Alternatives to Acute Care July 1996 Manitoba Centre for Health Policy and Evaluation Department of Community Health Sciences Faculty of Medicine, University of Manitoba Carolyn DeCoster, RN, MBA Sandra Peterson, MSc Paul Kasian, MD ACKNOWLEDGEMENTS The authors would like to acknowledge the efforts and expertise t~at many individuals contributed in completing this project and producing this report. We thank the following, and apologize in advance for anybody that we might have overlooked: • the health records staff and management of the 26 hospitals who participated in the study, with special thanks to Health Sciences Centre and St. Boniface General Hospital for assisting with the training of our abstractors; • the Health Services Utilization and Research Commission of Saskatchewan, especially Stewart McMillan, Steven Lewis and Joanne Hader, who generously shared applications of the InterQual methodology which they had developed and provided hours of support during our fieldwork and data analysis; • Charles Burchill for programming support in selecting the sample; • Drs. Brian Postl, Bryan Kirk, Ahmed Abdoh and Milton Tenenbein who reviewed the InterQual criteria; • the data abstractors: Dawna Bieniarz, Lonni Cruickshank, Sandy Gessler, Fran Home, Kay Linquist, Diane Mee, Nan Ouimet and Trish Rawsthome; • Marlyn Gregoire for data entry; • Keumhee Chough Carriere and Robert B. Tate for their statistical advice; • individuals who provided feedback on an earlier draft of this report: Noralou Roos, Evelyn Shapiro, Marian Shanahan and Mami Brownell; • Carole Ouelette, Linda Henderson and Trish Franklin who provided secretarial and administrative support; • the study Working Group: • Marylin Allen, RN, Director of Resident Care, Fred Douglas Lodge (member since March 1995) • Ross Brown, MD, Vice-President Medicine, St. Boniface General Hospital • Evelyn Fondse, CCHRA(C), Director, Medical Information Department, Health Sciences Centre • Sylvia Jennings, BN, MSA, Director of Resident Care, Middlechurch Home of Winnipeg (resigned as a member in January 1995) • Sally Longstaffe, MD, Associate Professor, Paediatrics and Child Health, Health Sciences Centre • Barry MacMillan, MD, BSc(H), CFCP, DIP in Sports Medicine, Family Practice, Winnipeg • Garry Mattin, CHE, Chief Executive Officer, Portage and District General Hospital, Seven Regions Health Centre, MacGregor District Health Centre and Douglas Campbell Lodge • Lois McMurchy, RN, BGS, Director of Patient and Resident Services, The Pas Health Complex • Marion Suski, RN, MEd, CHE, President and Chief Executive Officer, Victoria General Hospital • Rose Unger, Aboriginal Nurse and Independent Health Consultant • Cathy Winburn, BN, Westman Regional Coordinator, Home Care ii • Cornie Woelk, MD, CCFP, Family Practice, Winkler • those who responded to our request for feedback on the interim report: Ahmed Abdoh, N.R. Anthonisen, K.R. Brown, Vera Chernecki, Irwin Corobow, R.G. Danzinger, Sue Hicks, Elaine Isaac, John Kelly, Jack Litvack, Douglas MacEwan, Jerome Mauws, Andrew Morris, Fraser Mustard, Lindsay Nicolle, Carol Ringer, Leslie Roberts, Penny Sorenson, J.B. Sutherland, Larry Todd, Fred Toll, Ulrich Wendt, Linda West, Vic Wiebe, Hila Willkie, Catherine Winburn and Cornie Woelk. We acknowledge the financial support of the Department of Health of the Province of Manitoba. The results and conclusions are those of the authors and no official endorsement by Manitoba Health was intended or should be inferred. lll The Manitoba Centre for Health Policy and Evaluation The Manitoba Centre for Health Policy and Evaluation (MCHPE) is a unit within the Department of Community Health Sciences, Faculty ofMedicine, University of Manitoba. MCHPE is active in health services research, evaluation and policy analysis, concentrating on using the Manitoba health data base to describe and explain patterns of care and profiles of health and illness. Manitoba has one of the most complete, well-organized and useful health data bases in North America. The data base provides a comprehensive, longitudinal, population­ based administrative record of health care use in the province. Members ofMCHPE consult extensively with government officials, health care administrators, and clinicians to develop a research agenda that is topical and relevant. This strength, along with its rigorous academic standards and its exceptional data base, uniquely position MCHPE to contribute to improvements in the health policy process. MCHPE undertakes several major research projects, such as this one, every year under contract to Manitoba Health. In addition, MCHPE researchers secure major funding through the competitive grants process. Widely published and internationally recognized, they collaborate with a number of highly respected scientists from Canada, the United States and Europe. iv TABLE OF CONTENTS EXECUTIVE SUMMARY ............................................................................................... 1 DEFINITIONS USED IN THIS REPORT .................................................................... 14 INTRODUCTIONS ......................................................................................................... 20 PROCESS ......................................................................................................................... 24 Interqual Criteria ........................................................................................................ 26 Why InterQual? .......................................................................................................... 28 Alternate Levels of Care ............................................................................................. 29 Terms Used ................................................................................................................. 29 METHODOLOGY .......................................................................................................... 30 Sample ........................................................................................................................ 30 Hospitals ..................................................................................................................... 32 Data Collection ........................................................................................................... 34 Communication with Hospitals ........................................................................... 35 Co-ordination and Training. ............................................................................... 3 5 Inter-Rating Reliability ....................................................................................... 35 FINDINGS ........................................................................................................................ 36 Representativeness of the Sample .............................................................................. 36 Admissions ................................................................................................................. 37 Results by Hospital Group ......................................................................................... 40 Days of Care ............................................................................................................... 44 Results by Hospital Group ......................................................................................... 49 Paediatrics .......................................... , ....................................................................... 55 UNDERSTANDING THE PATTERNS ........................................................................ 60 Acuteness by Portion of Stay ..................................................................................... 60 Acuteness by Day of Admission ................................................................................ 62 Acuteness by Length of Stay ...................................................................................... 63 Comparison with MedisGroups Data ......................................................................... 64 v Acuteness by Patient Characteristics .......................................................................... 66 Socio-Economic Status ........................................................................................ 66 Treaty Indians ..................................................................................................... 67 Distance .from Hospital ....................................................................................... 70 Type ofDiagnosis ............................................................................................... 71 SECOND LOOK .............................................................................................................. 72 Physician Review ....................................................................................................... 73 Results of the Second Look ........................................................................................ 74 D ISCUSSI 0 N ................................................................................................................... 77 The Size of the Problem/Opportunity ........................................................................ 81 Limitations .................................................................................................................. 87 Observation ...............................................................................................................