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Correlation Between HbA1c Levels and Mortality Rates in Hospitalized COVID-19 Patients

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Objective

Throughout the coronavirus disease 2019 (COVID-19) pandemic, multiple factors have been associated with poor prognosis for those infected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. Age, obesity, and medical comorbidities have been linked to poor outcomes, including admission to the intensive care unit (ICU), acute renal failure, stroke, myocardial infarction (MI), mechanical ventilation, and even death for hospitalized COVID-19 patients. Although diabetes mellitus (DM) has also been included in this set of medical comorbidities, there have been inconsistencies in the currently available body of literature, suggesting that mortality rates may or may not be correlated to elevated glycosylated hemoglobin (HbA1c) levels. This study aims to determine whether there is a correlation or trend between a range of HbA1c values and in-hospital mortality among patients admitted to the hospital with a COVID-19 diagnosis.

Materials and methods

This study was a retrospective review of electronic medical records at Arrowhead Regional Medical Center in Colton, CA. Any patient above the age of 18 admitted to the hospital during a predetermined time frame, with either a positive COVID-19 PCR test on admission or during their hospital stay, was included in the study. These medical charts were reviewed for HbA1c values during admission or within three months prior to admission. In-hospital mortality was then recorded for each medical record with an available HbA1c value. Hospital discharge summaries were used to delineate comorbidities, including chronic kidney disease, cerebrovascular disease, coronary artery disease, congestive heart failure, cancer history, or history of deep vein thrombosis/pulmonary embolism among the patients included in the study. Average HbA1c values were recorded for the mortality and non-mortality groups, and their statistical significance was calculated.

Results

In this retrospective study, HbA1c levels were compared to mortality rates among adult patients admitted to the hospital with a concurrent COVID-19 diagnosis. From the analysis conducted, those with higher HbA1c levels did not have an increased rate of in-hospital mortality, and those with lower HbA1c levels did not have a decreased rate of in-hospital mortality. Comorbidity data as a confounding factor was also reviewed and excluded from the final analysis. The SARS-CoV-2 vaccine was also excluded as a confounder in this study by selecting a specific time frame for data collection. Based on our results, we propose that HbA1c levels likely have little to minimal correlation with mortality rates among hospitalized COVID-19 patients.

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Conclusion

In this study, we show that HbA1c levels, regardless of concurrent comorbidities, are unlikely to be correlated to mortality rates among hospitalized COVID-19 patients. HbA1c levels should not be used as a marker for whether these patients should be admitted to the hospital for further inpatient management or discharged from the emergency department.

Introduction

SARS-CoV-2, a single-stranded RNA virus in the coronavirus family that causes the COVID-19 infection, was first discovered in Wuhan, China, on January 7, 2020 [1,2]. Coronavirus 2019 (COVID-19) began to spread rapidly across borders through person-to-person transmission, and the first case in the US was reported on January 20, 2020, in Washington State [2]. By March 11, 2020, the World Health Organization had declared the outbreak, caused by the SARS-CoV-2 virus, a global pandemic [3]. Toward the end of 2020, there were over 80 million documented infections and 1.8 million deaths globally that were attributed to COVID-19 [1]. Those infected by the virus displayed various clinical signs, symptoms, and hospital courses, including mild respiratory illnesses, asymptomatic infections, and even severe pneumonia with multiorgan failure leading to death [4-6]. With this widespread disease activity and variation in disease severity, it became imperative to uncover associated factors that might lead to worse clinical outcomes among individuals. After a significant analysis of COVID-19 trends from hospitals globally, a subset of factors that increased the risk of acquiring severe SARS-CoV-2 infection was outlined. Older age and male gender, in addition to co-morbid conditions, such as cardiovascular disease, obesity, hypertension, and diabetes mellitus, have since been associated with worse outcomes in patients with COVID-19 [7-9]. These aforementioned co-morbidities have been denoted as risk factors for elevated morbidity and mortality in COVID-19 patients [1,10]. Diabetes mellitus has been specifically labeled as an independent risk factor for worse clinical outcomes among those admitted with SARS-CoV-2 infection. Patients with diabetes required hemodialysis, extensive antibiotic therapy, and mechanical ventilation at higher rates; additionally, these patients had an increased length of hospital stay [1,11]. Although diabetes has been shown to have worse outcomes in hospitalized COVID-19 patients, there has been some debate on whether poor long-term glycemic control and subsequently elevated glycosylated hemoglobin (HbA1c) levels (which signifies the average blood glucose levels over the past three months) correlate strongly with increased mortality [5,12-14]. A study conducted by Wu, et al. in Wuhan, China, claimed that elevated glucose levels at the time of admission were independently associated with an increased risk of progression to critical illness and death, including in-hospital mortality [15]. Aggressive glucose control was associated with shorter lengths of stay and overall decreased mortality rates as compared with poor glucose control [1]. On the other hand, a study conducted by Mehta et al. in 2021 showed that outpatient glucose control, inpatient glucose control, average glucose during hospital admission, or even level of HbA1c did not correlate with ventilator requirement, ICU admission, or mortality in patients hospitalized with COVID-19 [16]. Thus, there have been variations in data reported regarding diabetes, its specific markers, and its association or lack thereof with the severity of COVID-19 infection.

HbA1c has been shown to objectively delineate diabetes severity and overall glycemic control over an average of three months [14]. HbA1c levels greater than or equal to 9% have been associated with a significantly increased risk of hospitalization in COVID-19 patients [17]. Naturally, with a higher risk of hospitalization and clinically adverse events, one may assume that mortality would also be increased in these patients. A multicenter review performed by Kristan et al. demonstrates increased mortality rates in those with elevated HbA1c levels [1]. However, data presented in a study by Randhawa et al. in 2021, and subsequently by Patel, et al. in a single-center retrospective study, showed that there may not be any correlation between elevated HbA1c levels and mortality in hospitalized patients with a COVID-19 diagnosis; although elevated HbA1c levels have been linked to worse clinical outcomes and complications, mortality was not one of them [5,18]. Given the conflicting results of prior studies, more research is needed to illuminate the true risks that poorly controlled diabetes has on SARS-CoV-2 infection severity and in-hospital mortality. This may have a profound effect on whether or not a symptomatic patient who presents to the emergency department qualifies for admission to the hospital. Thus, our single-centered, retrospective study attempts to evaluate this topic further.

Materials & Methods

Study design

The goal of this study was to find the correlation between adult patients admitted to either medical floors or ICU carrying a diagnosis of COVID-19 (confirmed by polymerase chain reaction (PCR) testing of nasopharyngeal swabs for SARS-CoV-2 virus) with their documented HbA1c level. This study was a retrospective review of electronic medical records at Arrowhead Regional Medical Center in Colton, CA. It was reviewed and approved by the Arrowhead Regional Medical Center Institutional Review Board (Protocol# 22-35) on June 17, 2022. All medical records and reviews complied with HIPAA regulations. Patient identifiers were strictly limited to the medical record number, age, sex, ethnicity, body mass index (BMI), past medical history, comorbidities, and outcome of admission (disposition).

Inclusion and exclusion criteria

All the electronic charts were first filtered with basic search criteria. Any patient that was above the age of 18 and was admitted to the hospital (Floors/Wards or ICU) from March 1, 2020, to December 1, 2020, with either a positive COVID-19 PCR test on admission or during their hospital stay was included in the initial search. This was achieved through searching International Classification of Diseases (ICD) codes relevant to a COVID-19 or acute hypoxic respiratory failure due to COVID-19 diagnosis. The reason for choosing this specific time frame was to exclude the effect of the SARS-CoV-2 vaccine as a confounder to mortality data since the vaccine was first available for distribution in December 2020 [19]. Exclusion criteria for selection were any patient who was not admitted to the hospital, was admitted outside of the time frame listed above, was under the age of 18, or did not carry the diagnosis of COVID-19 infection during that specific hospital stay.

Data collection

Each of the selected charts was meticulously reviewed for an HbA1c level obtained during or within three months of the patient’s hospital stay. In-hospital mortality was then recorded for each medical record with an available HbA1c value, regardless of how high or low that value was. Hospital discharge summaries were used to aid in the collection of that individual’s medical history to delineate comorbidities, including chronic kidney disease, cerebrovascular disease, coronary artery disease, congestive heart failure, cancer history, or history of deep vein thrombosis/pulmonary embolism. Average HbA1c values were recorded for the mortality and non-mortality groups and their statistical significance was calculated using a p-value. After data were collected, HbA1c values were stratified in different groups and comorbidity data was excluded from the final calculation of mean values. The data were subsequently organized into a tabular format.

Results

Data from electronic medical records at our institution were reviewed from March 1, 2020, to December 1, 2020. Those cases that were above the age of 18, were admitted to the hospital on the floors or ICU, and had a diagnosis of COVID-19 were examined. There were 487 records reviewed in total. There were 193 females (40%) and 294 males (60%) in this cohort, and the median age was 58. Of those 487 cases, 379 of them were included in this study as they had a valid HbA1c level drawn during their hospital stay or within three months prior to their hospital stay. Out of those 379 cases, 87 (22.9%) suffered in-hospital mortality. The average age of these patients was 62.5. The average HbA1c level for mortality cases was 7.66%. HbA1c values for all the cases included were divided numerically from <5% to >14%. The groupings were in intervals of 1 percentage point. For example, 5.0-5.9% was one interval group while 6.0-6.9% was the next. The lowest mortality rate was 15.8% in the 11.0-11.9% HbA1c group. There were 19 cases documented in this group and three deaths. The highest mortality rate was in the > 14% HbA1c group at 33.3%; however, there were only three documented cases and one death. All the other groupings had a mortality rate between 21%-27%. The mortality rates in the 5.0-5.9%, 6.0-6.9%, and 7.0-7.9% HbA1c groups were 21.7%, 22%, and 25.5% respectively. The mortality rates in the 8.0-8.9%, 9.0-9.9%, and 10.0-10.9% HbA1c groups were 25.9%, 20.8%, and 26.9% respectively (Table 1).

Totals including patients with any comorbidities Total # Deaths
HbA1c values 379 87 (Total)
< 5% 8 2 (25%)
5-5.9% 92 20 (21.7%)
6-6.9% 109 24 (22%)
7-7.9% 47 12 (25.5%)
8-8.9% 27 7 (25.9%)
9-9.9% 24 5 (20.8%)
10-10.9% 26 7 (26.9%)
11-11.9% 19 3 (15.8%)
12-12.9% 12 3 (25%)
13-13.9% 12 3 (25%)
> 14% 3 1 (33.3%)

Of the 87 in-hospital deaths that occurred in this cohort, 26 (29.9%) patients had at least one documented comorbidity. The remaining 61 (70.1%) patients did not have any documented comorbidity. The comorbidities that were looked for in each case included a history of cerebrovascular disease, coronary artery disease, congestive heart failure, chronic kidney disease, cancer, or deep vein thrombosis (DVT)/ pulmonary embolism (PE). Of those that died in the 5.0-5.9%, 6.0-6.9%, 7.0-7.9%, 8.0-8.9% HbA1c groups, 35%, 33.3%, 25%, 28.6% respectively had at least 1 comorbidity. To account for comorbidities as a confounder in this study, data were filtered to exclude patients with any of the above-mentioned comorbidities. There was a total of 301 cases in that 387 original cohort used in the study for which there was no comorbidity documented as reviewed by physician discharge summaries and progress notes. From this group, there were 61 (20.3%) total deaths. Groupings for each interval were similar to the ones above. The lowest mortality rate was 15.4% in the 9.0-9.9% HbA1c group. There were 13 cases documented in this group and two deaths. The highest mortality rate was in the >14% HbA1c group at 33.3%; however, as mentioned earlier, there were only three documented cases and one death. The <5% HbA1c group and the 11.0-11.9% HbA1c group both had a mortality rate of 16.7%. The mortality rates in the 5.0-5.9%, 6.0-6.9%, 7.0-7.9%, and 8.0-8.9% HbA1c groups were 18.3%, 18%, 25.8%, and 25% respectively. Additionally, the mortality rates in the 10.0-10.9%, 11.0-11.9%, 12.0-12.9%, and 13.0-13.9% HbA1c groups were 25%, 16.7%, 20%, and 25% respectively (Table 2). In the end, when looking at the entire data collectively, the average HbA1c for the mortality group was 7.66 + 2.36, whereas the HbA1c for the non-mortality group was 7.65 + 2.34. The p-value was 0.964, indicating that there was no statistical significance between the HbA1c values of those that died in the hospital with a COVID-19 diagnosis versus those that did not.

Totals without including patients with any comorbidities Total # Deaths
HbA1c values 301 61 (Total)
< 5% 6 1 (16.7%)
5-5.9% 71 13 (18.3%)
6-6.9% 89 16 (18%)
7-7.9% 31 8 (25.8%)
8-8.9% 24 6 (25%)
9-9.9% 13 2 (15.4%)
10-10.9% 24 6 (25%)
11-11.9% 18 3 (16.7%)
12-12.9% 10 2 (20%)
13-13.9% 12 3 (25%)
> 14% 3 1 (33.3%)

Discussion

Our focus in this single-center, retrospective, observational study was to understand the correlation between HbA1c levels and mortality among patients admitted to the hospital with a diagnosis of COVID-19. HbA1c levels generally show the trend of glycemic control for the past three months, therefore illuminating the severity of an individual’s diabetes [14]. Since diabetes is a significant risk factor for a complicated hospital course and the severity of SARS-CoV-2 infection, we aimed to determine whether poorly controlled diabetes leads to increased rates of mortality [1,11]. Unraveling this data can potentially help individuals stratify their own risk of acquiring a severe disease and encourage them to take extra precautions to mitigate their risk of contracting COVID-19. Additionally, it could provide clinicians insight into which patients may benefit from admission to the hospital and whether they should be admitted to an ICU setting or general medical floor. Of note, prior studies have claimed that elevated HbA1c correlates with increased mortality; however, other studies do not suggest a correlation between HbA1c levels with mortality [1,5]. Our study was designed to evaluate this topic further and provide clarity by presenting data specific to our population at a county hospital in San Bernardino, California. The specific time interval chosen, which may be different from prior studies, was chosen to limit the confounding effects of the SARS-CoV-2 vaccination, which became available in December 2020 [19]. Thus, the study time frame ended on December 1, 2020. Based on the data obtained, there does not appear to be a clear correlation between HbA1c values and in-hospital mortality, regardless of whether a patient was admitted to the ICU or general medical floor. For each subset of the HbA1c level, the mortality rates were relatively comparable. This was further evidenced by the statistical insignificance of the average HbA1c values between the mortality group and the non-mortality group. The average HbA1c for the mortality group was 7.66 + 2.36, whereas the HbA1c for the non-mortality group was 7.65 + 2.34, with a p-value of 0.964. Notably, the lowest mortality rate was seen in the 11.0-11.9% HbA1c group, which generally signifies very poorly controlled diabetes. Even after accounting for comorbidities, which may have been a confounder, the mortality rates were not substantially different among each HbA1c subset. The mortality rate was 22.9% overall and when patients with a history of any medical comorbidities were excluded, the mortality rate dropped only slightly to 20.3%. The average HbA1c level among the mortality cases was 7.66%, which indicated moderately poor glycemic control. However, given the range of HbA1c levels seen in this specific population (ranging as high as 14%), it is difficult to say that higher HbA1c levels were associated with greater mortality. In fact, there may not be a significant correlation at all.

One specific point to consider is that this study was largely inpatient-focused. It did not include outpatient management and control of diabetes prior to hospital admission. Patients with a higher HbA1c may likely have been on diabetic medications previously, including insulin. It is unclear how being on diabetic medications, such as insulin and metformin, in the outpatient setting would affect these results. As noted by Patel et al. in their study, HbA1c values could potentially be skewed in certain populations such as those with chronic kidney disease and/or in patients with anemia, which may affect the accuracy of HbA1c values obtained [5]. One way to investigate this is to focus on glycemic control itself in the acute inpatient setting. As noted by Kristan et al., acute glycemic control may prove to have better outcomes, rendering HbA1c values useless in predicting mortality rates [1]. Interestingly, other studies, including one by Mehta et al., found that there was no correlation between inpatient glycemic control and mortality rates [16]. Taking it a step further, Randhawa et al. found that glycemic control may correlate strongly with severe complications in hospitalized COVID-19 patients but may not affect mortality specifically [18]. Ultimately, our data suggest that chronic outpatient glucose control in the setting of pre-existing diabetes may not correlate with in-hospital mortality in COVID-19 patients admitted to the hospital.

There are numerous avenues for further research into this topic. While particular comorbidities were incorporated into this study, more research could include other comorbidities, including liver and pulmonary diseases, such as cirrhosis and obstructive lung disease. Our study was designed to evaluate a pre-vaccination population and future studies could incorporate data from a broader time period to evaluate a post-vaccination population. Another potential area of focus for future research is the analysis of patients’ outpatient diabetic regimens, including prior insulin or metformin use, and tracking specific inpatient glycemic trends instead of HbA1c values.

A key limitation of our study is its single-centered nature, which solely represents the San Bernardino County population in California. Although similar data may be seen in other regions with a similar population, it is hard to generalize this data throughout all populations and regions. Another limitation of this study was that it was hard to delineate COVID-19 as the primary cause of patients’ mortality. It was difficult to rule out other comorbidities and complications during the hospital stay that may have played a significant role in the resulting mortality rates, even though physician discharge/death summaries were meticulously reviewed. That said, it is difficult to say with certainty that every single discharge/death summary reviewed in the study accurately reflected all the comorbidities and chronic conditions that the patient may have had in the outpatient setting. Thus, other unidentified comorbidities could have also played a significant role in mortality rates. Additionally, since the vaccine was excluded as a confounding factor, its presence may have modified the data and could change recommendations about specific individuals’ mortality risks.

Conclusions

Although comorbidities such as diabetes mellitus can predispose patients to severe COVID-19 disease and even result in hospitalization, there is no clear correlation between poorly controlled diabetes and mortality specifically among patients hospitalized with COVID-19. From this single-center study, higher HbA1c values did not correlate with higher mortality rates among patients who were admitted to the general medical floor or the ICU with a concurrent diagnosis of COVID-19 or respiratory failure due to COVID-19. This suggests that the risk of mortality is not inherently higher in patients with elevated HbA1c values. It also suggests that certain risk factors may not significantly increase the risk of mortality. This type of study can help highlight the need for hospitalization in some patients with COVID-19 regardless of their HbA1c value due to their increased risk of severe infection despite low levels and well-controlled diabetes mellitus. However, further studies are needed to help clinicians delineate whether certain comorbidities are inevitably a greater or lesser risk factor for disease severity in those that acquire COVID-19.

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B.C.’s economy, health care and housing to be the focus of throne speech: Eby

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VICTORIA — British Columbia’s economy will be a key focus for politicians as they return to the legislature for the spring sitting.

Premier David Eby says economists are predicating a “global slowdown and potentially recession” and his government is focused on keeping the economy strong by building trade relationships and supporting businesses.

The session starts with a speech from the throne today, which Eby says will outline the government’s key priorities of health care, housing, public safety and the economy.

However, Eby won’t be there for the start of the session.

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He’ll be travelling to Ottawa where Prime Minister Justin Trudeau is hosting a first ministers’ meeting to try to work out an agreement with the provinces and territories for increased funding for health care.

B.C. house leader Ravi Kahlon says the government has plans to introduce more than two dozen pieces of legislation during the session, which is set to conclude in May.

The government will table its budget at the end of the month.

This report by The Canadian Press was first published Feb. 6, 2023.

 

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Health

Canada Facing Difficult Battle with Mental Health Struggles

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Mental health is an important health issue that affects us all, and unfortunately, it’s an issue that is rarely discussed openly. According to the World Health Organization, approximately 20% of Canadians will experience a mental illness.

This makes mental health one of the most pressing issues facing Canadians today. Let’s take a closer look at why mental health is such an important issue in Canada.

 

The Need for Better Mental Health Care

In Canada, access to quality mental health care can be costly and difficult to obtain. Many Canadians are unaware of what services are available or how to access them due to a lack of public education about mental health.

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Additionally, there is still a stigma attached to seeking help for mental illness, which can make it difficult for those who need help to get it. As a result, many people cannot access the care they need in order to live happy and healthy lives.

This deficiency can have severe consequences; untreated mental illness can lead to increased risk for suicidal behavior, substance abuse, homelessness, unemployment, and other serious problems.

Additionally, research shows that early diagnosis and treatment can help prevent long-term complications and reduce the overall costs associated with mental health treatment.

Mental health services are especially important for marginalized populations such as Black Canadians, Latinx individuals, LGBTQ+ individuals, immigrants, and individuals with low incomes who have been underserved when it comes to healthcare access.

These communities often experience higher rates of poverty and discrimination which results in an even greater need for quality mental health services but also fewer resources available to them.

Given these facts, it is clear that there is a great urgency for better access to mental health services. To make meaningful progress towards addressing this issue we must first focus on breaking down barriers such as stigma against seeking help as well as lack of information about available services among vulnerable populations.

Furthermore, a greater investment must be made into training more providers so there are enough qualified professionals available who understand how to provide culturally competent care.

Particularly when working with traditionally underserved communities – while also ensuring accessibility through reduced cost or free options for those with limited insurance coverage or financial resources.

 

Mental Illness as an Invisible Disease

Unlike physical illnesses, mental illnesses are often invisible and difficult to diagnose. This makes it difficult for those living with a mental illness to get the help they need as well as understand what they are going through.

It also means that many people do not realize the severity of mental illnesses and the impact they have on the lives of those living with them until they experience it firsthand or hear stories from someone who has gone through similar struggles.

Mental illness affects more people than most realize. It can be difficult to comprehend the depth of mental health disorders, as they are often invisible and misunderstood. Mental illness is a disease, yet it can remain hidden while still having a profound effect on a person’s life.

 

The Impact on Society

Mental illness has far-reaching effects on society as a whole. Untreated mental illness can lead to substance abuse, homelessness, unemployment, and even suicide in some cases.

All of these have ripple effects throughout our communities, from increased crime rates and lower productivity at work to higher healthcare costs and fewer resources available for those in need, making this an issue that affects us all regardless of our personal situations.

We need to create a friendly environment in which those with invisible diseases feel comfortable sharing their stories and seeking help without fear of judgment or rejection.

Mental illness should not be ignored; rather it should be treated with respect and understanding just like any other type of medical condition.

By recognizing the reality of invisible diseases such as depression, anxiety, PTSD, bipolar disorder, and more we can begin to create a world where everyone gets the help they need regardless of whether or not their condition is visible on the surface.

With understanding comes empathy, and empathy leads us toward meaningful change for ourselves and our communities alike.

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Five things to know about health-care talks Tuesday between Trudeau, premiers

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OTTAWA — On Tuesday in Ottawa, Canada’s 13 premiers and Prime Minister Justin Trudeau will sit around the same table in person for the first time since COVID-19 hoping to find a path toward a new long-term health-care funding deal.

Both sides are optimistic a deal will emerge but there are some big divides to overcome, including how much more money Ottawa is willing to put on the table, and how much accountability the provinces are willing to put up in return.

The premiers have been asking for a new deal for more than two years. Trudeau kept punting until the COVID-19 crisis was largely over.

That time has come.

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Trudeau has been clear a deal is not going to be finished this week. But here’s a snapshot of how we got to this point, and what they’re going to be talking about.

Money, Money, Money, Money

This year Canada expected to transfer almost $88 billion to the provinces and territories for health, education, social supports and equalization. The Canada Health Transfer, or CHT, is $45.2 billion, or 51 per cent of that.

In their 2022-23 budgets, the provinces collectively forecast to spend $203.7 billion on health care. Ottawa’s transfer accounts for 22 per cent of that. The provinces want that increased to 35 per cent, which would mean $26 billion more this year alone.

“There’s been continual demands for an increase in the CHT although I’ve never seen quite as large a demand for an increase as this one,” said Gregory Marchildon, a professor emeritus at the Institute of Health Policy, Management and Evaluation at the University of Toronto.

Trudeau intends to put an offer on the table Tuesday. It will not be an immediate increase of $26 billion, but Ottawa has been silent on where it will land.

While it has existed in its current form only since 2004, some sort of federal health transfer dates from 1957, when Ottawa offered 50-50 funding for health care to provinces that agreed to provide public hospital services based on national standards.

It has evolved and changed at least five times since then, including splitting the federal share between cash and a transfer of tax points — when the federal government cut its income tax rates and the provinces could raise their own in exchange.

In 1995, then-finance minister Paul Martin, desperate to turn around Canada’s debt problems, slashed the health and social transfer by 20 per cent, followed by a 15 per cent cut in 1996. Some provinces have said their health systems have never recovered.

In 2004, a new deal was reached between the premiers and Martin, who by then was prime minister, to see the Canada Health Transfer increased six per cent a year for a decade.

The Conservatives under prime minister Stephen Harper kept that in place, but told the provinces that in 2017-18, the CHT increase would be based on a three-year average of economic growth, but with a minimum increase of at least three per cent.

Trudeau and the Liberals have maintained that.

With economic growth, the annual CHT increase has averaged five per cent since 2017-18.

Over the last 10 years, the CHT has increased 67 per cent, to $45 billion from about $27 billion in 2012-13.

An attempt in 2016 to negotiate a new CHT deal mostly failed, resulting in one-on-one agreements between Ottawa and the provinces and territories to share $11.5 billion over 10 years, beginning in 2017-18, to improve mental-health and home care.

Angling for Accountability

In the split jurisdictional world Canada’s governments live in, provinces are the ones who control health-care delivery. So for the most part, the federal government helps fund it and the provinces get to say how it’s spent.

The Canada Health Act, passed in 1984, sets out the guiding principles for recipients of the Canada Health Transfer, including that health-care systems must be universally accessible. Failing to abide by the principles can, and has, resulted in Ottawa clawing back some transfers.

Trudeau has made clear any increase to federal health transfers must be met with provincial accountability to show results. The federal government has been frustrated at the lack of accountability from provinces over transfers for health care made during COVID-19.

It is adamant that will not be the case with a new funding deal, and is looking at a combination of an annual increase to the CHT and separate deals to target specific problem areas, like health-care worker retention and training, access to family doctors, surgical backlogs, and data collection and sharing.

The 2017 deals on mental-health and home care will be a bit of a model. Those deals saw Ottawa promise $11.5 billion over 10 years for the two areas, but in exchange provinces had to agree to a common set of principles and goals, and to report results.

The Canadian Institute for Health Information was tapped to help collect and publish data. The most recent report in December is still laden with gaps and incomplete data. The reports note it will take time for the reporting to lead to change, and that provinces need to harmonize their data collection in order to better compare statistics across provincial lines.

Marchildon said one of the biggest problems for the federal government in demanding accountability is that measuring health outcomes is difficult, and hard targets are rare.

It’s all about the numbers

Of course, it’s difficult to measure progress if you’re not keeping track.

Data — or the lack of it — is a long-standing weakness of Canada’s federalized system, with 13 separate health-care systems working alongside one another but not necessarily in tandem.

In his first public overture to open negotiations with provinces on health funding in November, Health Minister Jean-Yves Duclos told provincial health ministers the federal government would increase the Canada Health Transfer if provinces agree to work together on a “world-class health data system for Canada.”

“It is the foundation for understanding what we’re doing, who’s receiving services, whether we’re making improvements,” said Kim McGrail, a professor with the University of British Columbia School of Population and Public Health.

McGrail was one of several experts the federal government tasked with reporting on what a “world-class health data system” would look like in Canada.

Gaps in Canada’s data tripped up the national health responses in dozens of different ways during the pandemic, from tracking the number of COVID-19 cases to reporting adverse effects from vaccines.

The same is true of tracking surgical backlogs and other information about how well, or not, the health system is working.

“Data informs every part of the way we think about health,” McGrail said, which includes the health of individual patients.

Canadians who move from one province to another can’t easily access their records because the technology isn’t compatible.

It’s a problem that exists even within provinces, as incompatible technology makes records inaccessible between hospitals and clinics.

“We need those technology systems to be able to talk to one another, to be able to to move data back and forth or to send messages back and forth in some way,” she said.

It’s an expensive problem to fix. Just last week, Nova Scotia government signed a $365-million contract to bring new electronic health-care records to the province, which may or may not be compatible with other provincial systems.

McGrail said investments will pay off if important information about the health of Canadians stops falling through the cracks.

The expert panel delivered a report last year that will likely serve as a road map for improving data sharing in Canada. It includes 31 recommendations, starting with provinces, territories and the federal government agreeing on a shared national vision for health data.

Ontario and Quebec have indicated a willingness to work with Ottawa on data, though other provinces have been less firm about it.

Aging gracefully

Provincial leaders have been able to agree with Ottawa on the need to reform Canada’s long-term care homes, though exactly how to accomplish that is still up for debate.

Duclos has said helping Canadians “age with dignity” is one of Ottawa’s priorities for a new health-care deal, and long-term care plays a major role in that.

So does home care, and the 2017 bilateral deals already began to advance improvements on that front.

Long-term care is an entirely different story.

The pandemic cast a glaring light on the dismal conditions in care homes across the country, when COVID-19 outbreaks led to thousands of deaths and inhumane living conditions for seniors. The military and the Red Cross were summoned to help.

In the early months of the pandemic, Canada had the worst record for COVID-19-related deaths in long-term care of the world’s wealthy countries.

Meanwhile, residents were isolated from the outside world and workers struggled to provide basic care and ensure dignity.

Experts and advocates say the problems long predate the pandemic, and have gone largely ignored until now.

“Given the devastation that we’ve seen in the COVID-19 pandemic and the impacts on our health-care system … we’re seeing this unprecedented moment where finally there’s some hope of collaboration,” said Dr. Amit Arya, a palliative care physician and founder of Doctors for Justice in Long-Term Care, which advocates for an overhaul of Ontario’s long-term care system.

Governments are now scrambling to improve the conditions, as the number of people who need specialized care grows every year and the number of workers willing to provide that care dwindles.

Several provinces have already announced plans to increase the number of hours of care residents receive per day and build new spaces for the growing number of seniors who are living longer with more serious cognitive and physical impairments.

The federal government created a $1 billion “safe long-term care fund” during the pandemic to help pay for immediate infection prevention and control measures to stop the spread of the virus.

The government also set aside $3 billion to help provinces bring homes in line with national standards for the design and operation of long-term care, though specific agreements with provinces haven’t yet been signed to deliver that money.

Those standards were publicly released last week but are unlikely to factor into the health-care talks.

Still, there is plenty of work that needs to be done if provinces have a hope of meeting the standards, especially when it comes to the workforce.

“I think we’re stepping into a crisis,” said Dr. Joseph Wong, the founder of Yee Hong Centre for Geriatric Care, the largest non-profit nursing home in the country.

He said Canada will need upwards of 100,000 new personal support workers to provide care over the next 10 to 15 years in order to provide adequate care to residents.

“It is a time bomb,” he said.

Essential Workers

The same could be said of the health system at large.

None of the lofty goals of the federal or provincial politicians will be possible if they don’t find a way to persuade workers to stay in hospitals, clinics and long-term care centres across Canada, said Linda Silas, president of the Canadian Federation of Nurses Unions.

“They don’t have the staff to do the job,” she said.

Staff shortages have been the common theme among some of the most serious issues underlying the public-health crisis in Canada.

Dozens of emergency rooms have been forced to close temporarily or reduce hours because there weren’t enough staff to treat urgent injuries and illnesses. The Canadian Medical Association estimates nearly five million Canadians don’t have a family doctor. And hundreds of thousands of Canadians are sitting on wait-lists for backlogged surgeries and diagnostic tests.

Health unions and professional associations want a national strategy to keep doctors, nurses and personal support workers in their jobs as well as train new staff to bolster their ranks.

Silas said after years of burnout and moral distress over not being able to care for their patients properly, nurses in particular have said, “I’ve had enough.”

Nurses in Ontario have also balked at a law limiting pay increases to one per cent a year.

Data from the Canadian Institute for Health Information shows that because of new graduates, the supply of nurses is still growing. However, many have chosen not to take full-time positions, and existing staff are increasingly eyeing early retirement, Silas said.

The heavier demands of the job since the pandemic, combined with fewer and fewer people to do the work, has created what even the federal health minister calls a crisis.

“We need to stop the bleed,” Silas said.

This report by The Canadian Press was first published Feb. 5, 2023.

 

Mia Rabson and Laura Osman, The Canadian Press

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