Occupational back pain--an unhelpful polemic.

In most industrialized countries, disability and work absence due to occupational back pain have risen steadily in recent decades. Conventional views of the causes of this slow epidemic tend to fall into one of the following three areas: (i) the clinical pathology view, which attributes the level of pain and disability to either the severity of the initial injury or to psychosomatic conditions; (ii) the biomechanical exposures view, which attributes the problem to hazardous and preventable conditions of work; and (iii) the perverse incentives view, which suggests that reporting and disability are influenced by a combination of work dissatisfaction and accessible disability benefits. This paper reviews, from an epidemiologic perspective, the specific methodological hurdles faced during investigations of the etiology of occupational back pain. It is argued that methodological issues have contributed to the perpetuation of the three distinct but incomplete views of the problem. New research directions are suggested and a broader interdisciplinary perspective is proposed to help resolve the existing polemic.

Trends and determinants of prescription drug expenditures in the elderly: data from the British Columbia Pharmacare Program.

This paper uses claims data from the prescription drug program for the elderly in British Columbia to describe temporal trends in prescription drug use and the determinants of those trends. Drug expenditures under the program increased by 317% from $21.6 million in 1981-82 to $90 million in 1988-89. Of the $68.4 million-dollar increase in overall expenditures, 34% was due to new drugs, 24% to increased age-specific utilization rates of old drugs, 21% to increased prices of old drugs, and 14% to the increased size of the elderly population. The analysis indicates that 61.5% of new drug expenditures can be attributed to four specific drugs and that the relative importance of price and utilization rates in determining changes in expenditures on old drugs varies by drug category. The paper provides a framework for understanding and predicting expenditures for drug benefit plans.

A human resources decision support model: nurse deployment patterns in one Canadian system.

Optimal deployment of current staff--as opposed to recruitment of new staff--has been recognized as an effective strategy for dealing with nurse human resource shortages in hospitals, especially during periods of overall nursing shortages. In this article we present a model for maximizing current nursing staff resources by incorporating three dimensions of staff deployment: workforce stability, employment mix, and average paid hours. Using centralized provincial payroll data from British Columbia, we analyzed a set of three indices that measure these factors to examine patterns of nurse deployment and their impact on total nurse human resource requirements. Furthermore, by constructing hypothetical scenarios and changing the parameters according to possible situations depicted by the model, it is possible to demonstrate the impact of alternate management strategies on nurse requirements. The results emphasize the need for dealing with staff deployment in a multidimensional manner that may vary by facility type; it is not the size of the full-time nursing component alone that should be the dominant consideration for all facilities. Innovative approaches to management are called for to maximize the deployment of a limited human resource pool.

Recent trends in acute care hospital utilization in Ontario for diseases of the circulatory system.

OBJECTIVE: To describe trends in the use of acute care hospital services for diseases of the circulatory system in Ontario. DESIGN: Observational study. DATA EXTRACTION: Information on diagnoses, procedures and demographic characteristics was obtained from routinely collected computerized abstracts of separations from all acute care hospitals in Ontario during 1979-80, 1983-84 and 1988-89. The data were combined with population estimates to calculate overall separation rates and rates specific for age, diagnosis and procedure. Resource intensity weights were used to estimate changes in resource use. MAIN RESULTS: The overall separation rate increased by 3% and the resource-intensity-weighted separation rate by 12% from 1979-80 to 1988-89. The overall medical separation rate increased by 2%, whereas the surgical rate increased by 12%. The surgical separation rate increased among patients 55 to 79 years of age but decreased in all the other adult age groups. The separation rates for coronary artery bypass surgery and cardiac valve surgery increased rapidly among patients 65 years of age or older. The medical separation rate decreased for patients of all ages except those less than 5 years and those 80 years or more. The medical separation rates decreased by less than 1% for diagnoses related to ischemic heart disease (IHD) and increased dramatically for coronary artery revascularization. CONCLUSIONS: The increasing elderly population has not resulted in large increases in acute care hospital utilization for diseases of the circulatory system. The impact of an aging population has been balanced by decreased utilization rates in the younger groups. The intensity of hospital care has risen primarily because of increases in surgical rates, especially in the elderly population. The large decrease in the rate of death from IHD over the past two decades has not been associated with similar decreases in acute care hospital utilization for this disorder.

Acute care hospital utilization under Canadian national health insurance: the British Columbia experience from 1969 to 1988.

This paper uses hospital separation abstracts to assess trends in acute care hospital utilization in British Columbia over the first 18 years of publicly funded health insurance in the province. Between 1969 and fiscal year 1987-88, the overall separation rate decreased by 16%, accompanied by a 23% decrease in average length of stay. For the elderly, the separation rate increased by 14% and three quarter of this increase was for surgical procedures, mostly new high-technology procedures. For the nonelderly, separation rates decreased by 25%. Lengths of stay decreased in both age groups. Over the last two decades overall separation rates in British Columbia were higher than or equal to separation rates in the United States, and lengths of stay were consistently higher in British Columbia. Since access to hospitals by the elderly is similar in the two countries, lower hospital costs in Canada result from factors other than lower overall hospital utilization or decreased access for the elderly.

Flat on your back or back to your flat? Sources of increased hospital services utilization among the elderly in British Columbia.

Between 1969 and 1985, the British Columbia hospital system allocated an increasing proportion of the province's total hospital days to elderly patients who stayed for 60 days or more. By 1985/86, long stay patients accounted for almost 50% of all days. In this paper, we explore the diagnoses which contributed the greatest number of patient days of increase among the elderly as a first step in evaluating the appropriateness of this response to the pressures of an aging population. Patient days of increase were not distributed smoothly across a large number of diagnoses, but could be explained by a small number of chronic conditions. Most important were conditions related to senility and senile dementia, the chronic sequelae of heart disease and stroke, and persons awaiting admission to adequate facilities elsewhere. Eighty percent of the increases were seen in extended care and rehabilitation beds and 20% in acute care beds. Seventy-seven percent of the increased patient days were attributable to females and only 23% to males. Since the major sources of increase in patient days were not related to conditions for which new, effective hospital care modalities are available, they call into question the appropriateness of the system's response to the health care needs of the elderly population.

The long good-bye: the great transformation of the British Columbia hospital system.

Much is made of the "threat" an aging population poses to North American health care systems. In this article, we present hospital utilization data from British Columbia over the period 1969-1985, which reinforce our earlier (Barer, Evans, Hertzman, et al. 1987) conclusion: it is not aging per se that poses the threat; rather, it is what we are choosing (through our health care system) to do to and with our elderly. In 1969, British Columbia hospital patients over 65 years of age and staying longer than 60 days accounted for 12.5 percent of all days; by 1985/86, they were accounting for 39 percent. Furthermore, in 1985/86, 1 patient in 200 was using one-quarter of all patient days and dying at the end of the process, and 2 patients in 100 (who stayed over 60 days whether discharged alive or dead) were accounting for almost one-half of all days.

Trends in use of medical services by the elderly in British Columbia.

We analysed physician fee-for-service use in British Columbia from 1974-75 to 1985-86. Over the study period use increased by 5.3% per year. This can be factored into increases attributable to changes in the age structure of the population (0.4% per year), general population growth (1.8%, for a combined annual "population effect" of 2.2%) and age-specific increases in per-capita use (3% per year). The average annual increase for people aged 75 years or more was 5.5% per capita. The area with the fastest growth in use by the elderly was specialist care, particularly diagnostic services. The average number of specialists seen by people aged 75 years or more doubled over the study period. Our results suggest that increased per-capita use among the elderly that is unrelated to aging of the population should be the main focus of future policy attention. Additional analyses are needed to determine the underlying dynamics of this dramatic increase in rates of use among the elderly.