  Table 25  School District Inpatient Hospital Utilization Equations with DCS. BEDS. BEDSQ and Socioeconomic Variables in 1971, 1981/82 and Pooled 1968-1982/83 Dataset  Year & Measure  INC  SE  UNEM  0.01 0.00 0.00 0.00 0.00 0.00  0.16 0.67 0.07 0.59 0.41  SE  WHITE  3.20 0.73 0.47 0.69 0.66 0.23  -1.33 -0.50 -0.07 -0.39 -0.39 0.08  1.63 0.51 0.38 0.40 0.39 0.18 0.77 0.07 0.13 0.22 0.20 ' 0.05  SE  PRIM  SE  CONST  R  0.85 0.19 . 0.13 0.18 0.18 0.06  -1.14 -0.19 -0.06 -0.22 -0.20 -0.01  0.66 0.15 0.10 0.14 0.14 0.05  145.18 38.27 24.47  38.80  24.82 27.78 9.17  0.6269 0.1182 0.2955 0.0813 0.0666 0.0955  -0.21 -0.13 -0.11 -0.09 -0.11 -0.08  0.43 0.14 0.10 0.11 0.10 0.05  -0.14 -0.10  0.39 0.12 0.09 0.09 0.09 0.04  0.7797 0.3821 0.4274 0.2025 0.1206 0.1639  19.59 6.10  -0.15 -0.07 -0.04 -0.06  -66.67 56.41 45.00 24.55 29.67 7.00  -0.15  0.20 0.06  -0.64  3  0.18 0.06  204.59 56.80  0.6444 .  -0.13 -0.10  1  0.03 0.05  25.72 48.67 41.28  0.2932 0.2858 0.3339  36.70 11.75 6.29 10.34  0.2886 0.2230  9.44 6.55  2  SE Y  Admissions:  SURG SURG-T&A SURG A SURG B SURG C  0.00 -0.00 -0.00 -0.00 -0.00 -0.00  1981/82 MED/SURG SURG SURG-T&A SURG A SURG B SURG C  0.00 0.00 0.00 0.00 0.00 0.00  1971 MED/SURG  Pooled  MED/SURG  1968-83 SURG SURG-T&A SURG A SURG B SURG C 1  2  3  p < 0.05 p < 0.01 p < 0.001  1  -0.00 -0.00  3  3  -0.00 -0.00 -0.00  3  -0.00  3  3  3  -0.22  0.00 0.00 0.00 0.00 0.00 0.00  -2.23 0.23 0.40  0.00 0.00 0.00 0.00 0.00  -2.57 0.30 0.22 0.02 0.19 0.03  0.00  0.26 0.24 0.30 3  1  1  1  0.11 0.04 0.18 0.12 0.06  3  1  3  0.03 0.06 0.05 0.01  2  -0.12 -O.ll  1  -0.03  1  1  0.05 0.01  5.07  8.87 5.71 8.35 7.97 2.74  4.53 4.76 4.68 2.16  .Continued  Table 25  School District Inpatient Hospital Utilization Equations with DCS, BEDS, BEDSQ and Socioeconomic Variables in 1971. 1981/82 and Pooled 1968-1982/83 Dataset  Year & Measure  DCS  SE  BEDS  SE  BEDSQ  1971 MED/SURG SURG SURG-T&A SURG A SURG B SURG C  2.34 -0.05 0.56  3.85 0.80 0.77 0.41 0.26 0.09  327.95 52.02 54.80 5.14  1981/82 MED/SURG SURG SURG-T&A SURG A  6.29 1.04 1.12 -0.19  1.98 0.76 0.76 0.24  SURG B SURG C  -0.22 -0.18  0.19 0.09  118.82 2.45 1.96 0.50 1.00  Pooled  MED/SURG  1968-83  SURG SURG-T&A SURG A  -3.45 -2.45  SE  CAN  SE  MTENG  SE  65.69 13.72 13.20 6.91 4.49 1.55  -15.44 -3.17 -3.27 -0.04  5.10 1.07 1.03 0.54 0.35 0.12  1.56 -0.02 0.23 1.11 -0.30 -0.02  8.58 1.79 1.72 0.90 0.59 0.20  -5.70 -0.27  8.94 1.87 1.80 0.94 0.61 0.21  25.32 9.75 9.74 3,06 2.38 1.14  -4.29 0.45 0.54 0.33 -0.06 -0.04  2.40  3.53 1.70 1.49 0.70 0.22 -0.09  3.44 1.33 1.32 0.42  20.21 5.04  -3.23 -1.83  3.11  2.40 0.60  -1.48 -0.71  2  0.25  0.10  4.38 2.76 1.55  3  12.19 5.29  1  0.03  2.53  0.43  -0.35 -0.15  0.14 0.04  Days:  SURG B SURG C  -0.97 -0.62 -0.04  1  1  2  1  3  3  3  -0.16 2.07 3  1.21  2  1.26  166.48  3  0.32 0.27 0.17  31.04 27.25  -1.41  3  -1.92 -1.22  3  -0.17  3  3  3  3  3  3  3  3  2  2  2  0.06 -0.07  0.92 0.92 0.29 0.22 0.11  3  3  1.83 0.46 0.40  0.18 0.15 0.63 0.02 -0.05  0.32 0.16  0.52 0.33 0.18 0.05  -0.99 0.00 0.53 -0.11 -0.40 -1.62 -1.33 -0.38 -0.30 0.10  3.80 1.46 1.46 0.46 0.36 0.17  -3.86  1  0.51 0.29 0.42 0.44  1.63 0.41 0.35  3  0.15  3  0.22 0.12 0.03  Table 25  . Cont i nued  Year & Measure  School District Inpatient Hospital Utilization Equations with DCS, BEDS, BEDSQ and Socioeconomic Variables in 1971, 1981/82 and Pooled 1968-1982/83 Dataset  IND  SE  RURAL  SE  EDUC  SE  ROOMS  SE  1  8.19 1.71 1.65 0.86 0.56 0.19  0.21 -0.36 -0.30 -0.14 -0.15 -0.06  1.53 0.32 0.31 0.16 0.10 0.04  -2.38 -0.28 -2.07 0.84 1.08 -0.50  23.85 4.98 4.79 2.51 1.63 0.56  -209.55 -12.72 -10.86 -12.11 4.77 4.38  3  2.15 0.83 0.83 0.26 0.20 0.10  0.04 0.30 0.32 -0.03 -0.07 -O.07  0.70 0.27 0.27 0.08 0.07 0.03  5.62 -0.33 -0.32 -0.46 -0.45 -0.24  5.70 2.19 2.19 0.69 0.53 0.26  -25.80 -31.44 -27.96 -6.44 -5.61 -0.79  -0.04 -0.21 -0.16 -0.17  0.48 0.12 0.11 0.07  _  _  -  -  Days: 1971 MED/SURG SURG SURG-T&A SURG A SURG B SURG C  16.56 -0.10  1981/82 MED/SURG SURG SURG-T&A SURG A SURG B SURG C  9.70 1.60 1.30 0.66 0.26 -0.02  Pooled MED/SURG 1968-83 SURG SURG-T&A SURG A SURG B  13.71 0.85 1.13 0.20 -0.30  2.17 0.54 0.47 0.30 0.17  0.02  0.05  SURG C  0.22 -0.21 -0.20 0.07  1  3  1  1  -0.12 -0.04  1  2  3  0.04 0.01  -  -  110.85 23.15 22.28 11.66 7.58 2.62 35.61 1  1  -297.20 -44.80 -34.41  3  3  3  -31.06 -11.96 -0.49  3  3  13.72 13.70 4.30 3.34 1.61 28.99 7.23 6.29 3.96 2.22 0.62  vo  OJ  .Continued  Table 25  Year & Measure  School District Inpatient Hospital Utilization Equations with DCS, BEOS. BEDSQ and Socioeconomic Variables in 1971. 1981/82 and Pooled 1968-1982/83 Dataset  INC  SE  UNEM  SE  WHITE  SE  PRIM  SE  CONST  R  0.07  0.08 0.02 0.02 0.01 0.01 0.00  -9.99 -5.59 -7.94 0.68 1.39 -0.41  21.29 4.45 4.28 2.24 1.46 0.50  -1.95  5.66  1313.09  1.18 1.14 0.60 0.39 0.13  -6.61 -0.53 -0.29 -0.80 -0.29 -0.03  4.41  -1.08 -0.03 -0.66 -0.86 0.17  0.92 0.89 0.46 0.30 0.10  264.68 238.25 88.87 64.09 21.60  0.7325 0.3537 0.3965 0.1698 0.0190 0.0678  257.79 53.84  0.01 0.01 0.01 0.00 0.00 0.00  -13.41 2.12 2.57 0.73 0.58 0.81  7.95 3.06 3.06  -1.91 -0.02 0.06 0.11 -0.21 -0.12  2.12 0.82 0.82 0.26 0.20 0.10  -1.38 -0.41 -0.56 -0.10 0.01 -0.08  1.89 0.73 0.73 0.23 0.18 0.09  -141.12 185.63 149.68 40.11 71.33 20.59  0.7719 0.2966 0.2514 0.4324 0.1513 0.1337  95.52 36.79 36.74 11.53 8.96 4.31  0.01 0.00 0.00 0.00 0.00 0.00  -29.39 -3.06 -3.01 -2.40 0.05 -0.10  1.47 0.37 0.32 0.20 0.11  -2.04 -0.20 -0.18 -0.34 -0.20 -0.08  1.37 0.34 0.30 0.19 0.10  2130.08 394.08 312.16 198.46 105.06  0.6721 0.3441 0.3248 0.3832 0.3149  0.03  15.48  0.2508  274.46 68.48 59.51 37.52 21.05 5.87  2  SE Y  Days 1971 MED/SURG SURG SURG-T&A SURG A SURG B SURG C  0.01 -0.00 -0.01  1981/82 MED/SURG SURG SURG-T&A SURG A SURG B SURG C  0.01 0.01 0.01 0.00 0.00 -0.00  Pooled  MED/SURG  2  3  1  SURG B  -0.01 -0.01 -o.oo -0.00 -o.oo  SURG C  -o.oo  1968-83 SURG SURG-T&A SURG A  1  0.02 0.01  p < 0.05 p < 0.01 p < 0.001  1  1  3  3  3  1  3  1  1  2  0.96 0.75 0.36 5.74 1.43 1.25 0.79 0.44 0.12  1  4.17 1.00 0.84 0.79  2  2  2  0.28 0.15  3  3  0.03  2  51.80 27.13 17.63 6.09  195 The any  adjustment  radical  f o r the socioeconomic  factors  changes t o t h e a s s o c i a t i o n  availability  and i n p a t i e n t  d i d not  between bed  utilization  (Tables  21 a n d 2 5 ) .  Although regression  c o e f f i c i e n t on BEDS d e c r e a s e d  MED/SURG e q u a t i o n s ,  the association  statistically surgical  highly  utilization  remained  slightly in  still  s i g n i f i c a n t . The b e d e f f e c t decreased  bring  s t r o n g and  on t o t a l  c l e a r l y i n 1981/82 b u t r e m a i n e d  a b o u t t h e same i n 1971 and i n t h e p o o l e d d a t a s e t .  The m o d e l  that  bed  included  availability percent  socioeconomic v a r i a b l e s ,  and day c a r e s u r g e r y a v a i l a b i l i t y  of the v a r i a t i o n  30-35 p e r c e n t  Adjustment significant  i n surgical  surgical  and i n p a t i e n t  different  insignificant,  (Tables  surgery  21 a n d 2 5 ) . I n  on DCS r e m a i n e d  equations remained  h a d no  almost  f o r socioeconomic  coefficients  on DCS i n  statistically  t h e o n l y e x c e p t i o n b e i n g SURG C d a y s  f o r which  c o e f f i c i e n t became s t a t i s t i c a l l y s i g n i f i c a n t a t 5 p e r c e n t  level.  Regression  coefficients  on DCS  f o r MED/SURG, SURG and  SURG-T&A d a y s i n 1981/82 were p o s i t i v e , coefficient equation. the  factors  between day c a r e  utilization  I n 1981/82 t h e r e g r e s s i o n surgical  12-38  a d m i s s i o n s and  of socioeconomic  coefficients  explained  days.  t h e same a s w i t h o u t a d j u s t m e n t  variables.  the  patient  f o r the effects  1971 t h e r e g r e s s i o n exactly  i n overall  e f f e c t on t h e a s s o c i a t i o n  availability  paediatric  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 only  These p o s i t i v e  substitution  although the  associations  hypothesis.  f o r MED/SURG  are hard t o explain  In the pooled data the  by  196 coefficient in a l l  on DCS was  equations.  adjusting support  The r e s u l t s  for effects  of  in  significant  1971 and 1981/82  socioeconomic v a r i a b l e s  t h a t day c a r e s u r g e r y  after give  more has  no e f f e c t on t h e o v e r a l l p a e d i a t r i c i n p a t i e n t u t i l i z a t i o n  and  that  is  In  the f i n d i n g  and s t a t i s t i c a l l y  availability  far  to  negative  e f f e c t on s u r g i c a l from  complete  addition  different  to  utilization, if  it  exists  socioeconomic v a r i a b l e s , specialties  was  availability  also entered into  regression  model f o r t h e p o o l e d 1973-1982/83  regression  c o e f f i c i e n t s on DCS to those  socioeconomic  availability  (results  The c o e f f i c i e n t on DCS was negative  only  f o r SURG A ,  SURG B and SURG C d a y s , percent  (SURG B - t y p e ) .  remained e s s e n t i a l l y significant admissions  for a l l  in this  data.  after  factors  implying  beds  and d a y s e q u a t i o n s  several  substitution  of  was  e v e n more  and than  12  availability  2  the  demographic  the causal plausible.  highly  f o r MED/SURG  c l e a r l y improved  social,  table).  and  less  statistically  The a d j u s t e d R  availability,  t o u t i l i z a t i o n seems  and  significant  The c o e f f i c i e n t on bed  equations.  and p h y s i c i a n  controlling  SURG B and SURG C a d m i s s i o n s  t h e same and was  e f f e c t of  were  are not presented i n a  and 77 p e r c e n t , r e s p e c t i v e l y ) . A f t e r e x p l o r i n g confounding  The  characteristics  statistically  of the  pooled dataset  i n i n d i v i d u a l years  f o r bed a v a i l a b i l i t y , physician  all,  substitution.  physician  more s i m i l a r  at  (71  percent  possible and  effect  economic from  197 4.6.3  It  is  Unmeasured c o n f o u n d i n g  possible  influences control.  that Also,  area/cross-year paediatric factors  that  the study v a r i a b l e s  d a t a has  80 p e r c e n t f o r  been l e s s  than  (general  specific  effects).  order to adjust  availability,  but constant  bed a v a i l a b i l i t y  s e v e r a l dummy v a r i a b l e s  specific  confounders  constructed,  others.  l e f t without  district-specific For  1.0  i n one  the eleven  a dummy v a r i a b l e  to  term. S i m i l a r l y  w h i c h had a v a l u e o f  on i t s  i n observations  and z e r o f o r a l l  others.  year-  was  was  district,  surgery  inpatient  s c h o o l d i s t r i c t - s p e c i f i c dummy v a r i a b l e s 1.0  are  (district-  t e n t i m e dummies  with the constant  are  common  or that  were c r e a t e d .  One o f  overall  between d a y c a r e  e a c h o f w h i c h had a v a l u e o f  y e a r and z e r o i n a l l was  a set of  there  but  and p a e d i a t r i c  f o r unmeasured t i m e - and  cross-  confounding  over time  the r e l a t i o n s h i p  to  cross-area/cross-  temporal e f f e c t s ) ,  factors,  collinearity  The  some c o n t r o l f o r unmeasured  for a d i s t r i c t  utilization  that  are s p e c i f i c to i n d i v i d u a l years  districts  (1982/83)  have n o t b e e n a b l e  have n o t been i d e n t i f i e d .  that  confounding  i n the pooled  specific  In  other  the explained v a r i a t i o n  year design allows  across  there are s t i l l  inpatient u t i l i z a t i o n implying,  that  factors  factors  specific  years prevent a set  of  74  c r e a t e d , each of  One s c h o o l  own  school  district  198 (Vancouver,  no.  39) was  above mentioned  reason.  Table  26 r e p o r t s  district-specific specific  l e f t without  results  without  confounders  confounders  a district  adjustment  for time-  and a f t e r a d j u s t i n g  , school d i s t r i c t - s p e c i f i c  a n d t i m e - and d i s t r i c t - s p e c i f i c c o n f o u n d e r s . number o f district  variables  with the  degrees  large  Coefficients table  for  of  is  high using  p o o l e d 1968-1982/83  were done  e f f e c t s which are d i s c u s s e d  t i m e - and  briefly  w i t h t h e DCS and BEDS v a r i a b l e s ,  t i m e dummies coefficient  showed s t a t i s t i c a l l y for a l l  admission  highly  district-  below.  all  the  positive  day e q u a t i o n s ,  o n l y e x c e p t i o n b e i n g t h e 1981/82 dummy. The y e a r  1981/82  showed s t a t i s t i c a l l y  the  percent  level)  reflecting  association  (at  the  five  o n l y w i t h SURG, SURG A and SURG B a d m i s s i o n s  and SURG B d a y s . coefficient  significant  the  different  significant  and h o s p i t a l  the  study  When b o t h t i m e a n d d i s t r i c t dummies were e n t e r e d i n t o equations  data.  for  c o n f o u n d i n g e f f e c t i n t h e r e l a t i o n s h i p between m a i n  specific  only  are not r e p o r t e d i n  t h e r e were s i g n i f i c a n t  and  many  cross-area/cross-year  f o r t h e dummy v a r i a b l e s  However,  the  dummies  s i n c e t h e s e were i n t r o d u c e d o n l y t o c o n t r o l  variables.  and  time-  Because  up a g r e a t  freedom, the analyses  the  confounders  i n the equation with d i s t r i c t  and y e a r dummies  statistical  dummy f o r  In  general,  the v a l u e of  decreased s t e a d i l y a general  t h e t i m e dummy  f r o m 1968 t o  temporal e f f e c t of  1981/82,  reducing  paediatric  Table 26 School District Inpatient Hospital Utilization Equations with DCS. BEDS, BEDSQ and Time and/or District Dunniies in Pooled 1968-82/83 Dataset  Admissions Measure  DCS  MED/SURG Time Dummy District Ouimiy Time & Oist Dummy  -0.67 0.43 -1.52 0.66  SURG  -0.58 -0.04 -0.99 -0.09  Time Dummy District Duimry Time & Dist Duimry SURG-T&A Time Dunny  3  1  3  3  3  -0.17  3  3  District Dumny Time & Dist Duimry  0.01 -0.31 -0.04  SURG A Time Dummy District Duimry Time & Dist Dunny  -0.62 -0.08 -1.02 -0.10  SURG B Time Dunny District Duimry Time & Dist Duimry  -0.52 -0.07 -0.85 -0.10  SURG C  -0.06 -0.01 -0.11 -0.07  Time Dummy District Durrmy Time & Dist Dummy 1  2  3  p < 0.05 p < 0.01 p < 0.001  3  3  3  3  3  3  3  3  SE  BEDS  0.17 0.19 0.16 0.18  37.82 37.67 20.70  0.05 0.05 0.06 0.07  4.67 4.56 4.32 2.89  0.03 0.03 0.03 0.04  3.27 3.23 3.95 3.63  0.05 0.04 0.05 0.06  3.01 2.74 2.75 0.47  0.04 0.04 0.05 0.05  2.13 1.89 1.79 -0.15  0.01  0.80 0.60 1.45 0.60  0.01 0.01 0.02  SE  BEDSQ  2.68 2.54 3.24 2.85  -1.28 -1.22 -1.02 -0.50  3  0.84  3  o:69  3  1.23 1.06  -0.35 -0.31 -0.26 -0.17  3  0.44  -0.18  3  0.42 0.66 0.67  -0.17 -0.21 -0.19  0.75 0.59 1.09 0.86  -0.22 -0.18 -0.14 0.00  0.68 0.56 0.97 0.82  -0.19 -0.15 -0.09 0.03  3  0.19  3  0.18 0.26 0.26  -0.06 -0.04 -0.07 -0.02  3  3  3  11.43  3  2  3  3  3  3  1  2  3  3  1  SE  CONST  0.26 0.24 0.27 0.23  36.30 -3.14 66.93 11.32  0.5744 0.6265 0.7951 0.8608  40.15 37.61 27.86  0.08 0.07 0.10 0.09  40.75 19.93 48.49 24.39  0.1946 0.4583 0.4256 0.6278  12.55 10.29 , 10.60 8.53  3  0.04  3  0.04 0.06 0.06  22.60 15.51 25.75 18.30  0.2088 0.3049 0.4143 0.4774  6.62 6.21 5.70 5.38  0.07 0.06 0.09 0.07  30.26 9.37 37.82 14.12  0.2137 0.5286 0.4521 0.6997  11.23 8.70 9.38 6.94  0.07 0.05 0.08 0.07  27.69 10.29 33.95 14.52  0.1704 0.4471 0.4391 0.6549  10.20 8.33 8.39 6.58  0.02 0.02 0.02  6.00 3.61 6.40  0.02  5.57  0.0645 0.1698 0.3984 0.4650  2.81 2.65 2.25 2.12  3  3  3  1  3  3  1  1  3  3  2  2  2  2  2  1  2  R  2  SE Y  22.97  ntinued  Table 26 School District Inpatient Hospital Utilization Equations with DCS, BEDS, BEDSQ and Time and/or District Dunmies in Pooled 1968-82/83 Dataset  Days Measure  MED/SURG  DCS  SE  Time Dummy District Duiimy Time & Dist Dummy  -7.95 4.32 -16.32 7.32  SURG Time Dummy District Duirniy Time & Dist Dunmy  -2.99 0.45 -5.23 0.66  SURG-T&A Time Dunmy District Dumny Time & Dist Dummy  -1.86 0.73  SURG A Time Dunmy District Dummy Time & Dist Dunmy  -2.24 -0.18 -3.63 -0.04  SURG B Time Dunmy District Dumny Time & Dist Dummy  -1.30 -0.27 -2.00 -0.23  SURG C Time Dunmy  -0.17  District Dumny Time & Dist Dummy 1  2  3  p < 0.05 p < 0.01 p < 0.001  SE  BEDSQ  SE  1.33 1.35 1.38 1.46  248.13 247.53 152.96 83.45  20.55 17.76 28.39  -5.31 -4.68 -5.32  22.65  -1.29  0.31 0.29 0.37 0.41  37.59  4.77 3.77 7.55 6.38  -2.03 -1.86 -2.85 -2.50  0.27 0.27  4.11 3.51  0.32 0.38  32.87 32.96 45.60 42.64  6.51 5.94  -1.58 -1.45 -2.66 -2.44  0.18 0.16 0.21 0.22  15.43 14.68 16.45 8.32  2.71 2.06 4.22 3.36  -0.83 -0.67 -1.05 -0.55  3  3  0.10  4.94  2  1.51  -0.39  2  2  0.09 0.11 0.12  4.34 4.17 -0.58  3  1.23 2.19 1.78  -0.30 -0.18 0.11  1  0.03  1.52 1.07 2.91 0.97  0.43 0.40 0.62 0.62  -0.09 -0.05 -0.11 0.00  3  2  3  3  3  3  3  2  -3.55 0.79  BEDS  3  1  3  3  3  1  3  -0.02 -0.33 -0.14  3  3  0.03 0.03 0.04  3  3  3  3  3  37.77 46.88 42.07  3  3  3  3  3  3  3  3  3  3  1  3  2  3  2  2  1  3  3  3  3  3  3  3  3  3  2  1  1  1  1.97 1.69 2.40  CONST  R  2  SE Y  0.5888 0.6985 0.7400  307.37 263.17 244.39  1.85  146.73 -276.38 434.97 -154.06  0.8546  182.79  0.46 0.36 0.64 0.52  162.16 42.10 199.89 49.67  0.2892 0.5633 0.4088 0.6297  71.29 55.88 65.02 51.46  0.39 0.33  0.2785 0.4935 0.4012 0.5617  61.52 51.96  0.55 0.49  123.36 34.04 149.14 39.72  0.26 0.20 0.36 0.28  78.84 2.65 106.53 15.05  0.2806 0.5904  40.52 30.57 36.35 27.13  0.14 0.12 0.19 0.15  60.31  0.2111 0.4898 0.4516 0.6813  22.58  0.04  14.27 7.15 16.34 12.01  0.0951  6.45  0.2269 0.3859 0.4617  5.96 5.32 4.98  0.04 0.05 0.05  20.54 75.11 29.26  0.4212 0.6776  56.04 47.95  18.16 18.83 14.35  201 hospitalizations care  s u r g e r y u s e and p a e d i a t r i c  Over h a l f and  d u r i n g t h e study p e r i o d independent o f day  of the different  statistically  significant  positive  f o r MED/SURG d a y s .  negative  implies that several school d i s t r i c t s  higher paediatric  showed  regression coefficient f o r  a n d a r o u n d 40 p e r c e n t  None showed s t a t i s t i c a l l y This  school d i s t r i c t s  significant  MED/SURG a d m i s s i o n s  bed c a p a c i t y .  coefficients.  i n B.C. h a v e h a d  h o s p i t a l i z a t i o n p a t t e r n s t h a n V a n c o u v e r , and  no one h a s h a d s i g n i f i c a n t l y  lower  hospitalization  practice  f o r a g i v e n bed s t o c k and day c a r e s u r g e r y u s e . A subsequent analysis  showed t h a t t h i s d i f f e r e n c e i n h o s p i t a l i z a t i o n  p a t t e r n s between Vancouver and o t h e r s c h o o l d i s t r i c t s independent different (no.  from socioeconomic  school d i s t r i c t s ,  Lillooet  admission  have had s i g n i f i c a n t l y  have had s i g n i f i c a n t l y  rates f o r the paediatric  However, o n l y one s c h o o l d i s t r i c t  lower  Agassiz  paediatric  surgery u t i l i z a t i o n  Vancouver.  ( V a n c o u v e r I s l a n d West, no. Vancouver  f r o m DCS, BEDS a n d t i m e - s p e c i f i c  ( n o . 76) a n d Summerland  h i g h e r and  surgical  age group than  84) h a s h a d h i g h e r s u r g i c a l d a y r a t e t h a n (independent  paediatric  dummy v a r i a b l e s showed t h a t n e a r l y 20  of school d i s t r i c t s  15 p e r c e n t  Nelson  patterns.  District-specific percent  Of t h e  ( n o . 29) a n d F o r t  81) showed t h e h i g h e s t d i s t r i c t - s p e c i f i c  hospitalization  about  characteristics.  was a l s o  effects).  ( n o . 77) showed t h e l o w e s t (admissions  and h o s p i t a l  days).  202 Almost a l l school d i s t r i c t s for  SURG-T&A  utilization  a g i v e n bed s t o c k and day c a r e s u r g e r y use than  Golden  ( n o . 18) a n d A g a s s i z  regression slightly  coefficients  f o r SURG-T&A a d m i s s i o n s  on d i s t r i c t dummy t h a n  had i n s i g n i f i c a n t  N e a r l y one t h i r d negative  positive n e g a t i v e one  The m a j o r i t y o f s c h o o l  coefficient  regression coefficient  coefficients,  a significant  f o r these  of the school d i s t r i c t s  w h e r e a s o n l y few d i s t r i c t s  and days. A  had a s i g n i f i c a n t  SURG A a n d SURG B e q u a t i o n s .  districts  Vancouver.  ( n o . 76) showed t h e l o w e s t  more s c h o o l d i s t r i c t s  coefficient for  showed l o w e r  showed  f o r SURG C  measures.  significant  utilization,  showed s i g n i f i c a n t  positive  i m p l y i n g t h a t most o f t h e s c h o o l d i s t r i c t s i n  B.C.  h a v e h a d SURG C u t i l i z a t i o n  rates equal  that  i n Vancouver given constant  bed c a p a c i t y and day c a r e  s u r g e r y use. utilization  ( n o . 18) showed t h e l o w e s t  f o rthe factors that are s p e c i f i c  across d i s t r i c t s ,  p r a c t i c e p a t t e r n s over availability overall  significant implying overall  such  SURG C  time,  t o a year but  as changes i n s u r g i c a l  i m p l i e d t h a t day care  does n o t have any s u b s t i t u t i o n e f f e c t  medical/surgical inpatient utilization  regression  than  patterns.  Adjustment constant  Golden  t o o r lower  coefficient f o r both  on t h e  (Table 26).  on DCS was p o s i t i v e a n d s t a t i s t i c a l l y MED/SURG a d m i s s i o n s  and p a t i e n t days,  t h a t day care surgery a v a i l a b i l i t y inpatient  surgery  utilization  time-dependent confounding  will  increase  w i t h a g i v e n b e d s t o c k when  f a c t o r s a r e c o n t r o l l e d . The  The  203 goodness of  fit  f o r the o v e r a l l equation i s  ( f r o m 57 p e r c e n t t o percent to dummies.  implies  with the a d d i t i o n of  the existence of  the included explanatory variables had t h e i n d e p e n d e n t e f f e c t o f  Adjustment between  f o r time f a c t o r s  day c a r e s u r g e r y  The c o e f f i c i e n t on DCS insignificant overall same f o r  utilization  fit  SURG B)  factors.  The p a t t e r n was  d a y s was  but  utilization.  exactly and t h e  for  the positive  statistically  in total  surgical  ( f r o m 20 t o  still  association  statistically  46 p e r c e n t  56 p e r c e n t f o r h o s p i t a l  less,  time.  day e q u a t i o n )  i n the o v e r a l l regression  slightly  i n t h e SURG A , for  i n the h o s p i t a l  increased substantially  The r e g r e s s i o n  inpatient  days).  equation  a f t e r adjustment  The a d j u s t m e n t  for  substantial.  (except  f o r the days  for time-specific  equation  improved  the adjusted c o e f f i c i e n t of determination s u b s t a n t i a l l y categories.  also  confounding  f o r t i m e - s p e c i f i c confounders  i n t h e s e more r e s t r i c t e d s u r g i c a l  for  The  c o e f f i c i e n t s on DCS became i n s i g n i f i c a n t  B and C e q u a t i o n s  in  that  2  m a r k e d l y and became  for hospital  a d m i s s i o n s and f r o m 29 t o  SURG-T&A was  surgical  The e x p l a i n e d v a r i a n c e  improvement o f  BEDS, B E D S ) ,  u t i l i z a t i o n e x c l u d i n g T&As,  on DCS  significant.  (DCS,  time  not captured  i n f l u e n c e d a l s o the  utilization.  surgical  coefficient  fell  factors  the  reducing u t i l i z a t i o n over  and  (and p o s i t i v e  surgical  improved  63 p e r c e n t f o r a d m i s s i o n s and f r o m 59  7 0 percent for days),  This  clearly  also  204  The a b o v e d e s c r i b e d f i n d i n g s already care  f o u n d when s t u d y i n g  surgery  availability  c o n f i r m more o r l e s s what  i n d i v i d u a l years  may h a v e  categories, level  of  but t h i s  total  surgery,  The r e g r e s s i o n surgical over of  factors  for  on p a e d i a t r i c  utilization.  the  the s u b s t i t u t i o n  side. for  few p e r c e n t and w e l l  use r e p r e s e n t s  p o t e n t i a l confounding  generation  eligible  surgical  (Table  26).  implying  a causal  further e f f e c t f r o m beds BEDS  to  2  district  The i m p a c t o f  on  day  dummies  improved s i g n i f i c a n t l y (from 5 7 t o  e x p l a i n e d was g r e a t e r importance of  determining variation  care  after  dummies.  74 percent f o r days)  greater  beds  u t i l i z a t i o n decreased only s l i g h t l y  o f MED/SURG e q u a t i o n s  variation  of  availability  c o e f f i c i e n t s on BEDS and  for time-specific  and f r o m 5 9 t o  t h e bed  e x a c t l y t h e same i n a l l MED/SURG, SURG and  equations  School  time-specific  inpatient u t i l i z a t i o n ,  Regression  SURG-T&A  adjustment  significantly  the p l a u s i b i l i t y  remained almost  fit  only  day c a r e s u r g e r y  d i d not a f f e c t  strengthening  of  at  surgery.  The a d j u s t m e n t  effect  surgery  even b e f o r e r e a c h i n g the m e d i c a l  inpatient utilization is of  Day  effect  inpatient  e f f e c t disappears  c o e f f i c i e n t s imply that  90 percent  new  substitution  separately.  weak s u b s t i t u t i o n  i n more n a r r o w l y d e f i n e d , d a y c a r e e l i g i b l e  was  the  goodness  80 percent for  (Table  2 6 ) . The  additional  t h a n w i t h t i m e dummies district  specific  in paediatric inpatient  days  alone,  factors  utilization  in  205 rates.  Also,  these d i s t r i c t s p e c i f i c factors  more i m p a c t on a d m i s s i o n  rates  seemed t o  t h a n on l e n g t h o f  i n c l u s i o n o f d i s t r i c t dummies i n t h e r e g r e s s i o n  have  stay.  The  equations  does  n o t c o n t r o l f o r t h e c o i n c i d i n g t r e n d s o f d e c r e a s i n g T&A r a t e and i n c r e a s i n g d a y c a r e s u r g e r y u t i l i z a t i o n o v e r t i m e a r e s u g g e s t e d t o be i n d e p e n d e n t b y t h e r e s u l t s years),  and t h u s  and h i g h l y  the regression  significant.  t h a t e x c l u d e T&As coefficients  As e x p e c t e d , t h e a s s o c i a t i o n  saved  lowest  i n those  (SURG-T&A and SURG C ) .  imply that  100  The  negative between  equations  regression  day c a r e s u r g e r y cases  152 i n p a t i e n t a d m i s s i o n s w i t h a v e r a g e  10.7 d a y s .  from i n d i v i d u a l  c o e f f i c i e n t on DCS i s  DCS and i n p a t i e n t u t i l i z a t i o n i s  (which  w o u l d have  l e n g t h of  stay  of  N i n e t y n i n e of t h e s e a d m i s s i o n s would have been f o r  surgery with average  l e n g t h of  p l a u s i b i l i t y that this  stay of  5.3  days.  The  r e f l e c t s a c a u s a l e f f e c t f r o m DCS  i n p a t i e n t u t i l i z a t i o n has  a l r e a d y been q u e s t i o n e d by  to  previous  results.  Introduction the r e g r e s s i o n  o f d i s t r i c t s p e c i f i c dummies d e c r e a s e d c o e f f i c i e n t s on bed a v a i l a b i l i t y  MED/SURG e q u a t i o n s , statistically  highly  but the c o e f f i c i e n t s s t i l l significant.  for  D i s t r i c t d i f f e r e n c e s i n bed  time-invariant e f f e c t s , leading to a  fit  of the equations  there are a l s o other important d i s t r i c t  of  district  high  c o r r e l a t i o n b e t w e e n BEDS and t h e d i s t r i c t s p e c i f i c However, t h e improvement o f  the  remained  a v a i l a b i l i t y w o u l d be one o f t h e p r i n c i p a l s o u r c e s specific,  slightly  dummies.  suggests  that  s p e c i f i c e f f e c t s . The  206 bed a v a i l a b i l i t y e f f e c t remained  about t h e same o r i n c r e a s e d  s l i g h t l y f o r t h e d i f f e r e n t s u r g i c a l equations a f t e r for d i s t r i c t - s p e c i f i c  adjusting  e f f e c t s , e x c e p t i o n b e i n g SURG B equation  i n which t h e c o e f f i c i e n t on BEDS decreased and became statistically  i n s i g n i f i c a n t both f o r admissions and days.  The adjustment  f o r both time and d i s t r i c t dummies y i e l d e d  the h i g h e s t a d j u s t e d c o e f f i c i e n t s o f d e t e r m i n a t i o n (86 percent f o r MED/SURG admissions, 63 percent f o r SURG admissions, 86 p e r c e n t f o r MED/SURG days, and 63 percent f o r SURG days) (Table 26). The a s s o c i a t i o n utilization  became a g a i n p o s i t i v e and 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 a s s o c i a t i o n was  between DCS and m e d i c a l / s u r g i c a l  with o v e r a l l s u r g i c a l  n e g a t i v e but i n s i g n i f i c a n t and the a s s o c i a t i o n  admissions with  s u r g i c a l days was p o s i t i v e and a l s o i n s i g n i f i c a n t . The s i t u a t i o n was t h e same w i t h SURG-T&A, but t h e p o s i t i v e c o e f f i c i e n t f o r h o s p i t a l days was s t a t i s t i c a l l y Only SURG C equations showed a c o n s i s t e n t  significant.  s i g n i f i c a n t negative  impact of DCS f o r both admissions and h o s p i t a l days. However, the s i z e of t h i s impact was s m a l l i m p l y i n g l e s s than 10 percent s u b s t i t u t i o n  by DCS i n t h i s subcategory of s u r g i c a l  utilization.  Simultaneous  adjustment  f o r time and s c h o o l d i s t r i c t dummies  decreased t h e bed e f f e c t on o v e r a l l p a e d i a t r i c utilization, statistically  but t h e a s s o c i a t i o n  remained  hospital  s t i l l powerful and  s i g n i f i c a n t f o r both admissions and days (Table  207 26).  The o b s e r v e d bed a v a i l a b i l i t y  reflecting  a spurious  association  some o t h e r v a r i a b l e . the impact of days.  beds  effect is  that  not  c o u l d be e x p l a i n e d  The s i m u l t a n e o u s  on s u r g i c a l  clearly  adjustment  admissions  decreased  b u t n o t on  hospital  But h e r e as w e l l t h e c o e f f i c i e n t on BEDS r e m a i n e d  and s t a t i s t i c a l l y  significant.  The a d j u s t m e n t  by  large  procedure  did  n o t h a v e a n y e f f e c t on t h e r e l a t i o n s h i p between bed availability  and SURG-T&A u t i l i z a t i o n . The e f f e c t on a l l  care s u r g e r y - e l i g i b l e statistically SURG B and C  u t i l i z a t i o n measures  insignificant  were c a l c u l a t e d a l s o  f o r SURG A and B a d m i s s i o n s  inpatient hospital including  socioeconomic v a r i a b l e s , simultaneously  1982/83 d a t a s e t  (Table  socioeconomic v a r i a b l e s coefficient  of  The r e g r e s s i o n  DCS,  27).  improved s l i g h t l y  c o e f f i c i e n t on DCS was  paediatric stay  coefficients implying  that  10 p a e d i a t r i c  of  the  positive  cases  i n p a t i e n t admissions  1968-  would  cases  inpatient  of  the  equation.  and and  days,  increase  b y 58 w i t h t h e  average  negative  on DCS were f o u n d f o r SURG C a d m i s s i o n s 100 d a y c a r e s u r g e r y  for  adjusted  The o n l y s i g n i f i c a n t  admissions  different  adjustment  f o r MED/SURG a d m i s s i o n s  8.7 d a y s .  equations  the  d e t e r m i n a t i o n f o r t h e MED/SURG d a y s  100 d a y c a r e s u r g e r y  of  and  district-specific  The a d d i t i o n a l  implying  length  2  i n t o t h e model i n t h e p o o l e d  significant  that  utilization  BEDS, B E D S ,  and t i m e - and  statistically  overall  and became  days.  The s c h o o l d i s t r i c t  dummies  fell  day  and  days,  would s u b s t i t u t e  SURG C - t y p e ,  with  for  the  208  .Continued  Table 27 School District Inpatient Hospital Utilization Equations with DCS. BEDS. BEDSQ, Socioeconomic Variables and Time and District Dutnnies in Pooled 1968-1982/83 Dataset  Measure  DCS  SE  BEDS  0.19 0.07 0.04 0.06 0.05 0.02  11.93 2.83 3.74 0.30 -0.36 0.56  1.43 0.42 0.39 0.22 0.12 0.04  97.05 44.40 45.18 8.51 -1.01  SE  BEDSQ  2.85 1.05 0.65 0.86 0.81 0.26  -0.53 -0.13 -0.17 0.03 0.07 -0.01  21.82 6.41 5.97 3.40 1.78 0.61  -2.74 -2.57 -2.53 -0.54 0.18 0.03  SE  CONST  0.23 0.09 0.05 0.07 0.05 0.02  170.26 -18.82 -9.28 -21.08  R  2  SE Y  Admissions: MED/SURG SURG SURG-T&A SURG A SURG B SURG C  0.58 -0.03 0.01 0.07 -0.06 -0.05  2  2  3  2  3  1  1  2  -34.00 -15.68  0.8641 0.6452 0.5153 0.7081 0.6668 0.4972  22.69 8.33 5.18 6.84 6.46 2.03  1.78 3005.56 0.52 388.31 0.49 387.55 0.28 125.39 0.15 -40.91 0.05 -24.91  0.8685 0.6354 0.5685 0.6786 0.6895 0.4889  173.80 51.06 47.57 27.08 14.17 4.85  Days: MED/SURG SURG SURG-T&A SURG A SURG B SURG C 1  2  3  p < 0.05 p < 0.01 p < 0.001  5.07 0.59 0.75 -0.12 -0.18 -0.10  3  2  3  3  3  1  0.87  3  3  209  average length on  the socioeconomic v a r i a b l e s ,  association inpatient  4.7.  In  between p a e d i a t r i c  hospital  in  utilization.  s p e c i a l t i m e dummy v a r i a b l e s , The  B E D S D  variable  the value of the  1 9 8 2 / 8 3  o f bed a v a i l a b i l i t y  p o l i c y environments o f i n c r e a s i n g  when t h e b e d c a p a c i t y  o r s t a b l e bed  B E D S  variable  these variables  described  BEDS  in  variable  in  1 9 7 5 - 1 9 7 6  was g e n e r a l l y  1 9 7 5 - 1 9 7 6  and  and  decreasing.  1 9 6 8 - 1 9 7 4  were  1 9 6 8 - 1 9 7 4  increasing, 1 9 8 1 / 8 2 -  The  BEDSQD  and t h e v a l u e o f  1 9 8 1 / 8 2 - 8 2 / 8 3 .  into the regression  as f o l l o w s  BEJQSCJD,  had t h e v a l u e o f z e r o i n  had t h e v a l u e o f zero i n 2  REnsn a n d  i n t h e P r o v i n c e was s l i g h t l y  when b e d c a p a c i t y  variable  of  and p a e d i a t r i c  on t h e one hand, and d e c r e a s i n g b e d s u p p l y on t h e  created.  the  bed a v a i l a b i l i t y  Roemer's Law a n d d e c r e a s i n g b e d s u p p l y  capacity other,  coefficients  suggesting a non-spurious  o r d e r t o examine t h e c o n s i s t e n c y  effect  and  o f 2 d a y s . The r e g r e s s i o n  were e s s e n t i a l l y t h e same a s w i t h o u t t h e a d j u s t m e n t  B E D S  for  of stay  Inclusion  e q u a t i o n c a n be  :  Y = a + b(DCS) + c(BEDS) + d ( B E D S ) + e(BEDSD) + f(BEDSQD) 2  210 where  a i s  DCS, on  the intercept,  c i s  the coefficient  BEDS . i s the  BEDSQD and  If  =  o n BEDS,  coefficient  0,  but i n  o n BEDSQD.In  coefficient on  and d i s the  Symbol e i s t h e r e g r e s s i o n  2  f  b i s the regression  coefficient  1968-1974  coefficient  o n BEDSD a n d  BEDSD =  0  and  1974-1976 a n d 1981/82-82/83 B E D S D = BEDS  BEDSQD = B E D S . 2  the bed a v a i l a b i l i t y effect  when b e d c a p a c i t y  i s decreasing  i s higher  during the years  (1975-1982/83), t h e n t h e  regression  e q u a t i o n w i t h BEDSD a n d BEDSQD v a r i a b l e s  a positive  and s i g n i f i c a n t  1968-1982/83 d a t a s e t . coefficient effect  negative,  and s t a t i s t i c a l l y  o f decreasing  e, o r the regression  coefficient  statistically utilization. substantially  bed capacity.  coefficient  significant,  Table  28  o n BEDSD w a s  and f , o r the  i na l l equations  The adjustment  significant  bed a v a i l a b i l i t y  o n BEDSQD w a s p o s i t i v e  significant  show  o n BEDSD i n t h e p o o l e d  o n BEDSD w o u l d i m p l y a l o w e r  and s t a t i s t i c a l l y  regression  (Tables  A negative  i n a nenvironment  shows t h a t  coefficient  would  and also  of inpatient  f o r BEDSD a n d BEDSQD i m p r o v e d  t h e goodness o f t h e f i to f t h e o v e r a l l  21 a n d 28). T h e r e g r e s s i o n  equation  f o rthe  equations  T a b l e 28  School D i s t r i c t  I n p a t i e n t H o s p i t a l U t i l i z a t i o n E q u a t i o n s w i t h DCS.  BEDS. BEDSQ. BEDSD and BEDSQD  Measure  DCS  SE  BEDS  0.17  42.14  0.05  6.50  0.03  3.84  0.05  4.83  0.04  3.66  0.01  0.98  1.24  294.63  0.29  4S.72  0.26  41.19  3  0.16  22.29  3  0.09  8.41  0.03  2.09  SE  BEDSQ  i n Pooled 1968-82/83 D a t a s e t  SE  BEDSD  0.25  -11.05  0.08  -6.12  0.04  -1.88  3  0.07  -5.85  3  0.06  -5.01  3  0.02  -0.67  1.79  -109.46  0.42  -30.48  0.37  -21.57  0.23  -20.34  0.13  -11.20  0.04  -1.99  SE  BEDSQD  SE  CONST  R  2  SE Y  Admissions: MED/SURG  -0.11  SURG  -0.35  SURG-T&A  -0.09  SURG A  -0.39  SURG B  -0.33  SURG C  -0.03  3  2  3  3  2  3  2.58  -1.54  3  0.78  -0.53  3  0.44  -0.24  3  0.68  -0.39  3  0.63  -0.34  3  0.19  -0.08  3  3  3  3  1.77  0.66  3  0.53  0.66  0.30  0.20  0.46  0.59  3  0.43  0.53  3  0.13  0.08  3  3  1  0.29  28.33  0.6184  38.02  3  0.09  38.34  0.3321  11.43  3  0.05  21.83  0.2547  6.43  3  0.08  27.69  0.3803  9.97  3  0.07  25.63  0.3188  9.24  3  0.02  5.82  0.0943  2.76  Days: MED/SURG  -1.96  SURG  -1.57  SURG-T&A  -0.79  SURG A  -1.37  SURG B  -0.86  SURG C  -0.10  1  p < 0.05  2  p < 0.01  3  p < 0.001  3  2  3  3  18.43  -7.65  3  4.31  -2.80  3  3.83  -2.10  3  2.41  -1.39  1.38  -0.72  0.43  -0.15  3  3  3  3  3  3  3  3  12.63  4.64  3  2.95  2.23  3  2.62  1.35  3  1.65  1.-78  3  0.95  1.14  3  0.29  0.23  3  1  2.04  54.73  0.6799  271.16  3  0.48  142.97  0.4378  63.40  2  0.42  108.22  0.3958  56.30  0.27  68.04  0.4502  35.42  0.15  55.44  0.3611  20.32  0.05  13.60  0.1499  6.26  3  3  3  212 medical/surgical  admissions  c a n be now w r i t t e n i n  1968-1974  as:  MED/SURG(a)  = 28.33 -  and f o r h o s p i t a l  MED/SURG(d)  In  years  O.ll(DCS)  + 42.14(BEDS)  = 54.73  -  1975-1982/83  1.96(DCS)  + 294.63(BEDS)  t h e same e q u a t i o n s  -7.65(BEDS ). 2  are  = 28.33  -  O.ll(DCS)  + 31.09(BEDS)  M/S(d)  = 54.73  -  1.96(DCS)  + 185.17(BEDS)  -  without  BEDSD  corresponding  adjustment  = 36.30 -  M/S(d)  = 146.73  These e q u a t i o n s  of  -  6.5  0.88(BEDS ) 2  3.01(BEDS ) 2  and  -  BEDSQD  + 248.13(BEDS)  1.28(BEDS ) 2  -  5.31(BEDS ). 2  i m p l y t h a t one a d d i t i o n a l b e d a t 3/1,000  would have c r e a t e d  per year i n  stay of  per year i n days,  + 37.82(BEDS)  7.95(DCS)  admissions  l e n g t h of  admissions stay  0.67(DCS)  bed s u p p l y of  additional average  equations  -  f r o m t h e T a b l e 21 a r e :  M/S(a)  existing  3  days  M/S(a)  The  -'1.54(BEDS )  7.6  1968-1974 w i t h  days,  25.8  32.9  marginal  additional  1975-1982/83 w i t h m a r g i n a l  and g i v e n t h e e q u a t i o n s  the  length  i n T a b l e 21 f o r  of the  213 whole p e r i o d of average that  1968-1982/83,  length of  stay of  7.2  30.1 a d d i t i o n a l a d m i s s i o n s days.  These r e s u l t s  suggests  i n the p o l i c y environment of d e c r e a s i n g a v a i l a b i l i t y  paediatric  beds  the e f f e c t of less  stable  a p o l i c y environment of  or increasing.  In  bed s u p p l y b o t h a d m i s s i o n declining  t h a n when t h e b e d s u p p l y  rates  and l e n g t h s  of  decreasing  stay  g e n e r a l l y g o i n g u p . The r e s u l t s  suggest that  is  than with length of  results  rates  i n T a b l e 28 i m p l y t h a t  relatively  greatest  particular, However,  with t o t a l  these r e s u l t s  this  surgical  declining  is  of  u t i l i z a t i o n and, inpatient  from which t o  conclude generally  For t h i s  are not presented i n a t a b l e ) .  f o r the e f f e c t s of  t h e s i z e and s i g n o f  significance.  remained s i g n i f i c a n t BEDS and B E D S  2  at  also  reason, into  the  The  time-specific factors  did  not  t h e BEDSD and BEDSQD c o e f f i c i e n t s  i n t h e e q u a t i o n f o r MED/SURG a d m i s s i o n s , statistical  The  (BEDSD and BEDSQD) may be c a p t u r i n g  other time-specific factors.  adjustment  is in  c a u s e d b y t h e d e c r e a s e i n bed a v a i l a b i l i t y .  (results  The  surgery.  were c a r r i e d o u t i n c l u d i n g t h e t i m e dummies  equations  affect  stay.  must be i n t e r p r e t e d w i t h c a u t i o n . The  does n o t p r o v i d e a b a s i s  two b e d - t i m e dummies  is  difference  t h e d e c r e a s e i n b e d e f f e c t when b e d s u p p l y i s  analyses  are  the d e c r e a s e i n bed e f f e c t  w i t h SURG A and SURG B t y p e o f  study design  effects  is  s l o w e r t h a n t h e y a r e i n c r e a s i n g when b e d s u p p l y  greater with admission  of  b e d s u p p l y on p a e d i a t r i c  inpatient utilization is  that  with  but decreased t h e i r  However, t h e c o e f f i c i e n t on BEDSD  5 percent l e v e l .  r e m a i n e d t h e same.  The c o e f f i c i e n t s on  The c o e f f i c i e n t s on BEDSD  214 and BEDSQD showed t h e same s i g n s the adjustment  f o r t h e t i m e dummies/  and s i g n i f i c a n c e . also  larger.  f o r MED/SURG d a y s as but i n c r e a s e d i n  The c o e f f i c i e n t s on BEDS and B E D S  These r e s u l t s  without  imply that  2  value became  the decrease i n  bed  a v a i l a b i l i t y e f f e c t on t h e o v e r a l l p a e d i a t r i c h o s p i t a l 1 9 7 5 - 1 9 8 2 / 8 3 , when b e d c a p a c i t y was other time-specific factors. time-dummies of  reduced, i s  t h e s i z e and  BEDSD was  significant  BEDSQD showed n e g a t i v e and regression  utilization,  surgical  statistically  c o e f f i c i e n t o n l y f o r SURG C  implying that  t h e bed a v a i l a b i l i t y e f f e c t would 1975-1982/83  t h e e a r l i e r p e r i o d when a c c o u n t i n g f o r t h e e f f e c t s o f  than day  statistically  Earlier  care  equations  were  insignificant.  regression  (Table  21)  equations  i n the pooled  1968-1976  and i n t h e p o o l e d 1 9 7 3 - 1 9 8 2 / 8 3  (Table  22)  i m p l y l o w e r b e d e f f e c t b o t h on MED/SURG and SURG u t i l i z a t i o n in  in  u s e a n d t i m e - s p e c i f i c c o n f o u n d e r s . The c o e f f i c i e n t s on  BEDSD and BEDSQD f o r o t h e r s u r g i c a l  dataset  and  statistically  h a v e b e e n h i g h e r on SURG C u t i l i z a t i o n i n  surgery  the  f o r SURG-T&A a d m i s s i o n s and SURG C a d m i s s i o n s  days whereas significant  a c t u a l l y p o s i t i v e and  for  significance  BEDSD and BEDSQD c o e f f i c i e n t s f o r t h e d i f f e r e n t  equations.  in  independent of  However, t h e a d j u s t m e n t  reduced s i g n i f i c a n t l y  use  1973-1982/83  than i n  1968-1976.  T h e s e same  equations  s u g g e s t a l s o a weaker n e g a t i v e a s s o c i a t i o n  b e t w e e n DCS  MED/SURG i n t h e e a r l i e r p e r i o d compared t o  latter.  and  However,  215 the strength utilization  In  of is  the negative the  association  effect  i n respect to  change  variables  change next.  increasing  A cross-tabulation  rate  as  DELTAUTIL  cells  ( b o t h change v a r i a b l e s  t h e o t h e r two c o r n e r s o f  bed c a p a c i t y  Next,  fell  a ratio districts  corner  of  of  increasing  DELTAUTIL  that  fell  i n t o the  positive),  but  more  fell being  partially  paediatric  independent  u t i l i z a t i o n increases than i t  falls  examined i n  of  those  DELTABED-/DELTAUTIL-  and compared t o t h e same  i n the opposite  one w o u l d e x p e c t h i g h e r districts  cells  DELTABED-  t o DELTABED was  the c r o s s - t a b u l a t i o n  school d i s t r i c t s  inpatient  least  into  than i n t o  the c r o s s - t a b u l a t i o n ,  at  the  changes.  school  in  percentage  revealed  /DELTAUTIL+ c o r n e r , r e f l e c t i n g a g e n e r a l d e c l i n e i n u t i l i z a t i o n rates,  as  Many s c h o o l d i s t r i c t s  i n t h e DELTABED+/DELTAUTIL- c o r n e r t h a n i n  hospital  two  f r o m one y e a r t o  i n the pooled dataset  d i f f e r e n c e s were n o t v e r y d r a m a t i c . into  calculated  DELTABED and DELTAUTIL  DELTABED and n e g a t i v e corner  bed s u p p l y  and DELTAUTIL  admission  of  t h a t more s c h o o l d i s t r i c t s  i n the opposite  availability  and d e c r e a s i n g  i n bed c a p a c i t y  in medical/surgical  negative  t h e bed  were c r e a t e d . DELTABED was  change  surgical  opposite.  o r d e r t o examine more c l o s e l y  percentage  with o v e r a l l  corner.  If  paediatric  more when b e d c a p a c i t y  when bed s u p p l y  is  DELTAUTIL/DELTABED  ratio  is  decreasing, ratios  for  where b o t h bed c a p a c i t y and u t i l i z a t i o n  are  then  school  increasing  than with  declining.  Examination  significant  school d i s t r i c t s / y e a r s  differences  of  this  where b o t h  r a t i o d i d not r e v e a l  between t h e two o p p o s i t e  are  any  corners.  217  5.  DISCUSSION  The m a i n o b j e c t i v e s relationships  thesis  s t u d y were t o e x a m i n e  "medical needs"  continues  t h e work i n i t i a t e d b y o t h e r s  f  "supply"  Evans  paediatric hospital  e t a 1.,  1983).  1978; Evans  Findings  of  this  services  (Evans and  and R o b i n s o n ,  day c a r e s u r g e r y results  of  1968-1976  this  is  its  and 1 9 8 1 - 1 9 8 3 .  However,  1980;  services  i n B.C.  Evans  in  and w h e t h e r specific  data over the  years  that  resemble those  Canada o r N o r t h A m e r i c a , t h e s e f i n d i n g s  ei  for  program  The  to the extent  it  Robinson,  and how,  promises.  s t u d y a r e b a s e d on B . C .  paediatric hospital in  fullfilling  This  the  and  s t u d y have i m p o r t a n c e  s h o u l d be e x p a n d e d , on what g r o u n d s ,  with  models.  i n B.C.,  d e c i d i n g whether t h e p a e d i a t r i c day c a r e s u r g e r y B.C.  hospital  a component i n a b r o a d e r a t t e m p t t o e x a m i n e of  al.  availability,  and  economics  1973;  the  and p a e d i a t r i c i n p a t i e n t u t i l i z a t i o n ,  reference to is  this  between d a y c a r e s u r g e r y  bed a v a i l a b i l i t y special  of  elsewhere  may be  generalizable.  This  study  variability other  supports of  studies  The v a r i a t i o n  the findings  paediatric hospital (Wennberg  and Kimm,  of  high  inter-area  u t i l i z a t i o n observed 1977; C o n n e l l e t a l .  among t h e p a e d i a t r i c p o p u l a t i o n  than i n the t o t a l population  i n B.C.  is  much  (Evans e t a l .  f  f  in 1981).  higher  1983).  218  Eighty  seven percent of the  cross-district/cross-year  v a r i a t i o n i n the o v e r a l l p a e d i a t r i c h o s p i t a l u t i l i z a t i o n  could  be accounted f o r by the v a r i a b l e s used i n t h i s study. T h i s l e s s than what Evans et a l .  (1983) e x p l a i n e d i n the  population using s i m i l a r regression h i g h as  admissions. T h i s ( 1 9 7 5 ) , who  i s consistent  total  models. They r e p o r t e d  92 p e r c e n t e x p l a n a t o r y power f o r w i t h Van  is  as  medical/surgical der Gaag et  al.  a l s o r e p o r t e d lower e x p l a i n e d v a r i a n c e f o r  c h i l d r e n ' s ' h o s p i t a l u t i l i z a t i o n than f o r a d u l t  utilization.  However, a c o e f f i c i e n t of d e t e r m i n a t i o n of 87 p e r c e n t i s sufficiently  h i g h t o a l l o w the drawing of some c o n c l u s i o n s  r e g a r d i n g the determinants of p a e d i a t r i c h o s p i t a l i z a t i o n .  The  study of the e f f e c t of day  care s u r g e r y a v a i l a b i l i t y  p a e d i a t r i c i n p a t i e n t u t i l i z a t i o n was  based on  estimating  i n p a t i e n t u t i l i z a t i o n as i t would have o c c u r r e d i n the of day  care surgery. The  construction  a l t e r n a t i v e s t a t e of the world was several  f a c t o r s which may  of t h i s  absence  hypothetical  achieved by i n c l u s i o n of  have importance i n d e t e r m i n i n g  inpatient u t i l i z a t i o n , into a regression  model on  the  assumption t h a t the e f f e c t of these c o n t r o l l e d v a r i a b l e s  on  i n p a t i e n t u t i l i z a t i o n i s not a f f e c t e d by the e x i s t e n c e of care s u r g e r y ( i . e . , no  on  i n t e r a c t i o n e f f e c t s ) . The  day  e f f e c t of  p o p u l a t i o n base i n determining i n p a t i e n t u t i l i z a t i o n  the  rates,  the age-sex d i s t r i b u t i o n of the p a e d i a t r i c p o p u l a t i o n ,  was  c o n t r o l l e d f o r by age-sex adjustment of the dependent and  main  independent v a r i a b l e s . Other f a c t o r s t h a t were c o n t r o l l e d  for  219  in  constructing  this alternative  state,  a l t e r n a t i v e s , were p a e d i a t r i c  bed  availability,  physicians  of  availability  of  unknown t i m e - and  These v a r i a b l e s reported  to  Findings  on  hospital  and  day  would not  paediatric  c a r e has  i n the  r e l a t i o n s h i p was  care  joint  surgical services l o w e r bed  population ratio.  influence  h a v e been  surgery  and  total  add-on t o  view  the  overall  and  of  bed  hospital that  alternative seemed  no-DCS to  studied  a statistical availability  inpatient  artifact on  utilization.  raises  availability,  after adjusting  availability,  reflects  than with a high the  possibility  w i t h day f o r the  unmet h o s p i t a l bed  capacity.  care  bed-tothat  bed  c a r e n e e d due  This  the  surgery  e f f e c t of  that  total  have b e e n i n t r o d u c e d more e a g e r l y  capacity  This  hospital  care  support the  hypothetical  f o u n d t o be  generation e f f e c t associated  insufficient  strongly  and  children.  c a r e when i t s e f f e c t was  care surgery a v a i l a b i l i t y  areas with  in  range  factors.  that  care surgery a v a i l a b i l i t y  alone, the  a  hospital-based u t i l i z a t i o n  i n the  for inpatient  day  factors  g e n e r a t e d new  sense of  A l t h o u g h , day  from the  range of  b e e n l a r g e l y an  have o c c u r r e d  specialty,  medical/surgical  utilization  physician  district-specific  r e l a t i o n s h i p between day  substitute  arising  by  of  school d i s t r i c t s ,  utilization  c a r e s y s t e m . I t has  utilization,  state.  the  inpatient  paediatric  the  affect hospital  availability surgical  cover well  a range  availability,  socioeconomic c h a r a c t e r i s t i c s of  u n m e a s u r e d and  or  to  hypothesis i s ,  both Day in  220 however,  not  s u p p o r t e d by t h e f i n d i n g  occupancy r a t e throughout declining  i n B.C.  marked i n  small  capacity this  since  hospitals  this  study  only  if  a confounding  a c t u a l l y made a v a i l a b l e  from the e x i s t i n g  day c a r e s u r g e r y  hospital  however,  is  surgery  capacity)  patients at  in hospital  with  the  examined of  in  nurses  approved  means  bed  severe i l l n e s s  day  If  is new  costs An  care  based treatment  t h a t were f o r m e r l y  offices.  If  additional  (including  of  generation  b a s e d on n e e d s o r n o t .  system c a p a c i t y  home o r i n p h y s i c i a n s '  occur,  it  would cause the h o s p i t a l  less  and  beds  saving perspective.  generated,  w h e t h e r t h e new u t i l i z a t i o n i s increase  in  due t o unmet n e e d s o r n o t ,  from a c o s t  utilization is  if  of  and may d e t e r m i n e t h e number  effect  crucial,  i.e.  but the supply  The q u e s t i o n o f w h e t h e r t h e o b s e r v e d  not  b e e n more  p a e d i a t r i c wards  capacity. of  been  utilization  c a p a c i t y was  factor,  ward  Existence  r a t h e r than the  physician  may e q u a l l y w e l l be i m p o r t a n t beds  1980).  f o r low o c c u p a n c y ,  were s t a f f  The a v a i l a b l e as  (Sheps,  c a n o n l y be i m a g i n e d  capacity constraints  have  1966, and t h e d e c l i n e has  on p a e d i a t r i c h o s p i t a l  were s t a f f e d  themselves.  a low p a e d i a t r i c  Occupancy r a t e s  paediatric units  constraints  situation  B.C..  of  these kind of  of  treated shifts  one must a l w a y s a s k w h e t h e r t h e y i m p r o v e t h e outcome  care to the extent that undesirable  Findings  effects  of  it  outweighs  hospital  a f t e r adjustment  and  s t a y on c h i l d r e n .  i n the i n d i v i d u a l years  1982/83 d a t a s e t  the increased costs  of  and i n t h e p o o l e d  f o r time s p e c i f i c  1968-  confounders  221 suggest that p e r c e n t of inpatient  day c a r e surgery surgery  generation As  over the p e r i o d 1968-1982/83,  of  closely  new a c t i v i t y  type  controlling  different  utilization, "saved"  that  positive  effects  of  cases.  T h i s means  after paediatric  paediatric  had no  of  paediatric  capacity  use.  the d i r e c t generation  on i n p a t i e n t of  and i n c r e a s e d p a e d i a t r i c  It  is  new h o s p i t a l - b a s e d inpatient  a result  of  and  by  utilization  and  s u g g e s t no bed  plausible surgical  day c a r e  that  activity  u t i l i z a t i o n through  introducing  the  facilities.  utilization  bed c a p a c i t y  constraints  increased  observed over  day c a r e s u r g e r y inpatient  hospital  w h i c h were  surgical  actually  the  surgical  patients  r e l a t i v e l y h i g h unused p a e d i a t r i c  as  of  factors.  beds  u s e were f i l l e d w i t h  that  p e r i o d i n the absence  v a c a t e d beds  SURG C -  availability  one c a n c o n c l u d e t h a t p a e d i a t r i c  Generally declining  of  for  characteristics  surgical  more  Statistically  and p r a c t i c a l l y no e f f e c t on o v e r a l l  by day c a r e s u r g e r y  whole.  more  e f f e c t on t o t a l m e d i c a l / s u r g i c a l  w o u l d h a v e d e c l i n e d more t h a n was study  cases.  day c a r e s u r g e r y  u t i l i z a t i o n b y non-DCS e l i g i b l e medical  which  and t i m e - and d i s t r i c t - s p e c i f i c  Given the findings  utilization  socioeconomic  a  seemed t o a f f e c t  u t i l i z a t i o n i n the pooled dataset  districts  slightly  as  revealed only  confounding  for  be  system  categories  e f f e c t was  for potential  bed c a p a c i t y ,  or  surgery  resemble day c a r e s u r g e r y - t y p e  inpatient  school  the s u b s t i t u t i o n  substitution  10  represented substitution  to the h o s p i t a l  defined inpatient  significant  than  and o v e r 90 p e r c e n t a p p e a r e d t o  one m i g h t e x p e c t ,  narrowly  less  fill-in  surgery  222  facilities,  in this  situation,  u n r e l a t e d to medical needs. to  estimate  how much o f  activity  represents  offices.  Higher  reflects  It  is  impossible,  the generation  a substitution  paediatric  supply  for  surgical  of  induced  in this  new  demand  study,  hospital-based  care i n  physicians'  utilization  facilitated  d i r e c t l y b y t h e i n c r e a s e d c a p a c i t y and i n d i r e c t l y b y t h e in  of  v a c a t e d beds  availability  is  High s u r g i c a l surgical  availability estimates  rates  of  the regression  in this  medical/surgical  data  in  and t o t a l  T&A u t i l i z a t i o n  eligible  f  population  surgical 1983).  coefficients  utilization,  Differences  for  coefficient  of  population.  The i m p a c t  excess  surgery  In  SURG A -  d e t e r m i n a t i o n was  the  to  except i n  with  the  the  pooled  independent  the  d i l u t e d at  the  relationship  u s e t o t h e same e x t e n t  However,  i n the r e s u l t s  of  the  not a f f e c t  and i n p a t i e n t  categories.  on DCS  of  in respect  over time, which i s  population.  differences  surgical  population.  c o e f f i c i e n t on d a y c a r e  l e v e l and d o e s  the p a e d i a t r i c  substantial  to a  1981).  f o r the t o t a l  (Evans e t a 1.  population  surgery  s t u d y d i d n o t d i f f e r v e r y much f r o m  between day c a r e s u r g e r y as  an a d v a n t a g e  c o u l d be e x p l a i n e d b y t h e e f f e c t o f  declining total  day c a r e  c a r r y w i t h them a h i g h r i s k  (Roos and R o o s ,  observed  pooled data  a consequence of  not n e c e s s a r i l y  deaths  Estimates  as  fill-  for  general,  there are the day the  day c a r e s u r g e r y  care  regression  C were h i g h e r also higher  also  and  i n the  the total  on t h e most  narrow  223 day c a r e s u r g e r y e l i g i b l e u n e x p e c t e d l y low i n t h i s  inpatient u t i l i z a t i o n  colleagues  these v a r i a b l e s  (1983)  different  i n t h e two s t u d i e s .  included surgical  into  t h e SURG A m e a s u r e ,  care  surgery procedures defined i n  1976.  In  this  surgery  was  also  shorter i n c r e a s i n g the p o s s i b i l i t y  eligibility period  over the study p e r i o d i n t h i s  s t u d i e d b y Evans  m e a s u r e was of  cutoff  et a l . .  in  stay  point  of  less  than s i x  f o r the length of  1982/83  (197 6 t o  that  there  surgery  study than i n  both studies although  the  t h e SURG B the  inclusion  was d i f f e r e n t . O n l y p a t i e n t s  p a e d i a t r i c day c a r e s u r g e r y . of  In  c o n s t r u c t e d t h e same way,  operative categories  length of  i n p e r c e i v e d day c a r e  only  t h a t had been  on 40 d a y c a r e s u r g e r y p a t i e n t s  h a v e b e e n more c h a n g e s  day  study,  were i n c l u d e d . The t i m e p e r i o d i n t h e e a r l i e r s t u d y 1968)  and  had  i n a d d i t i o n to the top twelve  t h o s e p r o c e d u r e s i n t h e t o p 30 DCS c a t e g o r i e s least  Evans  procedures that  p a r t i c u l a r p o t e n t i a l t o become p o p u l a r i n d a y c a r e  performed at  was  study.  T h e s e d i f f e r e n c e s may be due t o a s l i g h t l y c o n s t r u c t i o n of  (SURG C)  d a y s were i n c l u d e d .  with This  s t a y may be t o o h i g h  for  On t h e o t h e r h a n d , t h e  proportion  d a y c a r e s u r g e r y - t y p e p a e d i a t r i c i n p a t i e n t s whose l e n g t h  stay  falls  b e t w e e n , f o r e x a m p l e , t h r e e and f i v e d a y s  of  is  insignificant.  In  t h e s t u d y b y Evans  et a l .  a l l o c a t e d SURG B p a t i e n t s  (1983),  interviewed  specialists  i n t o t h e SURG C c a t e g o r y b y  age  224 group.  In  b y age  group b u t gave a t o t a l  patients surgery  this  that  study  This  which o b v i o u s l y if  distorts  response  of  (e.g.,  of  availability  in this  day c a r e s u r g e r y  school d i s t r i c t s  and a c r o s s  criteria  suggested,  t h e r e may be h i g h v a r i a t i o n  more o f  for adults.  the v a r i a t i o n  eligibility than f o r  population hospital  may h a v e i n t r o d u c e d more random e r r o r t o t h e measures, this  study  which a l s o c o n t r i b u t e s and t h e s t u d y  in total  (1981)  have  practice  may r e f l e c t paediatrics.  in this  study  utilization  t o t h e d i f f e r e n c e between population.  that  remained  use,  school d i s t r i c t s  to  The f a c t  use  to  criteria  community  in paediatric hospital  p o p u l a t i o n base of  lower  the  As C o n n e l l e t a l .  individual provider-based variation within  The s m a l l e r  study.  s t u d y may be due  of  of  utilization  i n respect to paediatric h o s p i t a l i z a t i o n .  unexplained than i n t o t a l higher  eligible  in this  inpatient  time,  comparable  styles  age-sex  T h i s may h a v e c a u s e d t h e l a c k  day c a r e s u r g e r y - e l i g i b l e  of  groups,  were u n e v e n l y  t h e SURG C measure t o DCS  higher v a r i a b i l i t y  of  care  age  t o t h e s e measurement d i f f e r e n c e s , t h e  day c a r e s u r g e r y  across  i n a day  applied to a l l  patients  allocation  the p r o p o r t i o n  o l d e r c h i l d r e n were more  or vice versa).  addition  of  t h e SURG C m e a s u r e a f t e r  day c a r e e l i g i b l e  responsiveness  In  estimate  p r o p o r t i o n was  d i s t r i b u t e d b y age than younger  d i d not d e f i n e the  c o u l d have been t a k e n c a r e o f  unit.  adjustment  specialists  225 Results effect  of  associated  population a higher in  this  this  (30-40  study  suggest that  w i t h day c a r e s u r g e r y percent)  is  actually  substitution  substitution dilatation study care  lower,  of  (1983),  nearly  true  This  and t h e i r e x p a n s i o n  strong  legal  support  causal  several  a  greater  Despite  paediatric population,  may  substitution.  to the  hospital  "supply"  utilization  use.  f  1983),  although  the stronger  factors  and u s e .  i n the p a e d i a t r i c  (Evans e t a 1 .  not v e r y marked.  of  day  constraints  which e x p l a i n e d  confounding  r e l a t i o n s h i p between beds  b e d e f f e c t was population  for  use the  was  substantially  i n the t o t a l  population.  lower  and  suggests  a  The o b s e r v e d  than i n the  total  t h e d i f f e r e n c e was  association  t h e e x p l a n a t o r y power o f  availability  alone  The  t h e b e d e f f e c t f r o m one y e a r t o a n o t h e r  adjustment  higher  and  as  a  f o r a g e - s e x d i f f e r e n c e s , t h e most  60 p e r c e n t o f m e d i c a l / s u r g i c a l of  effect  t h e r e may be  to abortions  p a e d i a t r i c bed a v a i l a b i l i t y ,  consistency after  that  factor i n determining paediatric h o s p i t a l  was  n o t mask  The o b s e r v e d  d e a l to the observed  study give  model. A f t e r a d j u s t i n g powerful  does  f o r whom t h e r e i s  procedure a f t e r removal of  this  1983)  (D&C). D&Cs were i n c l u d e d i n  have c o n t r i b u t e d a g r e a t  Results  population  e f f e c t c o u l d be r e l a t e d  and c u r e t t a g e  surgery  implying  total  e f f e c t from day c a r e s u r g e r y .  by Evans e t a l .  rates  f  effect in paediatric population. study  substitution  i n the  (Evans e t a 1 .  some s u b g r o u p s i n t h e a d u l t higher  t h e low  (nearly  in  the  bed  25 p e r c e n t )  The l o w e r c o e f f i c i e n t  of  than  226 determination variability individual rates  i n the p a e d i a t r i c population o f h o s p i t a l u s e due t o h i g h e r  provider  create  higher  styles. Also,  reflect  higher  variation i n  generally  lower  occupancy  p o t e n t i a l f o r v a r i a t i o n i n h o s p i t a l use  f o r t h e same b e d s t o c k in  may  and thus a l l o w  more random f l u c t u a t i o n  p a e d i a t r i c h o s p i t a l u s e when compared t o t h e t o t a l  population.  Comparison o f t h e bed e f f e c t i n p a e d i a t r i c and a d u l t populations  reveals  that despite  t h e low o c c u p a n c y r a t e i n  paediatric  h o s p i t a l s , t h e m a r g i n a l o c c u p a n c y r a t e o f one  additional  b e d w o u l d be h i g h e r  total  population.  population  implies  hospitalization. controlling  The h i g h e r higher  with p a e d i a t r i c s than i n the  bed s u p p l y  effect i n paediatric  d i s c r e t i o n i n respect  I t also implies  higher  to paediatric  potential for  t h e p a e d i a t r i c h o s p i t a l use by c o n t r o l l i n g the  number o f a v a i l a b l e b e d s . However, t h e r e g r e s s i o n the  pooled dataset  implied  u t i l i z a t i o n when t h e r e bed  supply  confirm the  decline  well.  the observed  this  However, t h i s  study could not  t h e r e may be o t h e r that u t i l i z a t i o n  i n bed s u p p l y  i s " s t i c k y downward".  resistance reflects  the longer  decreasing  l o w e r b e d e f f e c t was a r e s p o n s e t o  i n bed c a p a c i t y ;  to increases  utilization  in  i s a p o l i c y environment of  I t c a n be h y p o t h e s i z e d  directly  that  a lower decrease of i n p a t i e n t  than the reverse.  that  equations i n  run u t i l i z a t i o n  only  f a c t o r s as  responds  than t o decreases  more - i.e.  However, i t i s p l a u s i b l e a l a g g e d r e s p o n s e , and t h a t  changes i n r e s p o n s e t o bed  227 c a p a c i t y changes environment of  w o u l d be s y r n m e t r i c .  100 p e r c e n t o c c u p a n c y ,  r e s e a r c h w o u l d be n e e d e d t o t e s t  According to t h i s hospital through  study,  Law a p p l i e s  a r e more o r  less  when m e a s u r e d as  affected  It  the a v a i l a b l e  1)  physical  changed;  remains and 3)  a r e changed. ratio bed  in  stock  F o r example,  1 9 7 5 - 1 9 8 2 / 8 3 was  bed s t o c k  availability  2)  ratio  © x a m i n a t i o n of  this  is  physical is  and p o p u l a t i o n  base  bed-to-population physical  the p a e d i a t r i c p o p u l a t i o n , The d e c r e a s e i n a c t u a l  physicians  a r e more aware o f  a r e b a s e d on c h a n g e s  would a l s o  terms. changes  and t h a t  in physical  require a  bed  i n the bedbed  only i n the population base.  hypothesis  but  beds  in relative  than i n p o p u l a t i o n base  compared t o c h a n g e s  study.  bed s t o c k  e f f e c t s may be d i f f e r e n t when c h a n g e s  to-population  c a n be  a decrease both i n a c t u a l  larger.  One c a n h y p o t h e s i z e t h a t  only  bed s t o c k  exceeded the decrease i n p o p u l a t i o n  in physical  The bed  ratio,  t h e same;  the decrease i n  and i n t h e s i z e o f  with the former being vastly  physicians  unchanged but t h e p o p u l a t i o n base  both p h y s i c a l  work  is  bed s u p p l y .  a bed-to-population  i n t h r e e d i f f e r e n t ways:  More  paediatric  believed to  assumes t h a t  changed but t h e p o p u l a t i o n base remains stock  to  c o n c e p t i o n o f what  for hospitalization. aware o f  must be t r u e .  hypotheses.  u t i l i z a t i o n . The Roemer e f f e c t i s  appropriate  bed  an e x t r e m e  this  these  Roemer's  health professionals'  supply,  In  A  stock closer  separate  228 Socioeconomic  characteristics  of  a school d i s t r i c t  were  the  n e x t most p o w e r f u l f a c t o r i n d e t e r m i n i n g p a e d i a t r i c  hospital  utilization  control  for  rates.  possible  These f a c t o r s  confounding  study v a r i a b l e s , school d i s t r i c t  effects  populations. 1971 and i n  Since  only in  values  socioeconomic v a r i a b l e s  whole p e r i o d of  1968-1976  1 9 8 2 / 8 3 , when a n a l y z i n g c o u l d be c r i t i c i z e d constant large  as  time b l o c k s .  the pooled  hospital  in  1971 were e x t e n d e d t o f r o m 1981, t o  the pooled dataset. somewhat a r b i t r a r y ,  This  in  1971 and 1981/82  1981/82-  it  imposes  physician  conclusions  dataset.  factor i n determining  t h e main a s s o c i a t i o n s  as  interest,  i.e.  of  a  the  f o r the e f f e c t  by s p e c i a l t y d i d n o t m a r k e d l y of  by  such d i d not p l a y  The a d j u s t m e n t  improved the c o e f f i c i e n t of  equations.  paediatric  was p h y s i c i a n a v a i l a b i l i t y  between m a i n s t u d y v a r i a b l e s  availability  but  for  individual  l e d t o t h e same  Total physician a v a i l a b i l i t y  relationships  the  exercise  because  from the the  in paediatric hospitalizations.  overall  were  1981 i n t h e r e q u i r e d d e t a i l ,  and v a l u e s  u t i l i z a t i o n rates  specialty.  and DCS,  individual  socioeconomic data  But t h e f i n d i n g s  The t h i r d m e a n i n g f u l  role  of  between main  i n t e r - d i s t r i c t v a r i a n c e and no t i m e v a r i a n c e  year equations as  in relationships  caused by c h a r a c t e r i s t i c s  available of  were i n t r o d u c e d t o  of  change  t h o s e w i t h bed  supply  determination for  the  229 The a d j u s t m e n t implied that paediatric  there are d i s t r i c t - s p e c i f i c patterns  inpatient  independent of socioeconomic dummies  f o r d i s t r i c t - s p e c i f i c confounding  utilization, persisting  bed and d a y c a r e s u r g e r y factors.  confirmed that  The a d j u s t m e n t  decline  f o r time  The s t u d y  o c c u r r e d independently of availability.  T h e r e has  community t h a t  is  confirms  substituted this  substitution  artifact  This  If  it  w o u l d be n e e d e d f o r  reflects a  i n the pooled dataset  for  T&As.  C o n s t r u c t i o n of for  wi t h  was  (without However,  adenoidectomies had  s t u d y y e a r and  this  in the  statistical Analysis  that  substitution  n o t done i n t h i s  study.  an a g e - s e x s p e c i f i c DCS v a r i a b l e w i t h o u t  e a c h s t u d y y e a r w o u l d have meant c o n s i d e r a b l e  of  variable  the p o s s i b i l i t y  reflect real  was  see  only observed i n  time t r e n d .  e x c l u s i o n of  However,  has  one w o u l d h a v e e x p e c t e d t o  the equations inpatient  in  surgery  tonsillectomy  e x c l u d e s T&As w i t h t h e DCS  final  The  general  decline  day c a r e s u r g e r y  due t o t h e c a p t u r e d g e n e r a l that  the  f o r day c a r e s u r g e r y .  substitution  suggesting that  the pooled dataset  is  this  both i n each i n d i v i d u a l  the pooled dataset.  patterns  f e e l i n g i n the medical  and t o n s i l l e c t o m i e s  f o r i n p a t i e n t T&As,  pooled data,  that  been a g e n e r a l  a r e done i n d a y c a r e s u r g e r y .  of  specific  the i n c r e a s e i n day c a r e  not s u i t a b l e  both adenoidectomies  and  utilization, in particular  the s i n g l e o p e r a t i o n of  adenoidectomy)  time,  school d i s t r i c t s .  these time s p e c i f i c e f f e c t s  use.  through  there are a l s o time s p e c i f i c  in paediatric hospital  T&A s u r g e r y  of  availability  i n p a e d i a t r i c u t i l i z a t i o n , common t o a l l most c r u c i a l o f  effects  T&As  additional  230 database  development.  specific  dummies  the notion that unsuitable evidence  Results  and i n e a c h i n d i v i d u a l y e a r , tonsillectomies  f o r day c a r e s u r g e r y ,  for explaining  day c a r e s u r g e r y  availability  is  are generally  of  with  the s t a t i s t i c a l l y  sufficient  significant as  an  related to o v e r a l l  u t i l i z a t i o n i n t h e 0-14  p a e d i a t r i c bed a v a i l a b i l i t y .  Thus,  surgery paediatric  y e a r age  Roemer's  negative  artifact.  i n p a t i e n t u t i l i z a t i o n , but t h e main d r i v i n g  behind h o s p i t a l  with  considered  the study a r e t h a t day c a r e  not c a u s a l l y  time  together  were c o n s i d e r e d  e f f e c t i n the pooled dataset  The c o n c l u s i o n s  hospital  i n the equations  force  group  is  law a p p l i e s  to the  p a e d i a t r i c p o p u l a t i o n as w e l l . Q u e s t i o n s  of  the s i z e  of  b e d e f f e c t when bed s u p p l y  and when i t  is  declining need f o r surgery  is  increasing  c a n n o t be a n s w e r e d f u l l y i n t h i s further studies  availability,  paediatric  There i s  on t h e r e l a t i o n s h i p between d a y  p a e d i a t r i c bed a v a i l a b i l i t y  i n p a t i e n t u t i l i z a t i o n i n B.C.  more and more o f  study.  p a e d i a t r i c beds  i n the  have been c l o s e d .  a  care  and  1980s  a  when  6.  BIBLIOGRAPHY  A n d e r s o n J G : Demographic F a c t o r s A f f e c t i n g H e a l t h S e r v i c e s U t i l i z a t i o n : A C a u s a l M o d e l . Med C a r e 1 1 : 1 0 4 - 1 2 0 , 1973. A t w e l l JD: C h a n g i n g p a t t e r n s i n p a e d i a t r i c R C o l l S u r g Engl 60: 375, 1978.  surgical  care.  A t w e l l J D , B u r n JMB, Dewar AK, Freeman NV: Paediatric Case S u r g e r y . L a n c e t 2: 8 9 5 - 8 9 7 , 1973. A h l g r e n EW: P e d i a t r i c o u t p a t i e n t a n e s t h e s i a r e v i e w . Am J D i s C h i l d 126: 3 6 , 1973.  - A  Ann  Day-  four-year  A z a r n o f f P: P r e p a r a t i o n of C h i l d r e n f o r H o s p i t a l i z a t i o n . F i n a l R e p o r t t o NIMH. L o s A n g e l e s , UCLA, D e p a r t m e n t o f P e d i a t r i c s , 1975 ( u n p u b l i s h e d ) . Bakwin H: P s e u d o d o x i a 1945.  p e d i a t r i c i a . N Engl  J Med 282:  691,  B a r e r ML,  Wong-Fung P: F e e P r a c t i c e M e d i c a l Service per Capita 19R3-ft4 a n d F u l l - T i m e E q u i v a l e n t P h y s i c i a n s i n B r i t i s h C n 1 u m h i a 1979-80 t o 1983-84. HMRU R e p o r t 8 5 : 1 . V a n c o u v e r , B.C. 1985. RyppnHitnrPR  r  r  B e r k A A , C h a l m e r s T C : C o s t and e f f i c a c y o f a m b u l a t o r y f o r i n p a t i e n t c a r e . N Engl 1981.  the s u b s t i t u t i o n of J Med 304: 3 9 3 - 3 9 7 ,  B o m b a r d i e r C , F u c h s , VR, L i l l a r d , L A and Warner K E : Socioeconomic Factors A f f e c t i n g the U t i l i z a t i o n of Surgical Operations. N E n g l .T M e d 2 3 7 ( 1 3 ) : 6 9 9 - 7 0 5 , 1977 . Brain  D J , M a c l a y I: C o n t r o l l e d S t u d y o f M o t h e r s R r i t Mfid J 1 : 2 7 8 - 2 8 0 , 1968.  and C h i l d r e n .  232 B u e h l e r JW, S m i t h L F , W a l l a c e EM, H e a t h CW, K u s i a k R, H e r n d o n J L : U n e x p l a i n e d d e a t h s i n a c h i l d r e n ' s h o s p i t a l . N Engl J  Med 211-216, 1985.  C a n a d a : Royal Commission on H e a l t h S e r v i c e s . Volume I. P r i n t e r , Ottawa 1964.  Queen's  C h i a n g TM, S u k i s A E , Ross DE: T o n s i l l e c t o m y performed on an outpatient basis. R e p o r t o f a s e r i e s o f 40,000 c a s e s p e r f o r m e d w i t h o u t a d e a t h . A r c h O t o l a r y n g o l 88:307, 1968. C l o u d DT: The S u r g i c e n t e r : A f r e s h concept i n o u t p a t i e n t p e d i a t r i c surgery. J P e d i a t r S u r g 7:206-212, 1972. C o l l e AD, Grossman M: D e t e r m i n a n t s o f p e d i a t r i c c a r e u t i l i z a t i o n . J o u r n a l o f Human Rssources 1 3 : S u p p l e m e n t 1 1 5 - 1 5 8 , 1978. Conference of Health M i n i s t e r s : Community h e a l t h c e n t r e project. The Community h e a l t h c e n t r e i n C a n a d a . Vols I I , and I I I . I n f o r m a t i o n C a n a d a , O t t a w a 1972.  I,  C o n n e l l F A , Day RW, L o G e r f o J P : H o s p i t a l i z a t i o n o f M e d i c a i d C h i l d r e n : A n a l y s i s of Small Area V a r i a t i o n s i n Admission R a t e s . Am J P u b l i c Health 71: 606-613, 1981. C r i c h t o n A : Community h e a l t h c e n t r e s : Health care o r g a n i z a t i o n o f the f u t u r e ? Report t o the committee on Community H e a l t h C e n t r e p r o j e c t . H e a l t h and W e l f a r e C a n a d a , O t t a w a 1972. C r o c k e r , E : P r e p a r a t i o n f o r Surgery - A Research Report. H a l i f a x , I z a a h W a l t o n K i l l a m H o s p i t a l f o r C h i l d r e n , 1978 (unpublished). D a v e n p o r t HT, Shah C P , R o b i n s o n GC: Day s u r g e r y Can Med Assoc J 1 0 5 : 4 9 8 - 5 0 1 , 1971.  f o rchildren.  D&nzer B S , F e l s h i n G : The p r e t o n s i l l e c t o m y c l i n i c . J P e d i a t r  22:  239, 1943.  D i e h r P: S m a l l a r e a s t a t i s t i c s : l a r g e s t a t i s t i c a l J P u b l i c H e a l t h 74: 313-314, 1984.  p r o b l e m s . Am  233 Downey GW: A s c a n n e r f o r e v e r y h o s p i t a l ? 16, 1976. Duff  Mod H e a l t h Tare 5:  RS, Cook CD, Wanerka GR, Rowe DS, D o l a n T : Use o f u t i l i z a t i o n review to assess the q u a l i t y of p e d i a t r i c inpatient care. P e d i a t r i c s 4 9 : 1 6 9 - 1 7 6 , 1972.  D u t t o n DB: S o c i o e c o n o m i c S t a t u s and C h i l d r e n ' s H e a l t h . Care 2 3 : 1 4 2 - 1 5 6 , 1985. E g b u o n e r L , S t a r f i e l d B: C h i l d h e a l t h and s o c i a l P e d i a t r i c s 6 9 : 5 5 0 , 1982.  Med  status.  E v a n s RG: O t h e r e x p e r i e n c e s w i t h a l t e r n a t i v e c a r e : common p r o b l e m s and s u g g e s t e d s o l u t i o n s . I n : R o b i n s o n GC, C l a r k e HF ( e d s ) : The H o s p i t a l Care of C h i l d r e n . A r e v i e w of contemporary i s s u e s . O x f o r d U n i v e r s i t y P r e s s , New Y o r k 1980. Evans RG: S t r a i n e d mercy. The Economics of Canadian H e a l t h Ca r e . B u t t e r w o r t h s , T o r o n t o 1984. E v a n s RG, K i n n i s C, R o b i n s o n GC: A Cost A n a l y s i s o f A l t e r n a t i v e s t o T r a d i t i o n a l I n p a t i e n t Care i n a Children's Hospital. S u r g i c a l Day C a r e and C a r e b y Parent. F i n a l Report. H e a l t h and W e l f a r e C a n a d a , G r a n t No. 6 1 0 - 1 1 0 3 - 4 3 , O t t a w a , 1978 ( u n p u b l i s h e d ) . Evans RG, K l i e w e r EV, R o b i n s o n GC: The Impact of S u r g i c a l Day Ca re on Si i r g i ca 1 Tit i 1 i *a t i on : An A n a l y s i s of Ten Y e a r s ' E x p e r i e n c e i n B.C.. F i n a l Report. H e a l t h and W e l f a r e C a n a d a , G r a n t No. 6 6 1 0 - 1 2 1 2 - 4 6 , O t t a w a , 1983 (unpublished). E v a n s RG, R o b i n s o n GC: An E v a l u a t i o n of t h e Economic I m p l i c a t i o n s of a Day Care Surgery U n i t . F i n a l Report. H e a l t h and W e l f a r e C a n a d a , G r a n t No. 6 1 0 - 2 1 - 1 4 , O t t a w a , 1973 ( u n p u b l i s h e d ) . E v a n s RG, R o b i n s o n GC: S u r g i c a l d a y c a r e : M e a s u r e m e n t s e c o n o m i c p a y o f f , CM A . T o n m a l 1 2 3 : 8 7 3 - 8 8 0 , 1980.  of  the  234 Farquharson EL: E a r l y ambulation with s p e c i a l r e f e r e n c e to h e r n i o r r a p h y as an o u t p a t i e n t p r o c e d u r e . Lancet 2 : 5 1 7 5 1 9 , 1955. F e l d s t e i n , MS: H o s p i t a l Cost I n f l a t i o n : A Study of N o n p r o f i t P r i c e Dynamics. The American E c o n o m i c Review 6 0 : 8 5 3 - 8 7 2 , 1971. F r e u d A : O b s e r v a t i o n s on c h i l d d e v e l o p m e n t . Study o f the Chi Id V o l V I . New Y o r k , U n i v e r s i t i e s P r e s s , 1951 ( p . 1 8 - 3 0 ) .  The P s y c h o a n a l y t i c International  F u c h s VR: The S u p p l y o f S u r g e o n s and t h e Demand f o r O p e r a t i o n s . J o u r n a l o f Human R e s o u r c e s 1 3 : S u p p l e m e n t 3 6 , 1978.  35-  G i n s b u r g PB, K o r e t z DM: Bed A v a i l a b i l i t y and H o s p i t a l U t i l i z a t i o n : E s t i m a t e s o f t h e "Roemer E f f e c t " . H e a l t h Care F i n a n c i n g Review R {1 ) » R.7-Q7 1983. r  G o r a n M J , D o n a l d s o n MC: A m b u l a t o r y Hosp Prog 5 7 : 4 7 , 1976. G r o s s ML:  The D o c t o r s .  surgery  Random H o u s e ,  standards  New Y o r k ,  needed.  1966.  Hadaway E G , Ingram RM, T r a y n a r M J : Day c a r e s u r g e r y f o r s t r a b i s m u s i n c h i l d r e n . Trans Ophthalmol Soc TIK 9 7 : 2 3 , 1977. H a r r i s DM: E f f e c t o f P o p u l a t i o n and H e a l t h C a r e E n v i r o n m e n t on H o s p i t a l U t i l i z a t i o n . H e a l t h S e r v i c e s Research 10(3)-.229-243, 1975a. H a r r i s DM: An e l a b o r a t i o n o f t h e r e l a t i o n s h i p b e t w e e n g e n e r a l h o s p i t a l b e d s u p p l y and g e n e r a l h o s p i t a l u t i l i z a t i o n . J. H e a l t h Soc Rehav 1 6 : 1 6 3 - 1 7 2 , 1975b. H a r v a r d C h i l d H e a l t h P r o j e c t : C h i l d r e n ' s Medical Care Needs and Treatments. Report o f the Harvard C h i l d H e a l t h P r o j e c t . B a l l i n g e r P u b l i s h i n g Company, C a m b r i d g e , M a s s . 1977.  235 H e r Z f e l d GH: Hernia i n 3 9 : 4 2 2 - 4 2 8 , 1938.  infancy.  American  Jnnmal  of  finrggry  H o l l i n g s w o r t h H, Klem MC, Baney AM ( e d s ) : M e d i c a l C a r e and C o s t s i n R e l a t i o n t o F a m i l y Income. Government P r i n t i n g O f f i c e , W a s h i n g t o n , D.C. 1947.  Hynniman C E , C o n r a d WF, U r c h WA, R u d n i c k BR, P a r k e r P F : A comparison of m e d i c a t i o n e r r o r s under the U n i v e r s i t y of K e n t u c k y u n i t - d o s e s y s t e m and t r a d i t i o n a l d r u g d i s t r i b u t i o n s y s t e m s i n f o u r h o s p i t a l s . Am J Hosp Pharm 27: 8 0 2 - 8 1 4 , 1970.  I n n e s A , G r a n t A J , B e i n f i e l d MS: Experience with shortened hospital stay for postsurgical patients. JAMA 2 0 4 : 6 4 7 , 1968.  I s t r e GR, G u s t a f s o n T L , B a r o n RC, M a r t i n DL, O r l o w s k i J P : A m y s t e r i o u s c l u s t e r o f d e a t h s and c a r d i o p u l m o n a r y a r r e s t s i n a p e d i a t r i c i n t e n s i v e c a r e u n i t . N E n g l J Med 3 1 3 : 2 0 5 - 2 1 1 , 1985.  Joffe  J: M o b i l i t y Adjustments f o r Studies. i n q u i r y 16:350-355,  Kimm SYS: Case  Utilization  E f f e c t i v e n e s s of P e d i a t r i c H o s p i t a l i z a t i o n : o f T o n s i l l e c t o m y and A d e n o i d e c t o m y . Harvard  Health P r o j e c t :  Children's  t r e a t m e n t s . Volume U . S . A . , 1977.  Kozak  Small Area 1979.  2.  medical  Ballinger  care  needs  Publishing  The Chi Id  and  Company,  J , M c C a r t h y E: H o s p i t a l Use b y C h i l d r e n i n t h e U n i t e d S t a t e s and C a n a d a . DHHS P u b l i c a t i o n No. (PHS) 84-1477, Comparative  Tnternatinna1  Vital  and  Health  S t a t i s t i c s  R e p o r t s , S e r i e s 5, No. 1, N a t i o n a l C e n t e r f o r H e a l t h S t a t i s t i c s , U.S. D e p a r t m e n t o f H e a l t h and Human S e r v i c e s , H y a t t s v i l l e 1984.  Kroovand  RL,  P e r l m u t t e r AD:  urology.  LaLonde  M:  A  .T U r o l  New  Government  of  120:  Short  483,  Perspective  Canada,  stay  surgery  in  paediatric  1978.  on  Ottawa  the Health  1974.  of  Canadians.  236 L a w r i e R: O p e r a t i n g on c h i l d r e n as d a y - c a s e s . 1964.  T.ancet 2 : 1 2 8 9 ,  L e e Ms O u t p a t i e n t Treatment f o r Haemorrhoids by the e l a s t i c b a n d m e t h o d . Br .T CI i n Prant. 2 5 : 5 4 2 - 5 4 3 ,  1971  L e w i s AAM: Outpatient surgery i n developing country. 1 : 9 1 0 - 9 1 2 , 1975. Long MJ: The R o l e o f Consumer L o c a t i o n i n t h e Demand Inpatient Care. Tnqui r y 1 8 : 2 6 6 - 2 7 3 , 1981. L o r d P:  Day c a s e s u r g e r y .  P r o c R Soc Med 6 7 : 998,  T.ancet  for  1974.  M a c l u r e A , S t e w a r t GT: A d m i s s i o n o f c h i l d r e n t o h o s p i t a l s i n G l a s g o w : R e l a t i o n t o unemployment and o t h e r d e p r i v a t i o n v a r i a b l e s . T.ancet 2: 682-685, 1984. Mare RD: S o c i o e c o n o m i c e f f e c t s on c h i l d m o r t a l i t y i n t h e U n i t e d S t a t e s . Am .T P.I hi i c Health 7 2 : 5 3 9 , 1982. May  J J : U t i l i z a t i o n o f H e a l t h S e r v i c e s and t h e A v a i l a b i l i t y o f R e s o u r c e s . I n : A n d e r s e n R, K r a v i t s J J , A n d e r s o n OW ( e d s ) : E q u i t y i n Health S e r v i c e s : E m p i r i c a l Analyses i n S o c i a l P o l i c y . B a l l i n g e r P u b l i s h i n g Company, C a m b r i d g e , M a s s . 1975.  Meers  PD, A y l i f f e G A J , Emmerson AM, L e i g h DA, M a y o r - W h i t e RT, M a c k i n t o s h CA, S t r o n g e J L : R e p o r t on t h e N a t i o n a l S u r v e y of I n f e c t i o n s i n H o s p i t a l s , 1980. Journal of H o s p i t a l T n f e c t i on 2 : S u p p l e m e n t , 1981.  Myers GW: H o s p i t a l i z a t i o n E x p e r i e n c e o f a Government H o s p i t a l Care I n s u r a n c e P l a n . P a r t 2. Canadian Journal of P u b l i c Hea1th 4 5 : 4 2 0 - 4 2 9 , 1954. Nicholl JH: The S u r g e r y o f 2 : 7 5 3 - 7 5 4 , 1909.  infancy.  Br i t i sh Med i ca1 Jou rna 1  Osgood K, Bunch GP, S h o n i c k W: The Impact o f P e d i a t r i c P r a c t i c e on H o s p i t a l A d m i s s i o n s i n a R u r a l A r e a . Am J P u b l i c Health 70: 1100-1103, 1980.  237 O t h e r s e n HB, C l a t w o r t h y HW: Outpatient herniorraphy i n f a n t s . Am .T n i s c h i l d 1 1 6 : 7 8 , 1 9 6 8 .  for  P e r r i n JM, V a l v o n a J , S l o a n FA: Changing P a t t e r n s of H o s p i t a l i z a t i o n f o r Children Requiring Surgery. Pediatrics 77(4):587-592, 1986. P e t r i l l o M, S a n g e r S: Emotional Care of H o s p i t a l i z e d C h i l d r e n : An E n v i r o n m e n t a l A p p r o a c h . J.B. Lippincott Company, T o r o n t o 1 9 7 2 . Province of B r i t i s h Columbia: H o s p i t a l Insurance Act Regulations: H o s p i t a l I n s u r a n c e A c t . B.C. G a z e t t e , p a r t II, February 29,1968. P r o v i n c e of  B r i t i s h C o l u m b i a : R e p o r t on d a y c a r e s u r g e r y B r i t i s h Columbia. M i n i s t r y of H e a l t h , Research D i v i s i o n , H o s p i t a l Programs, V i c t o r i a , n . d . 1 9 8 3 . iqft?/tn  r  P r o v i n c e of B r i t i s h Columbia: Unpublished e s t i m a t e s of Columbia h e a l t h e x p e n d i t u r e s . M i n i s t r y of H e a l t h , V i c t o r i a , A p r i l 1985.  British  R e n n i e PH: Is A m b u l a t o r y C a r e Worth I t ? H o s p i t a 1 A d m i n i s t r a t i o n i n Canada, October 1 9 7 7 . Ro K-K: P a t i e n t C h a r a c t e r i s t i c s , H o s p i t a l C h a r a c t e r i s t i c s H o s p i t a l U s e . Med C a r e 7: 2 9 5 - 3 1 2 , 1 9 6 9 .  and  R o b e r t s o n A , Gandy J : P o l i c y , p r a c t i c e and r e s e a r c h : an o v e r v i e w . I n : Gandy J , R o b e r t s o n A and S i n c l a i r S ( e d s ) : I m p r o v i n g s o c i a l i n t . P r v P n t i on . C h a n g i n g s o c i a l p o l i c y and s o c i a l work p r a c t i c e t h r o u g h r e s e a r c h . Croom H e l m , L o n d o n and C a n b e r r a , S t . M a r t i n ' s P r e s s , New Y o r k 1 9 8 3 . Robertson J : Some r e s p o n s e s maternal care. Nursing  o f young c h i l d r e n t o t h e l o s s Times 4 9 : 3 8 2 - 3 8 6 , 1 9 5 3 .  R o b e r t s o n J : Young C h i l d r e n i n H o s p i t a l . P u b l i c a t i o n s , London 1 9 7 0 .  Tavistock  of  238 R o b i n s o n GC, C l a r k e HF ( e d s ) : The H o s p i t a l Care of C h i l d r e n A Review o f Contemporary I s s u e s . Oxford U n i v e r s i t y P r e s s , New Y o r k , O x f o r d 1980. R o b i n s o n GC, E v a n s RG: A Survey of P e d i a t r i c H o s p i t a l U t i l i z a t i o n by I n d i a n C h i l d r e n i n B r i t i s h Columbia. Canadian Journal o f P u b l i c Health 6 4 : 1 5 4 - 1 6 0 , 1973. R o b i n s o n GC, Shah C P , A r g u e C, K i n n i s C, I s r a e l s S: A s t u d y the need f o r a l t e r n a t i v e t y p e s of h e a l t h c a r e f o r c h i l d r e n i n h o s p i t a l s . P e d i a t r i c s 4 3 : 8 6 6 - 8 7 8 , 1969. Roemer MI: Bed S u p p l y and H o s p i t a l U t i l i z a t i o n : a experiment. Hospitals 3 5 : 3 6 - 4 2 , 1961.  of  natural  Roemer MI, S h a i n M: H o s p i t a l U t i l i z a t i o n U n d e r I n s u r a n c e . American H o s p i t a l A s s o c i a t i o n H o s p i t a l monograph s e r i e s n o . 6, C h i c a g o 1959. f  Roos L L : S u p p l y , W o r k l o a d and U t i l i z a t i o n : A PopulationBased A n a l y s i s of S u r g e r y i n R u r a l M a n i t o b a . Am J P n h l i o H e a l t h 7 3 ( 4 ) : 4 1 4 - 4 2 1 , 1983. Roos NP, F l o w e r d e w G, Wajda A , T a t e RB: V a r i a t i o n s i n Physicians' Hospitalization Practices: A Population-based S t u d y i n M a n i t o b a , C a n a d a . Am J P u b l i c H e a l t h 7 6 : 4 5 - 5 1 , 1986. Roos NP, Roos L L : H i g h and Low S u r g i c a l R a t e s : R i s k for Area Residents. American Journal o f P u b l i c 7 1 ( 6 ) : 5 9 1 - 6 0 0 , 1981.  Factors Health  R o s e n t h a l G: The Demand f o r G e n e r a l H o s p i t a l F a c i l i t i e s . A m e r i c a n H o s p i t a l A s s o c i a t i o n , H o s p i t a l Monograph sfirifis no 14, C h i g a g o 1964. R o t h F B , A c k e r MS, Roemer MI, M y e r s GW: I n f l u e n c i n g H o s p i t a l U t i l i z a t i o n In I n t e r i m R e p o r t . Canadian Journal o f 4 6 ( 8 ) : 3 0 3 - 3 2 3 , 1955.  Some F a c t o r s Saskatchewan. P u b l i c Health  Roth J A : The n e c e s s i t y a n d c o n t r o l o f h o s p i t a l i z a t i o n . S o c i a l S c i e n c e and M e d i c i n e 6 : 4 2 5 - 4 4 6 , 1972.  An  239 Rubin A, Rosenblatt A (eds): S o u r c e b o o k on R e s e a r c h U t i l i z a t i o n . C o u n c i l on S o c i a l Work E d u c a t i o n , New Y o r k 1979. Rudd WWH: L i g a t i o n o f h e m o r r h o i d s as a n o f f i c e p r o c e d u r e . CMA J o u r n a l 1 0 8 : 5 6 - 5 9 , 1973. S a u t e r V L , Hughes E F X : S u r g i c a l U t i l i z a t i o n S t a t i s t i c s : Some Methodologic Considerations. Med C a r e 2 1 ( 3 ) : 3 7 0 - 3 7 7 , 1983. S c h i m m e l EM: The h a z a r d s 6 0 : 1 0 0 - 1 1 0 , 1964.  o f h o s p i t a l i z a t i o n . Ann I n t e r n Med  Shah C P , R o b i n s o n GC: D a y - c a r e s u r g e r y i n B r i t i s h C o l u m b i a : a 7 - y e a r e x p e r i e n c e ( 1 9 6 8 - 7 4 ) . CM A .Tonrnal 1 1 6 : 1 0 3 1 - 1 0 3 2 , 1977 . Shah C P , R o b i n s o n GC, K i n n i s C , D a v e n p o r t HT: Day C a r e Surgery f o r C h i l d r e n : A C o n t r o l l e d Study of M e d i c a l C o m p l i c a t i o n s and P a r e n t a l A t t i t u d e s . Med Ca r e 10(5) : 4 3 7 - 4 5 0 , 1972. S h a i n M, Roemer MI: H o s p i t a l Costs Relate to the Supply of B e d s . The Modern H o s p i t a l 9 2 ( 4 ) : 7 1 - 7 3 and 168, 1959. Sheps S B : Hospital epidemiology. I n R o b i n s o n GC, C l a r k e HF (eds): The H o s p i t a l C a r e o f C h i l d r e n . A R e v i e w o f Contemporary Tssnes. (pp. 151-169). Oxford U n i v e r s i t y P r e s s , New Y o r k 1980. S m i t h B L , Young P N : Day s t a y a n a e s t h e s i a . 1976.  Anaesthesia  31: 181,  S m i t h F K , D e p u t y BS, B e r r y F A : O u t p a t i e n t A n e s t h e s i a f o r C h i l d r e n Undergoing Extensive Dental Treatment. J Dent Chi Id 4 5 : 1 4 2 - 1 4 5 , 1978. Solomon S L , W a l l a c e EM, F o r d - J o n e s E L : M e d i c a t i o n e r r o r s w i t h i n h a l a n t e p i n e p h r i n e m i m i c k i n g an e p i d e m i c o f n e o n a t a l s e p s i s . N E n g l .T Med 3 1 0 : 1 6 6 - 1 7 0 , 1984.  240 Spitz  RA: H o s p i t a l i s m : An i n q u i r y i n t o t h e g e n e s i s o f p s y c h i a t r i c c o n d i t i o n s i n e a r l y c h i l d h o o d . Psychoanal S t u d y C h i l d 1 : 5 3 - 7 4 , 1945.  S t a r f i e l d BH: C h i l d h e a l t h and s o c i o e c o n o m i c s t a t u s . P u b l i c H e a l t h 7 2 : 5 3 2 , 1982. S t e p h e n s F O , D u d l e y HAF: An o r g a n i z a t i o n s u r g e r y . L a n c e t 1:1042-1044, 1961.  for  Am J  outpatient  S t e w a r d D J : E x p e r i e n c e s w i t h an o u t p a t i e n t a n e s t h e s i a s e r v i c e f o r c h i l d r e n . A n e s t h A n a l g ( C l e v e ) 5 2 : 8 7 7 , 1973. S t o d d a r t G L , B a r e r ML: A n a l y s e s o f Demand and U t i l i z a t i o n through Episodes of M e d i c a l S e r v i c e . In: Van d e r Gaag J , P e r l m a n M ( e d s ) : H e a l t h . E c o n o m i c s , and H e a l t h E c o n o m i c s , ( p p . 1 4 9 - 1 7 0 ) N o r t h - H o l l a n d , Amsterdam 1981. T a y l o r MG: H e a l t h I n s u r a n c e and C a n a d i a n P n h l i o P o l i c y . The Seven D e c i s i o n s t h a t C r e a t e d t h e C a n a d i a n H e a l t h I n s u r a n c e System. McGi11-Queen's U n i v e r s i t y P r e s s , M o n t r e a l 1978. V a n d e r Gaag J , R u t t e n F F H , Van P r a a g BMS: Determinants of H o s p i t a l U t i l i z a t i o n i n the Netherlands. Hea1th S e r v i c e s Research 1 0 ( 3 ) : 2 6 4 - 2 7 6 , 1975. Van F u r t h , R ( e d ) : E v a l u a t i o n and Management o f H o s p i t a l Tnfecti ons. M a r t i n u s N i j h o f f P u b l i s h e r s , The Hague, B o s t o n , L o n d o n 1982. V a y d a E, A n d e r s o n GD: C o m p a r i s o n o f P r o v i n c i a l S u r g i c a l R a t e s i n 1968. The C a n a d i a n .Tonrnal o f S u r g e r y 1 8 : 1 8 - 2 6 , 1975. V a y d a E, M o r i s o n M, A n d e r s o n GD: C a n a d i a n P r o v i n c e s , 1968 t o of SnrgRry 19:235-242,  S u r g i c a l Rates i n the 1972. The C a n a d i a n J o u r n a l 1976.  V e r n o n DTA, F o l e y JM, S i p o w i c z RR, Schulman J L : The P s y c h o l o g i c a l Responses o f C h i l d r e n t o H o s p i t a l i z a t i o n and I l l n e s s . A R e v i e w o f t h e L i t e r a t u r e . C h a r l e s C Thomas P u b l i s h e r , S p r i n g f i e l d , I l l i n o i s 1965.  Weiss C: Research f o r P o l i c y ' s Sake: The Enlightenment F u n c t i o n . P o l i c y A n a l y s i s 6:532-545, 1977. W e i s s C : Knowledge C r e e p a n d D e c i s i o n A c c r e t i o n . Knowledge: Creation. Diffusion. Utilization 1:381-404, 1980. W e l l i v e r R C , M c L a u g h l i n S: U n i q u e E p i d e m i o l o g y o f N o s o c o m i a l I n f e c t i o n i n a C h i l d r e n ' s H o s p i t a l . Am J D i s C h i l d 138:  131-135, 1984.  Wennberg J , G i t t e l s o h n A : V a r i a t i o n i n M e d i c a l C a r e S m a l l A r e a s . S c i e n t i f i c A m e r i c a n 246: 120-134,  among 1982.  Wennberg J , Kimm S Y S : Common U s e s o f H o s p i t a l s : A L o o k a t Vermont. In Harvard C h i l d H e a l t h P r o j e c t : C h i l d r e n ' s m e d i c a l c a r e n e e d s and t r e a t m e n t s . Volume 2. Ballinger P u b l i s h i n g Company, U . S . A . 1977. Who:  Primary health care. Report of t h e I n t e r n a t i o n a l C o n f e r e n c e o n P r i m a r y H e a l t h C a r e , A l m a - A t a , USSR, 6-12 S e p t e m b e r 1978. W o r l d H e a l t h O r g a n i z a t i o n , Geneva 1978.  Who:  Formulating s t r a t e g i e s f o r h e a l t h f o r a l l hy the year 7.000. W o r l d H e a l t h O r g a n i z a t i o n , Geneva 1979  W i l d a v s k y A : Doing B e t t e r and F e e l i n g Worse: P a t h o l o g y o f H e a l t h P o l i c y . I n : Knowles B e t t e r and F e e l i n g Worse; H e a l t h i n t h e ( p p . 105-114, 121) W.W. N o r t o n a n d C o . ,  The P o l i t i c a l JH ( e d ) : Doing United States, I n c . , New Y o r k  1977. Y o s t BW: B l u e C r o s s A s s o c i a t i o n p e r s p e c t i v e o n a m b u l a t o r y s u r g e r y . I n : 0 ' D o n o v a n TR ( e d ) : A m b u l a t o r y S u r g i c a l C e n t e r s - D e v e l o p m e n t and Management. Aspen System C o r p o r a t i o n , Germantown, M a r y l a n d 1976. Zola  IK: M e d i c i n e as an i n s t i t u t i o n o f s o c i a l c o n t r o l . I n : Cox C , Mead A . ( e d s ) : A Sociology o f Medical P r a c t i c e ( p p . 170-185). C o l l i e r M a c M i l l a n , L o n d o n 1975.  

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0097633/manifest

Comment

Related Items