Individual and system-level factors associated with alternate level of care (ALC) in British Columbia

Background: Delayed discharge, or alternate level of care (ALC) as it is known in Canada occurs when patients stay in hospital even after they are medically fit for discharge as they wait for appropriate post-acute care services to become available. It is widely acknowledged as an ongoing issue of system inefficiency, and previous studies have examined patient characteristics associated with ALC. However, few studies have investigated ALC trends, the health system factors related to ALC, or accounted for the nesting of patients within health systems. Objective: The objectives of this thesis were to: (1) describe changes in ALC use in British Columbia (BC) from 2008 to 2019 and (2) examine the patient- and system-level factors associated with ALC designation. Methods: This thesis is a population-based retrospective analysis of all acute hospital discharges of patients 40 years and older in BC from 2008-2019 using linked administrative data and publicly available data. The first objective is addressed by describing trends in percent ALC hospitalizations and days based on selected characteristics from 2008-2019. The second objective is addressed using descriptive analyses and multivariable multi-level logistic regression modelling to examine patient-level and system-level characteristics associated with ALC hospitalization status from 2015-2019. Results: There was an upward trend in ALC use from 2008-2019 in BC; percent ALC hospitalizations rose from 6.0% to 6.9% while percent ALC days rose from 13.5% to 16.1%. Individual-level factors were dominant in predicting ALC use, with assisted living capacity being the only system-level factor significantly associated with ALC. Strong predictors of ALC included older age, longer acute length of stay, dementia, discharge designation, and fewer family physician visits after adjusting for other explanatory variables. Conclusion: ALC is a significant and growing issue in BC that has important policy implications. These findings highlight inequities in ALC use related to social determinants of health, and the importance of dementia, primary care access and discharge destination as predictors of ALC, suggesting investments in primary care and home and community care capacity are potential solutions. Future research should explore other health system factors and solutions related to delayed discharge.Medicine, Faculty ofPopulation and Public Health (SPPH), School ofGraduat