Rapid change in public hospital services

Canadian Institute for Health Information (CIHI) hospital data indicates big changes in hospital activity, particularly in the most recent four years reported. Ontario, especially, is experimenting with hospital cuts and restructuring.  

Hospital inpatient days are now dropping rapidly in Ontario – with a drop of 13.4% in inpatient days over the last four years. This has occurred even as inpatient days continue to increase in the rest of Canada (note: Quebec is excluded from the CIHI report as the data for that province is under review). 

The data suggests a sharp fall in Ontario in 2013/14 compared to 2012/13 (8.9%), a less sharp decline over the previous 3 years, and significant growth over the previous five year period.

Over the 15 years of data reported (1999/00 through 2013/14), Ontario inpatient days have increased 4.6%  -- even while population has increased at almost four times that rate (17.8 %) and the median age increased 4 full years (from 36.2 to 40.2 years). The rest of Canada has seen much faster growth -- 21.1% more inpatient days, despite only 16.8% population growth and somewhat less than 3.8 years growth in median age. 

Despite a more rapidly growing and more rapidly aging population, Ontario hospital inpatient days are falling further behind the rest of Canada.

For the sake of comparison between geographic areas like Ontario and the rest of Canada, services can be compared on the basis of service per person (i.e. service per-capita).  

Ontario had 0.68 inpatient days per person (per-capita) in 2013/14 (with a population of 13.55 million). The rest of Canada excluding Quebec (with a slightly smaller population of 13.45 million) had 0.82 inpatient days per-capita.

In other words, the rest of Canada had 20.5% more inpatient days per person. This is a much bigger gap than existed in 1999/2000 when Ontario had  0.77 days per-person while the rest of Canada had 0.79 days per-person.

As a result, in 1999/2000, the rest of Canada had 2.6% more inpatient days per person compared to Ontario; but by 2013/14 that gap had grown almost 8-fold to 20.5% more inpatient days per person. 

That's quite a change, with much of it occurring in just the last few years during deep cuts to real hospital funding in Ontario.  Clearly, Ontario provides a lot less inpatient days to its population than the rest of Canada and that trend is deepening.

Also note that Ontario inpatient days per-capita have declined almost 12% between 1999/2000 and 2013/14 (going from 0.77 per-capita to 0.68). (This despite a median population age that is now 4 years older than in 1999/2000.) In the rest of Canada, inpatient days per-capita have actually increased 3.7%. 

Increasing emergency visits: Despite  declining hospital inpatient days, Emergency Room visits continue to increase in Ontario. Indeed they are increasing at a faster pace than in the past.  

However, Ontario has far fewer Emergency Room visits per-capita than the rest of Canada: 0.44 visits per person in 2013/14 versus 0.55. In other words, there are 25% more emergency visits per-capita in the rest of Canada than Ontario.   Even with increased use of Emergency Rooms in Ontario, they are much more highly utilized in the rest of Canada. The idea that Ontario Emergency Rooms are over utilized is not borne out by this statistic. 

Despite the increased absolute number of emergency visits, Ontario has reduced hospital emergency visits per-capita slightly since 1999/2000 (from 0.45 visits per person to 0.44 per person).  However, all of the reduction occurred in the middle of the last decade and there has been an upward trend in more recent years. Unlike Ontario, the rest of Canada has seen increased emergency room visits per-capita (from 0.52 to 0.55). Again, the upwards trend became even more marked in recent years. 

Admissions: Total hospital inpatient admissions have been practically static in Ontario and in the rest of Canada since 1999/00.  

However with a rapidly increasing population in Ontario there has been a consistent and rapid downward trend in hospital admissions per-person, with a ten percent drop over the last 14 years reported. This again occurred despite a four year increase in the province's median age over that period. 

There are 3.3% fewer admissions in Ontario than the rest of Canada (0.089 admissions per-capita in Ontario in 2013/14, versus 0.092 per-capita in the rest of Canada).

Hospital Ambulatory Care:  Ambulatory care visits to hospitals in Ontario continue to increase - -but much less quickly than in the past and less rapidly than in the rest of Canada.  

So, Ontario is experiencing both a  dramatic loss of inpatient days and a marked slowdown in the growth of ambulatory care.  Since 2011-12 there has been an actual (albeit modest) decline on a per-capita basis.

Ontario still has more ambulatory care visits than the rest of Canada – 1.4 per person in Ontario in 2013/14 versus 1.24 per person in the rest of Canada. However, in 1999/2000 Ontario had 25% more ambulatory care visits per-capita than the rest of Canada, while now the gap is about half that (12.7%).  So the gap is shrinking quickly. 

This fits with the slowing growth  of ambulatory care in Ontario. On a per person basis, there has been very little growth in ambulatory care visits since 2005-6 in Ontario -- 3.7% (compared to 10.7% growth in the rest of Canada).  As noted, Ontario has actually seen a modest decline in ambulatory care visits per-capita since 2011-12 (from 1.43 to 1.38 per person). 

In sum:

• In key ways, hospitals provide fewer services in Ontario than in the rest of Canada.
• Ontario provides far fewer hospital inpatient days compared to the rest of Canada
• Inpatient days in Ontario are now falling even while they continue to increase in the rest of Canada.
• The loss of inpatient days in Ontario has increased since government funding cutbacks started at the end of the last decade.
• Ontario hospitals do provide somewhat more ambulatory care than in the rest of Canada and the amount of ambulatory care in Ontario has increased over the last 14 years.  
• The growth of ambulatory care however is slowing in Ontario and has recently come to a halt on a per-capita basis. Across Canada, it continues to grow and the gap in ambulatory care between the rest of Canada and Ontario has shrunk markedly.
• Despite fewer hospital inpatient days to treat patients, more and more patients are showing up at Ontario ER rooms (6.7% more ER visits and 13.4% fewer inpatient days over the last four years). 
• Emergency rooms are used much less in Ontario than in the rest of Canada.
• While inpatient admissions are somewhat lower in Ontario than the rest of Canada the gap is not so large as with inpatient days. Accordingly patients must be released more quickly in Ontario than the rest of Canada.

The years 2014/15 and 2015/16 saw real hospital funding cuts in Ontario so it will be interesting to see how they impact hospital service numbers when they are available. 

The data is reported below.