Hospital downsizing and trends in health care use among elderly people in British Columbia

Samuel B. Sheps,*† Robert J. Reid,* Morris L. Barer,*† Hans Krueger,*† Kimberlyn M. McGrail,* Bo Green,* Robert G. Evans,*‡ Clyde Hertzman*†

CMAJ 2000;163(4):397-401

• Abstract
• Introduction
• Methods
• Results
• Interpretation
• Conclusion
• References

Background: There has been considerable downsizing of acute care services in British Columbia over the past 2 decades. In this population-based study we examined changes in the proportion of elderly people who used acute care, long-term care and home care services between 1986–1988 and 1993–1995 to explore whether the downsizing has influenced use. Changes in death rates were also examined.

Methods: The British Columbia Linked Health Database was used to select all British Columbia residents aged 65 years, 75–76 years, 85–87 years or 90–93 years as of Jan. 1, 1986 (cohort 1), and Jan. 1, 1993 (cohort 2). Each person was assigned to 1 of 6 mutually exclusive categories of health care use reflecting different intensities of use (i.e., hospital, long-term or home care). The proportions of people within each category were compared between the 2 periods, as were the age-standardized death rates.

Results: There were 79 175 people in cohort 1 and 92 320 in cohort 2. Overall, the relative proportion of people in each use category was similar between the 2 study periods. The most substantial changes were an increase of 2 percentage points in the proportion of people who received no facility or home care services and a decrease of 2 to 3 percentage points in the proportion who received some acute care but no facility-based continuing care. The age-adjusted all-cause death rates for the earlier and later cohorts were virtually identical (15.7% and 15.8% respectively), although the rate increased from 63.6% to 70.1% among those in the "full-time facility with acute care" group.

Interpretation: Overall changes in health care use were small, which suggests that the repercussions of the decline in acute care services for elderly people have been minimal. The higher age-adjusted death rates in the later cohort in full-time care suggests that long-term stays are becoming reserved for a sicker group of elderly people than in the past.

[Contents]

In this population-based study we examined changes in the use of facilities (acute and long-term care) and home care by elderly people between 1986–1988 and 1993–1995. We asked 2 questions: Did the proportions of people using different levels of health care change between the 2 periods? Did the death rates within the different categories of use change between the 2 periods?

[Contents]

The study population was derived from the British Columbia Linked Health Database.¹¹ The population-based, person-specific linked data included acute care hospital separations, facility and home-based Continuing Care records, and death records from Vital Statistics files. We constructed 2 cohorts by selecting all British Columbia residents aged 65 years, 75–76 years, 85–87 years or 90–93 years as of Jan. 1, 1986 (cohort 1), and Jan. 1, 1993 (cohort 2). The age ranges increase from younger to older in order to balance the smaller populations at higher ages. The use of age-specific cohorts controls for the effect of population aging over this interval. We extracted records of health service use for a 3-year period. We used records of death to examine trends in mortality for either cohort.

Each person was assigned to 1 of 6 mutually exclusive categories of health care use (Appendix 1), ranked broadly by intensity of care, according to whether they used full-time or part-time hospital care, long-term care and publically funded home care over the 3-year period. For example, a person who received some home care and who spent at least 1 night in an acute care hospital would be assigned the the "part-time facility, no continuing care" category. The categories include a broad range of service, but at the aggregate level reflect meaningful differences in service intensity. People who were admitted to an acute care hospital while awaiting placement in continuing care were categorized as receiving continuing care services.

We did not examine the use of physician services or of pharmaceuticals.

[Contents]

The 2 cohorts included 79 175 people in 1986–1988 and 92 320 people in 1993–1995, an increase of 16.6%. This increase occurred entirely among the 3 higher age groups, with the largest growth among those aged 85–87 (Table 1). In the 1986–1988 cohort, almost half (45.2%) of the subjects were in the "no facility or home care" group. A further third (34.4%) were in the "part-time facility, no continuing care" group, indicating some use of acute care but no use of facility-based continuing care services. Nearly 14% of the cohort were "part-time" users of continuing care, either in facilities (8.9%) or at home (4.9%). A minority of the cohort (6.6%) were in facilities for the full study period or until death. Only 2.5% of the total cohort were in facilities for the entire study period and required acute care services.

On the whole, there were only minor changes in the distribution among use categories from 1986–1988 to 1993–1995. The most substantial changes were a reduction in the "part-time facility, no continuing care" group (34.4% v. 31.9%) and an increase in the "no facility or home care" group (45.2% v. 47.4%). There was a slight decrease among those who remained in facility care the entire time (6.6% v. 6.2%).

Changes in the "full-time facility" categories were relatively minor in the 2 lower age groups (less than 0.5 percentage points) and were more substantial in the higher 2. For example, among those aged 90–93 years, the proportion decreased from 28.1% to 26.0%. The decrease for this age group was pronounced (3.2 percentage points) for the "full-time facility with acute care" category but was somewhat offset by growth in the "full-time facility without acute care" category. The proportion of people in the "part-time facility with continuing care" category remained relatively constant for all age groups. The shifts were larger for the "part-time facility without continuing care" category, including a decline of about 4 percentage points among the 2 lower age groups. In contrast, the proportion of people aged 90–93 who used this type of care increased from 19.8% to 22.8%. There were only minor changes in the "some home care" category, except for an increase from 5.8% to 7.4% for the highest age group. Finally, in the "no facility, no home care" category, the 3 lower age groups grew in proportion (increase of 1.8 to 5.7 percentage points), whereas the proportion of those aged 90–93 decreased (3.2 percentage points). Thus, there was a trend toward greater use of facility and home care services in the highest age group.

In 1986–1988 and 1993–1995, there were 12 034 (15.2%) and 15 004 (16.3%) deaths respectively. After direct age adjustment using the combined population as the standard, the rates were virtually identical (15.7% and 15.8% respectively). The largest number of deaths in both cohorts was among the "part-time facility without continuing care" group (Table 2).

Fig. 1 shows the age-adjusted death rates in the 2 cohorts by category of health care use. The highest rates occurred among people in the "full-time facility with acute care" group, and the lowest were among those in the "no facility or home care" group.

The death rates within use categories differed over time. These differences were most pronounced in the full-time facility groups. The age-adjusted rates for full-time facility patients with acute care increased by 11% in the later cohort (95% confidence interval [CI] 5%–17%) and for those without acute care, by 16% in the later cohort (95% CI 11%–21%). The increase in mortality was shared across all age groups. Age-adjusted death rates among people in the "part-time facility with continuing care" category also increased, by about 14% (95% CI 10%–18%). Death rates in the 3 remaining use categories changed by less than 1%. Since mortality did not change overall, these findings imply that there were shifts in acuity among use groups, toward increasing acuity at more intensive levels of care.

[Contents]

The continuum of care provided through acute care facilities, long-term care institutions and home care services is interwoven such that decreases in one sector may be balanced by increases in another. This is particularly true for elderly people, who, on average, are heavy users across the continuum. In British Columbia, as in the rest of Canada, dramatic reductions have occurred in the capacity and use of acute care facilities in the last decade, accelerating a trend begun decades before.^3,4 Concerns have been raised that system changes may affect patient outcomes, including death.⁵ Our study was intended to address these issues through examining trends in service use and mortality over time.

In general, there were only minor changes in the distribution of elderly people across categories of facility and home care use between 1986–1988 and 1993–1995. The most substantial changes were an increase of 2 percentage points in the proportion of people who received no facility or home care services, and a decrease of 2 to 3 percentage points in the proportion who received some acute care but no facility-based continuing care. Thus, to the extent that changes did occur, it appears that people were moving out of health care facilities. Furthermore, elderly people did not shift from institutions to publicly funded home care services. Other research suggests that there were concomitent changes in the use of physician services and pharmaceuticals by British Columbia residents.^9,12

The shift out of facilities may be a reasonable public policy goal given patient preferences for care provided "closer to home."¹³ The question is whether people who are now in their homes rather than in facilities require home support services. The small increase in the "home care" group may reflect a constrained capacity in that sector. Alternatively, it may indicate a healthier "young old" population over time who do not require this type of care. The latter interpretation is consistent with the observed larger increases in the proportion of younger seniors who used neither facility care nor home care. Further research is required to determine the relative importance of each of these interpretations, to inform planning for the delivery of home-based health care services.

We found important differences in how elderly people of different ages shifted categories of health care use over time. For the "young old," the main shifts were from part-time facility use (with no continuing care) to the use of neither facilities nor home care. For the highest age group (90–93 years), however, this trend was inversed in the direction of more facility use. Taken together, these findings support clinical perceptions that institutional care is increasingly devoted to the "old old."

In the face of significant hospital downsizing, we found no changes in age-adjusted death rates over time. Within categories of health care use, however, there were shifts in death rates. For patients residing full-time in facilities, the age-adjusted death rate increased by about 7–8 percentage points, and for those receiving both some acute and some continuing care, the rate increased by about 5 percentage points. The increases in death rates are perhaps the most important finding of our research. Increasing mortality could be construed in several ways. It could be taken as evidence of an increasing efficiency of use of hospital beds; that is, hospital downsizing decreased the provision of facility care to people at lower risk for death. However, the same facts could be construed in the opposite way, increasing mortality indicating a "cost" to squeezing patients out of care. Studies of case-mix, acuity and quality of care would clarify the validity of these interpretations.

Our study has 2 main limitations. First, the categories of health care use contain within-group variations in service intensity. The "part-time facility" categories, for example, reflect a range of use from 1 day to just less than the full 3 years. We created these categories to capture meaningful differences in service intensity across several types of service use. They are successful in accomplishing that objective, as shown by the observed differences in death rates among groups. Second, we did not examine the use of community-based physician care, a vital component along the full continuum of care.

[Contents]

The large decreases in bed capacity during the 1980s and 1990s in British Columbia hospitals were not reflected in major shifts in the proportion of elderly people using different types of facility and home care services. This implies that the changes in capacity were absorbed by decreasing the amount of care received by each individual. In other words, the differences were not in getting through the hospital door but, rather, in the length of stay once through it. Some 40 years ago, White and colleagues¹⁴ made the observation that most people in the general population make no contact with the formal health care system. For elderly people, we observed the parallel finding that a substantial proportion have no contact with acute, long-term or home-based care. We also found no overall change in age-adjusted death reates between 1986–1988 and 1993–1995. There were, however, increases in death rates in the most intensive care categories. This finding raises the prospect that long-term stays are becoming reserved for a sicker group of elderly people than in the past.

This study was funded by grant 6610-2117-602 of the National Health Research and Development Program.

Competing interests: None declared.

[Contents]

Reprint requests to: Dr. Robert J. Reid, Centre for Health Services and Policy Research, University of British Columbia, Rm. 110, 2250 Wesbrook Mall, Vancouver BC V6T 1W6; rreid@chspr.ubc.ca

1.	Tully P, Saint-Pierre E. Downsizing Canada's hospitals, 1986/87 to 1994/95. Health Rep 1997;4(8):33-9.
2.	Anderson GM. Hospital restructuring and the epidemiology of hospital utilization: recent experience in Ontario. Med Care 1997;35(suppl):OS93-101. [MEDLINE]
3.	Nair C. Trends in hospital inpatient utilization, 1961B1988/89. Health Rep 1991;3(2):189-97. [MEDLINE]
4.	McGrail KM, Evans RG, Barer ML, Sheps SB, Hertzman C, Kazanjian A. The quick and the dead: "managing" inpatient care in B.C. hospitals, 1969–1995/96. Health Serv Res. In press.
5.	Brownell MD, Roos NP, Burchill C. Monitoring the impact of hospital downsizing on access to care and quality of care. Med Care 1999;37(Suppl):J135-50. [MEDLINE]
6.	Evans RG, Barer ML, Hertzman C, Anderson GM, Pulcins IR, Lomas J. The long good-bye: the great transformation of the British Columbia hospital system. Health Serv Res 1989;24:435-59. [MEDLINE]
7.	Hertzman C, Pulcins I, Barer ML, Evans RG, Anderson GM, Lomas J. Flat on your back or back to your flat? Sources of increased hospital services utilization among the elderly in British Columbia. Soc Sci Med 1990;30:819-28. [MEDLINE]
8.	Anderson GM, Pulcins IR, Barer ML, Evans RG, Hertzman C. Acute hospital utilization under Canadian national health insurance: the British Columbia experience from 1969 to 1988. Inquiry 1990;27:352-8. [MEDLINE]
9.	Anderson GM, Kerluke KJ, Pulcins IR, Hertzman C, Barer ML. Trends and determinants of prescription drug expenditures in the elderly: data from the British Columbia Pharmacare Program. Inquiry 1993;30:199-207. [MEDLINE]
10.	Barer ML, Pulcins IR, Evans RG, Hertzman C, Lomas J, Anderson GM. Trends in use of medical services by the elderly in British Columbia. CMAJ 1989;141(1):39-45. [MEDLINE]
11.	Chamberlayne R, Green B, Barer ML, Hertzman C, Lawrence W, Sheps SB. Creating a population-based linked health database: a new resource for health services research. Can J Public Health 1998;89(4):270-3. [MEDLINE]
12.	Evans RG, Barer ML, Hertzman C, Sheps SB, Kazanjian A. Does health care support independence or threaten it? A population-based, person-specific analysis of patterns of use by seniors. [Final report to Health Canada Seniors Independence Research Program.] Ottawa: Health Canada; 1998. National Health Research and Development Program project no 6610-2117-602.
13.	Seaton PD, Evans RG, Fyke KJ, Ford MG, Sinclair DR, Webber WA. Closer to home: the report of the British Columbia Royal Commission on Health Care and Costs. 3 vols (Summary, Report and Sources). Victoria: Crown Publications; 1991.
14.	White K, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885-92.

© 2000 Association médicale canadienne ou ses concédants