Avalanche or Glacier?: Health Care and the Demographic Rhetoric

Understanding and addressing changing administrative workload in primary care in Canada: protocol for a mixed-method study

INTRODUCTION

Many Canadians struggle to access the primary care they need while at the same time primary care providers report record levels of stress and overwork. There is an urgent need to understand factors contributing to the gap between a growing per-capita supply of primary care providers and declines in the availability of primary care services. The assumption of responsibility by primary care teams for services previously delivered on an in-patient basis, along with a rise in administrative responsibilities may be factors influencing reduced access to care.

METHODS AND ANALYSIS

In this mixed-methods study, our first objective is to determine how the volume of services requiring primary care coordination has changed over time in the Canadian provinces of Nova Scotia and New Brunswick. We will collect quantitative administrative data to investigate how services have shifted in ways that may impact administrative workload in primary care. Our second objective is to use qualitative interviews with family physicians, nurse practitioners and administrative team members providing primary care to understand how administrative workload has changed over time. We will then identify priority issues and practical response strategies using two deliberative dialogue events convened with primary care providers, clinical and system leaders, and policy-makers.We will analyse changes in service use data between 2001/2002 and 2021/2022 using annual total counts, rates per capita, rates per primary care provider and per primary care service. We will conduct reflexive thematic analysis to develop themes and to compare and contrast participant responses reflecting differences across disciplines, payment and practice models, and practice settings. Areas of concern and potential solutions raised during interviews will inform deliberative dialogue events.

ETHICS AND DISSEMINATION

We received research ethics approval from Nova Scotia Health (#1028815). Knowledge translation will occur through dialogue events, academic papers and presentations at national and international conferences.

Does the Availability of Hospital Beds Affect Utilization Patterns? The Case of End-of-Life Care

Hospital downsizing in Canada during the 1990s raised public concern over the availability of hospital care, in addition to heightening administrative interest in improving or maximizing hospital utilization. One ongoing concern about hospital utilization is that a disproportionately large share of hospital resources is used by terminally ill and dying people. A research study using 1992/1993–1996/1997 in-patient abstracts data for the province of Alberta, Canada, was undertaken to explore and describe hospital utilization by dying in-patients. This investigation found only 48.2% of all deaths in Alberta over the five years studied involved hospital in-patients. An 18.5% reduction in the number of in-patient deaths and an 83.3% reduction in length of final stay occurred when 50% of acute care beds were closed, which was followed by an increase when beds began reopening — in terms of both the number of in-patient deaths (4.8%) and the average length of stay (2.6%). The ratio of men to women, the average age of dying in-patients, and the intensity of hospital care changed relatively little over those five years. Most in-patients were admitted for nursing care; in 51.3% of all cases, no diagnostic or therapeutic procedures were performed prior to death. These findings indicate hospital bed availability influences admission to hospital and length of stay, but not treatment decisions affecting seriously ill and dying patients. In addition, reduced length of stay appears to have been a widespread response to hospital downsizing, with this change substantially preserving individual access to hospitals.

APOCALYPSE NO: Population Aging and The Future of Health Care Systems

Illness increases with age. All else being equal, an older population has greater needs for health care. This logic has led to dire predictions of skyrocketing costs “apocalyptic demography”. Yet numerous studies have shown that aging effects are relatively small, and all else is not equal. Cost projections rest on specific assumptions about trends in age-specific morbidity and health care use that are far from self-evident. Sharply contrasting assumptions, for example, are made by Fries, who foresees a “of morbidity” and falling needs. Long-term trends in health care use in British Columbia show minimal effects of population aging, but major effects, up and down, from changes in age-specific use patterns. Why then is the demographic apocalypse story so persistent, despite numerous contrary studies? It serves identifiable economic interests.

The Incidence of Poverty Among Seniors in Canada: Exploring the Impact of Gender, Ethnicity and Race

Cet article met en lumière l'incidence de pauvreté chez les personnes âgées au Canada en relevant les taux de pauvreté chez les femmes et les hommes provenant de sept différents groupes ethniques représentant les populations blanches ethniques et celles de minorités visibles (d'origines chinoise, autochtone, ukrainienne, juive, noire, grecque et italienne). Une attention particulière a été accordée à l'incidence de pauvreté chez les femmes âgées; on aborde également les raisons de ces taux différentiels de pauvreté chez les femmes âgées d'origine ethnique. On tente de relier ces questions à un programme de recherche gérontologique, de poUtique et de pratique, en plus de souligner le besoin de meilleurs services pour ces populations.

Medical Services Utilization Patterns by Seniors

Cette analyse documentaire vise à déterminer les principaux éléments du mode d'utilisation des soins médicaux chez les aînés dans le cadre du Consensus national sur la conception et la prestation d'une réforme des soins de santé visant à promouvoir l'autonomie des personnes âgées (Shapiro & Havens, 2000). On y présente une stratégie de recherche de la documentation pertinente depuis 1985 portant principalement sur des articles de revuses révisés par les pairs et on résume les conclusions de la recherche. On souligne les principaux articles, lesquels sont analysés et synthétisés à partir de modalités américaines ou canadiennes de fonctionnement institutionnel, de recours aux médecins, aux soin ambulatoires et sur des déterminants de l'utilisation de ces services.

Trends in the Utilization of Health Services by Seniors in Alberta

La prestation de services et de programmes exhaustifs et de qualité pour les aîné(e)s canadien(ne)s au cours des prochaines décennies représente un défi de taille pour les responsables des politiques et les professionnels des soins de santé. La présente étude visait à fournir aux décideurs des données actuelles sur l'utilisation des services de santé par les aîné(e)s en Alberta. Nous avons comparé les tendances en utilisation de services hospitaliers actifs (1992/93–1997/98), des services de soins à domicile (1994/95–1997/98), des demandes de règlement de consultations et de soins de médecins (1995/96–1997/98) et, des établissements de soins à long terme (1990–1996) pour les albertains de moins et de plus de 65 ans. Nous avons également évalué les tendances dans l'utilisation des médicaments presents (1992/93–1997/98) chez les albertains de 65 ans et plus. Les données des analyses proviennent des bases de données et des rapports du Alberta Health and Wellness. Dans l'ensemble, les tendances indiquent qu'un moins grand nombre de patients sont soignés en établissement mais qu'ils sont plus malades; aussi, un nombre plus important de patients est soigné dans la communauté. Les reçus de médicaments prescrits remis en dehors des établissements ont augmenté chez les aîné(e)s dans les dernières années. La portée et la pertinence de la substitution des soins en établissement par les soins dans la communauté, la qualité de ses soins et leurs répercussions sur l'amélioration, la détérioration ou le maintien de la santé constituent des thèmes importants d'études ultérieures.

Population Aging and the Maintenance of Social Support Systems

La génération des baby boomers est maintenant parvenue au milieu de sa vie et atteindra un âge avancé d'ici quelques décades. Les coûts de maintien des systèmes de soutien social actuels augmenteront à mesure que cette génération vieillira et la capacité ou la volonté de les assumer est remise en question. Dans cet article, nous abordons un certain nombre d'enjeux liés étroitement à la question du vieillissement de la population au Canada et aux «coûts» sociaux qui y sont associés, notamment les coûts des services publics. Nous concluons qu'il faut prévoir une augmentation des coûts liés aux services à la population et qu'il y aura lieu de réaffecter les ressources. Toutefois, l'ampleur des augmentations devrait se confiner à des proportions manoeuvrables.

Disability, Dependence, and Old Age: Problematic Constructions

This paper argues that fear of aging can more precisely be recognized as a fear of disability and that fear of disability can be centrally understood as a fear of dependence. Accordingly, we are not likely to see old people being treated as important members of society until we see a change in attitudes towards disability. The argument is developed with reference to a consideration of attitudes toward and treatment of elders and people with disabilities, a consideration of the social construction of dependency, and an examination of statistics on the Canadian population of people with disabilities. The ubiquity of disability across all age groups means that there needs to be a re-conceptualization of disability as part of the human experience.

Integrated Services for Frail Elders (SIPA): A Trial of a Model for Canada

Le complexe formé par les maladies chroniques, les épisodes de maladies aiguës, les déficiences physiologiques, les incapacités fonctionnelles et les problèmes cognitifs dominent les personnes âgées fragiles. Elles comptent sur l'aide des programmes sociaux et de Santé qui, au Canada, sont encore fragmentés. Le SIPA (Services intégrés pour les personnes âgées fragiles) est un modèle de services intégrés basé sur des services de proximité, une équipe multidisciplinaire et un gestionnaire de cas qui détiennent la responsabilité clinique de l'ensemble des services sociaux et de Santé requis, la capacité de mobiliser des ressources en fonction des besoins et l'application de protocole de soins. Le projet de démonstration SIPA a utilisé un devis expérimental avec assignation aléatoire de 1230 participants, de deux quartiers de Montréal, dans un groupe expérimental et un groupe témoin. Les coûts des services institutionnels ont été de 4270$; inférieur dans le SIPA comparés au groupe témoin, les coûts des services de proximité ont été supérieurs de 3394$;. La proportion des personnes en attente d'hébergement en hôpitaux de courte durée a été deux fois plus élevée dans le groupe témoin que dans le groupe SIPA. Les coûts des hospitalisations de courte durée des personnes du SIPA avec incapacité dans les activités de la vie quotidienne ont été inférieurs d'au moins 4000$; à ceux des personnes du groupe témoin. En conclusion, l'expérimentation SIPA démontre qu'il est possible de s'engager dans des projets de démonstration ambitieux et rigoureux au Canada. Ces résultats ont été obtenus sans augmentation des coûts globaux des services sociaux et de santé, sans diminution de la Qualité des soins et sans augmentation du fardeau des personnes âgées et de leurs proches.

Des services intégrés pour les personnes âgées fragiles (SIPA): expérimentation d'un modèle pour le Canada

The complex formed by chronic illness, episodes of acute illness, physiological disabilities, functional limitations, and cognitive problems is prevalent among frail elderly persons. These individuals rely on assistance from social and health care programs, which in Canada are still fragmented. SIPA (Services intégrés pour les personnes âgées fragiles) is an integrated service model based on community services, a multidisciplinary team, case management that retains clinical responsibility for all the health and social services required, and the capacity to mobilize resources as required and according to the care protocol. The SIPA demonstration project used an experimental design, with random allocation of the 1,230 participants from two areas of Montreal to an experimental and a control group. The costs of institutional services were $4,270 less for those in the SIPA group compared to the control group; the costs of community care were $3,394 more. The proportion of persons waiting in acute care hospitals for nursing home placement was twice as high in the control group as in the SIPA group. The costs of acute hospitalizations for persons in the SIPA group with ADL disabilities were at least $4,000 lower than those for persons in the control group. In conclusion, the SIPA trial showed that it is possible to undertake ambitious and rigorous demonstration projects in Canada. These results were obtained without an increase in the overall costs of health and social services, without reducing the quality of care, and without increasing the burden on elderly persons and their relatives.

Trends in the Utilization of Specific Health Care Services among Older Manitobans: 1985 to 2000

This paper examines 16-year trends in the utilization of hospital and physician services by Manitobans aged 75 and more, using data from the Manitoba Population Health Research Data Repository. Trends are examined across five measures of hospital services (separations, short-stay days, long-stay days, cataract surgeries, and hip/knee replacements) and two measures of physician care (overall visit rate, and proportion having seven or more visits). Results show changes in the utilization of these services among older adults living in Manitoba over time, with the extent of change varying with the service under consideration, age, and location of residence. Previously large utilization differentials are shown to be shrinking; for example, cataract surgery rates across regions and physician visit rates by age. For other services, such as the rates of hip or knee replacement surgery, the differences across regions are increasing. Findings indicate that global generalizations about the impact of older adults on the health care system are subject to question, as regional differences and differences between age groups (75–84, 85+) can be significant.

Growing Old Together: The Influence of Population and Workforce Aging on Supply and Use of Family Physicians

Canadians have expressed concern that access to a family physician (FP) has declined precipitously. Yet FP-to-population ratios remained relatively stable over the last decade, and there were perceptions of physician surpluses, at least in urban centres, 10 years ago. We evaluated whether demographic changes among patients and FPs, and in the volume of care received and provided over the period, contribute to this paradox. Given the relationship between age and FP use in fiscal year 1991/1992, an aging population should have been associated with a 2 per cent increase in visits by 2000/2001. Likewise, given the relationship between FP age and workloads in 1991/1992, an aging workforce should have been associated with a 12 per cent increase in service provision a decade later. Yet visit rates and average FP workloads remained unchanged. There was an increase in age-specific rates of FP use among older adults and a decline in rates among the young, and an increase in age-specific workloads such that older FPs provided many more services than their predecessors (30%) and younger FPs provided many fewer (20%). In terms of impact on future requirements for FPs, both changes in age-specific rates of use, and changes in age-specific patterns of FP productivity, trump population aging as key drivers.

Health Service Utilization among Older Adults in British Columbia: Making Sense of Geography

The utilization of health services by older adults has received increased attention over the past decade, but little is known about how service utilization varies between rural and urban areas. In an era of restructuring and downsizing within the Canadian health care system, there are concerns that rural older adults may be increasingly disadvantaged when it comes to accessing health care. This article examines the utilization of a range of health services by older adults living in urban and rural communities in British Columbia. A major strength of this article is its concurrent focus on a continuum of geographic communities and a broad range of services needed and used by older populations. The research utilizes provincial administrative health data from 48,407 older residents of British Columbia who used services in 1998–1999. Multivariate analyses of co-variance reveal some unique service utilization patterns by geographical area and population.

Anticipating Change: How Many Acute Care Hospital Beds Will Manitoba Regions Need in 2020?

Being able to anticipate future needs for health services presents a challenge for health planners. Using existing population projections, two models are presented to estimate the demand for hospital beds in regions of Manitoba in 2020. The first, a current-use projection model, simply projects the average use for a recent three-year period into the future. The second, a 10-year trend analysis, uses Poisson regression to project future demand. The current-use projection suggests a substantial increase in the demand for hospital beds, while the trend analysis projects a decline. The last projections are consistent with ongoing increases in rates of day surgeries and declines in lengths of stay. The current-use projections need to be considered in the context of relatively low occupancy rates in rural hospitals and previous research on appropriateness of stays in acute care hospitals. If measures are taken to ensure more appropriate use of acute care hospital beds in the future, then the current-use projections of bed shortages are not a cause for concern.

Driving forces behind increasing cardiovascular drug utilization: a dynamic pharmacoepidemiological model

AIMS

To investigate the driving forces behind increasing utilization of cardiovascular drugs.

METHODS

Using register data, all Danish residents as of 1 January 1996 were followed until 2006. Cohort members were censored at death or emigration. Cardiovascular drug utilization on the individual level was traced, applying registered out-of-hospital dispensing. The impact of population ageing on cardiovascular drug utilization was investigated using standardized intensities and prevalences. Based on a three-state (untreated, treated and dead) semi-Markov model, we explored to what extent increasing treatment prevalence was driven by changing incidence, discontinuation and mortality. Expected treatment prevalences were modelled, applying stratum-specific cohort prevalence in 1996 along with incidence, discontinuation and drug user mortality either throughout 1996-2004 or at fixed 1996 levels.

RESULTS

Treatment prevalence (ages > or =20 years) with cardiovascular drugs increased by 39% during 1996-2005 from 192.4 to 256.9 per 1000 inhabitants (95% confidence interval 256.5, 257.3). Treatment intensity grew by 109% from 272 to 569 defined daily doses 1000(-1) day(-1). Population 'middle-ageing' accounted for 11.5 and 20.3%, respectively. Increasing treatment incidence was the main driver of the rising treatment prevalence in most drug categories. Declining discontinuation drove some of the growth, declining drug user mortality less. Even with fixed incidence in the model, treatment prevalence continued to increase.

CONCLUSIONS

Age-related increases in treatment intensity and prevalence, rather than population ageing, drove the increasing treatment intensity with cardiovascular drugs. Increasing treatment prevalence in subgroups was primarily caused by increasing incidence. Due to pharmacoepidemiological disequilibrium, treatment prevalence will continue to grow even with unchanged incidence.

Use of physician services by older adults: 1991/1992 to 2000/2001

Canadians have expressed concern that access to family physicians (FP) has declined. Anonymized physician services data for 1991/1992 to 2000/2001 were used to evaluate changes in supply and age-specific rates of use of FPs and specialists in Winnipeg, Manitoba. Physician-to-population ratios declined 7.5 per cent, FP-to-population ratios declined 4.8 per cent, and specialist-to-population ratios declined 10.0 per cent. Among the general population, FP visit rates declined 3 per cent. Among older adults, physician visit rates increased 2.3 per cent, FP visit rates increased 10.9 per cent, and specialist visit rates declined 15.7 per cent. By comparison, we document declines in FP use by those younger than 5 years (25.5%) and those 6 to 19 years of age (18.6%). Increases in FP and declines in specialist use occurred primarily among those aged 65 to 84 years. By 2000/2001 older adults accounted for 25 per cent of all FP encounters. Gains in FP use among older adults was less attributable to the presence of more seniors and more related to the fact that a higher proportion of them are visiting a FP each year and, potentially, substituting primary for secondary care.

Trends in the health status of older Manitobans, 1985 to 1999

Trends in the health status of the entire senior population aged 65 years or older in Manitoba were examined over a 14-year period (1985-1999) using administrative data (about 50,000 individuals). Significant health gains were apparent for a number of important indicators, including acute myocardial infarction, stroke, cancer, and hip fractures, although some of these gains were restricted to urban areas. Improvements in these health indicators are significant, as they can have major implications for individuals' need for health services and ability to live independently. In contrast, chronic diseases were on the rise, with the prevalence of diabetes, hypertension, and dementia increasing substantially over the 14-year period. These trends suggest a need for a policy emphasis on prevention, such as reducing the prevalence of obesity, which is one risk factor for diabetes. Moreover, having sufficient care options in place for the growing number of individuals with dementia is an issue that will have to be addressed.

Prescription drug expenditures and population demographics

OBJECTIVE

To provide detailed demographic profiles of prescription drug utilization and expenditures in order to isolate the impact of demographic change from other factors that affect drug expenditure trends.

DATA SOURCES/STUDY SETTING

Demographic information and drug utilization data were extracted for virtually the entire British Columbia (BC) population of 1996 and 2002. All residents had public medical and hospital insurance; however their drug coverage resembled the mix of private and public insurance in the United States.

STUDY DESIGN

A series of research variables were constructed to illustrate profiles of drug expenditures and drug utilization across 96 age/sex strata.

DATA COLLECTION/EXTRACTION METHODS

Drug use and expenditure information was extracted from the BC PharmaNet, a computer network connecting all pharmacies in the province.

PRINCIPAL FINDINGS

Per capita drug expenditures increased at an average annual rate of 10.8 percent between 1996 and 2002. Population aging explained 1.0 points of this annual rate of expenditure growth; the balance was attributable to rising age/sex-specific drug expenditures.

CONCLUSIONS

Relatively little of the observed increase in drug expenditures in BC could be attributed to demographic change. Most of the expenditure increase stemmed from the age/sex-specific quantity and type of drugs purchased. The sustainability of drug spending therefore depends not on outside forces but on decisions made by policy makers, prescribers, and patients.

Projected incidence of mechanical ventilation in Ontario to 2026: Preparing for the aging baby boomers*

OBJECTIVE

The aging baby boomers are expected to have a significant impact on the healthcare system. Mechanical ventilation is an age-dependent, costly, and relatively nondiscretionary medical service that may be particularly affected by the aging population. We forecast the future incidence of mechanical ventilation to the year 2026 to understand the impact of aging baby boomers on critical care resources.

DESIGN

Population-based, sex-specific, and age-specific mechanical ventilation incidences for adults for the year 2000 were directly standardized to population projections to estimate the incidence of mechanical ventilation, in 5-yr intervals, from 2006 to 2026. Sensitivity analyses were performed by varying population projections and mechanical ventilation incidence for the elderly.

SETTING

Province of Ontario, Canada.

PATIENTS

Noncardiac surgery, mechanically ventilated adults.

INTERVENTIONS

None.

MAIN RESULTS

The projected number of ventilated patients in 2026 was 34,478, representing an 80% increase from 2000. The crude incidence increased 31%, from 222 to 291 per 100,000 adults. The annually compounded projected growth rate during this 26-yr period was 2.3%, similar to the actual growth rate experienced in the 1990s. The projected incidence was relatively insensitive to changes in assumptions, with estimates for 2026 ranging from 31,473 to 36,313 ventilated adults.

CONCLUSIONS

The incidence of mechanical ventilation projected to the year 2026 will steadily increase and outpace population growth as occurred in the 1990s. In the current environment in which intensive care unit resources are limited and ventilated patients already use a significant proportion of acute care resources, planning for this continued growth is necessary. Existing evidence-based strategies that improve both the efficiency and efficacy of critical care services should be carefully evaluated for widespread implementation.

Drug spending in Canada: recent trends and causes

BACKGROUND

Canadians spent almost dollars 15 billion, over dollars 460 per capita, on prescription drugs in 2002, yet there is little published evidence regarding the nature and causes of these expenditures.

OBJECTIVE

: The objective of this study was to describe the nature and determinants of prescription drug expenditures in Canada during a recent period of rapid expenditure inflation, 1998 to 2002.

RESEARCH DESIGN

: Trends in overall expenditures and investment in specific therapeutic categories are decomposed using nonstochastic index-theoretical methods.

MEASURES

Changes in per capita expenditures on oral solid prescription drugs are attributed to the cost-impact of changes in the 6 determinants that fall into 3 broad categories: volume effects, price effects, and therapeutic choices.

RESULTS

A majority of spending was concentrated among only 5 therapeutic classes. After adjusting for generic drug use, prices for unchanged drugs declined over the period of analysis. Increased utilization of prescription drugs explained over half of the overall increase in per capita spending. Changes in therapeutic choice also contributed to cost increases.

CONCLUSIONS

Findings suggest that the combined affect of federal price regulations, provincial price freezes, and generic substitution policies are controlling price-related determinants of drug spending in Canada. However, the cost-impact of increased drug utilization and changes in therapeutic choices illustrate the potential pitfalls of cost-management strategies that focus primarily on prices.

Is the Canadian health care system fiscally sustainable?

Current concerns over escalating health care costs and the sustainability of the Canadian health care system are based on analytical concepts and models that have their own limitations and deficiencies. Measuring health care costs across subsectors over the long-term period, the authors argue that Canada's health care costs, especially those under the direct control of provincial governments, are relatively stable. Using appropriate measures of sustainability, there is no indication that Canada's public health care expenditure is unsustainable. Nor is there any indication that Canada's public health care expenditures are out of line with those of its main trading competitors, including the United States.

The role of wages in the migration of health care professionals from developing countries

Several countries are increasingly relying on immigration as a means of coping with domestic shortages of health care professionals. This trend has led to concerns that in many of the source countries - especially within Africa - the outflow of health care professionals is adversely affecting the health care system. This paper examines the role of wages in the migration decision and discusses the likely effect of wage increases in source countries in slowing migration flows.This paper uses data on wage differentials in the health care sector between source country and receiving country (adjusted for purchasing power parity) to test the hypothesis that larger wage differentials lead to a larger supply of health care migrants. Differences in other important factors affecting migration are discussed and, where available, data are presented.There is little correlation between the supply of health care migrants and the size of the wage differential between source and destination country. In cases where data are available on other factors affecting migration, controlling for these factors does not affect the result.At current levels, wage differentials between source and destination country are so large that small increases in health care wages in source countries are unlikely to affect significantly the supply of health care migrants. The results suggest that non-wage instruments might be more effective in altering migration flows.

Does the aging of the population really drive the demand for health care?

In the debate on health policy, it is widely believed that the aging of the U.S. population is a major driver of the annual growth in the demand for health care and in national health spending. This essay draws on the research literature and on data from the Medical Expenditure Panel Surveys (MEPS) to debunk that myth. Although in any year per capita health spending for people age sixty-five or older tends to average three to five times that for younger Americans, the aging of the population is too gradual a process to rank as a major cost driver in health care.

Outcomes and Costs Among Seniors Requiring Hospitalization for Community-Acquired Pneumonia in Alberta

OBJECTIVES

To determine the age-specific rates of hospital discharge, cost per day, and overall in-hospital 1- and 4-year mortality for seniors who required hospitalization for the treatment of community-acquired pneumonia (CAP).

DESIGN

Retrospective analysis of two administrative health service databases.

SETTING

Province of Alberta, Canada.

PARTICIPANTS

Residents of Alberta aged 18 and older.

MEASUREMENTS

Hospital abstracts and vital statistics from April 1, 1994, to March 31, 1999, were analyzed, and mortality and cost outcomes statistically modeled by regression.

RESULTS

There were 8,500 annual hospital discharges for CAP costing more than $40 million per year. The overall in-hospital all-cause mortality rate was 12%, and the 1-year mortality rate was 26%. The mean age of pneumonia cases increased (P<.000) from 62.8 in 1994/1995 to 67.2 in 1998/1999. The proportion of hospital discharges in those aged 85 and older was 13% in 1994/1995, increasing to 18% in 1998/1999 (P<.000). The age-specific hospital discharge rate and length of hospitalization increased with age. After adjustment for other factors using modeling, it was found that the relative risk (RR) of in-hospital and 1-year mortality increased with age, the RR of using special medical care and higher-than-average daily hospital cost decreased with age, and the RR of greater-than-average daily hospital cost was not associated with an increase in comorbidity. Total costs per hospital stay were similar in patients aged 85 and older to those in patients aged 65 to 74, despite a one-third longer length of stay, which was consistent with reduced use of special medical care in those aged 85 and older.

CONCLUSION

The increased use of hospital resources for CAP in the setting of an aging population may have been partially avoided because of limitations in care provided for seniors aged 85 and older.

Long-term care funding in Canada: a policy mosaic

When Canada was founded, health care was delegated as a provincial responsibility. Although the federal government shares a portion of health care costs, it is not directly responsible for the planning, delivery, and governance of health services. The 1984 Canada Health Act set national standards for the provision of physician and hospital services, but it does not apply to home care and long-term care facilities. Consequently, each province has established a unique approach to long-term care, resulting in a health policy mosaic. This paper examines different approaches to funding long-term care with a particular emphasis on the impacts of regionalization and of the implementation of case-mix-based funding systems.

[Increase in hospital services utilization by persons aged 55 years or older: population ageing and response of the health system]

OBJECTIVES

To examine changes in hospital service utilization between 1985 and 1994 in Spain and Andalucía and to estimate the proportion of change due to population ageing.

METHODS

The increase in hospitalization rates between 1985 and 1994 was calculated. Expected hospital discharges in 1994, were calculated by multiplying hospital discharge rates in 1985 by the population in 1994 for each age group.

RESULTS

Between 1985 and 1994 hospitalization rates increased among persons aged 55 years old order. The increase ranged from 20.01% (55-64 years old) to 52% (more than 75 years old). The percentage of this increase due to population ageing was slight (range: 2.8 to 14.8%).

CONCLUSIONS

The increase in hospitalization rates among persons aged 55 years old or older is only partially explained by population ageing, which can be attributed to supply and demand of services.

Fragmentation of care for frail older people--an international problem. Experience from three countries: Israel, Canada, and the United States

Cross-national comparisons of healthcare systems can help us to better understand them and to offer possible solutions for problems identified within these jurisdictions. Because multiple discontinuities present in most healthcare systems interfere with the appropriate clinical care of frail older people, we were interested in comparing the situation in three countries with markedly different healthcare systems. At one end of the spectrum we find Canada, with an almost fully socialized system. At the other stands the United States, where market forces are allowed the freest rein in any developed nation. Israel offers an intermediate model with elements held in common with both the U.S. and Canadian systems. Although the problems outlined in this paper can be addressed at the "micro" level, it is through an improvement in the structuring and organization of national systems of care that the appropriate conditions for the care of frail older people can be truly bettered. This international comparison offers insights for policy makers in these three states in particular and other countries in general.

Alberta's Deficit-Elimination Agenda — How Have Seniors Fared?

En juin 1993, le gouvernement de l'Alberta lança un plan de trois ans pour éliminer le déficit provincial. Le point central de ce plan était la réduction de dépenses. Malgré ce processus visant à l'élimination du déficit, la plupart d'Albertains n'ont pas trouvé des changements en ce qui a trait aux services gouvernementaux, et aussi que le transfert des coûts au consommateurs a eu peu de conséquences. Cependant, les personnes âgées different à bien des égards de la population generale. L'effet combiné des réductions directes de bénéfices ainsi que les augmentations du coût de la vie et les changements dans l'accessibilité des services ont créé plus de répercussions pour la majorité des personnes agées. Ces répercussions sont illustrées dans une étude de cas qui dresse le bilan des changements qu'ont occasionné les réformes fiscales du gouvernement Klein pour un couple âgé de revenu moyen. Ce travail indique qu'une évaluation plus en profondeur des répercussions des changements aux politiques sociales sur les groupes vulnérables devrait être entreprise par d'autres jurisdictions qui désirent adopter des changements d'une telle envergure.

The eyes have it: cataract surgery and changing patterns of outpatient surgery

Health care utilization by the elderly has increased during recent times. However, a number of investigators have indicated that this increase has had less to do with increasing numbers of elders than with increasing age-specific utilization rates for a variety of health services. 1985 and 1993 health data for British Columbia were used to examine changes in outpatient surgical utilization among the general population and changes in cataract surgical utilization among the elderly. Utilization increases in the older persons exceeded what would be expected on the basis of population increase. Furthermore, cataract surgery alone accounted for more than 29 percent of the entire utilization increase observed for outpatient surgery. Despite this increase, the average age at cataract surgery has not changed—seniors of all ages are much more likely to receive cataract surgery now than a decade ago. The authors' findings suggest that a part of this observed increase is due to operating on individuals at preoperative levels of better visual function.