One of the
most interesting health policy questions of this decade is "Why
is there such a disconnect between what we know from the headlines
and what we
know from the data?"
In this issue
(page 397) Samuel Sheps and colleagues 1 use data to describe
the
consequences of bed closures and hospital downsizing. British
Columbia closed
30% of its acute care beds over the 5-year period 1991-1996. "Doom
and
gloom" headlines in the Vancouver papers claimed that these
cuts caused
crises and disasters for British Colum-bians and their medical
care system
("Expect more deaths as hospitals reorganized, nurses' union
says";2 " Prescription for disaster' union
and hospital
staff decry ministry's closure of Shaughnessy";3 "It's
tougher to get into hospital"4). One would expect, however,
that if more
people had bad experiences after bed closures than before, these
results should
be showing up in the "data." If the nurses' union is
right, we
should find a higher death rate after bed closures, particularly
among
vulnerable groups such as elderly people. If indeed it is "tougher
to get
into hospital", we should find fewer people getting in. Is
this what the
data tell us? Sheps and colleagues have, in effect, added up all
the anecdotes
and all the bad and good experiences before and after bed closures,
and what do
they find?
Were there
more deaths after bed closures? No - the overall
death rate
was unchanged. Were fewer people getting into hospital? Not really
-
despite the sizeable bed closures, there were "only minor
changes" in
the proportion of elderly people who received no facility care
or acute care (by
my calculations an increase of 2.5%). How could this be? Doctors
and nurses
served patients well; presumably, they adapted to bed closures
by shortening
the amount of time patients spent in hospital. Bed closures have
not made it
tougher for sick elderly patients to get into hospital. Claims
to the contrary
are false.
But does this
mean patients were discharged quicker and sicker, another frequent
allegation of those claiming crisis and imminent system collapse?
Data from
Winnipeg, where 21% of hospital beds were closed between 1992
and 1995, provide
more facts about bed closures. The Winnipeg findings about bed
closures 5
parallel those of Sheps and colleagues. The closures had little
effect on access
to hospital care; stays were shortened, and many inpatient procedures
moved
to the outpatient setting. Death rates were unchanged. There was
also no
evidence that patients were discharged quicker and sicker; there
was no
increase in readmissions, and no increase in emergency department
or physician
office visits in the 30 days after hospital discharge. Despite
bed closures,
there were dramatic increases in the numbers of high-profile surgical
procedures,
such as angioplasty and bypass and cataract surgery.
But was the
Winnipeg press any more accurate in its reporting on the effects
of
downsizing? Not at all. The resulting closures were a constant
source of
alarmist headlines; " We're at breaking point,'
HSC
doctor warns";6 and "City braces for ER crisis; patients
will likely
suffer winter bed shortage, gov't admits."7
Like Sheps
and colleagues' data, the Winnipeg findings are based "only"
on cold, hard facts. What about those treated in the system? What
do they have
to say? Shapiro and associates 8 interviewed elderly Winnipeg
residents before
and 1 year after substantial bed closures. The opinions about
access to hospital
and about the overall quality of care in Manitoba among those
who were admitted
to hospital during the period when most of the beds were being
closed were
significantly more favourable than the opinions of those admitted
to hospital
before the bed closures. The former group were more positive about
quality of
care and access than those who had never been admitted to hospital
-
but whose opinion was presumably influenced by what they read
in the newspapers.
These findings
are consistent with those of other investigators. Although only
20% of Canadians report having confidence in the health care system,
more than
50% say that the medical care they and their family personally
received in the
last year was very good or excellent.9
Physicians
also point to this gap between headlines and facts. At a rally
in
Edmonton against Premier Ralph Klein's privatization Bill 11,
on Apr. 16 of
this year, Walley Temple, chief of surgical oncology at the Tom
Baker Cancer
Centre, Calgary, after reviewing available research and his experience
working
in various systems, stated;
I assure you
that our public health care system is a veritable, most equitable,
most compassionate, most economic [system] and has health outcomes
that are
truly awesome.
So does it
really matter that there is a wide gap between data describing
how
the health care system operates and what we read in the papers?
Most assuredly
it does. The perpetual "doom and gloom" stories persuade
the public
that drastic changes are necessary. Temple, speaking at the same
rally,
noted;
Why would
we want to experiment with another model known to be expensive,
unreliable...? Why would we want to replicate a problematic system
where there
will be no turning back and where the results will be measured
in people's
lives? Our doctors, our nurses, our health care workers have truly
broken their
backs to help this province out of debt and keep the system working.
And now the
government will break our hearts with Bill 11.
Sheps and
colleagues have provided us with an important set of facts about
the
robustness of British Columbia's health care system after downsizing.
We
would be well advised to use these to inform our media-fed misconceptions.
References
1. Sheps SB,
Reid RJ, Barer ML, Krueger H, McGrail KM, Green B, et al. Hospital
downsizing and trends in health care use among elderly people
in British
Columbia. CMAJ 2000;163(4);397-401. Available; http://www.cma.ca/cmaj/vol-163/issue-4/0397.htm
2. Wigod R.
Expect more deaths as hospitals reorganized, nurses' union
says. Vancouver Sun 1995 May 2;Sect B;4.
3. Easton
S. "Prescription for disaster" - union
and
hospital staff decry ministry's closure of Shaughnessy. The Province
[Vancouver] 1993 Feb 16;Sect A;6.
4. It's tougher
to get into hospital. Vancouver Sun 1994 May 20;Sect
A;2.
5. Brownell
MD, Roos NP, Burchill C. Monitoring the impact of hospital
downsizing on access to care and quality of care. Med Care 1999;37(6);JS135-50.
6. Oswald
B. "We're at breaking point," HSC doctor warns.
Winnipeg Free Press 1994 Jan 13;Sect B;1.
7. City braces
for ER crisis; patients will likely suffer winter bed shortage,
gov't admits. Winnipeg Sun 1998 Sep 5;Sect A;1.
8. Shapiro
E, Tate RB, Wright B, Plohman J. Changes in the perception of
health
care policy and delivery among Manitoba elders during the downsizing
of the
hospital sector. Can J Aging 2000;29(1);18-34.
9. Health
care in Canada; a first annual report. Ottawa; Canadian
Institute for Health Information; 2000. p. 12.
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Accession Number: 00002792-200008220-00013
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