Gauging the health of our health care system

Samuel Sheps and colleagues interpret their data to show that changes in health care use among elderly British Columbians after downsizing of acute care services were small and that no overall changes in age-related death rates were demonstrable.1 The latter conclusion is counterintuitive if one looks at the data presented.

In the study, cohort size increased by 16.6%, from 79 175 people in the first cohort (1986–1988) to 92 320 in the second cohort (1993–1995). The number of deaths increased by 24.7%, from 12 034 in the first cohort to 15 004 in the second. Age-adjusted proportionate 3-year death rates in Fig. 1 were uniformly higher in every category in the second than in the first cohort. I have no reason to dispute the report that the crude death rate rose from 15.2% to 16.3%, nor the report that after direct age adjustment using the combined population as the standard the death rate was 15.7% in the first cohort and 15.8% in the second. I dispute the suggestion that these results are “virtually identical”; the death rates reflect an increase in death after adjustment for age of 0.1%, or 1 death for every 1000 people 65 years or over.

Age-specific death rates have reportedly been declining steadily for decades in the United States,2 in the United Kingdom and Western Europe3 and in Australia.4 Even if we were to accept that an age-adjusted death rate increment of 0.1% represents “no overall change,” why has British Columbia failed to demonstrate the decline in mortality rate in this age group seen in other areas of the Western world? The obvious answer is that a 30% reduction in acute care capacity has had a demonstrably deleterious effect.

There were estimated to be 518 825 British Columbians aged 65 years and over in 1999.5 If we accept the authors' findings that the age-adjusted death rate rose by 0.1% between the late 1980s and the mid 1990s, this would translate into 519 deaths of British Columbians annually that might not have occurred if acute care services had been maintained at 1986–1988 levels.

Evidently, in the minds of some, the potentially preventable deaths of over 500 elderly people per year represent an acceptable price to pay to achieve the benefits of so-called health care reform. Apologists for the status quo might even describe these as minimal repercussions. I see these effects of deliberate health care downsizing as a cause for shame. Perhaps there is a connection between the data and the headlines after all.6