While it might be anticipated that this reduction in hospital admissions would be accompanied by a compensatory increase in the use of outpatient health, the Atlas report showed the opposite to be true. The report that looked at the use of outpatient health services showed an 11% decrease in paediatric OHIP billing volume between 1991/92 and 1997/98 despite a 7% increase in the paediatric population in the province over this period. Total OHIP expenditures on children in this period decreased by 6%, and per capita OHIP expenditures decreased from $241 to $212 per child.
The researchers note they were unable to assess whether these reductions in use of outpatient services resulted in a need for more urgent care such as emergency room visits. The rate of emergency department visits by paediatric patients has not been measured in Ontario because of OHIP coding practices. The patterns of use of emergency services by children remain an important research question.
However, the Atlas report on inpatient use was able to document the negative impact of one type of hospital service reduction in the province, namely the move by many hospitals to develop policies for early discharge following an uncomplicated delivery. These policies were developed because of publications indicating routine stays in hospital following uncomplicated childbirth are unnecessary.
The Atlas report showed a 61% increase in the rate of admission for neonatal jaundice and dehydration between 1991/92 and 1997/98, a time period characterized by significant decreases in inpatient admission rates for children.
In fact, jaundice was the second most common diagnosis responsible for admission, after acute bronchiolitis, in the under one-year-old group. The researchers who produced the Atlas report feel this marked increase relates most likely to policies of early discharge. The Ontario Ministry of Health and Long-Term Care has reversed the policy, and as of August 1999 the province has committed resources to allow mothers and their newborns to stay up to 60 hours in hospital following uncomplicated deliveries. It will be important to document whether this policy is successful in decreasing the number of newborns requiring hospital admissions.
There was another provocative trend in admissions - the significant increase in admissions for mental disorders among teenagers of both genders. Whether this is a result of an increase in disease burden, diagnosis or the off-loading of community services to inpatient services is not known - issues that require further investigation.
The inpatient report also highlights that previously documented regional variations in admission rates continue to exist across the province. Because the relative positioning of regions with respect to high or low hospitalization rates remained constant over the study period, the authors speculate that the trend towards decreasing hospitalization rates is linked to overall health system factors rather than regionspecific changes or the implementation of appropriate therapeutic interventions.
Both Atlas reports caution against drawing conclusions about the meaning of the documented decrease in health services utilization by Ontario children in the 1990s. The authors highlight the need for more research into the relationship between decreased utilization and health outcomes, as well as the need to document trends in the use of emergency services, home care and other community care services, which are not captured in the data used for these reports.
AcknowledgmentFor more information: Judy Hodgson at 416-480-4055 ext 3781, or by email at firstname.lastname@example.org
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