title: Hospital utilization, efficiency and access to care during and shortly after restructuring acute care in Newfoundland and Labrador.
abstract: OBJECTIVE
  Since the 1990s restructuring, including regionalization and downsizing, has largely been driven by a desire for cost containment. Regionalization, hospital closure and changes in management processes occurred in Newfoundland and Labrador (NL), Canada between 1995 and 2000. The objectives of the current study were: to describe trends in the utilization of acute care hospital services by residents of NL during and shortly after restructuring; to examine trends in the efficiency of utilization of acute care beds in the province during the same time frame; and to compare the trends in St John's with the rest of the province, taking account of confounding events, in an attempt to understand the impact of aggregation of hospitals in this region.
  
  
  METHODS
  Hospital discharge and day surgical data were analysed for all facilities in NL from 1995/96 to 2000/01. Analyses were by facility of service and also by region of residence directly standardized to the provincial population for 1996. Efficiency of bed utilization was examined on three occasions by concurrent utilization review using a modified version of the Appropriateness Evaluation Protocol. Trends in the St John's region (where most tertiary services are located and greater aggregation of hospitals occurred) were compared with the rest of the province.
  
  
  RESULTS
  Admissions declined by 14% in St John's facilities and by 17% elsewhere. Inpatient days fell by 9% in St John's and by 12% elsewhere. Average length of stay and Resource Intensity Weight changed little, apart from a rise in the final study year, with the largest change in St John's. Standardized hospital admission rates declined by 10% and inpatient days by 5.6% for residents of St John's region, and by 16% and 14% respectively for residents of other regions. There was no change over time in the use of day surgery. Efficiency of acute care bed use improved in 2002 in St John's, but was unchanged in other regions. Use of acute care beds by elderly patients for extended stay, or when an alternate level of care would have been appropriate, was greater in St John's with the disparity persisting over time. Waiting time for continuing care in the St John's region was unchanged comparing 1995/96 and 1999/00.
  
  
  CONCLUSIONS
  The degree to which acute care restructuring or financial pressures and constraints imposed at the provincial level contributed to observed utilization trends is unclear. Aggregation of hospitals in the St John's region may have contributed to more efficient use of acute care beds. Restructuring as carried out did not integrate health care sectors, and problems at the acute care/continuing care boundary were not resolved in St John's, where access to continuing care remained difficult.
authors.affiliation: Clinical Epidemiology Unit, Faculty of Medicine, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada. bbarrett@mun.ca
authors.forename: Brendan
authors.initials: B
authors.lastname: Barrett
authors.forename: Christine
authors.initials: C
authors.lastname: Way
authors.forename: Jackie
authors.initials: J
authors.lastname: McDonald
authors.forename: Patrick
authors.initials: P
authors.lastname: Parfrey
mesh_terms: D000328:Adult; D000368:Aged; D017598:Efficiency, Organizational / Q000706:statistics & numerical data*; D005260:Female; D018166:Health Care Reform; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006752:Hospital Planning; D006754:Hospital Restructuring / Q000458:organization & administration*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D009523:Newfoundland and Labrador; D012040:Regional Health Planning / Q000458:organization & administration*; D014600:Utilization Review