MONITORING THE WINNIPEG HOSPITAL SYSTEM:Does closing hospital beds translate to a decline in health care? In Manitoba, that has been the question since downsizing of Winnipeg hospitals began. This report by the Manitoba Centre for Health Policy (MCHP) - the first of several planned - offers a preliminary answer to that question. Happily, at this point the answer appears to be no.
The First Report, 1990-1992
Beginning in 1991 and throughout 1992, 335 of Winnipeg's acute care hospital beds were closed. Acute care beds are the type used by the typical hospital patient - those in for surgery or because of serious illness. As expected, there was an immediate protest from some physicians and other concerned Manitobans that a reduction in hospital beds meant a reduction in the quality and availablity of health care in Manitoba. Put simply, they felt fewer beds meant poorer health.
On the other hand, there were those who believed that a reduction in hospital beds would not adversely affect health care in Manitoba and might, in fact, make Manitoba hospitals more efficient. Hospitals can respond to bed closures by increasing occupancy, shortening lengths of stays or increasing outpatient surgery.
When Manitoba Health began this downsizing, MCHP agreed to monitor and report annually on the effects of the bed closures. To sharpen the focus of that monitoring, physicians, nurses and others were interviewed to determine their major areas of concern. With those main concerns as a focal point, and using the data available from the Manitoba Health data base - one of the most complete and useful data bases in North America - MCHP has prepared a first report. Our analysis of information collected from 1990-1992 offers promising news, albeit tentative, about the health of health care in Manitoba and should allay the fears of those who predicted ill effects from downsizing.
The MCHP study addresses three major questions: Do these actions reduce access to hospital care? Do they reduce the quality of care provided by hospitals? Do they negatively affect the health status of the city's population?
Do these actions reduce access to hospital care?
The changes appeared to have little effect on access to hospital services.
The response to fewer beds was to favour more serious cases for hospital admission as inpatients, and to increase the referrals of less serious cases for treatment on an outpatient basis (fig. 1). Additionally, among those admitted to hospital, the short-stay patients (60 days or less) were discharged faster. Despite a 9.2% reduction in beds, nearly half of the seven hospitals studied showed a decrease in occupancy rates. Overall, hospital occupancy rates increased by less than 1%; vacancy rates still average over 16%. Access to Winnipeg hospitals by residents and non-residents of Winnipeg was unaffected by bed closures (fig. 2). In fact, rural residents' rates of surgery - specifically coronary artery bypass, cataracts, hip replacement and knee replacement -showed an overall increase in 1992. Reductions in hospital use were not made at the expense of the poor. In fact, those from poorer neighborhoods spent proportionately more time in hospital than did the more affluent. Since there is a strong relationship between economic status and health - the poorer you are, the sicker you are likely to be - this suggests that access to hospitals now corresponds more directly to need. It also speaks well for the doctors, nurses and others in the health care system who are responding positively to downsizing by giving priority to the most ill.Do these actions reduce the quality of care provided by hospitals?
The quality of care delivered by Winnipeg hospitals was closely examined. Particular attention was paid to: (1) the rate of death within three months of admission for heart attacks, hip fractures and cancer surgery; (2) the rate of readmission to hospital within 30 days of discharge (any hospital, not just the one the patient was treated in) for fourteen common types of patients; (3) the rate of patients contacting physicians within 30 days of discharge.
To date, we have no evidence that reduced use of hospitals nor increased financial pressures has negatively influenced the quality of care delivered to patients. Nor is there indication of negative impact on patients due to earlier discharge. Rates of death among those admitted for heart attacks, hip fractures and cancer surgery showed no significant change. In fact, they decreased in 1992 for patients with hip fractures. There was no jump in the rate of patients returning to hospital within 30 days of discharge. Some feared that bed closures meant patients would be discharged "too quick and too sick"; if true, increases in readmission rates in 1992 were likely. Instead, we found some rates increased and some decreased - not a pattern suggesting adverse effects from downsizing. Five of the fourteen types of patients did show increased rates of readmission in both 1991 (before bed closures) and 1992, so we investigated whether the general trend towards earlier discharge might be creating problems. We compared hospitals whose stays are shorter than average to hospitals whose stays are longer than average and found that the patients treated at one did not return to hospital any more so than those treated at the other, so earlier discharge appears unrelated to their readmissions. There was no increase in the rate at which individuals contacted physicians within 30 days of hospital discharge.Do these actions negatively affect the health status of Winnipeg residents?
While it is early to detect changes in the health status of Winnipeg residents associated with bed closures and fiscal restraints, at this point the changes in Winnipeg's acute hospitals appear to have had no detectable adverse impact on the health of Winnipeg's population.
Mortality rates from all causes, as well as from specific diseases, including cancer, heart disease (ischemic) and injuries, were similar over the three year period. Of particular note, the rate among the elderly - the highest users of hospitals and considered at greatest health risk - also showed no significant change. In fact, for those aged 75-89 there was a modest decrease. MCHP's monitoring systems have unearthed significant differences in health status across Winnipeg's population, including the strong link between health and neighborhood income levels. While some of these findings may not relate to downsizing, they fly in the face of those who might dismiss our indicators (mortality rates for example) as "not discriminating enough" to accurately monitor health status. Finding these "needles" in the health "haystack" attests to the sensitivity of our indicators - both for the subtle and the substantial - and speaks well of the scope and reliability of our findings.Additional insights from the analyses
As expected, as inpatient surgery decreased, outpatient surgery increased. However, some forms of outpatient surgery expanded beyond just replacing inpatient procedures, showing rapid growth in each of the three years (fig. 3). While the number of short stay hospital inpatient days per 1000 Winnipeg residents dropped over the three year period, it is difficult to assess patterns among long stay (more than 60 days) inpatients. Their hospital use patterns varied from year to year with no discernable trend and many of these patients were transferred as part of acute bed closures. However, it is significant to note that those awaiting transfer to a nursing home from hospital showed no increase in average waiting time. This, despite a 3% increase in persons aged 75 or over (the predominant users of nursing home care) in both 1991 and 1992, and a 2% reduction in the ratio of nursing home beds per 1000 residents in each of those years. Differences in neighborhood income levels are strongly linked to health status. Each rise in income level from the poorest to the wealthiest segment of the population results in better health and fewer days spent in hospital.Limitations
Although hospital budgets were tighter throughout the period of study, most of the bed closures occurred in 1992, and not all of them at the beginning of the year. Therefore, not all the beds were closed during the entire period of study, so the results of the analyses must be interpreted with a measure of caution. One can speculate that the full impact of the 1992-93 changes will only be felt in subsequent years. Also, since additional closures and budget restrictions occurred in 1993-94, these conclusions must be regarded as preliminary and tentative.
Downsizing Manitoba hospitals has not led to a decline in health care nor do we detect any change in the health status of Manitoba residents. Post-surgical mortality rates, hospital readmissions, physician contacts - all indicate that the quality of care has not suffered.
Bed closures have not necessarily led to a decrease in hospital use in Manitoba, but, arguably, to a better use. We have seen an increase in patient transfers to alternative care facilities, the more timely discharge of patients and an increase in outpatient treatment. The people who work in these institutions deserve credit for their adaptability. Per capita expenditures on hospitals (after adjusting for inflation) declined 1% a year starting in 1991 and there are no signs of adverse effects on the health of Manitobans.
The rapid expansion of outpatient surgery has had the positive effect of making surgery more available to both Winnipeg and non-Winnipeg residents. But it is not without its problems. Outpatient treatment has increased above bed-replacement levels, representing an add-on cost to health care expenditures. Expansion limits should be set consistent with bed closures and absolute need. On a case by case basis, the health benefits from such increases must be carefully considered.
The link between health status and neighbourhood income levels - the wealthier you are, the healthier you are and the less your need for hospitalization - is significant in any discussion of hospital downsizing. It strongly suggests that a reduction in hospital use (and a corresponding reduction in expenditures) would likely occur if the health status of low and middle income residents is improved. Rather than relying solely on the health care system, improved health status might be realized more fully and economically through well-targeted community initiatives. Improving quality of life may be the best and cheapest medicine. Finding the means to achieve this goal is a major challenge to public policy.
In 1990, Winnipeg had over 335 more hospital beds than it does today. This does not mean health care declined, any more than having fewer tools makes one a lesser mechanic. The aim is to have the optimum amount of equipment for the needs. The effects of past or future bed closures should continue to be monitored. Early indications are that the quality of care in Manitoba and the health of its people have not been compromised; time will tell us more. Are these measures simply cost-cutting or are they streamlining? Is health care in Manitoba being minimized? Is it being optimized? MCHP's next report is planned for early 1995.
Summary written by RJ Currie, based on the report: Monitoring the Winnipeg Hospital System: The First Report 1990-1992: by Noralou Roos and Evelyn Shapiro.
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