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Globe and Mail public health reporter Andre Picard

john morstad The Globe and Mail

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Imagine if every single person living in Medicine Hat, Alta., was in hospital at the same time. That's how many hospital beds we have in Canada: about 70,000.

Yet, it is often stated, as unassailable fact, despite the $60.5-billion we spend on hospital care alone, that we don't have enough beds. This is obvious, it is said, because they're always full.

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What is rarely discussed is how beds are used. In Canada we tend to focus obsessively on volume and very little on appropriateness.

That's why a new report from the Manitoba Centre for Health Policy, Who's In Our Hospitals…And Why?, is a welcome contribution of fact and analysis to an often-emotional debate.

Manitoba, with a population of 1.2 million, a variety of urban and rural facilities and a multicultural mix, offers up an excellent scale model of what's going on Canada-wide.

Manitoba has 4,006 hospital beds in 71 hospitals. Each year, those hospitals have about 133,000 admissions and provide 1.1 million days of care.

Pregnancy and birth are the single most common reason for hospital stays, accounting for 27 per cent of admissions.

By contrast, all other medical issues combined make up 39 per cent of hospitalizations, while surgery accounts for 22 per cent, treatment of mental illness 4 per cent, and alternate level of care (ALC) patients, 4 per cent.

We will return to the all-important ALC patients in a moment.

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Thankfully, women who give birth in hospital don't stay very long, so they account for fewer than 9 per cent of total hospital days so that dampens the impact of the high admission rate a bit.

Surgical patients also tend to get in and out relatively quickly, but still account for 19 per cent of all days. Some surgery could be moved to specialized clinics, but that would shift, not reduce costs.

Medical patients – the most complex of all – use almost 40 per cent of hospital days. Medical and surgical patients are, of course, what acute care hospitals are designed to treat.

Patients with severe mental illness are among those who have the longest and most frequent stays in hospital, in large part because many psychiatric hospitals have been closed and replaced with designated beds in general hospitals.

But the hospital population that needs the most scrutiny and public policy attention are the infamous ALC patients.

Alternate level of care is a euphemism. It means, essentially, that a patient has been discharged but there is nowhere to send them – they are too frail to send home alone and there is no available nursing home bed and no available homecare.

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The MCHP study estimates that 3.5 per cent of patients are ALC, and they consume 17 per cent of all hospital days.

Put another way, one in six of every hospital days is used by someone who shouldn't be in hospital. And Manitoba is a jurisdiction that has among the fewest number of bed blockers – as alternate level of care patients are known. The pejorative term derives from the fact that their presence creates a back-log for beds, contributes to surgical waits and delayed admissions, and adds substantial costs.

Consider that a hospital bed costs about $842 a day, compared to $126 for a bed in a long-term care facility and $55 a day to provide homecare. (In many cases, ALC patients pay for their room, as they would in a nursing home.)

The ALC problem is not, by any means, unique to Manitoba. The province is doing better than most because it has a well-developed homecare system.

The Canadian Institute for Health Information estimates, quite conservatively, that 5 per cent of hospitalizations are ALC, the equivalent of 580 beds.

The Canadian Health Services Research Foundation (which has since been renamed the Canadian Foundation for Healthcare Improvement), for its part, says that fully 14 per cent of hospital days patients across Canada are consumed by patients who are ALC, the equivalent of 7,500 beds being filled with bed-blockers. In Ontario, it's 13 to 15 per cent, according to the Ontario Hospital Association, and in B.C. anecdotally, we know that, in some hospitals, more than 30 per cent of beds are ALC.

These wide variations remind us that data collection and interpretation can be tricky (especially when you collect data that embarasses governments) and, the devil is in the details.

In fact, saying that 5per cent of admissions and 14 per cent of hospital days are ALC is very much the same thing. That's because alternate level of care patients stay in hospital a long time. Stays in excess of 100 days are not unusual.

Regardless, dealing with alternate level of care patients needs to be a priority in every province and territory, especially that research shows, if things remain the same, the number of ALC patients will grow by 32 per cent in the next decade.

It is absurd – not to mention financially irresponsible – that thousands of Canadians are living in hospitals. Hospitals should not be de facto nursing homes.

When you consider that it would be much cheaper to put every ALC patient up at The Ritz than to have them where they are now, it beggars belief that we are not rushing to invest more in homecare and long-term care facilities.

André Picard is The Globe's health columnist.

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