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Provincial Variations in Publicly-Funded Nursing Home Bed Supply in Canada: Exploring
What “Matters”
Saskia Sivananthan, Malcolm Doupe, Margaret McGregor
Study Rationale
• Population aging• While rates of institutionalization are
decreasing, nursing homes are still a common venue for care of the very frail who are unable to live independently
• Literature focussed on bed projections• Little work examining the factors that relate to
variation in bed supply nor how the variation affects the healthcare system more generally
How many receive care in institutions?*
15-16/09/2009 Conference on Healthy and Dignified Ageing – Swedish Presidency of the EU Presentation by Bernd Marin
6.5%
Institutional care covers only a small percentage of older people
Share of older people receiving care in institutions (most recent date)
Source: Huber et al. (2009 forthcoming) Own calculations based on OECD, NOSOSCO , WHO, Eurostat and national sources.
First Study Goal
• An exploration of factors related to provincial variation in Canada’s publicly funded nursing home (NH) bed supplyAre bed numbers related to variation in
distribution of oldest seniors (85+)?Is variation bed supply related to provincial
wealth?Is there an inverse relation of bed supply and
provincial investment in home care?
Second Study Goal
• Explore the extent to which publicly-funded bed supply is related to healthcare system “efficiency”Is publicly-funded bed supply inversely related to
ALC days waiting admission to a nursing home bed
Methods
Data Sources
Need for comparable data from valid sources! Statistics Canada – Demographics, Gross Domestic
ProductCUPE - (Irene Janzen, Janice Murphy) – NH bed # CIHI - All other measures (home care*, Alternate
Level of Careˆ) Most data from 2008 - 2011
* Public-Sector Expenditures and Utilization of Home Care Services in Canada: Exploring the Data; CIHI 2007
ˆ Obtained directly from CIHI
Definitions• Demographics, Publically funded NHs, Bed Supply
Focus on people 85+ years old – majority NH users from both a population and user-based perspective
Facilities funded by government to provide 24/7 care - includes respite, for profit, not-for-profit sector
Bed Supply: density (i.e., # of beds per capita).
• Alternate Level of Care (ALC) Days Hospitalized people who no longer require acute care ALC people / days waiting for nursing home admission.
Analytic Approach
• Descriptive reports & regression analysis Extent that provincial variation in bed supply is related to
population size 85+, wealth, etc. Identifies provinces with > / < than average bed supplyApproach allows us to explain (or not) inter-provincial
trends in nursing home bed supply.
Results
British Columbia
Alberta Manitoba Saskatchewan Ontario Quebec New Brunswick
Newfound-land
& Labrador
Nova Scotia Prince Edward Island
0
5
10
15
20
25
30
35
40
All Ages
% A
cros
s P
rovi
nce
s
N~ 34.5 million people
Population Distribution Across Canada - 1
Ontario & Quebec house ~ 2/3s of our population, plus ~ 1/4 in BC & Alberta.
Manitoba, Saskatchewan, & Atlantic Canada house 13.5% of our population.
British Columbia
Alberta Manitoba Saskatchewan Ontario Quebec New Brunswick
Newfound-land
& Labrador
Nova Scotia Prince Edward Island
0
5
10
15
20
25
30
35
40
All Ages
65-74
75-84
85+
% A
cros
s P
rovi
nce
s
N~ 34.5 million people
Population Distribution Across Canada - 1
This is true also for older adults, except that relatively:
i) Fewer live in Albertaii) More live in Quebec, BC
Publically Funded NH Bed Supply in Canada
NH Bed supply varies across Canada, especially for people 85+ years old:i) Highest in MB, Sask, Nova Scotia, PEIii) Lowest in New Brunswick, BC, Alberta
Canada British Columbia
Alberta Manitoba Saskatchewan Ontario Quebec New Brunswick
Newfoundland & Labrador
Nova Scotia Prince Edward Island
200
220
240
260
280
300
320
340
360
380
# of
NH
Bed
s /
1000
pop
ulati
on 8
5+N~ 198,000 Publically Funded NH Beds
Besides Population Size – what factors could influence NH Bed Supply?
Canada BC AB MB SASK ONT QB New B NFDL & L
Nova Scotia
PEI
Gross Domestic ProductValue per capita $47,112 $44,388 $69,754 $43,347 $60,084 $45,824 $40,029 $38,987 $54,966 $38,327 $34,387
Home Care Expenditures (1997 dollars)
Value per capita $93.6 $86.8 $91.0 $142.2 $82.0 $99.8 $79.9 $163.4 N/A $116.7 $55.5
Alternate Level of Care Days Waiting Admission to a NH
% of all hosp patients with 1+ ALC day, Waiting Admission to a NH
3.2 3.5 2.2 4.3 4.6 3.2 N/A 2.6 1.2 N/A 4.7
Of all hosp days, % ALC Waiting Admission to a NH
5.7 4.7 3.4 11.9 6.0 5.1 N/A 12.4 4.5 N/A 6.8
Population Size 85+ – how does it impact NH Bed Supply?
0 100,000 200,000 300,000 400,000 500,000 600,000 700,000 800,000 900,000 1,000,00070.0
75.0
80.0
85.0
90.0
95.0
100.0
105.0
110.0
115.0
f(x) = − 1.4766278998254E-05 x + 94.0189260264163R² = 0.103116447835195
# of people 85+ years old
NH
Bed
Sup
ply
(# /
1,0
00 8
5+)
↓ than average NH bed supply based on population size
↑ than average NH bed supply based on population size
Population Size 85+ – how does it impact NH Bed Supply?
0 25,000 50,000 75,000 100,000 125,000 150,000 175,000 200,000 225,000 250,000 275,000 300,000220
240
260
280
300
320
340
360
380
BC99175, 264
AB54135, 267.2
MB28619, 338.3
SASK26409, 324.7
ONT262051, 297.2
QC159195, 287.9
New B17247, 256.7
NFLD & L8719, 303.9
Nova S21492, 319.7
PEI2894, 363.2
f(x) = − 0.000125832086749995 x + 310.833006847234R² = 0.0920342912200893
# of people 85+ years old
Bed
Supp
ly (#
/ 1
,000
peo
ple
85+
year
s old
)
Population Size 85+ – how does it impact NH Bed Supply?
0 25,000 50,000 75,000 100,000 125,000 150,000 175,000 200,000 225,000 250,000 275,000 300,000220
240
260
280
300
320
340
360
380
MB28619, 338.3
SASK26409, 324.7
NFLD & L8719, 303.9
Nova S21492, 319.7
PEI2894, 363.2
f(x) = − 0.000125832086749995 x + 310.833006847234R² = 0.0920342912200893
# of people 85+ years old
Bed
Supp
ly (#
/ 1
,000
peo
ple
85+
year
s old
) Size Doesn’t Matter (R2=.06)
Population Size 85+ – how does it impact NH Bed Density?
0 25,000 50,000 75,000 100,000 125,000 150,000 175,000 200,000 225,000 250,000 275,000 300,000220
240
260
280
300
320
340
360
380
BC99175, 264
AB54135, 267.2
MB28619, 338.3
SASK26409, 324.7
ONT262051, 297.2
QC159195, 287.9
New B17247, 256.7
NFLD & L8719, 303.9
Nova S21492, 319.7
PEI2894, 363.2
f(x) = − 0.000125832086749995 x + 310.833006847234R² = 0.0920342912200893
# of people 85+ years old
Bed
Supp
ly (#
/ 1
,000
peo
ple
85+
year
s old
)
Maybe it does(R2=.91)
GDP & NH Bed Supply?
30,000 35,000 40,000 45,000 50,000 55,000 60,000 65,000 70,000 75,000220.0
240.0
260.0
280.0
300.0
320.0
340.0
360.0
380.0PEI
$34,387, 363.2
Nova Scotia$38,327, 319.7
New B$38,987, 256.7
QB$40,029, 287.9
MB$43,347, 338.3
BC$44,388, 264
ONT$45,824, 297.2
NFDL & L$54,966, 303.9
SASK$60,084, 324.7
AB$69,754, 267.2
f(x) = − 0.000867655842607305 x + 343.065125834172R² = 0.0779796465681788
Per Capita GDP
Bed
Supp
ly (#
/ 1
,000
pop
ulati
on 8
5+)
Per Capita Home Care Expenditure & NH Bed Supply?
50 70 90 110 130 150 170180.0
200.0
220.0
240.0
260.0
280.0
300.0
320.0
340.0
360.0
380.0PEI
$55, 363.2
QB$80, 287.9
SASK$82, 324.7
BC$87, 264.1
AB$91, 267.2
ONT$100, 297.2
Nova Scotia$117, 319.7
MB$142, 338.3
New B$163, 256.7
f(x) = − 0.34157371212792 x + 336.918064743692R² = 0.0972122716196831
Per Capita Home Care Expenditure
Bed
Supp
ly (#
/ 1
000
popu
latio
n 85
+ ye
ars o
ld)
R2=.25
R2=.27
Impact of NH Bed Supply on ALC Days
240 260 280 300 320 340 360 3800.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
AB267.2, 3.4
NFDL & L287.9, 4.5
BC264.1, 4.7
ONT297.2, 5.1
SASK324.7, 6.0
PEI363.2, 6.8
MB338.3, 11.9
New B256.7, 12.4
f(x) = 0.0145918361818516 x + 2.47390763374584R² = 0.0271180681788405
Bed Supply (# / 1000 population 85+years old)
% o
f all
Hosp
ital D
ays t
hat a
re A
LC d
ays w
aitin
g N
H Ad
miss
ion
R2=.85
In SummaryExtent that NH Bed Supply is Impacted by
Provinces NH Bed Supply
Population Size (# of 85+ year olds) GDP Home Care
Expenditures
ALL ↔ ↔ ↔ ↔
MB, SASK, PEI, Nova Scotia, NFLD&L
↑ No obviousrelation
No obviousrelation
More HC ↓ bed supply
Ontario, AB, BC, New Brunswick
↓ More people↑bed supply
No obviousrelation
More HC↓ bed supply
Greater NH Bed Supply is associated with more ALC Days waiting admission – Manitoba and NB are outliers
Discussion: Why is NH Supply Positively Associated with % ALC
Days waiting NH Admission?
Discussion: “Stuff” not measured that may matter
• The effect of different policy decisions by provincial governments in power
• Differences in how homecare is deployed (post-op vs. longterm substitution for NH care)
• Unmeasured regulatory factors?Provincial “bed hold” policies?Policy on NH “leeway” to refuse admission?“First available bed” policies?Block vs. case-mix adjusted payment systems?