MONITORING THE WINNIPEG HOSPITAL SYSTEM:Does closing hospital beds translate to a decline in health care in Manitoba? This is the second time MCHP - the Manitoba Centre for Health Policy and Evaluation - is responding to that question. The answer, perhaps more timely than ever, again appears to be no. And it's not just a case of hospitals continuing to do the same with less. Due to a remarkable response by nurses and physicians, they are actually doing more.
The Update Report, 1993/94
When Manitoba Health began downsizing hospitals, MCHP agreed to monitor the effects of bed closures. Monitoring the Winnipeg Hospital System: The First Report focussed on the years 1990 through 1992, and was our initial look at what impact, if any, these reductions were having on Manitobans. At that time, we found no adverse effects - access to care, quality of care and the health of Winnipeg residents had not been compromised. However, since the first major bed closures occurred during 1992, we acknowledged that The First Report was preliminary; more time was needed to assess the impact of downsizing.
This Update Report focusses on 1993, a full year after the first major bed closures (approximately 10%) occurred, a year in which an additional 8% of Winnipeg hospital beds were closed. As such, it provides a more informed answer to complex questions about the impact of bed closures, though by no means final as beds continue to be closed. As before, we focus on three key questions: have the bed closures adversely affected Manitobans' access to care? the quality of care delivered? the health of the population?
AccessWinnipeg residents had relatively the same or better access to hospitals in 1993 as they did in the years preceding. In fact, there were more patients cared for by Winnipeg hospitals in 1993 than there were in 1990 or 1989 (fig. 1), despite considerable reductions in bed numbers and expenditures. This was accomplished by hospitals, nurses and physicians changing the way care was delivered. Between 1992 and 1993:
The number of days patients spent in hospital decreased. The days per 1000 residents dropped by 9%.
Use of hospitals by adult medical patients changed very little. Hospitalizations decreased by only 1% (fig. 2); days spent in hospital decreased by only 3%.
There was no noticeable decrease in access to hospitals for paediatric patients, non-Winnipeg patients nor patients from the poorest neighbourhoods.
Comparing 1993 back through to 1990, surgical procedures were actually up from what they were! There was more surgical care in outpatient settings; less in inpatient settings (fig. 2). The length of stay for surgical inpatients also decreased. Access to procedures such as angioplasty and cataracts increased dramatically between 1992 and 1993; knee replacements jumped from 432 in 1992 to 575 in 1993 (fig. 3). Concerns about bed closures leading to reduced access to surgical procedures appear to have been unfounded.
Quality of Care
Mortality rates among those admitted for heart attacks, cancer surgery or hip fractures remained low. Even amongst the elderly, the most vulnerable group of patients, no increase in mortality occurred.
Due to concerns from nurses and physicians that downsizing might mean discharging patients "too quick and too sick" from hospitals, we examined readmission rates for thirteen common types of patients. The rates did not change significantly in 1993: some rates rose slightly, some rates fell slightly. Regardless of whether they rose or fell, we could find nothing to connect them to shorter hospital stays.
Although readmission rates are typically higher for the more vulnerable groups (such as the elderly or those from the poorest neighbourhoods), readmission rates for these groups remained stable in 1993. We took particular note of this because if there were negative effects from downsizing, odds are that these groups would feel them first; a jump in their readmissions would soon follow.
What this all suggests is that quality of care remained high. We found no evidence that downsizing negatively influenced the quality of care delivered to patients.
Health StatusThe health of the Winnipeg population remained stable between 1990 and 1993.
Contrary to sensational headlines and public fears, mortality rates did not increase following bed closures - not even among the poor and the elderly, whose typically poor health and few resources make them the most dependent on hospitals and the first likely to be negatively affected by downsizing.
Additional InsightsContrary to headlines and the impression of some in the system, despite cutbacks, overall nursing hours per case did not decrease over the period studied. Reports from nurses suggest that more recent data may show decreases. However, such data were unavailable for this report.
While quality of care was largely unaffected by downsizing, we found areas where it actually improved. For example, an increase in beds available at long-term care facilities and Personal Care Homes helped hospitals respond to downsizing, allowing them to move more long-stay (60+ days) patients out of hospital. This more appropriate placement of patients was responsible, at least in part, for a notable 14% reduction in long-stay hospital days.
While there was growth in the private sector, we found nothing to connect that growth with downsizing. For example, cataract surgery in the private sector expanded by over 125% between 1990 and 1993 (from 284 up to 649 procedures). But at the same time, there were also many more procedures performed in the Winnipeg public hospitals; cataract surgeries jumped from 3,556 to 4,634 procedures (fig. 3). So while there was an increase in the private sector, it could not be blamed on belt-tightening in the public system; there were just more procedures performed in both sectors. If such increases in the private sector continue, despite good public system access, a closer review of the implications for Manitobans will be in order.
The strong relationship between neighbourhood income levels and health status has again been highlighted. Winnipeg residents from middle income neighbourhoods have poor health relative to that of residents of high income neighbourhoods. They also spend more days in hospital. Residents of lower income neighbourhoods have dramatically poorer health and spend considerably more time in hospital than both those groups.
The absence of routinely collected data on home care services creates a major gap in the information available for monitoring the impact of these changes in the health care system. As more patient care shifts from hospital to the community, the need to fill the gap becomes increasingly critical.
Mortality rates and readmission rates are measures widely used by researchers to gauge quality of hospital care. What these measures lack is information on the quality of life patients experience once discharged, as well as family satisfaction with hospital care - data unavailable to us at the time of this report. However, the Manitoba Health Reform Impact Study is looking specifically at these indicators, and will be able to add an important perspective to the downsizing/quality of care discussion.
While 1993 data should accurately reflect the changes wrought by 1992 bed closures, an additional 200 beds were closed in 1993 and downsizing has continued since then. In a health care system so rapidly changing, no report, regardless of how carefully conducted, can be up to date. So while this report focusses on 1993, our last full year of data, as soon as preliminary data from 1994 became available, we investigated whether the same trends have continued. Once again, the answer is yes. Our first look at 1994 data shows access to hospital care, quality of hospital care and health in Manitoba still unaffected by bed closures. However, it would be a mistake to think that reports by health care providers of escalating pressures on the system are false. Indeed, 33 beds at one Winnipeg hospital had to reopen temporarily at different times during the past year, indicating how real the stresses are. As pressures on and demands for acute care continue, it will be vital for hospitals to retain this kind of flexibility.
It would appear to be time to move beyond our preoccupation with the potential negative effects of hospital downsizing. Findings in this report are consistent with findings in The First Report: all our indicators - hospitalizations, mortality rates, readmissions, surgical procedures - collectively suggest that Manitobans are in relatively the same state of health and can get much the same level of care as readily as before downsizing began. Hospitals are performing remarkably well under difficult circumstances, due in no small part to the dedication and hard work of their nurses and physicians.
What we see is a system that has absorbed cutbacks well, that continues to provide high quality of care to as many, if not more, patients. Moreover, it's a system that is functioning more efficiently than before cutbacks began. Many positive trends noted in the first report have continued, including patient transfers to alternative care facilities, the more timely discharge of patients and increases in outpatient treatment. The latter has translated into Manitobans receiving more surgery, not less. Yet, overall expenditures are down. Again, much of the credit goes to the people who work in these institutions. They are to be commended for their adaptability and considerable efforts.
This improved efficiency at urban hospitals suggests it is time to critically assess the delivery of care in rural hospitals, particularly since rural residents, in general, make more use of hospital services than do urban residents. It is likely that substantial inefficiencies exist in the rural hospital system, that there's room for decreasing their lengths of stay and expenditures while maintaining access to care for rural Manitobans.
While much of what we say here we've said before, there is one point that can't be made often enough: as important as they are, hospitals and physicians are not the only important determinants of health. There is a persistent and insidious link between health status and neighbourhood income levels. Simply put, the wealthier you are, the healthier you are and the less you use hospitals. The fact that as socio-economic status goes up, the average amount of hospital time goes down seems particularly germane to the issue of hospital downsizing. It strongly suggests that improving the health of low and middle income groups could lead to an overall reduction in hospital use and a corresponding reduction in expenditures - an initiative we could all support.
The positive preliminary indications of our first report were not misleading. One full year of study later, the news from 1993 data continues to be good; early indications from 1994 data equally so. Downsizing appears to have led to increased efficiencies: access to care seems undiminished, quality of care remains high, and we detect no change in the health status of Manitoba residents. At a time of great fiscal restraint, hospitals and their staff have shown the necessary resourcefulness to make the system work. Yes, closing over 500 beds has ushered in changes in the way care is being delivered, but it seems to be a change for the better.
We need to shake off our fixation with medical services - more beds? more physicians? more procedures? Clearly, medical services are necessary, but rather than relying solely on the health care system to treat poor health, we need to start dealing with the social causes of it as well. Investments in community initiatives, investments in early childhood, such initiatives may have long-term pay-offs in reduced health care requirements. It's worth repeating that improving all Manitobans' quality of life may be the best and cheapest medicine.
Summary written by RJ Currie, based on the report: Monitoring the Winnipeg Hospital System: The Update Report: by Marni Brownell and Noralou Roos.
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