Hospital Trends in Canada

Transcription

1 Hospital Trends in Canada Results of a Project to Create a Historical Series of Statistical and Financial Data for Canadian Hospitals Over Twenty-Seven Years N a t i o n a l H e a l t h E x p e n d i t u r e D a t a b a s e

2 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system now known or to be invented, without the prior permission in writing from the owner of the copyright, except by a reviewer who wishes to quote brief passages in connection with a review written for inclusion in a magazine, newspaper or broadcast. Requests for permission should be addressed to: Canadian Institute for Health Information 377 Dalhousie Street Suite 200 Ottawa, Ontario K1N 9N8 Telephone: (613) Fax: (613) ISBN (PDF) 2005 Canadian Institute for Health Information TM Registered Trade-mark of the Canadian Institute for Health Information Cette publication est disponible en français sous le titre : «Tendances relatives aux hôpitaux canadiens, Résultats d un projet d élaboration d une série historique de données statistiques et financières sur les hôpitaux canadiens pour les vingt-sept dernières années» ISBN (PDF)

3 Hospital Trends in Canada Table of Contents Acknowledgements... i Highlights... iii Background... v Part 1 Hospital Statistics... 1 Section 1: Key Characteristics of the Hospital Data Hospital Databases Size of the Hospital Sector Response Rates... 3 Section 2: Summary of Results All Hospitals Admissions and Separations Average Length of Stay for Inpatients... 7 Section 3: Summary of Results Acute Care Hospitals Separations and Inpatient Days per 1,000 Population Average Length of Stay for Inpatients Section 4: Visits to Ambulatory Care Units Section 5: Methodology Issues in Matching and Extrapolating Data Comprehensiveness Beds Staffed and In Operation Extrapolation of Totals Peer Groups Were Responding Hospitals Representative of all Operating Hospitals? Conclusions Part 2 Hospital Expenditures Introduction Section 6: Hospital Expenditure Trends Section 7: Hospital Expenditure by Functional Centre Functional Center Breakdown Functional Centre Distributions in the HS-1 and HS-2 and the CMDB Trends by Type of Expense from to Section 8: Hospital Expenditure by Type of Expense Type of Expense Breakdown Expense Distributions in the HS-1 and HS-2 and the CMDB Trends by Type of Expense from to Section 9: Hospital Expenditure by Functional Centre and Type of Expense Functional Center and Type of Expense Breakdown Trends by Functional Centre and Type of Expense Conclusions... 40

4 Hospital Trends in Canada Table of Contents (cont'd) Data Tables Table 1 Series Statistics Table 2 Series Expenditure Appendix A Statistical Variables and Data Matching... A 1 List of Figures Figure 1 Trends in Hospital Beds, Canada, 1976 to Figure 2 Response Rates in HS-1 and HS-2 and CMDB, Canada, to Figure 3 Hospital Admissions, Canada, to Figure 4 Hospital Separations and Admissions, Canada, to Figure 5 Hospital Separations and Admissions in CMDB and HMDB, Canada, to Figure 6 Average Inpatient Days, Canada, to Figure 7 Hospital Beds Staffed and In Operation, Reporting Hospitals, Canada, Selected Years... 9 Figure 8 Inpatient Days per 1,000 Population, Canada, Selected Years Figure 9 Average Days per Separation, Canada, Selected Years Figure 10 Visits Ambulatory Care Units, Canada, to Figure 11 Distribution of Hospital Expenditure, Reporting Hospitals, Canada, Selected Years Figure 12 Alternative Measures of Hospital Beds, Canada, to Figure 13 Figure 14 Hospital Expenditure Trends from the NHEX Database and from the Reporting Hospitals to CMDB, Canada, 1976 to Distribution of Hospital Expenditure by Functional Centre, Reporting Hospitals, Canada, and

5 Hospital Trends in Canada List of Figures (cont d) Figure 15 Figure 16 Figure 17 Figure 18 Figure 19 Figure 20 Figure 21 Figure 22 Figure 23 Figure 24 Figure 25 Figure 26 Figure 27 Share of Hospital Expenditure by Selected Functional Centres, Reporting Hospitals, Canada, to Share of Hospital Expenditure by Selected Functional Centres, Reporting Hospitals, Canada, to Share of Hospital Expenditure by Selected Functional Centres, Reporting Hospitals, Canada, to Share of Hospital Expenditure by Selected Functional Centres, Reporting Hospitals, Canada, to Share of Hospital Expenditure by Selected Functional Centre, Reporting Hospitals, Canada, to Distribution of Hospital Expenditure by Type of Expense, Reporting Hospitals, Canada, and Share of Hospital Expenditure by Selected Type of Expense, Reporting Hospitals, Canada, to Share of Hospital Expenditure by Selected Types of Expense, Reporting Hospitals, Canada, to Share of Hospital Expenditure by Selected Types of Expense, Reporting Hospitals, Canada, to Share of Hospital Expenditure by Selected Types of Expense, Reporting Hospitals, Canada, to Distribution of Salaries and Benefits, Reporting Hospitals, Canada, and Distribution of Ambulatory Care Expense, Reporting Hospitals, Canada, and Distribution of Emergency Care Expense, Reporting Hospitals, Canada, and

6 Hospital Trends in Canada List of Tables Table 1 Characteristics of CIHI Hospital Databases... 2 Table 2 Comparison of Statistics for Average Length of Stay, Canada, to Table 3 Hospital Beds by Type of Hospital, Canada, Table 4 Table 5 Table 6 Table 7 Table 8 Trends in Hospital Utilization per 1,000 Population, Canada, Selected Years Beds in Hospitals Reporting Admissions, Inpatient Days, Discharges as a Percent of Beds in Hospitals Reporting Any Statistics, and Bed Counts in Hospitals Reporting Any Statistics, Canada, to Hospital Expenditure and the Percentage Distributions by Functional Centre, Canada, Selected Years Expenditure Weights and Annual Rates of Increase, Administrative and Support Services, Canada, Hospital Expenditures by Functional Centre and Type of Expenses, Canada, List of Data Tables Table 1 Series Statistics Table 1.1 Selected Statistics, All Hospital Types, Canada, to Table 1.2 Table 1.3 Selected Statistics, General Public Hospitals Without Long Term Units, Pediatric Hospitals, and Private Hospitals, Canada, to Selected Statistics, General Hospitals With Long Term Units and Federal Hospitals, Canada, to Table 1.4 Selected Statistics, Teaching Hospitals, Canada, to Table 1.5 Table 1.6 Selected Statistics, Short Term Psychiatric Hospitals, Canada, to Selected Statistics, Long Term Psychiatric Hospitals, Canada, to

7 List of Data Tables (cont d) Table 1 Series Statistics (cont d) Hospital Trends in Canada Table 1.7 Selected Statistics, Other Specialty Hospitals, Canada, to Table 1.8 Selected Statistics, Rehabilitation Hospitals, Canada, to Table 1.9 Selected Statistics, Extended Care Hospitals, Canada, to Table 1.10 Selected Statistics, Other Hospitals, Canada, to Table 2 Series Expenditure Table 2.1 Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Table 2.2 Table 2.3 Table 2.4 Table 2.5 Table 2.6 Table 2.7 Table 2.8 Table 2.9 Table 2.10 Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars... 68

8 List of Data Tables (cont d) Table 2 Series Expenditure (cont d) Table 2.11 Hospital Trends in Canada Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Table 2.12 Table 2.13 Table 2.14 Table 2.15 Table 2.16 Table 2.17 Table 2.18 Table 2.19 Table 2.20 Table 2.21 Table 2.22 Table 2.23 Table 2.24 Table 2.25 Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars... 83

9 List of Data Tables (cont d) Table 2 Series Expenditure (cont d) Table 2.26 Hospital Trends in Canada Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars Table 2.27 Hospital Expenditure by Functional Centre and Type of Expense, Canada, Current Dollars... 85

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11 Acknowledgements The Canadian Institute for Health Information (CIHI) would like to acknowledge and thank many individuals who contributed to the development of this report and in particular, Vern Hicks, Health Economics Consulting Services; Brigitte Chavez and Rob Dunphy, Statistics Canada; and Jingbo Zhang, CIHI. For more information about this project or about this report please contact: Ms. Jingbo Zhang, Senior Analyst National Health Expenditures Canadian Institute for Health Information Suite Dalhousie Street Ottawa, Ontario K1N 9N8 Tel.: (613) Fax: (613) Web: i

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13 HOSPITAL TRENDS IN CANADA H IGHLIGHTS Highlights This report provides the first complete set of comprehensive statistical and financial data on hospital utilization and financial trends over the last 27 years. The data confirm fewer inpatient hospitalizations over the last 15 years and a reallocation of resources within the hospital sector as far back the mid-1970s. Highlights include: Relatively stable use of hospital inpatient care for approximately 15 years: 1. Hospital admissions and separations in Canada were relatively stable during the 15 years from fiscal to , with rates of growth in these statistics less than the rate of growth in the Canadian population. 2. The total number of hospital beds was relatively stable until the mid-1980s, but began to decline after Average length of stay for hospital inpatients remained stable during the 1980s. Rapidly changing utilization patterns during the last decade: 4. Hospital beds and inpatient utilization fell rapidly during the period of cost restraint and reorganization in the 1990s. Trends appear to be stabilizing at present. Changing patterns of resource allocation and hospital care: 5. Hospitals are the largest category of national health expenditure. Increases in hospital expenditure have been less than the average for all health expenditures, resulting in a drop in their share of national health expenditure from 45% in calendar 1976 to 30% in A considerable amount of hospital care and financial resources have been shifted from inpatient settings to ambulatory clinics. This trend is confirmed by both statistical and financial data. Visits to ambulatory care units have increased consistently. The number of patient visits to ambulatory units in acute care hospitals, including day surgery visits, is estimated to have exceeded 50 million in Ambulatory care, emergency departments and operating rooms have increased their share of hospital expenses. The shares of nursing inpatient and hospital support services have declined. 7. Staff salaries and benefits fell from 76% of hospital expenses in to 68% in Physicians remuneration, drugs and medical supplies have all increased their shares of expenditure. Utilization and financial data in this report were both projected to annual totals based on survey and administrative databases from Statistics Canada and the Canadian Institute for Health Information (CIHI). The project provided insights about the ability to match data between the Statistics Canada HS-1 and HS-2 surveys and CIHI s Canadian MIS Database to inform ongoing analysis and future development of hospital databases. iii

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15 HOSPITAL TRENDS IN CANADA B ACKGROUND Background The Canadian Institute for Health Information (CIHI) maintains the Canadian MIS Database (CMDB), which consists of financial and statistical information primarily on Canadian hospitals. The CMDB replaced the Annual Return of Health Care Facilities Hospitals (traditionally known as HS-1 and HS-2), 1 which was carried out by Statistics Canada from 1932 until fiscal CIHI and Statistics Canada carried out a project in 2002 to match financial data from the two sources. The results were published as an Analytical Focus article in the publication, National Health Expenditure Trends, 1975 to Details about the data matching project and methods used to match data from the two databases are available in a documentation manual published by CIHI and Statistics Canada in 2003 which is available on CIHI s web site. 2 A second project was carried out in 2004 and 2005 to match statistical data from the two sources. Part 1 of this report presents the results of that project. An updated copy of the 2002 financial analysis is also included as Part The Annual Returns were submitted in two parts. Part 1 (HS-1) contained the most detail and primarily was used in this project. Part 2 (HS-2) contained audited information but at higher levels of aggregation. 2. A Project to Establish a Historical Series of Hospital Spending by Function and Type from 1976 to CIHI, Ottawa, Available at < v

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17 HOSPITAL TRENDS IN CANADA P ART 1 HOSPITAL STATISTICS Part 1 Hospital Statistics SECTION 1: KEY CHARACTERISTICS OF THE HOSPITAL DATA 1.1 Hospital Databases CIHI maintains three distinct databases of hospital utilization data. 1. The Canadian MIS Database (CMDB) consists of financial and statistical information on Canadian hospitals. The CMDB is updated annually from data submitted by provincial and territorial health ministries. The database is intended to include all hospitals, including public hospitals operated by provinces/territories or health authorities, federal hospitals and proprietary or private hospitals. CMDB data are based on expenditure and statistical categories contained in CIHI s Guidelines for Management Information Systems in Canadian Health Service Organizations (MIS Guidelines). The first data submissions covered data from fiscal Data results are now reported annually. The CMDB replaced the Annual Return of Health Care Facilities Hospitals (HS-1 and HS-2), which was carried out and published in annual reports by Statistics Canada from calendar 1932 until fiscal In only the preliminary survey was carried out. The Statistics Canada survey was based on reporting standards defined in the Canadian Hospital Accounting Manual (CHAM), which was replaced by the MIS Guidelines in the mid-1990s. 2. The Discharge Abstract Database (DAD) contains complete clinical data for inpatient acute care hospital separations in Canada (excluding Quebec and non-winnipeg facilities in Manitoba). The DAD also contains partial clinical data from chronic, rehabilitation, psychiatric and same day surgery facilities. Source data are abstracted from clinical records. The database includes information on patient characteristics, diagnoses and procedures. Inpatient acute care cases are categorized using Case Mix Groups or CMG TM methodology and measures of relative resource use are assigned by a Plx TM classification system. Day surgery cases are categorized using Day Procedure Groups or DPG TM methodology. 3. The Hospital Morbidity Database (HMDB) is a national data holding that captures administrative, clinical and demographic information on hospital inpatient events. It provides national discharge statistics from Canadian health care facilities by diagnoses and procedures. Discharge data are received from acute care facilities and select chronic care and rehabilitation facilities across Canada. Discharge data from psychiatric facilities, as well as day procedures (e.g. day surgeries) and emergency department visits are not captured in this database. 1

18 HOSPITAL TRENDS IN CANADA P ART 1 HOSPITAL STATISTICS See Table 1 for the summary of relevant key characteristics of the three databases. Table 1 Characteristics of CIHI Hospital Databases Data Characteristics CMDB DAD HMDB Scope of data Level of detail Central focus Inpatient Separations: Exclusions Financial and statistical Aggregate by institution Comprehensive financial and statistical data Inpatient separations and day surgery Case oriented* Acute care Inpatient separations Case oriented* Acute care 3,512,628 2,356,224 2,770,128 No systematic exclusions. All types of hospital care are intended to be included. Ambulatory clinics. Although all inpatient separations are included, the CMG grouping methodology focuses on acute care. Ambulatory clinics, chronic care hospitals in Ontario and BC, and Psychiatric hospitals. * Case oriented data in DAD and HMDB include certain characteristics of cases separated (e.g. age, sex, diagnosis). 1.2 Size of the Hospital Sector Canada spent $34.4 billion on the hospital sector in 2002, equivalent to 30% of total health expenditure. 3 In 1976, hospitals accounted for 45% of health expenditure. Hospital expenditures have grown during most of the last three decades except for three years between 1993 and In most years, the declining share of hospital expenditure in total health expenditure reflects more rapid growth of other categories of expenditure. The period during the mid-1990s when hospital expenditures decreased was a period of significant change in the Canadian health care system, as provincial governments restrained expenditure growth in most programs in order to balance budgets. In health care, there were initiatives to move the location of care from expensive inpatient acute care to day surgery or home care. In the three years from 1993 to 1996 the share of health expenditure allocated to hospitals dropped from 37.4% to 33.7%. The deployment of real resources in the hospital sector began to change during the 1980s. The number of beds approved by provincial governments peaked in at 179,256 (Figure 1). The number of beds declined slowly for the next three years but then increased in , mainly due to the reclassification of ten facilities in Ontario with 3,376 beds changing from residential care facilities to long term psychiatric hospitals. During the three years from to , the number of beds 3. National Health Expenditure Trends, 1975 to Canadian Institute for Health Information, Ottawa

19 HOSPITAL TRENDS IN CANADA P ART 1 HOSPITAL STATISTICS dropped by 20.7%, while expenditure decreased by 5.7%. Hospital expenditure began increasing again in The number of beds continued to drop until , when they leveled out at approximately 115,000 with small year-to-year variations. Expenditure data in Figure 1 are not adjusted for price inflation. Price inflation was relatively high in the 1970s and 1980s, but dropped to a range of 2% to 3% in the 1990s. Figure 1 Trends in Hospital Beds, Canada, 1976 to 2002 Expenditure ($ millions) 40 Beds (000) Expenditure (per calendar year) 25 Beds (per fiscal year) Year Sources: Canadian Institute for Health Information and Statistics Canada. The striking changes to the hospital sector outlined above have led to public debate about overall levels of funding for health care, waiting times for hospital care and the adequacy of support programs for patients who now spend less time in hospital or have care provided on a same-day basis. Solid information on the utilization of hospital resources is required in order to inform debate on these important public issues. These circumstances illustrate the relevance of a valid series of hospital utilization data and provide context to the project to create a consistent series of hospital statistics. 1.3 Response Rates Circumstances that increase the difficulty of producing a consistent series of hospital data include the switch from a mandatory survey by Statistics Canada to CMDB data submitted directly by provinces/territories, with a one-year gap in Response rates (beds in reporting hospitals as a percentage of beds in all operating hospitals) were lower during the four years from to , although they have recovered during the 2000s to levels similar to response rates under the Statistics Canada surveys in the early 1990s (Figure 2). 3

20 HOSPITAL TRENDS IN CANADA P ART 1 HOSPITAL STATISTICS A growing gap between approved beds and beds staffed and in operation was a second confounding factor. Beds staffed and in operation were 3.0% less than approved beds in By , the gap had increased to 9.8% and in reached 22.8%. Bed counts shown in Figure 1 are approved beds until Under the CMDB provinces/territories report only one set of bed counts. In most jurisdictions reported approved beds but some provinces have since switched to beds staffed and in operation (see discussion in Methodology section). A third issue is the classification of beds in certain facilities. Statistics Canada reports that between and over half the decline in the number of approved beds occurred in extended care hospitals and long term care units of general hospitals. 4 Many of these institutions were reclassified to residential care facilities, which were not included in the HS-1 and HS-2 surveys. The change in accounting and reporting standards from the CHAM to the MIS Guidelines also create difficulties in time series analyses. These circumstances provided limitations and challenges to analysts who carried out the match between Statistics Canada s HS-1 and HS-2 and CIHI s CMDB hospital data. The summaries of results that follow discuss the strategies to improve comparability as well as limiting factors % Figure 2 Response Rates in HS-1 and HS-2 and CMDB, Canada, to % 80.0% 70.0% 60.0% Year Sources: Canadian Institute for Health Information and Statistics Canada. 4. Tully, P, Saint-Pierre E. Downsizing Canada s hospitals, 1986/87 to 1994/95. Health Reports, 1997-V8 (4), pg

21 HOSPITAL TRENDS IN CANADA P ART 1 HOSPITAL STATISTICS S E C T I O N 2 : S U M M A R Y O F R E S U L T S ALL HOSPITALS 2.1 Admissions and Separations Hospital admissions provide a highly aggregate indicator of access, and utilization of hospital resources. Admissions would not necessarily follow the same trend as number of beds. Changes in care patterns, such as shorter stays and higher bed occupancy rates, would allow more admissions for a given bed complement. Average length of stay is discussed later. Bed occupancy rates in acute care hospitals increased from 84.7% in to 90.9% in and then dropped back to 86.6% by Admissions tended to be fairly constant between and at approximately 4.0 to 4.2 million per year (Figure 3). Admissions began declining in , dropping from 4.2 million in to 4.1 million in During the following years the number of admissions continued to drop, leveling out at 3.3 million to 3.1 million between and (000) 4,500 Figure 3 Hospital Admissions, Canada, to ,500 Raw data Extrapolation 2,500 1, Year Sources: Canadian Institute for Health Information and Statistics Canada. The estimates in Figure 3 include raw data reported by hospitals and an extrapolation that adjusts for the drop in survey response rates during the early 1990s and the initial years of the CMDB. Estimation techniques are discussed in the Section 5. Admissions also include newborns, which represent approximately 10% of total admissions. 5. CIHI data prepared for OECD Health Data. 5

22 HOSPITAL TRENDS IN CANADA P ART 1 HOSPITAL STATISTICS While the exact numbers in the extrapolated series are subject to a degree of uncertainty, the trends in beds and admissions are compelling. Between and , the number of beds and admissions reported by provincial/territorial governments dropped by 36% and 26% respectively. Hospital separations are defined as the number of cases discharged plus the number of inpatient deaths. Separations are usually the preferred variable to measure hospital inpatient throughputs since they measure the number of completed cases, while admissions measure the number of cases that entered treatment. The number of admissions and separations were almost identical for most years between and , with differences normally less than two-tenths of one percent (Figure 4). Differences were greater in and subsequent years, possibly reflecting greater variability due to lower response rates. (000) 4,500 Figure 4 Hospital Separations and Admissions, Canada, to ,500 Separations Admissions 2,500 1, Year Sources: Canadian Institute for Health Information and Statistics Canada. Figure 5 compares the extrapolated series of separations from to from the CMDB with data from the HMDB publications. Separations from HMDB are not extrapolated but historically reporting to HMDB has been more complete than for the other hospital databases (the CMDB and the DAD). Data published in the HMDB reports cover facilities that provide acute care and exclude same day surgery, extended care facilities, psychiatric and chronic care hospitals. HMDB also excludes newborns born in the reporting facility from published series. Newborns represent approximately 10% of hospital separations and were added into the HMDB separation statistics for purposes of comparisons in Figure 5. The two series correspond in most years, indicating that trends in hospital separations are consistent between the two independent sources of data. 6

23 HOSPITAL TRENDS IN CANADA P ART 1 HOSPITAL STATISTICS (000) 4,500 Figure 5 Hospital Separations in CMDB and HMDB, Canada, to CMDB HMDB 3,500 2,500 1, Year Sources: Canadian Institute for Health Information and Statistics Canada. 2.2 Average Length of Stay for Inpatients Average length of stay (ALOS) is a statistic that is measured by dividing the total days stay since admission for separated patients by the number of separations. There were data quality problems with the total days stay variable in the early years of the CMDB. Consequently, average inpatient days during the year per separation was considered to be a more reliable indicator of the overall tendency in average duration of an episode of inpatient care since there was a continuous series from to the present. The main difference between this statistic and average length of stay is in the calculation for patients whose stay in hospital extends over two fiscal years. In the ALOS statistic all days since admission are included for patient separations during the year (including days in the previous year); in the average inpatient days per separation statistic all inpatient days during the year are divided by total separations for that year. Average inpatient days per separation may slightly understate average time in hospital. On the other hand, patients who remain in hospital for more than one year are uncommon except in extended and long term care facilities, and could be considered outliers that would tend to skew estimates of norms for time spent in hospital before separation. While the conceptual differences above provide important context for analysts, the two series were very similar between and as shown in Table 2. Both variables followed the same trend through time (Figure 6). Both statistics showed that average inpatient days remained relatively constant during the 1980s, between 13.0 and 13.9 days per separation, and then began to decline in Average days per separation declined from 13.3 in 1989 to 10.1 in Variations in the trend in and may result from data variability in extrapolations from reported data (inpatient days, discharges and deaths were extrapolated separately and the average inpatient days statistic was calculated from the resulting estimates). 7

24 HOSPITAL TRENDS IN CANADA P ART 1 HOSPITAL STATISTICS Table 2 Comparison of Statistics for Average Length of Stay, Canada, to Average Days Per Separation ALOS Mean Value Standard Deviation Sources: Canadian Institute for Health Information and Statistics Canada Figure 6 Average Inpatient Days, Canada, to Inpatient Days per Separation Average Length of Stay Year Sources: Canadian Institute for Health Information and Statistics Canada. S E C T I O N 3 : S U M M A R Y O F R E S U L T S ACUTE CARE HOSPITALS Trends in beds and utilization were not the same in all sectors of hospital care. Between and , the year in which beds actually staffed and in operation reached a peak, the number of beds in general hospitals 6 that offered only short term care fell while beds in hospitals 7 offering both short term and long term care grew (Figure 7). While a detailed analysis of this trend was not carried out, it seems reasonable to assume that a number of hospitals that were exclusively short term care in introduced long term care beds over the next ten years. Beds in teaching hospitals and hospitals 6. This category also includes public pediatric hospitals and private hospitals which account for a small portion of the entire category. Refer to Section 5 for further details. 7. Federal hospitals are also included in this category. 8

25 HOSPITAL TRENDS IN CANADA P ART 1 HOSPITAL STATISTICS dedicated to short term psychiatric care, other specialties and rehab services also grew during this period. 8 The number of extended care hospital beds grew during the decade, but at lower rates than the other two categories in which growth occurred. 70,000 Figure 7 Hospital Beds Staffed and in Operation, Reporting Hospitals, Canada, Selected Years 50,000 30,000 10, p Year Public General With No Long Term Units; Pediatric and Private Hospitals Public General With Long Term Units and Federal Hospitals Teaching, Short Term Psychiatric, Other Specialty and Rehabilitation Hospitals Extended and Long Term Psychiatric Hospitals p = preliminary data Source: Statistics Canada. Between and , beds staffed and in operation fell in all categories of hospitals, with the greatest percentage reductions occurring in extended care hospitals (54%) and hospitals offering only short term care (34%). Reductions in beds staffed and in operation were greater than reductions in approved beds, especially during the 1990s (see discussion in the Methodology section). The reclassification of some hospitals from extended care hospitals to residential care facilities was an important factor in the reduction of extended care beds. Statistics Canada reports that approximately 14,000 approved beds were reclassified to residential care in Alberta and Quebec during the early and mid-1990s. 9 Numbers were not provided for beds staffed and in-operation that were reclassified. Statistical data for residential care facilities are contained in a separate database the Residential Care Facilities (RCF) database and when hospitals are reclassified their statistics are no longer recorded in the HS-1 and HS-2 surveys or the CMDB. Consequently, trend data that include extended care facilities prior to their transfer to the RCF database tend to overstate reductions in utilization during years when the transfer took place. In order to understand trends without this confounding factor, this section focuses on hospitals that offer primarily acute care. The definition of acute care hospitals 8. The category that includes teaching hospitals in Figure 7 had 44,442 beds in , 38,464 of which were beds in teaching hospitals. 9. Downsizing Canada s Hospitals, 1986/87 to 1994/95. Patricia Tully, Etienne Saint-Pierre. Health Reports, Spring 1997, Vol.8, No.4. 9

26 HOSPITAL TRENDS IN CANADA P ART 1 HOSPITAL STATISTICS in this analysis is based on that of the OECD. 10 It includes hospital types found in the CMDB which are general hospitals, specialty hospitals except long term psychiatric hospitals, and rehabilitation hospitals. Extended care facilities and long term psychiatric hospitals, which were included in the previous section, were excluded in this section. Both the HS-1 and HS-2 and the CMDB classify hospitals according to type of service and size. Although the two classification systems were not identical, it was possible to combine hospitals into comparable groups. Hospitals included in the analysis had approximately 132,500 approved beds and 103,900 beds staffed and in operation in (Table 3). They had an average of 9.3 days stay per separation, while extended care and long term psychiatric care hospitals had an average of days. While hospitals included in this analysis are referred to as acute care, it is important to note that many of these hospitals may provide a mix of short term acute care and longer term care. The HS-1 and HS-2 data distinguished between short term and long term units in hospitals. In the CMDB series, short term and acute care are subsumed in the CMDB hospital types of general hospitals, specialty hospitals and rehabilitation hospitals and are not identified as separate categories. Table 3 Hospital Beds by Type of Hospital, Canada, Type of Hospital Approved Beds Beds Staffed and In Operation Inpatient Days per Separation (1993) Public general with no long term units* Public general with long term units** 24,470 18, ,458 51, Teaching 37,263 29, Short term psychiatric; other specialty and rehab 5,315 4, Sub-total acute care 132, , Extended care and long term psychiatric 24,041 16, Total 156, , * This category also includes public pediatric hospitals and private hospitals which account for a small portion of the entire category. ** Federal hospitals are also included in this category. Source: Statistics Canada. 10. OECD Health Data 2004, 3 rd Edition. 10

27 HOSPITAL TRENDS IN CANADA P ART 1 HOSPITAL STATISTICS 3.1 Separations and Inpatient Days per 1,000 Population Hospital separations per 1,000 population decreased throughout the 27 years from to , 11 with the largest annual decreases in the years after There was little difference between all hospitals and acute care hospitals in the number of separations per 1,000 population or rates of change. There were marked differences in the number of inpatient days (Table 4, Figure 8), reflecting the relatively high average days stay in extended care hospitals. Rates of change in inpatient days were similar between the two hospital groups, with small increases between and , followed by decreases in subsequent years. The higher rate of decrease between and for all hospitals includes the effects of transferring beds and associated utilization from hospital to RCF status (Table 4). Table 4 Trends in Hospital Utilization per 1,000 Population, Canada, Select Years All Hospitals Acute Care Hospitals Separations Inpatient Days Separations Inpatient Days , , , , , , to to to Annual Rates of Change -0.9% 0.2% -1.0% 0.1% -1.6% -3.4% -1.6% -3.6% -3.9% -5.7% -3.8% -4.2% 11. Data in Section 1 show modest growth in admissions and separations until , but rates of growth in these statistics were less than the rate of growth in the population. 11

28 HOSPITAL TRENDS IN CANADA P ART 1 HOSPITAL STATISTICS 2,500 Figure 8 Inpatient Days per 1,000 Population, Canada, Selected Years All Hospitals Acute Care Hospitals 2,000 1,500 1, Year Sources: Canadian Institute for Health Information and Statistics Canada. 3.2 Average Length of Stay for Inpatients Average inpatient days per separation increased between and in acute care hospitals (Figure 9). Average days decreased over the next 16 years, reaching 9.0 days in , a reduction of 15.9% from the 10.7 days recorded in Average days per separation reported here are higher than estimates in the HMDB due to additional exclusions in that database. Figure 9 Average Inpatient Days per Separation, Canada, Selected Years Year Sources: Canadian Institute for Health Information and Statistics Canada. 12

29 HOSPITAL TRENDS IN CANADA P ART 1 HOSPITAL STATISTICS SECTION 4: VISITS TO AMBULATORY CARE UNITS Ambulatory care units include clinics, emergency departments and day surgery. Day surgery procedures are identified in CIHI s Discharge Abstract Database (excludes Quebec; Alberta since ; and Manitoba hospitals outside the Winnipeg area). The DAD reported 2.0 million day surgery procedures and 1.4 million day surgery visits in Visits to ambulatory care departments did not follow the same trend as separations. Visits increased in virtually all years, following a linear trend in which total visits in acute care hospitals almost doubled between (23 million) and (41 million). 12 If trends in the ten years ending in continued, the number of visits would exceed 50 million by (Figure 10). Trends in visits provide an important counterpoint to trends in inpatient services, demonstrating that a considerable amount of hospital care was transferred from inpatient to ambulatory services during the period when hospital beds were decreasing. (000) 50,000 Figure 10 Visits Ambulatory Care Units, Canada, to ,000 30,000 20,000 10,000 HS-1 and HS-2 Linear Trend (HS-1 and HS-2) Source: Statistics Canada. Year Visits under the HS-1 and HS-2 were reported for clinics, outpatient programs, emergency departments and day surgery. The term ambulatory care refers to ambulatory care units in the hospital but includes visits by both outpatients and inpatients for example those who are required to go to emergency departments for care not available in the inpatient service to which they were admitted. In the CMDB, visits were reported as either scheduled or unscheduled visits until April 2002, when they were replaced by visits face to face. The MIS Guidelines break down statistics into functional centres that include specialty clinics, emergency departments, surgical suite and other ambulatory care. As a 12. Visits in acute care hospitals represented 96.5% of all visits reported to HS-1 and HS-2 in

30 HOSPITAL TRENDS IN CANADA P ART 1 HOSPITAL STATISTICS result, the structure of the two reporting systems allows a match of statistics for visits to ambulatory care units, both in aggregate and in some detail regarding the type of unit in which the visit took place. After the transition from the HS-1 and HS-2 to the CMDB, the reporting of visits became somewhat erratic. This might have resulted from under-reporting in some jurisdictions or misinterpretation of how visits and other ambulatory services, such as lab procedures, should be reported. At an early stage during the matching process it was determined that the distinction between scheduled and unscheduled visits was unclear in data from a number of jurisdictions (for example, one might expect that most visits to emergency departments would be coded as unscheduled, but this was not the case). As a result of these findings, data on trends in the number of visits after were not included. Investigation of these issues is ongoing as part of the CMDB s quality control procedures and visit data is expected to be available in the future. Trends in hospital expenditures for ambulatory care units in the HS-1 and HS-2 and the CMDB confirm the shift of hospital care to ambulatory units. Hospital expenditures by functional centre show increasing shares of hospital budgets allocated to emergency departments, ambulatory care and operating room (Figure 11). The share of expenses allocated to emergency departments and ambulatory care more than doubled between and Taken together, these functional centres accounted for 12.4% of hospital expenditure, or $4.1 billion, in , compared to 4.9% in Operating rooms increased their share more modestly (4.7% to 5.9%). Operating room expenditures include both inpatient and day surgery cases. 8.0% 7.0% 6.0% Figure 11 Distribution of Hospital Expenditure, Reporting Hospitals, Canada, Selected Years Emergency Ambulatory Care Operating Room 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% Year Sources: Canadian Institute for Health Information and Statistics Canada. 14

31 HOSPITAL TRENDS IN CANADA P ART 1 HOSPITAL STATISTICS SECTION 5: METHODOLOGY 5.1 Issues in Matching and Extrapolating Data Reporting standards in the HS-1 and HS-2 and the CMDB databases are based on two different accounting systems (the CHAM and the MIS Guidelines respectively). Challenges in matching financial data reported under the two standards are discussed in some detail in the financial project documentation manual available on CIHI s web site. Both types of data can be matched at certain levels of detail, but the prospect for matching is limited as the levels of detail become finer. The Annual Hospital Surveys collected data at more aggregate levels than the CMDB. The MIS Guidelines used in the CMDB require more detailed data, which can be rolled up to aggregate levels for trend comparisons. Statistical data can be separated into two types of variables: 1. those that allow analysis of utilization trends (e.g. inpatient separations, inpatient days and ambulatory visits); 2. those that complement financial data in the analysis of hospital efficiency (e.g. hours worked in specific functional centres). The utilization data were defined in a similar way in both HS-1 and HS-2 and CMDB. The efficiency-related data tend to be consistent at certain levels, but tend at more detailed levels to have the same limitations on consistency as financial data. The financial data matching project was able to provide annual estimates of expenditure by type of expense and hospital functional centre. This two-way breakdown was achieved by first calculating percentage coefficients for each cell in a data matrix, based on HS-1 and HS-2 returns and data submission to CMDB, and then applying the coefficients to estimates of total hospital expenditure from NHEX. Part 2 of this report consists of updated financial estimates first presented in While financial breakdowns can all be seen as allocations within a hospital budget, statistical variables must be extrapolated independently. A two-way breakdown was not feasible for most variables. In some cases variables were naturally concentrated in certain functional centres or were mainly interesting at aggregate levels, e.g. hospital admissions. Statistical extrapolations based on sample data can normally be assigned a specific margin of error within a defined level of probability (95% is usually the level of probability at which differences within random samples are considered significant). This is possible when the samples from which data are drawn are random and reflect the characteristics of the sector from which they are drawn. A second assumption is that survey respondents provide accurate responses subject to random errors that will tend to cancel out. 15

32 HOSPITAL TRENDS IN CANADA P ART 1 HOSPITAL STATISTICS 5.2 Comprehensiveness Both the Statistics Canada surveys and the provincial data collected for the CMDB cover all hospitals, not a random sample. The HS-1 and HS-2 surveys were compulsory under the Statistics Act and compliance appears to have been almost universal, except for a decline in the 1990s (see Figure 2). Response rates were lower in the early years of the CMDB, although this fact alone would not obstruct extrapolation of the data collected so long as the non-responses were random rather than systemic. There is no evidence of systemic non-response for the major utilization variables discussed in Section 1, although there were years in which fewer than half of hospitals in Newfoundland, Prince Edward Island, Nova Scotia, Saskatchewan and territories reported. A second concern with respect to response rates relates to whether all questions were answered. Both databases contain data elements that are broken down by operating department (e.g. admissions or visits). In the HS-1and HS-2 these data elements also have a total for all departments. The CMDB contains high-level accounts that could be used to record aggregate data in lieu of detail. In some cases only the variable total or high level account was reported. These situations limit the extent to which some data can be disaggregated, even after adopting strategies to distribute the high level accounts. In the matching project high level accounts were distributed to lower level accounts (see financial project documentation manual for details). 5.3 Beds Staffed and In Operation The data in Figure 12 are based on provincial master lists of hospitals and their bed capacity. Different definitions have been used to measure capacity. Rated beds (based on hospital technical capacity), approved beds (based on provincial budget allocations) and beds staffed and in operation were all reported to the HS-1 and HS-2. Bed counts were as of the last day of the fiscal year. Rated and approved beds followed similar trend lines with absolute differences of 4,000 to 5,000 beds until Between and there was very little difference between rated beds and approved beds (Figure 12). However, the number of approved beds and the number actually staffed and in operation tended to diverge. In the difference was equivalent to 10%. There were large decreases in both approved and operating beds in , and the gap between approved and operating beds increased to 23%. Part of this reduction can be explained by the transfer of a number of extended care hospitals to residential care facilities and the loss of their data to the hospital databases (see Table 3 and Section 1). Provincial/territorial ministries of health provide master lists of beds to the CMDB as of the beginning of the fiscal year. Provinces/Territories report either approved or operating beds, with a recent trend toward reporting operating beds. From until , the number of beds reported on the provincial master lists remained above the number of beds reported to be in operation in