Comparison of long-term care
in an acute care institution
and in a long-term care institution
Ruby Friedman, MD; Norman Kalant, MD
Abstract
Background: Acute care hospitals in Quebec are required to reserve 10% of their
beds for patients receiving long-term care while awaiting transfer to a long-term
care facility. It is widely believed that this is inefficient because it is more costly
to provide long-term care in an acute care hospital than in one dedicated to
long-term care. The purpose of this study was to compare the quality and cost of
long-term care in an acute care hospital and in a long-term care facility.
Methods: A concurrent cross-sectional study was conducted of 101 patients at the
acute care hospital and 102 patients at the long-term care hospital. The 2 groups
were closely matched in terms of age, sex, nursing care requirements and major
diagnoses. Several indicators were used to assess the quality of care: the number
of medical specialist consultations, drugs, biochemical tests and radiographic
examinations; the number of adverse events (reportable incidents, nosocomial
infections and pressure ulcers); and anthropometric and biochemical indicators
of nutritional status. Costs were determined for nursing personnel, drugs and
biochemical tests. A longitudinal study was conducted of 45 patients who had
been receiving long-term care at the acute care hospital for at least 5 months
and were then transferred to the long-term care facility where they remained for
at least 6 months. For each patient, the number of adverse events, the number of
medical specialist consultations and the changes in activities of daily living sta-
tus were assessed at the 2 institutions.
Results: In the concurrent study, no differences in the number of adverse events
were observed; however, patients at the acute care hospital received more drugs
(5.9 v. 4.7 for each patient, p < 0.01) and underwent more tests (299 v. 79 labo-
ratory units/year for each patient, p < 0.001) and radiographic examinations (64
v. 46 per 1000 patient-weeks, p < 0.05). At both institutions, 36% of the patients
showed anthropometric and biochemical evidence of protein-calorie undernu-
trition; 28% at the acute care hospital and 27% at the long-term care hospital
had low serum iron and low transferrin saturation, compatible with iron defi-
ciency. The longitudinal study showed that there were more consultations (61 v.
37 per 1000 patient-weeks, p < 0.02) and fewer pressure ulcers (18 v. 34 per
1000 patient-weeks, p < 0.05) at the acute care hospital than at the long-term
care facility; other measures did not differ. The cost per patient-year was $7580
higher at the acute care hospital, attributable to the higher cost of drugs ($42),
the greater use of laboratory tests ($189) and, primarily, the higher cost of nurs-
ing ($7349). For patients requiring 3.00 nursing hours/day, the acute care hospi-
tal provided more hours than the long-term care facility (3.59 v. 3.03 hours),
with a higher percentage of hours from professional nurses rather than auxiliary
nurses or nursing aides (62% v. 28%). The nurse staffing pattern at the acute
care hospital was characteristic of university-affiliated acute care hospitals.
Interpretation: The long-term care provided in the acute care hospital involved a
more interventionist medical approach and greater use of professional nurses (at a
significantly higher cost) but without any overall difference in the quality of care.
Résumé
Contexte : Les hôpitaux de soins actifs du Québec doivent réserver 10 % de leurs lits
aux patients qui reçoivent des soins de longue durée et attendent un transfert à un
établissement de soins de longue durée. On croit en général que cette mesure est
Evidence
Études
From the Department of
Medicine, McGill University,
Montreal, Que.
This article has been peer reviewed.
CMAJ 1998;159:1107-13
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CMAJ • NOV. 3, 1998; 159 (9) 1107
© 1998 Canadian Medical Association (text and abstract/résumé)
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A
cute care hospitals in Quebec are required to de-
vote 10% of their beds to patients requiring long-
term care who are awaiting transfer to an appro-
priate long-term care institution. Frequently the number
of such patients exceeds 10%, which reduces the number
of beds available for patients requiring acute care. A com-
mon argument against this arrangement is that it is inef-
ficient because it is more costly to provide long-term care
in institutions devoted to acute care than in those de-
voted to long-term care. But why should this be? Long-
term care patients in acute care hospitals have been
treated for their acute illnesses and are in stable condition
but require care for chronic illness at a level that cannot
be provided at home. Each patient recommended for this
Friedman and Kalant
15521 November 3/98 CMAJ /Page
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1108 JAMC • 3 NOV. 1998; 159 (9)
inefficace parce que les soins de longue durée coûtent plus cher dans un hôpital
de soins actifs que dans un établissement réservé aux soins de longue durée. Cette
étude visait à comparer la qualité et le coût des soins de longue durée dans un
hôpital de soins actifs à ceux d’un établissement de soins de longue durée.
Méthodes : On a procédé à une étude transversale simultanée portant sur 101 pa-
tients à l’hôpital de soins actifs et sur 102 patients à un établissement de soins de
longue durée. Les deux groupes ont été jumelés de près selon l’âge, le sexe, les
soins infirmiers requis et les principaux diagnostics. On a utilisé certains indica-
teurs pour évaluer la qualité des soins : le nombre des consultations de médecins
spécialistes, des médicaments, des analyses biochimiques et des radiographies
utilisés; le nombre d’événements indésirables (incidents à déclaration obliga-
toire, infections nosocomiales et plaies de pression); et les indicateurs anthro-
pométriques et biochimiques de l’état nutritionnel. On a détérminé les coûts du
personnel infirmier, des médicaments et des analyses biochimiques. On a
procédé à une étude longitudinale sur 45 patients qui recevaient des soins de
longue durée à l’établissement de soins actifs depuis au moins cinq mois et qui
ont été ensuite transférés à l’établissement de soins de longue durée, où ils sont
demeurés au moins six mois. Dans chaque cas, on a évalué le nombre d’événe-
ments indésirables, le nombre de consultations de médecins spécialistes et les
changements des activités de la vie quotidienne aux deux établissements.
Résultats : Au cours de l’étude simultanée, on n’a observé aucune différence quant
au nombre d’événements indésirables, mais les patients à l’hôpital de soins actifs
ont reçu plus de médicaments (5,9 c. 4,7 pour chaque patient, p < 0,01) et ont
subi plus d’examens (299 c. 79 unités de laboratoire/année pour chaque patient,
p < 0,001) et d’examens radiographiques (64 c. 46 pour 1000 semaines–
patients, p < 0,05). Aux deux établissements, 36 % des patients ont montré des
signes anthropométriques et biochimiques de dénutrition protéique et calorique;
28 % des patients à l’hôpital de soins actifs et 27 % de ceux de l’établissement
de soins de longue durée présentaient une faible saturation sérique en fer et en
sidérophiline, compatible avec une carence en fer. L’étude longitudinale a mon-
tré qu’il y avait plus de consultations (61 c. 37, p < 0,02) et moins de plaies de
pression (18 c. 34, p < 0,05) à l’hôpital de soins actifs qu’à l’établissement de
soins de longue durée. Il n’y avait pas de différence entre les autres éléments de
mesure. L’année-patient coûtait 7580 $ de plus à l’hôpital de soins actifs, ce qui
est attribuable au coût plus élevé des médicaments (42 $), à la plus grande utili-
sation d’analyses de laboratoire (189 $) et surtout aux coûts plus élevés du per-
sonnel infirmier (7349 $). Dans le cas de patients qui avaient besoin de 3,00
heures de soins infirmiers/jour, l’hôpital de soins actifs a fourni plus d’heures que
l’établissement de soins de longue durée (3,59 c. 3,03 heures), et un pourcen-
tage plus élevé d’heures d’infirmières professionnelles que d’heures d’infirmières
auxiliaires ou d’aides infirmières (62 % c. 28 %). Les tendances de la dotation en
personnel infirmier à l’hôpital de soins actifs étaient caractéristiques des hôpitaux
de soins actifs affiliés à une université.
Interprétation : Les soins de longue durée dispensés à l’hôpital de soins actifs
comportaient une démarche médicale plus interventionniste et une plus grande
utilisation des infirmières professionnelles (à un coût beaucoup plus élevé) sans
toutefois entraîner de différence globale dans la qualité des soins.
Docket: 1-5521 Initial: JN
Customer: CMAJ Nov 3/98
type of care is assessed by a long-term care team and, if
deemed eligible, is moved to the long-term care unit
while awaiting transfer to a long-term care institution. In
Quebec the standardized process for evaluating such pa-
tients involves the completion of a “classification par type
en milieux de soin et services prolongés” form (classifica-
tion by types of program in extended care and service fa-
cilities; CTMSP). This form provides a detailed descrip-
tion of the patient’s medical, functional and social
support status, based on input from physicians, nurses
and social workers familiar with the patient. It is submit-
ted to the Ministry of Health and Social Services, where
it is “scored” to estimate the nursing care required (hours
per day); on the basis of the score and other pertinent in-
formation, the patient is assigned to a specific long-term
care institution. In theory, patients in acute care hospitals
awaiting transfer are in the same state as they will be after
the transfer and therefore require and should receive the
same level of care in both institutions. If the same level of
care is provided, the cost of care should be the same, re-
gardless of the setting. To obtain some insights into the
relative costs of care, we compared the level of medical
care, the quality of care and the direct costs of care re-
ceived by long-term care patients in an acute care hospi-
tal and in a long-term care institution.
Methods
Hospitals
The acute care hospital selected for study is a 600-bed
general hospital with some tertiary-level services. The
long-term care service has 101 nonpsychiatric beds di-
vided into 3 nursing units of 25–40 beds each. Patients are
assigned to nursing units on the basis of bed availability.
The long-term care institution selected for the study has
9 nursing units of approximately 35 beds each, for a total
of 300 beds. To a degree, patients are assigned to nursing
units on the basis of the amount of nursing care required
and the principal diagnosis; consequently, there is a rough
gradation of the nursing units from one where patients re-
quire minimal or custodial care to one where patients re-
quire intensive care and supervision. These institutions
were chosen for our comparison in part because a signifi-
cant number of patients in the acute care hospital are
transferred to the long-term care facility for permanent
placement; this allowed us to conduct both a concurrent
and a longitudinal study.
Study design
Two complementary studies were carried out: a con-
current cross-sectional study, in which we compared dif-
ferent groups of patients over the same period, and a lon-
gitudinal study, in which we assessed one group of pa-
tients in the different settings at different times. This
study was approved by the research ethics committee at
each institution.
For the concurrent study, patients in the 2 institutions
were compared during July 1996; the short study period
minimized the effect of patient turnover. For this type of
comparison, the features that may influence the variables
of interest must be similar in the 2 groups. From a pre-
liminary survey we determined that 3 of the nursing units
at the long-term care facility had patients with mean
CTMSP scores very similar to the mean score of the total
long-term care population at the acute care hospital. Be-
cause the combined population of the 3 units at the long-
term care facility (102 patients) and the population at the
acute care hospital (101 patients) were also similar in
terms of other important attributes (Table 1), they were
therefore appropriate for the concurrent study.
For the longitudinal study, we identified 45 patients
who were transferred from the acute care hospital to the
long-term care facility between Apr. 1, 1993, and June 1,
1997, and who had spent 5 months or more at each insti-
tution, excluding the first month after transfer. Informa-
tion on patient status was extracted from the medical
records for equal periods of time immediately before the
Long-term care in different settings
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Mean age (and SD), yr 85.4 (6.6)
Dementia (all forms)
Sex, % male 33
CTMSP rating of mean nursing
hours/day (and SD)
3.00 (0.83)
Mean length of stay,* days (and SD) 201 (14)
Prevalence of major diagnoses,
% of population
Characteristic
Acute care
hospital
n = 101
938 (31)
2.99 (0.69)
37
84.9 (8.1)
Demographic characteristics
Long-term
care hospital
n = 102
59 53
Parkinson’s disease 13 12
Cerebrovascular syndrome (e.g.,
stroke residua, TIA)
30 32
Other CNS disorder (e.g., mental
disorders, degenerative diseases)
6 10
Cardiac disorder 43
Table 1: Characteristics of the patient populations in the concurrent
study of long-term care provided in an acute care and a long-term
care institution in Quebec
37
Renal disorder 8 6
Diabetes 24 18
Musculoskeletal disorder 20 27
Neoplasm 7 13
Peripheral vascular disorder 6 8
Note: SD = standard deviation; CTMSP = classification by types of program in extended care
and service facilities; TIA = transient ischemic attack, CNS = central nervous system.
*Length of stay in the long-term care unit before the concurrent study began. SD is based on a
Poisson distribution (confirmed by a distribution plot).
transfer (at the acute care hospital) and beginning
1 month after the transfer (at the long-term care facility).
The month immediately after transfer was excluded be-
cause for such patients a change in locale may be associ-
ated with a temporary deterioration in health status and
function.
1,2
Five months was selected as the minimum stay
to ensure a long enough period for comparison and a
large enough group of patients.
For both studies, the intensity of medical care was
evaluated by determining the numbers of medical spe-
cialist consultations, drugs used, and biochemical tests
and radiographic examinations performed.
Despite the development of minimum data set require-
ments to provide information on patients in nursing
homes
3
and general agreement on the relevant domains
of care and the importance of outcomes rather than
processes of care,
4
there are no established methods to
measure quality of care. Because of a lack of understand-
ing and definition of “good” care, studies on quality of
care have focused on the avoidance of “bad” care.
We chose to assess the quality of care by measuring
commonly accepted clinical indicators from the minimum
data set requirements
5,6
for which data were available in the
medical charts of patients at both hospitals. We used 4 spe-
cific clinical indicators plus nutritional status. We obtained
from patient charts information about “reportable” events,
such as the number of incident reports for falls or injuries
and the number of medication errors. For nosocomial in-
fections, a physician’s written diagnosis or a diagnostic
urine culture along with the prescription for an antibiotic
were taken as evidence of urinary tract infection; a written
report of physical findings and diagnosis or a diagnostic
chest radiograph were taken as evidence of pneumonia.
We recorded the frequency of pressure ulcers rated by the
nursing staff on a 4-step scale of severity.
7
Deterioration in
activities of daily living (ADL) was measured using a pro-
cedure modified from Rudman and colleagues:
5
a 1-step
decrease in autonomy in any of the ADL categories was
given a score of –1 and an increase a score of +1. These
values were summed to provide a change-in-ADL score
(see Appendix 1 for details on rating ADL status). To eval-
uate nutritional status, loss of soft tissue was determined by
standard anthropometric measurements: triceps skin-fold
thickness, mid-arm circumference, mid-arm muscle cross-
sectional area and body mass index.
8
The age- and sex-specific percentile distributions of
Falciglia and others
9
for triceps skin-fold thickness, mid-
arm circumference and mid-arm muscle cross-sectional
area in elderly patients were used. Because a number of the
patients were unable to stand erect, height (needed for cal-
culation of body mass index) was estimated from leg length
for all patients.
10
Laboratory markers of protein–calorie
undernutrition
11–13
were serum albumin less than 35 g/L
and pre-albumin less than 0.14 g/L,
11
cholesterol less than
4 mmol/L,
14
hemoglobin less than 120 g/L in men and less
than 110 g/L in women,
15
total iron-binding capacity less
than 45 µmol/L,
16
and total lymphocyte count less than
1.5 × 10
9
/L.
11
Because there is no accepted comprehensive
index of nutritional status, a simple scoring system was de-
vised: for each patient, each anthropometric measurement
in the fifth percentile of the normal age- and sex-specific
range, a body mass index of less than 20 and each bio-
chemical marker indicating protein–calorie undernutrition
were given a rating of 1. These were summed to yield a
score with a maximum of 10. A patient was considered to
be undernourished if the score was 3 or higher. In addi-
tion, a serum iron level of less than 10 µmol/L combined
with transferrin saturation of less than 16% was taken as
evidence of iron deficiency.
17
All analyses were performed
in the laboratories at the acute care hospital.
To determine the costs of care, we examined costs for
nursing personnel, drugs and biochemical tests. The ac-
tual costs of nursing personnel are affected by the number
of hours worked by each category of personnel employed,
the seniority levels of the people employed during any
given period and the number of hours paid but not
worked (e.g., statutory social benefits, including vacation,
and various forms of leave with pay, such as maternity
leave and prolonged illness). Because seniority and hours
paid but not worked are variable and uncontrollable, the
actual costs of care do not provide a sound basis for com-
parison. Therefore, the number of hours worked and the
mean hourly rate of pay for each category of personnel
were used to estimate nursing costs. The numbers of
hours worked per year (1995/96) were obtained from the
personnel department at each institution. The hourly
rates of pay for each category of staff were the same at the
2 institutions; the midpoint of the range for a given cate-
gory of staff was taken as the mean hourly rate. The nurse
staffing patterns of the 2 institutions were compared with
those of similar metropolitan-area institutions by means
of data from a recent survey of extended-care facilities
18
and with those of other university-affiliated acute care in-
stitutions by means of information provided in annual sta-
tistical reports.
Information on drug use and costs was provided by the
pharmacy department of each institution for the following
categories
19
of medications: antibiotics; anticoagulants;
cardiac drugs; psychotherapeutic agents; anxiolytics, seda-
tives and hypnotics; and diuretics. The cost of laboratory
tests was determined from the number of tests and the
number of standardized laboratory units assigned to each
type of test. For all statistical analyses, the 2-tailed t-test
was used to compare means, the 2-tailed z distribution
was used to compare counts and the χ
2
test was used to
compare proportions.
20
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Results
Concurrent study
The patient populations were similar in terms of age,
sex, nursing care requirements and major diagnoses
(Table 1). There was no difference in the number of con-
sultations, but the use of drugs, biochemical tests and ra-
diographic examinations was greater at the acute care
hospital (Table 2). There was no significant difference in
the incidence rates of reportable events; the most fre-
quent type of incident was that classified as a fall, at 36
and 38 per 1000 patient-weeks at the acute care and the
long-term care institutions respectively (in the large ma-
jority of cases there was no associated injury). The inci-
dence rates of nosocomial infections and the prevalence
rates of pressure ulcers were similar at the 2 hospitals. At
both institutions there were substantial numbers of pa-
tients with evidence of protein–calorie undernutrition
and iron deficiency (Table 2); however there was no dif-
ference in patients’ nutritional status between the 2 insti-
tutions. Loss of subcutaneous fat was widespread; 99% of
patients at the acute care hospital and 96% at the long-
term care facility had triceps skin thickness in the 50th
percentile.
Longitudinal study
Because of the experimental design, the period of study
was different for different patients, averaging 305 (stan-
dard deviation [SD] 94, range 157–474) days. The num-
ber of consultations was higher at the acute care hospital
(61 v. 37 per 1000 patient-weeks, p < 0.025). The inci-
dence rate of pressure ulcers was higher at the long-term
care facility (18 v. 34 per 1000 patient-weeks, p < 0.025),
but most ulcers at both institutions were of grade 1 sever-
ity (least severe). The number of reportable events (55 v.
62 per 1000 patient-weeks) and nosocomial infections
(12 v. 15 per 1000 patient-weeks) and the net change in
ADL scores (–7.7 v. –8.2) were not significantly different.
Costs
The hours worked by nursing personnel and the costs
per bed are shown in Table 3. Because the cost of the
mandatory social benefits package (18% of salary) must be
added to the estimated annual difference in cost of $6228
per patient, the total annual difference was $7349 per pa-
tient or $742 253 for the 101 beds at the acute care hospi-
tal. In Table 4 the staffing patterns of the 2 institutions
studied are compared with those of similar metropolitan-
area institutions in Quebec. On average, acute care hospi-
tals and long-term care hospitals provided the number of
nursing care hours required according to the CTMSP
score, whereas the acute care hospital under study pro-
vided about 20% more hours than required. At acute care
university-affiliated hospitals, including the acute care hos-
pital under study, professional nurses provided a greater
proportion of the nursing hours than at acute care hospi-
tals in general. The long-term care facility was similar to
comparable institutions in its provision of nursing care.
For the drug categories selected, the combined an-
nual cost per bed was $290 at the acute care hospital and
$248 at the long-term care facility (antibiotics account-
ing for $111 and $83 respectively). For laboratory tests,
the yearly costs per bed were $254 at the acute care hos-
pital and $65 at the long-term care facility.
The total difference in costs for nursing personnel,
drugs and biochemical tests per patient-year was $7580.
Interpretation
There is wide variability in the level of nursing care re-
quired by long-term care patients. Those with a CTMSP
score of 2.5 or less are considered to require custodial
care; those with higher scores, such as the 2 groups of pa-
Long-term care in different settings
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Consultation requests per 1000
patient-weeks
78
Patients tested, %
Medications per patient*
Regular 5.9
As required 4.1
Use of biochemical tests‡
Element of care
Acute care
hospital
n = 101
3.5†
4.7†
68
Medical practice
Long-term
care hospital
n = 102
78 47§
Standardized laboratory work
units/bed, no./yr
299 79§
Radiographs, no. per 1000
patient-weeks
64 46
Adverse events
Incidents reported, no. per 1000
patient-weeks
56
Table 2: Elements of care at the 2 institutions in the concurrent study
56
Nosocomial infections, no. per
1000 patient-weeks
27 24
Prevalence of pressure ulcers,
% of patients
5.7 6.8
Nutritional status
Prevalence of protein–calorie
undernutrition, % of patients
36 36
Prevalence of iron deficiency,
% of patients
28 27
*Regular medications were administered on a regular basis at prescribed intervals. As-required
medications were administered at the discretion of the nurse, for specified indications.
†p < 0.01.
‡Extrapolated from data for a 2-month period.
§p < 0.001.
Docket: 1-5521 Initial: JN
Customer: CMAJ Nov 3/98
tients compared in this study, have more severe degrees of
illness or disability. Care for the more severely ill or dis-
abled is organized on a “medical model”; consequently, in
this study quality of care was compared on the basis of
commonly used “medical” criteria, and the comparison
does not reflect the psychosocial aspects of care. Patient
satisfaction with care was not assessed for several reasons.
First, there are a number of problems in measuring satis-
faction,
21
as well as with the validity and meaning of the
concept of satisfaction.
22
Second, there is general agree-
ment that scales of satisfaction are insensitive — most
studies show high levels of satisfaction regardless of the
context.
23
Third, because of the high prevalence of cogni-
tive deterioration and dementia, the information from
many patients would be of questionable validity.
Overall, there was no consistent difference in quality of
long-term care provided at the 2 institutions studied here.
In the concurrent study the numbers of untoward events,
nosocomial infections and pressure ulcers did not differ.
Similarly, in the longitudinal study the numbers of nosoco-
mial infections and of reportable incidents at the 2 hosp-
tials did not differ significantly. However, the long-term
care hosptial had a higher incident rate of pressure ulcers,
a finding that may be related to the time period for which
the data were collected: a program for prevention of pres-
sure ulcers was instituted at the long-term care facility
shortly before we began our concurrent study, but it was
not in place during the period covered by the longitudinal
study. The prevalence rates we found compare favourably
with those reported in surveys of nursing homes.
7,24,25
The
prevalence rates of protein–calorie undernutrition and iron
deficiency were similar at the 2 institutions and were
within the range of values reported by others.
26–30
Our results show a greater use of medication and more
medical specialist consultations, biochemical tests and ra-
diographic examinations at the acute care hospital. In
view of the similarities in the rates of infection, falls and
deterioration in functional status, this may reflect a more
“interventionist” approach on the part of physicians at the
acute care hospital, rather than increased need.
In this study we concentrated on direct costs of care;
we assumed that overhead costs such as heating, electric-
ity, cleaning and nutritional services did not differ signifi-
cantly among institutions. There were small differences in
cost attributable to the diagnostic procedures and the
greater use of medication at the acute care hospital, but
the major difference was associated with the provision of
nursing care. The CTMSP score is a measure of nursing
workload and thus reflects diagnosis, comorbid conditions
and other factors that affect medical and nursing require-
ments for the individual patient; in addition it is scored by
a central body, independent of the hospitals. It was there-
fore taken as a valid basis for our interhospital comparison
of nursing-hour needs. The long-term care facility pro-
vided the number of hours of care indicated by the
CTMSP ratings, whereas the acute care hospital provided
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Institution in this study 3.01
University-affiliated hospitals† 2.89
Long-term care institutions
Mean for Quebec
18
2.25
Institution in this study‡
Daily patient care,
h/patient
2.99 3.03
2.15
Type of institution Required*
3.22
3.59
Long-term care nursing units
in acute care hospitals
3.11Mean for Quebec
18
3.19
Provided
*As determined by CTMSP score.
†Source: annual statistical reports of university-affiliated acute care institutions.
‡Only for nursing units included in this study (see Methods).
28
22
43
62
22
Time provided
by professional
nurses, % of total
Table 4: Provision of nursing care for long-term care patients in
Quebec metropolitan areas
Nurse RN 607.8
Nurse clinician 4.8
Auxiliary nurse 90.4
Nursing aide 396.3
Clerk
Care provided, h/bed
43.3 24.3
653.0
Category of worker
Acute care
hospital
192.3
NA
196.3
Unit head and assistant 31.1
46.3
41.9
Nurse BSc 181.7
Long-term
care hospital
14.37
13.12
19.0
–256.7
–101.9
4.8
411.5
15.36
135.4
–10.8
Difference*
23.20
Table 3: Costs of nursing care at the 2 institutions for fiscal year 1995/96
19.28
22.10
28.00
Mean
cost/h, $
273
–3372
–1565
111
7934
2992
–302
Difference in
total cost/bed,† $
Other 15.7 2.6 13.1 12.00‡ 157
Total 1371.0 1157.0 214.0 NA 6228§
Note: NA = not applicable.
*Acute care hospital – long-term care hospital.
†Difference in care provided × mean cost/h.
‡Approximate mean value.
§If employee benefits (18% of salary) are included, the total difference is $7349.
approximately 20% more hours of care than indicated. As
well, the proportion of hours of care provided by profes-
sional nurses was twice as great at the acute care hospital.
In a survey of long-term care facilities in Quebec,
18
it was
found that acute care hospitals and long-term care institu-
tions both provided the number of nursing hours required,
and 22% of the hours of nursing care were provided by
professional nurses. In contrast, professional nurses pro-
vided 43% of the hours of care in university-affiliated acute
care hospitals. In view of the similarity of the outcomes of
care at the institutions studied here, one might question
what benefits are obtained from having a higher proportion
of hours of care provided by professional nurses. Because of
financial constraints experienced by hospitals in recent
years, there has been a move to replace some nurses with
nursing aides;
31
this change has been controversial,
32
but
there has been little investigation of its effect on patient
care. Our results suggest that for long-term care the ratio of
nursing assistants to nurses can be as high as 3:1 or 4:1
without any effect on the quality of care.
In the acute care nursing units of university-affiliated
hospitals, 72% (SD 6%) of nursing hours are provided by
professional nurses (data from annual statistical reports).
The high proportion of professional-nurse hours on the
long-term care units, together with greater physician in-
volvement at the acute care hospital, suggests that there is
an inappropriate carryover of patterns of care from the
acute care units to the long-term care units, an example of
“overmedicalization.”
33
This may be an important factor
in jurisdictions where long-term care is more costly in
acute care hospitals.
We thank Doreen Wan-Chow-Wah and Elana Bloom for their
conscientious assistance in collection and collation of the data.
We are indebted to the staff at both hospitals for their coopera-
tion and assistance in all phases of this study.
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Long-term care in different settings
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Mobility (transfer
and ambulation)
Independent
Requires supervision
Requires assistance
Dependent (requires turning and positioning in bed)
Activity Rating
Feeding Independent
Requires assistance
Dependent (requires feeding)
Bowel function Continent
Incontinent
Bladder control Continent
Incontinent
Appendix 1: Criteria used to determine activities of daily living (ADL) status
