Corrine D. Truman

The rapidly changing location of death in Canada, 1994-2004.

This 2008 study assessed location-of-death changes in Canada during 1994-2004, after previous research had identified a continuing increase to 1994 in hospital deaths. The most recent (1994-2004) complete population and individual-level Statistics Canada mortality data were analyzed, involving 1,806,318 decedents of all Canadian provinces and territories except Quebec. A substantial and continuing decline in hospitalized deaths was found (77.7%-60.6%). This decline was universal among decedents regardless of age, gender, marital status, whether they were born in Canada or not, across urban and rural provinces, and for all but two (infrequent) causes of death. This shift occurred in the absence of policy or purposive healthcare planning to shift death or dying out of hospital. In the developed world, recent changing patterns in the place of death, as well as the location and type of care provided near death appear to be occurring, making location-of-death trends an important topic of investigation. Canada is an important case study for highlighting the significance of location-of-death trends, and suggesting important underlying causal relationships and implications for end-of-life policies and practices.

Location of death in Canada. A comparison of 20th-century hospital and nonhospital locations of death and corresponding population trends.

This report compares 20th-century Canadian hospital and nonhospital location-of-death trends and corresponding population mortality trends. One of the chief findings is a hospitalization-of-death trend, with deaths in hospital peaking in 1994 at 80.5% of all deaths. The rise in hospitalization was more pronounced in the years prior to the development of a national health care program (1966). Another key finding is a gradual reduction since 1994 in hospital deaths, with this reduction occurring across all sociodemographic variables. This suggests nonhospital care options are needed to support what may be an ongoing shift away from hospitalized death and dying.

Influence of Aboriginal and Socioeconomic Status on Birth Outcome and Maternal Morbidity

OBJECTIVE To assess the association of Aboriginal and socioeconomic status with birth outcome and maternal morbidity in Alberta. METHODS A retrospective cohort study using Alberta health service and vital statistics data from 1997 to 2000. Aboriginal women registered with the Department of Indian and Northern Development (DIAND) were linked to a personal health number. Low socioeconomic status was defined as either receiving subsidization for the Alberta Health Care Insurance premium or receiving welfare. RESULTS Women registered with DIAND and women receiving subsidy or welfare were younger, more often unmarried, smoked more, consumed more alcohol, and abused more illicit drugs than other women in Alberta during the time period studied. Fewer women registered with DIAND and women receiving subsidy or welfare had physician prenatal visits, attended prenatal classes, had forceps or vacuum deliveries, and more of these women frequently had gestation ages less than 37 weeks. Women registered with DIAND had more deliveries in smaller, non-metropolitan facilities; and more of these women delivered outside their region of residence; more had longer lengths of hospital stay; more mothers and neonates were re-admitted to hospital within 28 days of discharge after delivery; fewer delivered small for gestational age neonates; fewer delivered neonates with birth weight less than 2500 g, but more delivered neonates with birth weight greater than 4000 g. There were fewer Caesarean sections in women registered with DIAND (OR = 0.84, 95% CI 0.76-0.93) and in women receiving subsidy or welfare (OR = 0.88, 95% CI 0.82-0.93). CONCLUSION Women receiving subsidy or welfare and women registered with DIAND had many demographic similarities and generally had worse maternal and neonatal outcomes than other women in Alberta. Medical system interaction may be different for these two groups of women than it is for other women in Alberta.

Hospital practice more than specialty influences the choice of regional or general anesthesia for Cesarean section

PurposeDescribe the influence of specialty certification and practice style upon the anesthetic technique used for Cesarean deliveries.MethodsAlberta physician claims and hospital abstracts between April 1, 1998 to March 31, 2000 were used to determine the technique of anesthesia (regional or general). The influence of practice (volume of deliveries, geographic location, presence of regional analgesia providers) and specialty (anesthesiologist or family/general practice) is explored by logistic regression.ResultsHospital abstracts of 13,884 Cesarean sections were analyzed. Anesthesiologists performed 76% of the anesthetics: epidural (33%), spinal (45%), and general anesthesia (22%). Comparing only regional and metropolitan hospitals, the percent of general anesthesia performed by anesthesiologists varied between 5% to 50%. After adjusting for other factors, we found, in order of importance, the following determined the use of general anesthesia for Cesarean sections: 1) hospitals with more epidural procedure providers during labour were 3% less likely to have providers choose general anesthesia; 2) larger, regional and metropolitan hospitals were less likely to have providers choose general anesthesia; 3) hospitals with a high volume epidural procedure provider during labour were 64% less likely to have providers choose general anesthesia; 4) anesthesiologists were 32% less likely to choose general anesthesia.ConclusionThe overall use of regional anesthesia for Cesarean sections in Alberta is high. The chance of receiving a general anesthetic for a Cesarean delivery varies across the province and was more related to practice environment than specialty.RésuméObjectifDécrire l’influence de la spécialité et du style de pratique sur la technique anesthésique utilisée pour l’accouchement par césarienne.MéthodeLes demandes de paiement des médecins et les résumés de dossiers hospitaliers de l’Alberta du 1 avril 1998 au 31 mars 2000 ont permis de connaître la technique d’anesthésie utilisée, régionale ou générale. L’influence de la pratique (nombre d’accouchements, localisation géographique, présence de personnel pouvant administrer l’analgésie régionale) et la spécialité (anesthésiologie ou médecine familiale/générale) est explorée par régression logistique.RésultatsLes résumés de 13 884 césariennes réalisées en milieu hospitalier ont été analysés. Les anesthésiologistes ont fait 76 % des anesthésies: épidurale (33 %), rachidienne (45 %) et générale (22 %). Si on compare les hôpitaux régionaux à ceux des grandes villes, le pourcentage de l’anesthésie générale administrée par les anesthésiologistes varie de 5 % à 50 %. Après des modifications en fonction d’autres facteurs, nous avons, par ordre d’importance, ce qui détermine l’utilisation de l’anesthésie générale pour la césarienne: 1) dans les hôpitaux oú un plus grand nombre de médecins peuvent administrer une anesthésie épidurale pendant le travail, il y a 3 % de moins d’anesthésie générale; 2) dans les grands hôpitaux, les centres régionaux et municipaux, les médecins ont moins tendance à choisir l’anesthésie générale; 3) dans les hôpitaux oú les médecins offrant l’anesthésie épidurale sont nombreux, il y a 64 % moins d’anesthésie générale; 4) les anesthésiologistes choisissent l’anesthésie générale dans 32 % moins de cas.ConclusionEn Alberta, il y a un taux élevé d’anesthésie régionale pour la césarienne. La possibilité de recevoir une anesthésie générale pour la césarienne varie et est davantage reliée à l’environnement de la pratique qu’à la spécialité.