Evelyn Shapiro

The Manitoba longitudinal study on aging: preliminary findings on health care utilization by the elderly.

This research links survey data from a large probability sample of the elderly population of one Canadian province with provincial insurance data documenting all their health care use during the years before and after the interview. The data show that “the elderly” are not high users of the health care system. Instead, a small proportion of those age 65 and older account for a disproportionately large share of service utilization. The study also identifies several predictors of high health-care use and discusses the implications of its findings for health care policy, practice, and research.

Does a Small Minority of Elderly Account for a Majority of Health Care Expenditures?: A Sixteen-Year Perspective

Canadian and American analysts commonly find that a small proportion of the elderly is responsible for a large share of health care expenditures. Data on a representative cohort in Manitoba indicate that the longer the time frame studied, the less health care usage concentrates in a single small group of elderly people. Over the sixteen-year period treated, the average older persons risks of using hospital and nursing home services is nevertheless notably higher than reported to date; yet, one-half of the elderly make relatively minimal demands on the health care system. The results reinforce calls for targeting the needs of intensive consumers of health care services and highlight the variability of cumulative usage patterns among older Manitobans.

Predictors of Long Term Care Facility Use among the Elderly

This research uses data from the Manitoba Longitudinal Study on Aging and multiple logistic regression analysis to assess the impact of twenty-eight sociodemographic and health status variables on nursing home admission. The results indicate that 1) all the short-term predictors continue to be significantly associated with facility bed use in the long run, suggesting that the high risk elderly can be identified relatively early; 2) the key sociodemographic characteristics are better predictors of admission than health and physical functioning characteristics; and 3) time itself appears to change the relationship of the study variables to admission.

From research to policy: what have we learned?

The Manitoba Centre for Health Policy and Evaluation has now had eight years of experience as an academic research unit interfacing with policymakers. Most of our research has focused on the determinants of health and on the delivery of health care from a population perspective. Each project that we have undertaken has made its own contribution and reinforced or built on the contribution of others. By communicating closely with policymakers at all levels, while maintaining an arms-length relationship and the right of publication, MCHPE acts as a knowledgeable non-stakeholder with a commitment to inform the broader public.

Do Nursing Homes Reduce Hospital Use

This study applies data from the Manitoba Longitudinal Study on Aging for two purposes. First examined were the hospital-utilization patterns of elderly nursing home admissions during the 2 years before and 2 years after entrance into a facility. In addition, use of the hospital by these new admissions and by long-term nursing home residents was compared with that of the use by the elderly living in the community. When age, sex, and mortality rate are taken into account, the results indicate that, although both new admissions and longterm nursing home residents are sicker than their community counterparts, they are significantly less frequently hospitalized.

Monitoring the Outcomes of Quality of Care in Nursing Homes Using Administrative Data

Routinely-collected administrative data and Coxs proportional hazards models are used to compare outcomes of care while controlling for age, sex and dependency level. The results indicate that the overall quality of nursing home care in Manitoba is good but that residents in certain regions and in certain types of nursing homes have specific outcomes that are poorer than others. These outcome indicators must not be treated as definitive signs of poorer care but as “triggers” suggesting a need for a closer look because the methodology and outcomes used in this study are still in the experimental stage. The results also indicate that secondary data provide a relatively inexpensive starting point for evaluating outcomes of nursing home care.

Elderly nonusers of health care services. Their characteristics and their health outcomes.

Sociodemographic, health, and health care utilization data on a large representative sample of elderly and multiple logistic regression were used to compare persons making no visits to physicians for 2 years with those making few (one to three) visits but in contact with health practitioners. Results suggest that elderly nonusers are more likely than low users to be single, to have some degree of mental impairment, and to have low educational attainment. Using Coxs proportional hazards model to compare outcomes over the next 7 years, no differences were found in the subsequent hospitalization rate of the two groups, but nonusers were at greater risk of a hospitalization episode of 16+ days and appeared to die sooner than low users. However, they were at no greater risk of poor health outcomes than elderly making four or more physician visits in 2 years. The policy implications of the findings are discussed.

USING THE INFORMATION SYSTEM TO ASSESS CHANGE : THE IMPACT OF DOWNSIZING THE ACUTE SECTOR

A population-based approach was used to monitor impact of hospital bed closures in Winnipeg, Manitoba. Four years of administrative data were analyzed. Access to hospital services was not adversely affected: The reduction in beds resulted in increases in outpatient surgery and earlier discharges. In addition, access favored the admission of persons with more health care needs. Quality of care, as measured by mortality within 3 months of admission, readmission rates within 30 days of discharge, and increased contact with physicians within 30 days of discharge, did not change. The health status of the Winnipeg population, measured by premature mortality, did not change. However, health status and hospital use was found to be strongly related to socioeconomic status. In light of this gradient, the authors conclude that well designed and evaluated experiments that focus on the determinants of health, rather than on providing more health care services, could help identify ways of reducing hospital use.

The Impact of a Mental Status Score and a Dementia Diagnosis on Mortality and Institutionalization

Scores from the Mental Status Questionnaire (MSQ) obtained from interviews with a 1976 representative sample of community-dwelling elderly and 17 years of health care use data in the Manitoba Longitudinal Study on Aging were used to estimate the prevalence of cognitive impairment and the incidence rate of dementia diagnoses. Estimates of relative risk from Coxs proportional hazard models indicate that, in addition to age and sex, both MSQ scores and the presence or absence of a dementia diagnosis significantly affect mortality, whereas a diagnosis of dementia is the greatest contributor to institutionalization.

Is Health Care Use Changing?: A Comparison Between Physician, Hospital, Nursing-Home, and Home-Care Use of Two Elderly Cohorts

This study used log-linear survival analysis, and log-rank tests to compare 1) the characteristics of two elderly cohorts; 2) their use of physician, hospital, nursing-home and home-care services over 8.5 years; and 3) physician and bed supplies during the two periods. Both cohorts were similar in health status and in their use of hospital, nursing-home, and home-care resources despite a steady decrease in hospital beds during both periods and a shrinking supply of nursing-home beds for the later cohort. Although physician supply increased more rapidly for the first (1971) than for the second (1976) cohort, the later cohort used significantly more ambulatory care than the earlier cohort. Home care appears to substitute for year-to-year variations in nursing-home admissions but not for variations in hospital lengths of stay.