Prepared for EvidenceNetwork.ca by Ann Silversides
Scope of the issue
For decades, healthcare researchers have been writing about the implications of the aging of the demographic bulge produced by the boom-bust sequence (a large number of baby-boomers born between 1946 and 1964 followed by years of low fertility and smaller cohorts). Here is how Statistics Canada has modelled the coming changes:
Despite some scare mongering commentaries in the media, there won’t be a sudden, overwhelming impact on healthcare costs. As the above graphic indicates, the boomers will reach age 65 over a period of almost 20 years, which represents a relatively slow pace of demographic change.
And it’s not as if boomers, once they turn 65, suddenly become a drag on the economy and the healthcare system. Many continue to work. They will also volunteer, provide direct care for others, and contribute to the economy.
Cost increases across the age spectrum
As the province-by-province graph below shows, aging of the population typically accounts for only a small fraction of inflation-adjusted health cost increases.
Cost increases are driven by changes in the quantity and types of healthcare received by Canadians of all ages, not by demographic changes (e.g., visits to specialists, increased incidence of laboratory testing across populations).
An aging population does provide opportunities for all sorts of interventions without good evidence of increased health or quality of life, but it’s important to note unnecessary interventions are an issue for all Canadians, not just older adults.
The goal of the Choosing Wisely Canada campaign is to encourage and help physicians and patients to “engage in conversations about unnecessary tests, treatments and procedures’, and to help them “make smart and effective choices to ensure high-quality care.” (For evidence on the issue of increased, and questionable, intensity of healthcare provision, see here).
Increased diagnostic testing in all age groups, increased visits to specialists in all age groups, increased consumption of prescription drugs, and up until recently, rising pay to doctors, are all far bigger drivers of health costs than aging population.
Why change is needed
The aging of the population highlights how the system, with its emphasis on hospital-based acute care, is not designed to best meet the population’s need for preventive and chronic care. Changes in the organization and provision of various types of healthcare for senior citizens are required to contain costs and improve quality of care.
A key issue is to ensure that the number and type of healthcare workers is appropriate for an aging population, and that there is appropriate infrastructure to deploy them to best meet needs in a cost-effective and high quality manner.
The availability and quality of continuing care (home care and residential care) are concerns for many of Canada’s present and future senior citizens, and some key reports on these issues, and the need for appropriate and well trained health workers for these sectors, are cited below.
Many Canadians do not realize that these types of care for seniors (home care, long term care, assisted living, etc.) are not covered by the Canada Health Act—that is, there are no federal requirements for provision of this care and quality and availability of these types of care varies considerably across the country.
There is far more national-level documentation on the healthcare costs incurred by today’s seniors for hospitals care and prescription drugs. However, a snap shot of current trends for hospital and drug spending provides a context and reveals some key areas where changes to current approaches to care will likely improve care and hold down costs.
Hospital costs for seniors
Top costs: COPD, pneumonia and heart failure
In 2012/13, Canadians over 65 years of age accounted for 78 per cent of the three most expensive types of hospitals stays by diagnosis: COPD, pneumonia, and heart failure without angiogram, according to the Canadian Institute for Health Information. (“Most expensive” refers to high total cost for care, not average cost per day, CIHI notes.)
Another CIHI report, Unplanned Hospital Readmission Rates and Return to the Emergency Department, suggests that the system does not deal well with many of these patients.
That study found that patients with COPD had the highest rates of readmission to hospital, and of return within seven days to emergency department. Patients with heart failure and viral/unspecified pneumonia followed closely afterwards.
What can be done? The home care/home visit answer
Evidence shows that more home and integrated care for patients with COPD reduces costly hospital admissions and emergency department visits. The Canadian Foundation for Healthcare Improvement (CFHI) has launched a nation-wide collaborative to improve care for people with COPD and their caregivers.
Similarly, a review of high quality evidence found that “patients with heart failure that receive home-visits and/or attend clinics for those with heart failure delivered by multidisciplinary teams have lower rates of hospital readmission and are less likely to die compared to patients receiving usual care” (McMaster Optimal Aging Portal).
The research, and the evidence, noted above point to the need for changes in the makeup and deployment of the health workforce.
Coordinating care in hospital and at the hospital/home interface
Better coordination of care at the hospital and between the hospital and the home is essential in order to reduce unnecessary hospital visits and improve quality of care. As one example of this, Mount Sinai Hospital in Toronto has established an Acute Care for Elders unit. It has also teamed up with House Calls an interdisciplinary mobile team that provides home visits in part of the city. The team is comprised of a nurse practitioner, an occupational therapist, a physiotherapist, a social worker and three physicians.
Spending on prescription drugs is the second most costly component of healthcare—in 2013 it accounted for almost 14 per cent ($29-billion) of Canada’s annual healthcare spending, according to the 2014 Statistics Canada report Prescription medication use by Canadians aged 6 to 79.
The rise in the number of pharmaceutical drugs prescribed by doctors to senior citizens (and to the entire population) is striking and “deprescribing” initiatives have been launched to reduce potentially inappropriate prescriptions.
For example, prescription claims and the number of claims per person 65 years and old increased dramatically from 1997 to 2006, according to an Ontario retrospective study of 10-year prescribing trends by family physicians.
The steepest increases in prescribing were to older women, particularly those 85 and older and, for all seniors, the steepest increase was for medications used to prevent health problem. Yet many of the drugs used preventatively are quite controversial because of the documented harms of overprescribing (e.g., the use of statins to prevent heart disease and drugs for osteoporosis). The increase prescribing of statins to women is increasingly controversial. The lowest increases were for primarily symptom-based therapies, according to the study.
These trends “raise serious questions concerning quality of care, safety and cost,” the authors state.
The proportion of patients prescribed more than 10 classes of medication almost tripled over the 10 years, a fact which underscores concerns about polypharmacy and the possibility of iatrogenic harm, the authors state.
The Statistics Canada study provides a snapshot, not a change over time, about what is happening with polypharmacy. It found that, in 2013, about 30 per cent of 65 to 79 year olds take at least 5 prescription medicines concurrently. For people in that age group, lipid modifying agents (which include statins) were by far the most commonly prescribed class of drug from 2007 to 2011. These drugs were prescribed to 47.9 per cent of men in the study group (and to 18.9 per cent of men 45 to 64) and to 35.6 per cent of women (to 11.5 per cent of women 45 to 64).
In terms of spending, the Canadian Rx Atlas 2013 shows that, for those age 65 and older, the most money per capita was spent on anti hypertensive drugs , followed by cholesterol lowering drugs (statins).
Tackling polypharmacy in older adults: the rise of “deprescribing”
The efforts to reduce polypharmacy and improve the health of elderly patients has come to be known as deprescribing.
One of the initiatives to provide evidence-based guidance on deprescribing is the Ontario Pharmacy Research Collaboration, which is developing and evaluating deprescribing guidelines for health professionals. A similar effort in Ireland led to the creation of screening tools for geriatric medicine prescription.
Polypharmacy that is not carefully scrutinized can harm elderly persons, and add unnecessary costs to the healthcare system—drug costs and hospital costs. Polypharmacy can cause confused states, and widely prescribed drugs such as anti-hypertensives can increase the risk of falls among older adults. Falls are one of the greatest contributors to subsequent poor health and early death.
When a 77 year old woman arrived at a geriatric day hospital in Ottawa, sedated and in a wheelchair, physicians found that she had been prescribed 32 pills a day. The case was written up in the CMAJ in 2013. When she was discharged, after 12 weeks of twice-weekly visits, the woman daily intake of drugs had been cut almost in half to 17 pills a day.
The drugs had been prescribed by many different physicians and in these circumstances no one physician had “an overall view of how the combination of medications affects the patients.” Further, authors of the article speculated that family physicians “may be reluctant to modify or stop medications prescription by consultants or started in hospital.”
Experts available for interview
Further reading about healthcare system planning for the phenomenon of the aging baby boomers:
Health human resource planning issues
Selected reports on nursing home spending/provision/beds
Home care need, availability & costs
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