canadian journal on aging la revue canadienne du ...

Volume / volume 24

Supplement / supplément 1, 2005

CANADIAN JOURNAL ON AGING LA REVUE CANADIENNE DU VIEILLISSEMENT Health and Health Care Use Among Older Adults: Using Population-Based Information Systems to Inform Policy in Manitoba Les soins de santé et leur utilization par les aînés: L’utilisation de systèmes d’information fondés sur la santé de la population pour guider l’élaboration de politiques au Manitoba PUBLISHED BY/ PUBLIÉE PAR

Canadian Association on Gerontology

Association canadienne de gérontologie

CANADIAN JOURNAL ON AGING / LA REVUE CANADIENNE DU VIEILLISSEMENT EDITORIAL BOARD / COMITE´ DE RE´DACTION Editor-in-Chief/Re´dacteur en chef Mark Rosenberg, Queen’s University Managing Editor/E´ditrice Anne Marie Corrigan, University of Toronto Press Health Sciences and Biological Sciences/Sciences de la sante´ et sciences biologiques Carole Cohen, University of Toronto Social Policy and Practice/Politiques et pratiques sociales Daniel W.L. Lai, University of Calgary Educational Gerontology/Ge´rontologie e´ducative Elaine Gallagher, University of Victoria

Psychology/Psychologie Thomas Hadjistavropoulos, University of Regina Norm O’Rourke, Simon Fraser University at Harbour Centre Social Sciences/Sciences sociales Ingrid Arnet Connidis, University of Western Ontario Book Reviews/Comptes rendus Lucie Richard, Universite´ de Montreál

The Canadian Journal on Aging is a refereed, quarterly publication of the Canadian Association on Gerontology. It publishes manuscripts on aging concerned with biology, educational gerontology, health sciences, psychology, social sciences, and social policy and practice. Acceptance or rejection of manuscripts will be on the recommendation of Editors representing the five divisions of the CAG, in consultation with reviewers. Normally, two or more reviewers, in addition to the Editors, will review the manuscript. The Canadian Association on Gerontology and the Editors accept no responsibility for views and statements of the authors. The journal is currently indexed and abstracted in / Les articles sont re´sume´s et indexe´s clans Abstracts in Social Gerontology, AgeInfo CD-ROM, Ageline, Australasian Medical Index, Bibliographic internationale de la litte´rature pe´riodique, Bibliographie internationale des recensions, Canadian Periodical Index, Current Index to Journals in Education, EMBASE/ Excerpta Medica, Index to Periodical Literature on Aging, Index de Pe´riodiques canadiens, International Bibliography of Book Reviews, International Bibliography of Periodical Literature, New Literature on Old Age, PAIS Bulletin, Psychological Abstracts, Science Culture, Social Work Research and Abstracts, Sociological Abstracts, Social Sciences Citation Index and Current Contents, Social and Behavioural Sciences. La Revue canadienne du vieillissement, revue trimestrielle doteé d’un comite´ de lecture; est l’organe de 1’Association canadienne de ge´rontologie. La revue publie des articles sur le vieillissement clans les disciplines suivantes: biologie, ge´rontologie e´ducative, sciences de la sante´, psychologie, sciences sociales et politiques et pratiques sociales. Les manuscrits sent accepte´s ou refuse´s sur la recommandation des re´dacteurs repre´sentant chacune des cinq sections de 1’ACG, et apre´s consultation avec les membres du comite de lecture´. Les manuscrits sont normalement soumis a` l’approbation des re´dacteurs et de deux lecteurs ou plus. Les opinions exprimeés dans la revue n’engagent que leurs auteurs. Published quarterly by the Canadian Association on Gerontology Members of CAG, membership $135.00 (www.cagacg.ca) includes $40 for the Journal Annual Subscription: (þ7% GST) Canada / Outside Canada (US dollars) Individuals $55.00 (Payable by personal cheque, VISA, MC, and AMEX) Students $30.00 Institutions $85.00 Single Copy $25.00

Revue trimestrielle publieé par l’Association canadienne de ge´rontologie Membres de 1’ACG, inscription 135.00 $ (www.cagacg.ca) dont 40 $ pour la Revue Abonnement annuel: (þ7% TPS) Canada / EU et autre pays (US$) Personnel 55.00 $ (Payer seulement par che`que personnel, VISA, MC, et AMEX) Étudiants 30.00 $ Institutions 85.00 $ Prix de 1’exemplaire 25.00 $

Correspondence/Correspondance Address all correspondence concerning editorial matters to:/Prie´re d’adresser toute correspondance concernant le contenu de la revue (manuscrits, comptes rendus, etc.) a`: Mark Rosenberg, CJA/RCV Editor-in-Chief, Canadian Journal on Aging Department of Geography Queen’s University Kingston, ON K7L 3N6 E-Mail/Courriel: [email protected]

Orders, Advertising/Abonnements, Publicite´ Address all correspondence concerning subscriptions, reprints, back issues, advertising to:/Prie´re d’adresser toute correspondance concernant les abonnements, tire´s a` part, numeros de´ja parus, ainsi que la publicite´ a`: CJA/RCV Re´dacteur en chef de la Revue canadienne du vieillissement Department of Geography Universite´ Queen’s Kingston ON K7L 3N6 E-Mail/Courriel [email protected]

Copyright: Canadian Association on Gerontology. All correspondence relating to reprinting articles should be addressed to the Business Office./Droit d’auteur: l’Association canadienne de ge´rontologie. Toute correspondance ayant trait aux reímpressions des articles doit eˆtre adresseé au Bureau de re´daction. CANADIAN POSTMASTER: Name of the journal Canadian Journal on Aging Publication Mail Agreement Number 40010098

Send address changes to: University of Toronto Press Inc. 5201 Dufferin Street, Toronto, ON M3H 5T8

PAP Registration Number 09457/PAP enregistrement no. 09457. We acknowledge the financial assistance of the Government of Canada, through the Publications Assistance Program (PAP), toward our mailing costs./Nous reconnaissons l’aide financie`re du gouvernement du Canada, par l’entremise du Programme d’aide aux publications (PAP), pour nos de´penses d’envoi postal. Supported in part by grants from the Social Sciences and Humanities Research Council of Canada and the Canadian Institutes of Health Institute of Aging/ Revue subventionneé par le Conseil de recherches en sciences humaines du Canada et l’Institut du vieillissement des Instituts de recherche en sante´ du Canada.

´ ENT 1, 2005 SUPPLEMENT/SUPPLEM

ISSN 0714-9808

CANADIAN JOURNAL ON AGING LA REVUE CANADIENNE DU VIEILISSEMENT Volume 24 Supplement 1

Spring/printemps 2005

volume 24 supplement 1

Contents/Sommaire This issue is dedicated to Betty Havens, who died on March 1, 2005

Articles Introduction Verena H. Menec

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Trends in the Health Status of Older Manitobans, 1985 to 1999 Verena H. Menec, Lisa Lix, and Leonard MacWilliam

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Trends in the Utilization of Specific Health Care Services among Older Manitobans: 1985 to 2000 Marcia Finlayson, Lisa Lix, Gregory S. Finlayson, and Terry Fong

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Use of Physician Services by Older Adults: 1991/1992 to 2000/2001 Diane E. Watson, Petra Heppner, Robert Reid, Bogdan Bogdanovic, and Noralou Roos

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Growing Old Together: The Influence of Population and Workforce Aging on Supply and Use of Family Physicians Diane E. Watson, Robert Reid, Noralou Roos, and Petra Heppner

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Non-Clinical Factors Associated with Variation in Cataract Surgery Waiting Times in Manitoba Carolyn De Coster

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Patterns in Home Care Use in Manitoba Lori Mitchell, Noralou P. Roos, and Evelyn Shapiro

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Regional Variation in Home Care Use in Manitoba Sandra Peterson, Evelyn Shapiro, and Noralou P. Roos

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Pharmaceutical Use among Older Adults: Using Administrative Data to Examine Medication-Related Issues Colleen Metge, Ruby Grymonpre, Matthew Dahl, and Marina Yogendran

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Use of Acute Care Hospitals by Long-Stay Patients: Who, How Much, and Why? Carolyn De Coster, Sharon Bruce, and Anita Kozyrskyj

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Discharge Outcomes in Seniors Hospitalized for More than 30 Days Anita Kozyrskyj, Charlyn Black, Dan Chateau, and Carmen Steinbach

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Exploring Reasons for Bed Pressures in Winnipeg Acute Care Hospitals Verena H. Menec, Sharon Bruce, and Leonard MacWilliam

121

Anticipating Change: How Many Acute Care Hospital Beds Will Manitoba Regions Need in 2020? Gregory S. Finlayson, David Stewart, Robert B. Tate, Leonard MacWilliam, and Noralou Roos

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A Methodology for Estimating Hospital Bed Need in Manitoba in 2020 Robert B. Tate, Leonard MacWilliam, and Gregory S. Finlayson

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Data Quality in an Information-Rich Environment: Canada as an Example Leslie L. Roos, Sumit Gupta, Ruth-Ann Soodeen, and Laurel Jebamani

153

Commentary Betty Havens

171

Introduction Verena H. Menec, Guest Editor University of Manitoba That the population is aging is a well-known fact, and much has been written about the potential impact this might have on the health care system and society as a whole. It is therefore becoming increasingly important to have an understanding of trends in health and health care use, as well as factors related to them – all in an attempt to inform policy decisions that have implications for current and future cohorts of seniors. The papers in this special issue all examine health and health care use among older adults in Manitoba. Like the other provinces and territories, Manitoba has seen a steady increase in the proportion of seniors, with the proportion of adults aged 65 or over increasing from 11.9 per cent in 1981 to 13.5 per cent in 2001. Manitoba currently ranks second among the provinces and territories in the proportion of older adults; only Saskatchewan has a higher proportion. As is the case for the other provinces, the proportion of older adults is expected to rise substantially in the next 20 years in Manitoba. Thus while the papers in this special issue focus on Manitoba’s seniors, the research clearly has implications beyond Manitoba’s borders, as researchers and policy makers across the country grapple with similar issues related to the implications that the aging population will have on the health care system and society. Besides their focus on health and health care use, another common theme of the papers in this special issue is that they are all based on work by researchers at the Manitoba Centre for Health Policy (MCHP), a university-based research unit within the Department of Community Health Sciences at the University of Manitoba. Most of the papers come out of reports that MCHP conducted as part of its contract with the provincial Health Ministry. Each year, MCHP conducts five major reports for the ministry, with the topics being identified in discussion with policy makers. The research is built around the extensive and well-developed administrative data available in Manitoba, the Population Health Research Data Repository, which is housed at MCHP (see http:// www.umanitoba.ca/centres/mchp for further information). Administrative data are data that are collected not for research purposes specifically, but

rather as part of administering the health care system. For example, each time a patient sees a physician, a claim is filed by the physician with the provincial Health Ministry for reimbursement. Similarly, each hospitalization is recorded on a hospital discharge abstract. Administrative data files, therefore, contain virtually complete records of encounters with the publicly funded health care system in Manitoba. The Population Health Research Data Repository contains a wide range of data, including hospital, physician, and nursing home files, as well as the population registry. More recently, home care data and prescription drug data have been added to the repository. Public access Census data can be linked to these data to allow examination of potential socio-economic differentials in health and health care use. A strength of these data is that they are populationbased, which means that virtually the entire population of Manitoba – or senior population as the case may be – can be included in studies. Moreover, they allow examination of trends over time (papers in this issue extend over as many as 15 years) and space (e.g., across regional health authorities). Are recent cohorts of seniors healthier than the previous cohorts? How does the changing age structure of the population and physician workforce relate to physician visits? Does home care use vary across regional health authorities? How many hospital beds will be needed in different regions of Manitoba in 2020? These are just some of the questions that are addressed in this issue, using the repository. Repository data are supplemented in three papers by additional sources of information to allow more detailed examination of specific issues. The addition of the Cataract Surgery Waiting List Registry allows examination of waiting times for cataract surgery. It illustrates the rich data environment that can be created by linking clinical databases to administrative data. Actual reviews of patient hospital charts provide a fuller picture of hospital use in two papers – in this case, appropriateness of hospital admissions and stays – than is possible using administrative data alone. It is another example of how administrative data can usefully be supplemented by other sources of data.

Canadian Journal on Aging / La Revue canadienne du viellissement 24 (Suppl. 1) : 1 - 2

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Canadian Journal on Aging 24 (Suppl. 1)

The papers in this special issue cover a broad range of topics – from trends in health status and select surgical procedures, such as knee and hip replacements, to trends in family physician use and home care use, to predictors of cataract waiting times, to case studies illustrating the use of the prescription drug data. Several papers focus on hospital use, including an examination of long-stay patients – those in hospital more than 30 days – and the factors that predict discharge outcome, as well as some of the reasons for winter bed pressures in acute care hospitals. Two companion papers project into the future, addressing the question of the number of acute care beds needed in 2020; one paper presents the results, the second in detail the methodology used to derive projection estimates. Last, the issue concludes with a review paper on the quality of administrative data.

V. H. Menec

Together, the papers identify areas that policy makers in Manitoba and elsewhere should pay attention to, such as the implications of an aging family physician workforce, and ways to ensure that patients who do not require acute care can be discharged to alternative levels of care in a timely manner, to name just two, as well as areas where the system appears to be working, as evidenced by the lack of regional variation in home care use, for instance. These are important conclusions that an information-rich environment makes possible, which have implications for policy decisions in Manitoba and can inform policy in other jurisdictions. The peer review process for all the manuscripts in this issue was handled by the Canadian Journal on Aging’s former Editor-in-Chief, Carolyn J. Rosenthal

Introduction ´dactrice d‘inviteé Verena H. Menec, Re Universite´ du Manitoba Le vieillissement de la population est un fait bien connu et ses retombeés sur le syste`me de sante´ en particulier, et la socie´te´ en geńe´ral, ont fait couler beaucoup d’encre. Il est donc de plus en plus important de savoir interpre´ter les tendances en matie`re de sante´ et d’utilisation des services de sante´ et les facteurs connexes, si l’on veut faciliter l’e´laboration des politiques qui auront des re´percussions sur les cohortes actuelles et futures de personnes aˆgeés. Les articles retrouve´s dans ce nume´ro spećial traitent tous de la question de la sante´ et de l’utilisation des services de sante´ chez les aıˆne´s manitobains. Comme dans les autres provinces et territoires, le nombre de personnes aˆgeés augmente re´gulie`rement au Manitoba ; le pourcentage d’adultes de 65 ans et plus est passe´ de 11,9 % en 1981 a` 13,5 % en 2001. Le Manitoba est, apre`s la Saskatchewan, la province canadienne ayant le plus fort pourcentage d’aıˆne´s et, comme dans les autres provinces et territoires, on s’attend a` ce que leur nombre augmente de façon notable au cours des vingt prochaines anneés. Les articles pre´sente´s ici sont axe´s sur les aıˆne´s manitobains, mais il est clair que la recherche a des implications qui de´passent les limites du Manitoba. Les chercheurs et les dećideurs des quatre coins du pays sont aux prises avec les meˆmes questions lieés aux retombeés du vieillissement de la population sur le syste`me de sante´ et la socie´te´. En plus d’examiner la question de la sante´ et l’utilisation des services de sante´, tous les articles sont le re´sultat de travaux effectue´s par des chercheurs du Manitoba Centre for Health Policy (MCHP), une unite´ de recherche universitaire du Department of Community Health Sciences de l’Universite´ du Manitoba. La plupart des articles sont tire´s de rapports soumis par le MCHP dans le cadre de son contrat avec le ministe`re de la Sante´ provincial. Chaque anneé, le MCHP pre´pare cinq grands rapports pour le ministe`re, les sujets e´tant choisis au cours de discussions avec les dećideurs. La recherche s’articule autour des nombreuses donneés administratives bien documenteés disponibles au Manitoba, soit le Population Health Research Data Repository (une base de donneés centrale) qui se

trouve au MCHP (pour de plus amples renseignements, consultez le site : ). Les donneés administratives sont des donneés qui ne sont pas recueillies exclusivement a` des fins de recherche, mais plutoˆt dans le cadre de la gestion du syste`me de sante´. Ainsi, chaque fois qu’un patient consulte un me´decin, ce dernier remplit une demande de re`glement qu’il transmet au ministe`re de la Sante´ provincial. De meˆme, chaque hospitalisation est enregistreé dans une base de donneés une fois le conge´ d’hoˆpital reçu par le patient. Les banques de donneés administratives contiennent donc le registre quasi-inte´gral des activite´s du syste`me de sante´ public du Manitoba. Le Population Health Research Data Repository contient une multitude de donneés, parmi lesquelles les dossiers des hoˆpitaux, des me´decins et des maisons de soins infirmiers, ainsi que le registre de la population. Rećemment, on y a ajoute´ les donneés sur les soins a` domicile et les me´dicaments d’ordonnance. En reliant les donneés publiques de recensement a` ces donneés, on peut e´tudier les facteurs socio-ećonomiques susceptibles d’influer sur la sante´ et l’utilisation des services de sante´. L’un des grands avantages de ces donneés est qu’elles sont baseés sur un ećhantillon repre´sentatif de la population, c’est-a`-dire que la quasi-totalite´ de la population du Manitoba – ou de la population d’aıˆne´s selon le cas – peut eˆtre incluse dans les e´tudes. Qui plus est, elles permettent d’examiner les tendances a` la fois dans le temps (certains des articles portent sur des e´tudes meneés sur 15 ans) et dans l’espace (p. ex., entre autorite´s sanitaires re´gionales). Les cohortes rećentes de personnes aˆgeés sont-elles en meilleure sante´ que les preće´dentes ? En quoi les nouvelles tendances du vieillissement de la population et des me´decins en exercice influent-elles sur les consultations me´dicales ? Utilise-t-on diffe´remment les soins a` domicile d’une autorite´ sanitaire re´gionale a` l’autre ? De combien de lits d’hoˆpitaux aura-t-on besoin dans les diffe´rentes re´gions du Manitoba en 2020 ? Ce ne sont la` que quelques-unes des questions abordeés a` partir de la base de donneés centrale. Dans trois articles, on utilise les donneés de la base centrale paralle`lement a` d’autres sources d’information pour examiner plus a` fond certaines questions,


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comme le registre des de´lais d’attente pour une ope´ration de la cataracte. Ce registre est un bon exemple des possibilite´s innombrables qu’offre l’association des bases de donneés cliniques a` des donneés administratives. Deux articles se penchent sur les dossiers des hoˆpitaux – et notamment sur la pertinence des admissions et des se´jours a` l’hoˆpital – et dressent un portrait beaucoup plus prećis de l’utilisation de ce type de services que ne le permettrait les seules donneés administratives, preuve que ces donneés peuvent eˆtre avantageusement e´tayeés par d’autres sources d’information. Les articles publie´s dans ce nume´ro spećial couvrent un vaste e´ventail de sujets : tendances lieés a` l’e´tat de sante´ et a` certaines interventions chirurgicales, comme les ope´rations du genou ou de la hanche ; tendances en matie`re d’utilisation des services me´dicaux et des soins a` domicile ; pre´dire les de´lais d’attente pour une ope´ration de la cataracte ; e´tudes de cas expliquant a` quoi servent les donneés sur les me´dicaments d’ordonnance. Plusieurs articles s’inte´ressent a` l’utilisation des services hospitaliers, notamment aux se´jours de longue dureé – ceux qui durent plus de 30 jours – et aux facteurs permettant de pre´voir les re´sultats de la mise en conge´, et explorent certaines des raisons qui font que le taux d’occupation des lits de soins actifs est plus e´leve´ pendant les mois

V. H. Menec

d’hiver. Deux articles comple´mentaires font des projections sur le nombre de lits de soins actifs dont on aura besoin en 2020 ; un article pre´sente les re´sultats, l’autre explique en de´tail la me´thodologie employeé pour obtenir ces projections. Le nume´ro spećial se termine enfin par une synthe`se sur la qualite´ des donneés administratives. Ensemble, les articles cernent non seulement les questions sur lesquelles les dećideurs du Manitoba et d’ailleurs devront se pencher (les retombeés du vieillissement des me´decins de famille en exercice, et les strate´gies a` mettre en place afin que les patients qui n’ont pas besoin de soins actifs puissent eˆtre rapidement achemine´s vers d’autres niveaux de soins, par exemple), mais aussi des secteurs ou` le syste`me semble eˆtre performant, comme en te´moigne l’utilisation uniforme des soins a` domicile d’une re´gion a` l’autre. Ces prećieuses conclusions, que l’on doit a` l’abondance des donneés disponibles, seront importantes pour la prise de dećisions au Manitoba et l’e´laboration de politiques dans d’autres compe´tences. Les evaluations des articles pour cette nume´ro ont e´te´ coordonneés par Carolyn J. Rosenthal, re´dactrice en chef de preće´dente, La Revue canadienne du vieilissement

Trends in the Health Status of Older Manitobans, 1985 to 1999 Verena H. Menec, Lisa Lix, and Leonard MacWilliam University of Manitoba ´SUME ´ RE Les tendances relatives a` l’e´tat de sante´ de toute la population du Manitoba aˆgeé de 65 ans ou plus ont e´te´ e´tudieés sur une pe´riode de 14 ans, au moyen de donneés administratives (environ 150 000 personnes). Des gains conside´rables en sante´ ont e´te´ observe´s pour un certain nombre d’indicateurs, notamment du point de vue des infarctus aigus du myocarde, des accidents ce´re´braux vasculaires, des cancers et des fractures de la hanche. Cependant, certains de ces gains n’ont e´te´ observe´s que dans les zones urbaines. Les ame´liorations relatives a` ces indicateurs de la sante´ sont importantes, puisqu’elles peuvent avoir des conse´quences majeures sur les besoins des personnes en matie`re de soins de sante´ et sur leur aptitude a` vivre de façon autonome. Par contre, la pre´valence de maladies chroniques a augmente´ ; le diabe`te, l’hypertension et la de´mence ayant augmente´ de façon substantielle au cours de la pe´riode de 14 ans. Ces tendances laissent supposer qu’il faut mettre l’accent sur les politiques de pre´vention, afin notamment de re´duire la pre´valence de l’obe´site´, qui constitue l’un des facteurs de risque du diabe`te. Par ailleurs, il faudra se pencher sur la question de savoir si l’on dispose de suffisamment d’options en matie`re de soins pour le nombre croissant de personnes atteintes de de´mence.

ABSTRACT Trends in the health status of the entire senior population aged 65 years or older in Manitoba were examined over a 14-year period (1985–1999) using administrative data (about 150,000 individuals). Significant health gains were apparent for a number of important indicators, including acute myocardial infarction, stroke, cancer, and hip fractures, although some of these gains were restricted to urban areas. Improvements in these health indicators are significant, as they can have major implications for individuals’ need for health services and ability to live independently. In contrast, chronic diseases were on the rise, with the prevalence of diabetes, hypertension, and dementia increasing substantially over the 14-year period. These trends suggest a need for a policy emphasis on prevention, such as reducing the prevalence of obesity, which is one risk factor for diabetes. Moreover, having sufficient care options in place for the growing number of individuals with dementia is an issue that will have to be addressed.

Manuscript received: / manuscrit reçu : 15/02/03 Manuscript accepted: / manuscrit accepte´ : 04/03/04 Mots cle´s : analyse des tendances; compression de la morbidite´; donneés administratives; maladies chroniques; vieillissement Keywords: trend analysis; compression of morbidity; administrative data; chronic diseases; aging Requests for offprints should be sent to: / Les demandes de tire´s-a`-part doivent eˆtre addresseés a` : Verena H. Menec, Ph.D. Department of Community Health Sciences University of Manitoba 750 Bannatyne Avenue Winnipeg, MB R3E ON3 ([email protected])

Introduction That the Canadian population is aging is a certainty. In Manitoba, the proportion of individuals aged 65 and over is expected to increase from 13.5 per cent in 2000, to 17.8 per cent in 2020, to 22.5 per cent in 2040 (Manitoba Bureau of Statistics, 2000; Robson, 2001).

What is uncertain, however, is what impact the increasing senior population will have on the health care system. One view is that the growth in the senior population will have a major negative effect. Indeed, the aging population is already blamed for current pressures on the health care system, ranging from


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overcrowding of emergency rooms (Mackenzie & Wild, 1998) to the escalation of health care costs (Northcott, 1994). Even more dire consequences are predicted for the future, with the increasing health expenditures, it is argued, being no longer sustainable, given the current organization and funding of the health care system in Canada (Foot & Stoffman, 1996). The term apocalyptic demography has been coined to refer to this doomsday scenario (Gee & Gutman, 2000). The logic behind the apocalyptic scenario is straightforward: health declines with age and, consequently, health care use increases as people get older. Over time, as the number of seniors rises, more health care services will therefore be required, which will consequently place an increasing burden on the health care system. While nobody would question that health declines and health care use increases with age, at the heart of the population aging debate is the question of the magnitude of the problem that the increasing senior population will pose for the health care system. As Barer and his colleagues put it, the question is whether the effects of the demographic trends move like glaciers or like avalanches (Barer, Evans, & Hertzman, 1995). Proponents of the apocalyptic scenario clearly favour the avalanche view. A more optimistic alternative to the apocalyptic scenario has also been proposed, however. This more moderate view takes several important factors into account. First, most older adults, particularly young-old individuals – those 65 to 74 years of age – have few health problems and disabilities and continue to live independent and healthy lives into old age (National Advisory Council on Aging, 2001). Second, increases in health care use may be driven not so much by an increasing number of seniors, but by a health care system that does much more for them now than was the case even a decade ago (Barer et al., 1995). Indeed, research indicates that the aging population has contributed only minimally to the increase in health care cost (Evans, McGrail, Morgan, Barer, & Hertzman, 2001). Third, the health status of older adults seems to be improving. Over 20 years ago, Fries (1983) argued that people will not only live longer, but that the onset of diseases will occur later, with morbidity being compressed into a shorter period before death. Consistent with this compression of morbidity hypothesis, studies indeed show that healthy or disability-free life expectancy has been increasing in Canada (Manuel & Schultz, 2001; Martel & Belanger, 1999) and elsewhere (Crimmins & Saito, 2001; Doblhammer & Kytir, 2001). Moreover, several studies

V. H. Menec et al.

show that the functional status of recent cohorts of older adults is better than that of previous cohorts (Chen & Millar, 2000; Cutler, 2001; Manton, Stallard, & Corder, 1998; Statistics Canada, 1999; Waidman & Liu, 2000). The present study was designed to further examine trends in the health status of older adults among the entire Manitoba senior population to determine if recent cohorts of older adults are healthier than their counterparts in the past. Specifically, we were interested in trends in a range of health indicators, including mortality, acute conditions such as heart attacks, and chronic diseases like diabetes. Given that older adults are not a homogenous group of individuals, we examined trends across different age groups – young-old (65–74 years old), middle-old (75–84 years old), and old-old (85 years old and over) seniors – and across different geographic regions of the province (rural versus urban areas). Of particular interest in the present study was whether health gains would be evident across all three age groups and both rural and urban regions.

Methods Data Sources We used anonymized administrative data to examine health trends between 1985 and 1999. Previous research shows that administrative data can effectively be used to measure prevalence and incidence of certain health conditions (see Roos, Gupta, Soodeen, & Jebamani, this issue). For instance, hospitalizations for myocardial infarction and stroke tend to reflect the incidence of disease, given that there is consensus on the need for hospitalization (Wennberg, Freeman, & Culp, 1987; Wennberg, Freeman, Shelton, & Bubolz, 1989). Similarly, administrative data have been used to identify individuals with chronic conditions, such as diabetes and hypertension (Black, Roos, Fransoo, & Martens, 1999; Blanchard et al., 1996; Hux & Tang, 2002; Robinson, Young, Roos, & Gelskey, 1997). Study data were obtained from the following files of the Population Health Research Data Repository housed at the Manitoba Centre for Health Policy: Vital Statistics records, hospital separation abstracts, physician billing claims, and population registry. These data have been found to be a complete, valid, and reliable source of data (Roos & Nicol, 1999). Mortality data were obtained from computerized death records maintained by the Vital Statistics Branch. Each record contains information on the date and cause of death. Deaths of Manitoba residents that occurred outside of the province and deaths

Trends in the Health Status

occurring in Manitoba to non-residents were excluded from this study. The population registry contains one record for each Manitoba resident eligible to receive insured health care services. It was used to obtain population counts for each study year by age, sex, and location of residence. Location of residence was defined using regional health authority (RHA) boundaries. Urban regions encompassed the two major urban centres in Manitoba (Winnipeg and Brandon), while rural regions included all remaining Manitoba RHAs.

Measures Mortality Trends in all-cause mortality were investigated, as were trends for select leading causes (Menec, MacWilliam, Soodeen, & Mitchell, 2002; Statistics Canada, 1995), including cardiovascular disease (ICD-9 codes 390–459); cerebrovascular disease, a subset of cardiovascular disease that includes stroke (430–438); cancer (140–239); pneumonia and influenza (480–487); chronic obstructive pulmonary diseases (COPD), such as chronic bronchitis and asthma (490–496); and injuries (800–999). Hospitalizations for Acute Conditions Trends in hospitalizations were examined for acute myocardial infarction (AMI) (ICD-9-CM code 410); stroke (430–432, 434, 436); hip fractures (820); cancer (140–239); and injuries (800–999). With the exception of injuries, we identified patients with these conditions using the diagnosis that at discharge from hospital was deemed responsible for the patient’s hospital stay. Chronic Disease Diagnoses The following chronic diseases were identified based on diagnoses: diabetes (ICD-9-CM code 250), hypertension (401–402), congestive heart failure (428), COPD (490–496), and dementia (290–292, 294, 331, and 797). In keeping with previous research (Blanchard et al., 1996; Robinson et al., 1997), diabetics were defined as individuals with either two physician visits or one hospitalization during a 3-year period with the relevant ICD-9-CM diagnosis (e.g., 1985– 1987, 1988–1990, etc.). Note that this definition does not differentiate between Type 1 and Type 2 diabetes. Similarly, consistent with previous research (e.g., Black et al., 1999), congestive heart failure, hypertension, and COPD were defined in terms of at least two physician visits with a relevant diagnosis during a 3-year period.

La Revue canadienne du viellissement 24 (Suppl. 1)

7

A slightly broader definition was used for dementia, in that we classified individuals with either one physician visit or one hospitalization with one of the relevant diagnostic codes in a 3-year period as having dementia. Nursing home residents were excluded from these analyses, as we likely underestimate dementia prevalence in nursing homes using administrative data. This definition was chosen because it provided prevalence estimates that quite closely corresponded to those derived from the Canadian Study on Health and Aging (CSHA) in which dementia diagnoses were based on clinical assessments (Canadian Study of Health and Aging Working Group, 1994). For instance, while the CSHA (community sample) demonstrated a dementia prevalence of 173 per 1,000 among men 85 years or older in 1991, our prevalence for the 1991–1993 period was 186 per 1,000 population. Similarly, among women aged 85 years or older, the dementia prevalence was 180 per 1,000 in the CSHA, compared to 160 per 1,000 in our study. Data Analyses Regression techniques for correlated data were used to model measures of health status as a function of the independent variables of age, sex, location of residence, and time period (Carrie`re, Roos, & Dover, 2000). The data were analysed from a generalized linear models (GLM) perspective, using generalized estimating equations (GEE) to account for the correlated structure of the data (Liang & Zeger, 1986). Under a GLM framework, the data distribution is specified – a Poisson distribution for the present dependent variables – along with a link function, which describes the relationship between the dependent and independent variables, given the nature of the data distribution. The unit of analysis was a segment of the population defined by age, sex, and region of residence, and the dependent variable was the rate of a health event for that segment of the population. Age was entered into the regression models as a categorical variable with three levels: 65–74 years, 75–84 years, and 85 years and over. Location of residence was as a dichotomous variable: urban versus rural. Year was also treated as a categorical variable in the regression models to allow comparisons of specific time periods. As well, by not treating year as a continuous variable in the model, the assumption that the effect of time has been constant and incremental was avoided. All regression models contained the main effects of age, sex, region, and year, as well as the age-by-year and region-by-year interactions. Focused contrasts were used to test for differences in the rates of a health

8


event over time for each age group and region. More specifically, we were interested in testing whether the difference in a health event for one age group or one region was constant for the most recent 6 years (1994 to 1999) relative to the earliest 6 years (1985 to 1990). Combining several years of data is advantageous, given the small number of events for some indicators (e.g., injury deaths) in each age by sex by region stratum in a given year. We report trends in terms of relative risk/rate (RR), which describes the rate of a health event in one period relative to another. A relative rate above 1 indicates that the rate of a given health event was higher in the most recent period relative to the reference period; a relative rate lower than 1 indicates that the rate was lower. All significance tests were performed at ¼ .05 using a Wald test statistic that follows a 2 distribution with a single degree of freedom. The Bonferroni multiple comparison procedure was used to control the Type I error rate (Dunn, 1961).

Results Table 1 provides descriptive information for all measures for the most recent year (1999) or, in the case of chronic diseases, period (1997–1999). Both age-specific rates (per 1,000 population) and actual number of cases are shown. Noteworthy is the high prevalence of chronic diseases. For instance, 342 per 1,000 65- to 74-year-olds had a hypertension diagnosis in 1997–1999; the rate increased to 420 per 1,000 75- to 84-year-olds, and 372 per 1,000 85-year-olds and older. Other chronic diseases were also very prevalent. For example, 223 per 1,000 of those who were 85 and older and were dwelling in the community had a dementia diagnosis. Trends in Mortality

V. H. Menec et al.

young-old individuals, it should be kept in mind that these causes of death constituted relatively small proportions of all deaths. For example, in 1999, pneumonia and influenza and injury deaths combined constituted only 5.4 per cent of all deaths among 65- to 74-year-old Manitobans, in contrast to cardiovascular disease, which made up 33.9 per cent of all deaths in that age group. It is noteworthy that among the oldest-old individuals, injury deaths increased. Examination of specific causes of injury deaths showed that, over the 15 years, falls were responsible for 75.4 per cent of all injury deaths among the oldest-old. Men had higher rates of injury deaths; this was the case for all individuals over 65, as well as more specifically among those 85 years and older. For example, the relative risk of dying of an injury was 22 per cent higher among men than among women. A second regression model was used to tease out the specific nature of this effect; this model included all main effects, as well as the age-by-gender-by-year threeway interaction and all relevant two-way interactions. Contrasts were used to test for a difference in injury mortality rates over time for men and women in this oldest age group. This analysis revealed that the increasing trend in injury deaths was evident for women aged 85 and over (RR ¼ 1.11, p ¼ .024) but not for men (RR ¼ 1.02, ns). Results for location of residence (see Table 2) showed that death rates declined primarily in urban areas for all causes, cerebrovascular disease, cardiovascular disease, and pneumonia and influenza. In contrast, although the relative risk of dying of cardiovascular disease and pneumonia and influenza also declined in rural areas, the relative risk of cancer deaths increased significantly. To further explore this effect, we conducted a supplementary regression analysis. The rural region was consequently classified into three areas: North, Centre, and South based on RHA boundary definitions that have been used in previous research to examine health status disparities for the entire population (Brownell et al., 2003). A regression model that contained main effects as well as the region-by-year and age-by-year interactions was used. Results indicated that relative cancer mortality rates increased in Northern areas from the earliest to the most recent time period (RR 1.31, p ¼ .019); cancer trends were largely stable from the earliest to the most recent period in both the South (RR ¼ 1.07, p ¼ .032) and Centre (RR ¼ 1.06, p ¼ .059).

Table 2 presents the results of the contrasts that were used to test for differences in all-cause and causespecific mortality between the most recent 6-year period (1994–1999) and the earliest 6-year period (1985–1990) of the study for each age group and the two regions. Relative death rates declined significantly among young-old individuals (those aged 65 to 74) for all causes, cerebrovascular diseases (primarily stroke), cardiovascular diseases (which include stroke and all forms of heart disease, including heart attacks), pneumonia and influenza, and injuries. For the middle-old and old-old age groups there were statistically significant decreases only in cardiovascular disease death rates.

Trends in Hospitalizations for Acute Conditions

Although the relative risk of death due to pneumonia and influenza and injuries decreased among

As Table 3 shows, declines in AMI and stroke hospitalization rates were apparent among young-old



9

Table 1: Descriptive information for outcome measures – Rates per 1000 population and number of cases 65–74 Years Rate per 1000

75–84 Years No. of Cases

Rate per 1000

85þ Years No. of Cases

Rate per 1000

No. of Cases

Mortality (1999) All causes

20.9

1659

51.2

2844

149.9

3004

Cancer

8.3

656

14.5

806

21.7

434

Cerebrovascular

1.0

79

4.3

236

17.2

344

Cardiovascular

7.1

563

20.3

1127

68.8

1379

COPD

0.9

74

2.8

158

8.0

160

Pneumonia & flu

0.5

36

2.3

128

14.1

283

Injury

0.7

54

1.3

72

4.9

98

AMI

7.8

620

11.1

618

13.3

266

Stroke

5.3

417

10.5

581

17.2

344

Cancer

39.2

3112

48.6

2703

36.9

740

2.2

178

9.2

513

26.9

539

14.3

1136

25.2

1403

43.7

876

342.3

27443

420.6

23243

372.4

7107

38.6

3092

100.6

5561

229.0

4369

COPD

131.4

10537

171.1

9459

219.8

4194

Diabetes

144.9

11616

153.5

8485

128.0

2443

27.0

2172

89.8

4863

222.7

3563

Hospitalizations (1999)

Hip fracture Injury Chronic Diseases (1997–99) Hypertension Congestive heart failure

Dementiaa

Rates are age-specific crude rates per 1000 population. COPD ¼ chronic obstructive pulmonary diseases; AMI ¼ acute myocardial infarction a Dementia cases and rates do not include nursing home residents.

Table 2: Relative risk of mortality by age group and location of residence, 1994–1999 versus 1985–1990 All Causes

Cancer

Cerebro-vascular

CVD

COPD

P&I

Injury

65–74 years

0.91

1.02

0.87

0.82

0.98

0.67

0.82

75–84 years

0.95

1.06

0.97

0.86

1.04

0.94

0.99

1.02

0.96

0.94

1.15

0.96

Rural

0.97

1.08

0.94

0.88

1.00

0.92

0.99

Urban

0.93

0.99

0.93

0.86

1.11

0.78

1.10

Age Group*

85þ years Location of Residence

1.00 1.40

y

CVD ¼ cardiovascular diseases; COPD ¼ chronic obstructive pulmonary diseases; P & I ¼ pneumonia and influenza *Bold values are statistically significant at ¼ .017 (.05/3) y Bold values are statistically significant at ¼ .025 (.05/2)

10


and middle-old seniors and in urban regions, albeit not among the oldest-old and in rural areas. The relative risk of being admitted for cancer also declined in two of the three age groups and in urban areas. The risk of being admitted for a hip fracture declined among the oldest-old. It also declined in urban regions by 11 per cent, but increased in rural regions by 6 per cent. A regression model was used to examine the specific nature of this effect. Again, we used a model in which the rural region was subdivided into South, Centre, and North areas, and which contained all main effects as well as the regionby-year and age-by-year interactions. The contrasts that compared the rate of hip fracture hospitalizations between the first and last 6-year periods of the study indicated that the increase was restricted to Southern areas, where the relative risk of a hip fracture admission increased by 12 per cent over time ( p < .0001).

V. H. Menec et al. Table 3: Relative rate of hospitalizations for select acute conditions by age group and location of residence, 1994–1999 versus 1985–1990

AMI

Stroke Cancer

Hip Fractures Injury

Age Group* 65–74 years

0.84 0.90

0.96

0.98

1.17

75–84 years

0.86 0.96

0.94

0.99

1.10

85þ years

0.95

1.01

0.86

0.96

1.09

Rural

0.98

0.99

0.94

1.06

1.06

Urban

0.80 0.92

0.89

0.89

1.17

Location of Residencey

AMI ¼ Acute myocardial infarction Bold values are statistically significant at ¼ .017 (.05/3) y Bold values are statistically significant at ¼ .025 (.05/2) *

Trends in Chronic Conditions In Table 4 we present results for relative changes in chronic conditions over time. Evident are the increases in the relative rates of hypertension, diabetes, and dementia across all age groups and both rural and urban areas (see also Figure 1 for overall trends). The increases were substantial. For instance, the relative risk of diabetes increased by 29 per cent among the young-old, by 15 per cent among the middle-old, and by 11 per cent among the oldestold. The relative risk of dementia increased by 30, 38, and 26 per cent for young-old, middle-old, and oldestold individuals, respectively.

Discussion Seniors in Manitoba are living longer than ever (Manitoba Health, 2002; Menec et al., 2002), as is the case nationwide. The present study shows that the relative risk of all-cause mortality correspondingly declined for individuals aged 65 to 74 (by 9% between 1994–1999 and 1985–1990). This drop was primarily the result of a decline in deaths due to cardiovascular diseases, which decreased by 18 per cent when comparing 1994–1999 to 1985–1990. This change is in line with previous research showing that death rates due to heart disease have been declining in Canada and the United States (Heart and Stroke Foundation, 1999; Sahyoun, Lentzner, Hoyert, & Robinson, 2001). Consistent with the mortality trends for heart disease, hospitalizations for AMIs and strokes also declined. In combination, these findings may reflect both healthier lifestyles of more recent cohorts of seniors, as well as better treatment for heart attacks and strokes, which may prevent deaths.

Although these are clearly encouraging trends, it is important to note that our regional analysis indicates that health gains related to heart disease were observed primarily in urban areas; no similar gains emerged in rural areas. Whether this difference relates to lifestyle factors or access to health care services cannot be determined from the present data. However, socio-economic factors may well play a role. Northern Manitoba in particular is a socioeconomically depressed area, with residents being in considerably poorer health than in the rest of Manitoba (Martens et al., 2002). In this respect, the present study also shows that the relative rate of cancer deaths actually increased in Northern areas. This difference may be related to socio-economically related factors, which may be taking their toll in more recent cohorts of seniors. In contrast to cancer mortality rates, which, except for the North, remained constant, hospitalizations for cancer showed downward trends for two of the age groups (young-old and oldest-old) and in urban areas. This change is consistent with Canadian data that suggest that the incidence of certain cancers has been declining, such as lung cancer among men (Health Canada, 2001). As with heart disease–related events, however, no similar declines emerged in rural areas. Again, the cause of this discrepancy between rural and urban areas cannot be determined from the data, but it is clearly a topic that needs to be examined further. For instance, regional disparities in socio-economic status might explain some of the urban–rural differences.



11

Table 4: Relative rate of select chronic disease diagnoses by age group and location of residence, 1994–1999 versus 1985–1990

Hypertension

Congestive Heart Failure

COPD

Diabetes

Dementia

65–74 years

1.07

1.07

1.09

1.29

1.30

75–84 years

1.15

1.15

1.12

1.15

1.38

85þ years

1.28

1.28

1.01

1.11

1.26

Rural

1.18

1.18

1.03

1.19

1.24

Urban

1.14

1.14

1.11

1.17

1.39

Age Group*

Location of Residencey

COPD ¼ chronicobstructive pulmonary diseases Bold values are statistically significant at ¼ .017 (.05/3) y Bold values are statistically significant at ¼ .025 (.05/2) *

1.60

Dementia Diagnoses Diabetes Diagnoses Hypertension Diagnoses

Relative Rate (Compared to 1985–87)

1.40

1.20

1.00

0.80

0.60

0.40 1985–87

1987–90

1991–93

1994–96

1997–99

Figure 1: Trends in chronic disease diagnoses among Manitobans aged 65þ, 1985–1987 to 1997–1999

In contrast to the downward trends for some of the mortality and hospitalization measures, chronic diseases, specifically hypertension, diabetes, and dementia, showed clear and consistent increases over time for all age groups and both in rural and urban areas. The finding for diabetes corroborates previous research that also demonstrates the rising

prevalence of this disease in Canada and other countries (Chen & Millar, 2000; Mokdad et al., 2000; Statistics Canada, 1999). Do the present findings suggest that recent cohorts of seniors are sicker than cohorts in the past? That may be the case, in part. For example, the prevalence of

12


V. H. Menec et al.

obesity, a risk factor for diabetes and heart disease, has been increasing in Canada (Katzmarzyk, 2002). Obesity-related morbidity can therefore also be expected to increase. However, this is unlikely to be the only explanation for the upward trends in chronic diseases found here. Given that we identify individuals with these conditions using diagnoses, trends likely to a large extent also reflect changes in how physicians diagnose patients, rather than true increases in morbidity. For example, guidelines for diagnosing diabetes have changed, and would result in more individuals being identified as having the disease (Meltzer et al., 1998). Moreover, greater awareness of dementia and having treatment options for it may encourage physicians to diagnose patients with suspected dementia. Indeed, the positive aspect of upward trends in chronic diseases may be that changes in physician diagnosing and better treatment options may result in better control of chronic conditions, thereby allowing people to remain healthier longer. Research shows, for instance, that people live longer with diabetes now than in the past (Hux & Tang, 2002).

between 1985–1990 and 1994–1999. Given the aging population, and assuming that incidence remains constant, the number of older adults with dementia can therefore be expected to increase substantially in the coming decades. Previous research suggests that the number of individuals with dementia will likely almost triple by 2030 in Canada (Canadian Study of Health and Aging Working Group, 1994). Providing formal and informal care options for these individuals will be a challenge for families and the health care system that will have to be addressed.

A few additional findings warrant discussion at this point. Hospitalizations for injuries increased among all age groups and both in rural and urban areas. The relative risk of dying of an injury also increased among the oldest-old women. The majority of injury deaths and hospitalizations involved falls. It is not clear why these rates increased. One possibility is that, given that the oldest-old in Manitoba are living in the community longer now than in the past (Menec et al., 2002), the risk of falls may correspondingly increase among community residents. Alternatively, the findings may reflect regional differences in hospital admission patterns.

In sum, the present findings suggest that predictions of the apocalyptic impact of the aging population on the health care system are overstated, given that the health of older adults appears to be improving in terms of a number of important indicators, including acute myocardial infarction, stroke, cancer, and hip fractures. Improvements in these health indicators are significant, as they can have major implications for individuals’ need for health services and ability to live independently. At the same time, however, the rising prevalence of several chronic diseases (hypertension, diabetes, and dementia) warrants concern as they affect the demand for health services. Although these trends may in part reflect changes in physician diagnosing (Meltzer et al., 1998), they do suggest the need for a policy emphasis on prevention, such as reducing the prevalence of obesity, which is one risk factor for diabetes. Moreover, having sufficient care options in place for the growing number of individuals with dementia is an issue that will have to be addressed.

Nevertheless, these trends suggest the need for a continued – and increasing – emphasis on fall prevention, as older adults are living in the community longer. In this respect, it is also noteworthy that although hip fractures, which are a common outcome of falls among older adults (Menec et al., 2002), declined among the oldest-old, they were still quite common. In 1999, for instance, almost three per cent of Manitobans aged 85 or older were hospitalized for a hip fracture. Hip fractures are a particular concern because they often lead to functional decline, ultimately requiring nursing home admission (Dunn, Furner, & Miles, 1993; Kiel, O’Sullivan, Teno, & Mor, 1991). Last, the findings for The relative risk of markedly over time. among those 85 and

dementia warrant highlighting. dementia diagnoses increased For example, the relative risk over increased by 22 per cent

From a methodological perspective, it is noteworthy that the dementia prevalence obtained in the present study was remarkably similar to estimates for the community sample of the Canadian Study of Health and Aging (CSHA) (Canadian Study of Health and Aging Working Group, 1994). Although studies like the CSHA that included clinical assessments of dementia are clearly useful and needed, they are time consuming and costly and, therefore, not easily repeated. Thus, the present findings suggest the potential usefulness of administrative data in studying dementia.

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Trends in the Utilization of Specific Health Care Services among Older Manitobans: 1985 to 2000 Marcia Finlayson,1,2 Lisa Lix,2 Gregory S. Finlayson,2 and Terry Fong1 ´SUME ´ RE Cet article porte sur les tendances 16 anneés en matie`re d’utilisation des hoˆpitaux et des services me´dicaux par des Manitobains aˆge´s de 75 ans ou plus. Les donneés ont e´te´ tireés du Manitoba Population Health Research Data Repository. Les tendances sont e´tudieés en fonction de cinq mesures relatives aux services hospitaliers (les conge´s des hoˆpitaux, les se´jours de courte dureé, les se´jours de longue dureé, les ope´rations de la cataracte ainsi que les remplacements de la hanche ou du genou) de meˆme que de deux mesures relatives aux soins prodigue´s par des me´decins (le nombre global de consultations ainsi que la proportion de personnes qui ont sept consultations ou plus). Les re´sultats de´montrent des changements, au cours du temps, dans l’utilisation de ces services par les personnes aˆgeés vivant au Manitoba, l’e´tendue de ces changements variant selon le service e´tudie´, l’aˆge et le lieu de re´sidence. Des diffe´rences autrefois conside´rables en matie`re d’utilisation sont en train de diminuer, notamment le taux d’ope´rations de la cataracte selon les re´gions ainsi que la fre´quence des visites chez le me´decin selon l’aˆge. Pour d’autres services, notamment le taux de remplacements de la hanche ou du genou, les diffe´rences entre les re´gions sont en train de s’accroıˆtre. Les re´sultats indiquent que les geńe´ralisations relatives a` l’impact des personnes aˆgeés sur le syste`me de sante´ peuvent eˆtre remises en question, puisque les diffe´rences entre les re´gions et entre les groupes d’aˆge (75 a` 84, 85 ou plus) peuvent eˆtre conside´rables.

ABSTRACT This paper examines 16-year trends in the utilization of hospital and physician services by Manitobans aged 75 and more, using data from the Manitoba Population Health Research Data Repository. Trends are examined across five measures of hospital services (separations, short-stay days, long-stay days, cataract surgeries, and hip/knee replacements) and two measures of physician care (overall visit rate, and proportion having seven or more visits). Results show changes in the utilization of these services among older adults living in Manitoba over time, with the extent of change varying with the service under consideration, age, and location of residence. Previously large utilization differentials are shown to be shrinking; for example, cataract surgery rates across regions and physician visit rates by age. For other services, such as the rates of hip or knee replacement surgery, the differences across regions are increasing. Findings indicate that global generalizations about the impact of older adults on the health care system are subject to question, as regional differences and differences between age groups (75–84, 85þ) can be significant.

1

Department of Occupational Therapy, University of Illinois at Chicago

2

Department of Community Health Sciences, University of Manitoba

Manuscript received: / manuscrit reçu : 01/04/03 Manuscript accepted: / manuscrit accepte´ : 23/06/04 Mots cle´s : soins de sante´ pour les aıˆne´s; hospitalisation : tendances et utilisation; visites chez le me´decin : tendances et utilisation; excision de la cataracte : tendances et utilisation; chirurgie orthope´dique : tendances et utilisation; vieillissement Keywords: health services for the aged; hospitalization, trends & utilization; physician use, trends & utilization; cataract extraction, trends & utilization; orthopedic surgery, trends & utilization; aging


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Requests for offprints should be sent to: / Les demandes de tire´s-a`-part doivent eˆtre addresseés a` : Marcia Finlayson, Ph.D. Department of Occupational Therapy University of Illinois at Chicago 1919 West Taylor Street Chicago, IL 60612-7250 ([email protected])

Introduction For over 20 years there has been discussion and debate about the implications of an aging population on health care utilization; for example, primary care, specialist services, and acute, chronic, and long-term care. Some authors have argued that the growing number of older adults, an aging baby boomer cohort, and more expensive health care services will ultimately break the Canadian health care system if no action is taken (Robson, 2001). Others have suggested that improvements in the health status of the older population and the increasing evidence supporting the compression of morbidity hypothesis mean that the impact of the aging population on the health care system will be more gradual (Barer, Evans, & Hertzman, 1995; Chen & Millar, 2000; Doblhammer & Kytir, 2001; Hubert, Bloch, Oehlert, & Fries, 2002). This paper examines differences in health care utilization between 1985 and 2000, by region and age, among Manitobans aged 75 to 84, and 85 and over, in order to contribute to a longitudinal analysis to the literature on the impact of population aging on health care use. People aged 75 years and older were selected for this study because they are the heaviest users of health care services (Menec, MacWilliam, Soodeen, & Mitchell, 2002) and because their relative size in the population has grown substantially during this 16-year period. People aged 75 years and over represented only 3.3 per cent of the total Manitoba population in 1985, but approximately 5.5 per cent by 2000 – an increase of slightly more than 65 per cent. Patterns of growth of the group aged 75 and over in Manitoba are similar to what has been seen in most other Canadian provinces (Statistics Canada, 2004). The time period (1985–2000) was selected for study because it encapsulates a series of important health care delivery changes, for example, hospital bed closures, increasing emphasis on primary care and day surgeries, and the shift to regional health authorities. These changes also occurred in the majority of other Canadian provinces within this time frame. Consequently, by investigating this age group and period, this paper explores how the rapid increase in the relative numbers of the heaviest users of health care (i.e., those 75þ), influenced rates of utilization in one Canadian province. By considering

health care use in this population regionally, this paper also provides an opportunity to examine the accuracy of global generalizations of the impact of population aging on health care use.

Literature Review The use of health care services among older adults is known to be influenced by factors such as age, sex, residential location (e.g., rural versus urban), socioeconomic status, the nature of social support, and health related factors (e.g., functional status, presence of specific diseases, self-rated health). Utilization of hospital and physician services among older adults has been examined in a wide variety of ways in the literature, for example, intensity of use (e.g., number of visits in a specified period, length of stay), length of time since the most recent visit, or simple use versus non-use over a specified period (Blazer, Landerman, Fillenbaum, & Horner, 1995; Chi, Brayne, Todd, & Pollitt, 1995; Schwarz, 2000; Wolinsky, Stump, & Johnson, 1995). Regardless of how the service is measured, overall research shows that utilization is influenced by both age and sex. These influences occur cross-sectionally as well as over time, although the nature of the relationships varies by the type of service under consideration. Younger age (within the 65þ group) has been found to be associated with higher volume of hospital admissions, if other factors such as insurance and previous hospitalizations are not considered (Wolinsky et al., 1995), while older age has been linked to greater physician utilization (Black, Roos, Havens, & MacWilliam, 1995; Dansky, Brannon, Shea, Vasey, & Dirani, 1998). Using Manitoba data, the work of Black et al. (1995) examined trends in utilization and found that the relative increase in use over time was greatest for persons over the age of 85. When considering the influence of sex on utilization, Blazer et al. (1995) found that older females were less likely to receive outpatient treatment in a hospital setting, while Lum et al. (1999) found that being male was associated with greater hospital use. Trend studies of hip and knee arthroplasties have generally found that women are more likely to receive these surgeries, but when men receive them, the surgeries are done at a younger

Trends in Health Care Utilization

age (Balasegaram, Majeed, & Fitz-Clarence, 2001; Madhok et al., 1993). Residence location, which has been used as a proxy for socio-economic status as well as a measure of proximity to health care resources, has also been examined in numerous studies of the use of health care services among older adults. Older persons in rural areas in the United States have been found to have lower rates of utilization of both hospitals and physicians, compared to their urban counterparts, using measures of hospital days and physician office visits (Dansky et al., 1998), and of outpatient care in a hospital setting, ambulatory visits, and single nights in a hospital (Blazer et al., 1995). Other researchers found that urban residents were more likely than their rural counterparts to use physician services for their arthritis care (Saag et al., 1998). In only one study was the rural–urban utilization finding going in the opposite direction. An Irish study found that older persons in rural areas were more likely to receive total hip arthroplasties than their urban counterparts (Willis, Kee, Beverland, & Watson, 2000). Research in the United States focusing on knee replacements has shown steady increases in the rates of these surgeries over time, but that the relative increases vary significantly across regions (Katz et al., 1996). No rural–urban pattern differences were identified. Across all of these studies examining rural–urban differences in utilization, it is unclear whether the differences found are a function of resource proximity, availability of individual socioeconomic resources (which often vary by region), or their interaction. Based on this literature, and the types of data available in the Manitoba Population Health Research Data Repository, this research focused on the use of hospital-related services, selected highprofile surgical procedures, and physician utilization. Specifically, we examined hospital separations, days for short hospital stays (