When a doctor admits a patient to hospital, it is because he or she has determined that supervised care is needed, and hospitals have traditionally been the place to receive that care. Hospital care is expensive; if these patients could be treated without being hospitalized, significant savings would likely be realized. So Manitoba Health asked MCHP (the Manitoba Centre for Health Policy) to study the question: Are there patients in our hospitals whose health care needs could effectively be met in an alternate setting - such as long-term care, home care, outpatient? Hence, the title of our study: Alternatives to Acute Care.

A large body of research conducted outside of Manitoba shows that from 7% to 51% of adult admissions and from 27% to 59% of hospital days do not require the level of services provided by acute care hospitals - though most do require some form of supervised care. At a time when hospital cutbacks are a reality and saving health care dollars is a priority, we need to know what alternative health care services are needed to permit hospital downsizing, while ensuring patients access to safe, effective health care.

The role of MCHP is to analyze and interpret data to assist in understanding and improving Manitoba's health care system. We want to promote efficiency - not simply to reduce costs, but to preserve Medicare in Manitoba. Studies and reports like this one are undertaken to help understand how the health care system works and suggest policy changes to improve it.

Our study began in late 1994. It focussed on adult hospitalizations for the 1993/94 fiscal year, but also reviewed paediatric cases at four of the hospitals in the study.

We reviewed the charts of a large sample of medical admissions only; surgical, obstetrical and psychiatric cases were not included. Medical patients comprised 49% of all admissions in 93/94. Although we looked at a sample of patients, we did statistical tests to be sure that the patients we looked at were typical of the medical patients in each hospital.

Hospitals were divided into four groups: Urban, Major Rural, Intermediate Rural and Small Rural. Charts at all eight urban hospitals and at six hospitals in each of the other three groups were reviewed. Our entire process was carried out under the guidance of a Working Group. Its members comprised a broad cross-section of the health care sector - physicians, nurses, hospital administrators and other health care workers - from both rural and urban Manitoba.

Eight Registered Nurses were trained to conduct the review, using a set of criteria called InterQual. To be assessed as Acute at admission (requiring the services of an acute care hospital), a patient had to meet the criteria within 72 hours of admission. Each day of the hospital stay was also reviewed. Whenever a patient was assessed as not Acute, the Alternate Level of Care needed by the patient was determined.

The InterQual system uses a set of indicators to answer two questions: (1) Is the patient sick enough to be in a hospital? and (2) Is the patient receiving hospital-level care? The answer to both of these questions must be "Yes" in order for a patient to be Acute. InterQual sets a baseline for all acute hospital care, regardless of location or size of hospital. InterQual has been used in similar studies in British Columbia, Saskatchewan and Ontario.

Hundreds of hours of dialogue with practicing physicians have gone into InterQual's development and annual revisions. Still, we felt it was critical for our study's credibility that InterQual be accepted here in Manitoba - especially by physicians, since they decide when to admit, how to treat and when to discharge patients. Individual physicians, both members of the Working Group and others, reviewed the criteria extensively, as did the Working Group, whose members included both physicians and nurses. Minor revisions were suggested, but otherwise everyone agreed that the criteria were fair and reasonable.

Alternative Levels of Care
After reviewing alternate care levels from InterQual and from the Health Services Utilization and Research Commission of Saskatchewan, the Working Group adopted as a guideline the alternatives developed in Saskatchewan, modifying them to fit the Manitoba situation.
Two characteristics of hospital use were of interest: the proportion of medical patients that were Acute at admission, and the proportion of medical days that were Acute.
Adult Medical Admissions
We found that 50% of the adult patients were Acute when admitted to hospital - the percentage was highest in the Urban hospitals and lowest in the Small Rural hospitals (fig.1). Another 25% were assessed as requiring Observation (fig. 2). Given that Observation Units are located in a hospital, these patients also needed hospital care, even if only for a short time. Of the remaining 25% of admissions, over 23% were assessed as requiring either long term institutional care, home care, outpatient care or other services. A very small number of patients - less than 2% - required No Health Care. In other words, virtually all of the medical patients admitted to Manitoba hospitals were ill and needed health care, but not always the level offered in a hospital.
Adult Medical Days
Overall, only 33% of days were assessed as requiring acute care, which means two of every three days that Manitobans spent in hospital for medical conditions could potentially be in another setting - if one were available. Because a few long stays could skew the results, we also analyzed Acuteness for just the first thirty days of stay, and found that the proportion Acute was 39%. As for the analysis of admissions, the proportion of days that were Acute declined across hospital categories from Urban to Small Rural (fig. 3). Again, only a small proportion (7%) of the overall days required No Health Care. This finding is critical; physicians are not using hospitals frivolously - their patients are genuinely ill. If alternative, less resource-intensive health care settings are made readily available and yield equal or superior outcomes, they could substantially reduce our need for hospitals.

The proportion of days assessed as requiring Observation is only 7%, much lower than the 25% of admissions requiring Observation. This is because many of these patients had very short hospital stays. The largest portion of days which were not Acute - 27% - could have been provided in a place designed to meet the needs of long term care patients: a rehab, chronic care or nursing home facility.

Over the four hospitals reviewed, 44% of the paediatric admissions were assessed as Acute. As it was for the adults, a large proportion (39%) of paediatric patients were assessed as requiring Observation at the time of admission. By adding the two proportions, we find that 83% of the paediatric patients needed some hospital care at the time of admission. Only 1% required No Health Care at the time that they were admitted.

We assessed 52% of the paediatric days as Acute. Approximately one-quarter of the days required Observation. Unlike adults, very few paediatric days required a long stay institution.

Additional Findings
  • The likelihood that a patient can be cared for at an alternate health care level increases with length of stay. For patients assessed as Acute when admitted, by the eighth day of stay, only 47% were still Acute. By Day 30, only 27% were Acute.

  • Three diagnostic categories accounted for 54% of the admissions and 51% of the days in our study: Circulatory, Respiratory and Digestive. For Circulatory and Digestive, 45% of the days were Acute, and for Respiratory 38% of the days were Acute.

  • Patients aged 75 or older were particularly likely to spend more days in acute care than needed. While the proportion of patients assessed as Acute at admission is similar across all age groups, only 30% of hospital days were Acute for patients aged 75 or older compared with 56% for those in the 25 to 34 year age group.

  • There is considerable discussion in the media and among health care practitioners about the prevalence of so-called unnecessary "social admissions" among the poor and disadvantaged. If this were true, we would expect to find that these patients would have lower levels of Acuteness. Our data did not support this stereotype. We divided Winnipeg patients into five income categories based on where they lived. We found that patients in the lowest income category had similar levels of Acuteness to those in the highest income categories.
    Consistent with other studies, our Manitoba data suggest that up to 50% of adult medical patients in acute care hospitals could be effectively cared for in an alternative setting. And when we compare the expense of a day in hospital - $288 to $540, depending on the size of hospital - to a day in a nursing home for example - $79 - substantial health care savings appear possible.

    That being said, it is essential to point out what is not being said. We are not suggesting that Manitoba doctors are placing patients in hospital who don't need care; by far the majority of patients studied (98.4%) required some form of health care at the time they were admitted. Furthermore, we are not suggesting that all these alternatives exist, and that now all we have to do is start moving patients to them and close hospital beds. Quite the contrary; when we translate percentages into numbers - up to 34,000 patients and 429,000 days of care - it is highly likely that many patients are in hospital because there aren't enough alternate facilities.

    This conclusion was supported by several physicians who commented on the report. One stated that only six of the twelve medical units at Health Sciences Centre are truly "acute care," and that patients admitted to the other six might conceivably be cared for in an alternate health care setting. Other physicians pointed out that there are sub-categories of medical patients that most likely do not need the level of care provided in a hospital.

    Even when alternatives exist, physicians also commented that the system in some ways encourages admitting or keeping patients in hospital. For example, it is usually easier and faster to arrange certain diagnostic tests, like a CT scan or stress test, for an inpatient than for an outpatient. Also, that way the test results are in the patient's chart and hence are easier to locate. Placing patients outside of hospital makes the "paper trail" longer. Obviously, these problems need to be worked out.

    Our data suggest several starting points for identifying patients who are ready to be transferred to other levels of care. Length of stay is one; after the first week of stay, more than half of the patients no longer needed hospital-level care. The patient's diagnosis is another; patients with Circulatory, Digestive and Respiratory diagnoses use a large proportion of hospital days, many of them at a non-Acute level. Age is also a consideration; over half of the days spent in hospital by patients 75 years or older were not Acute.

    To change the system of health care and to create effective alternative services will require breaking down a lot of barriers - regulatory, administrative, professional and intellectual. Our reliance on hospitals has developed because they are historically the most well-funded and politically visible institutions in the health care system. They were the first part of the system to be universally insured, and access is based on need without financial barriers. Any system of alternatives to acute care must share these characteristics.

    But first, the alternatives have to be in place and readily accessible. Before closing hospital beds, bridge funding should be available to encourage such development. At the same time, it makes no sense to develop these alternatives without a firm commitment and timetable for closing hospital beds.

    Treating patients without hospitalizing them is not merely a cost-cutting measure. There are potential benefits for the patient, including: less exposure to infectious diseases common in hospital; a more personal, less clinical environment; getting treatment closer to home - if not in home - easing separation anxiety in children and disorientation in the elderly, plus allowing more family contact. Physicians can also benefit by having more options for the treatment of their patients.

    In short, these are not just safe substitutes for hospitalization, they can be more appropriate. At the same time, the health care dollars saved could help preserve Medicare for all Manitobans. When properly in place, alternatives to acute care should benefit everyone.


    Summary written by RJ Currie, based on the report: Alternatives to Acute Care: by Carolyn De Coster, Sandra Peterson and Paul Kasian.

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