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An interrupted time series study using administrative health data to examine the impact of the COVID-19 pandemic on alternate care level acute hospitalizations in Ontario, Canada


Background — Many health systems struggle with delayed discharges (known as alternate level of care [ALC] in Canada). Our objectives were to describe and compare patient and hospitalization characteristics by ALC status, and to examine the impact of the initial period of the COVID-19 pandemic on ALC rates in Ontario, Canada.

Methods — We conducted an interrupted time series using linked administrative data for acute care hospital discharges in Ontario between Feb. 28, 2018, and Nov. 30, 2020. We measured the monthly ALC rate among discharges before and after the onset of the COVID-19 pandemic (Mar. 1, 2020). We used interrupted time series regressions to examine the association between the onset of the pandemic and average ALC monthly rates.

Results — We identified no meaningful differences in patient and admission characteristics, irrespective of time; however, differences were identified by ALC status. The overall average monthly rate of ALC discharges before the COVID-19 pandemic was 4.9% and after the onset of the pandemic was 5.0%. These discharges dropped to 4.3% (n = 3558) in March 2020 but then rebounded to their peak of 5.8% (n = 3915). There was no significant change in the average level of ALC rates per month after the onset of the pandemic (increase of 0.36% average per month, 95% confidence interval [CI] −0.11% to 0.83%) or monthly rate of change (slope) after the onset of the pandemic (−0.08%, 95% CI −0.15 to 0).

Interpretation — We identified a continued high rate of hospital discharges with an ALC component despite the considerable efforts in hospital to reduce hospital occupancy during the COVID-19 pandemic. Future research should examine why ALC rates remain high despite hospital efforts.



Guilcher SJT, Bai YQ, Wodchis WP, Bronskill SE, Kuluski K. CMAJ Open. 2023; 11(4):E621-9. Epub 2023 Jul 12.

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