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 Pro

vinc

es

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 Pro

vinc

es

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

Beds

/ 10

00 p

opul

ation

85+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?