Disparities in Primary Health Care Experiences Among Canadians With

Disparities in Primary Health Care Experiences Among Canadians With
March 2012
Disparities in Primary Health Care
Experiences Among Canadians With
Ambulatory Care Sensitive Conditions
Supporting Factors
Influencing Health
Highlights
This report uses the 2008 Canadian Survey of Experiences With Primary
Health Care to fill an important gap in our knowledge of primary health
care for individuals who have ambulatory care sensitive conditions. An
examination of differences in access, use and appropriateness of care
according to income, geography, health conditions and sex reveals
the following:
•
Individuals with ambulatory care sensitive conditions in the lowest
income group, in rural areas or with multiple chronic conditions were
twice as likely to report that their last visit to an emergency department
was for a condition that they perceived as being treatable by their
primary health care provider.
•
Women with ambulatory care sensitive conditions were less likely than
men to report receiving all four recommended tests for chronic disease
monitoring, to have medication side effects explained or to be provided
with tools to self-manage their condition.
•
Compared with those in the highest income group, individuals with
ambulatory care sensitive conditions in the lowest income group were
less likely to report that their primary health care physician involved them
in clinical decisions or helped them make a treatment plan to manage
their conditions.
Federal Identity Program
Production of this report is made possible by financial contributions from Health Canada
and provincial and territorial governments. The views expressed herein do not necessarily
represent the views of Health Canada or any provincial or territorial government.
www.cihi.ca
Introduction
Ambulatory care sensitive conditions cause considerable illness, hospitalization and death among Canadians
and result in a high use of health care services. They affect an estimated 6.8 million Canadians age 20 to 74,
and they result in an estimated 95,000 hospitalizations and almost 13,000 deaths annually. Examples of
ambulatory care sensitive conditions are asthma, chronic obstructive pulmonary disease, diabetes, high blood
pressure and some heart diseases. These conditions can generally be managed with adequate primary health
care on an outpatient basis (see the Terminology box).1
The burden of ambulatory care sensitive conditions is not shared equally among all population groups. For
example, those who live in rural or disadvantaged areas experience a higher burden from these conditions,
compared with those living in urban and less disadvantaged areas. Disparities in hospitalization and mortality
rates by socio-economic and geographic conditions are greater than disparities in the underlying prevalence
of these conditions in the community (see Table B1 in Appendix B). This suggests that the treatment and
management of these conditions through primary health care or in acute care settings may not be as appropriate
or as effective for some groups of the population. This is supported by various studies that have related an
individual’s health and social conditions to use of primary health care and/or need for hospitalization.3–5
This report fills an important gap in our knowledge of primary health care for Canadians with ambulatory care
sensitive conditions. It aims to establish whether there are any systemic differences by socio-economic and
geographical conditions, health condition and sex in the access to, use of and appropriateness of primary
health care experiences for people diagnosed with ambulatory care sensitive conditions. The results will help
identify barriers to and difficulties in accessing primary health care services and assess whether all Canadians
are receiving an appropriate level of care according to their needs. The analyses presented in this Analysis in
Brief are based on information collected in the 2008 Canadian Survey of Experiences With Primary Health
Care (see Appendix A).
Terminology
Timely and effective primary health care can help prevent the onset of health complications and may prevent
hospitalizations associated with certain chronic medical conditions. These conditions are considered
ambulatory—that is, they can be managed with adequate primary health care on an outpatient basis and are
thus termed “ambulatory care sensitive conditions.”1, 2 Based on the information available through the 2008
Canadian Survey of Experiences With Primary Health Care and other studies, the following were considered
ambulatory care sensitive conditions in this study: asthma, chronic obstructive pulmonary disease (including
emphysema), diabetes, high blood pressure and heart disease.6 While many studies have focused on
hospitalizations for ambulatory care sensitive conditions, this study examines the experiences of those being
treated for these conditions through primary health care services, such as general practices, community health
centres and outpatient services.
2
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
Methods
The 2008 Canadian Survey of Experiences With Primary Health Care was used to report on primary health
care experiences, including accessibility, utilization, clinical management and support for self-management
of chronic conditions. This survey was co-sponsored by the Canadian Institute for Health Information (CIHI)
and the Health Council of Canada and was conducted by Statistics Canada. The results are based on the
population age 18 and older, living in private dwellings and reporting having been diagnosed with an
ambulatory care sensitive condition (sample size of 4,138, equating to an estimated 7.9 million Canadians).
Descriptive analysis was undertaken to estimate the prevalence of selected primary health care measures
across different population groups according to sex, adjusted household income, rural or urban residence and
presence of multiple chronic conditions. Individuals with multiple chronic conditions were selected as a group for
analysis to identify whether experiences with primary health care within the population that has been diagnosed
with an ambulatory care sensitive condition vary according to need. Multiple logistic regression analysis was
also undertaken to determine whether differences across population groups persisted after controlling for other
characteristics. Refer to Appendix A for further details on the survey and analytical methods.
Profile and Highlights of Primary Health Care Experiences
for Canadians With Ambulatory Care Sensitive Conditions
This analysis uses the Canadian Survey of Experiences With Primary Health Care to examine factors associated
with primary health care experiences. According to this survey, in 2008, there were an estimated 7.9 million
individuals age 18 and older, representing almost one in three adults (31%), living with an ambulatory care
sensitive condition in Canada. Of these, two-thirds reported having high blood pressure (66%) and 18% reported
heart disease, while diabetes and asthma were reported by 25% and 27%, respectively; chronic obstructive
pulmonary disease (including emphysema) was reported by 6% of individuals with ambulatory care
sensitive conditions.
More than one-third (39%) of individuals with ambulatory care sensitive conditions reported having been
diagnosed with only one condition and just under one-third (30%) had three or more chronic conditions that
included at least one ambulatory care sensitive condition (the other chronic conditions could include arthritis,
cancer, stroke, mood disorders including depression and/or chronic pain).
Of those with an ambulatory care sensitive condition, almost 9 in 10 (87%) were age 18 to 74 (16% were
age 18 to 44 and 51% were age 45 to 64).
Most adults with ambulatory care sensitive conditions reported having a place to go when they were sick or
needed health advice (96%) and having a regular medical doctor (94%). In the previous 12 months, most
(87% to 89%) had had no difficulties obtaining needed routine/ongoing care or health information/advice, and
the majority reported positive experiences interacting with their providers (56% to 70%). Almost three-quarters
(74%) of those with ambulatory care sensitive conditions reported receiving coordinated care from other doctors
and places when needed (see Table 2 and Appendix C).
Despite almost all reporting a regular medical doctor and a regular place of care, one in five (21%) of those
with ambulatory care sensitive conditions did not report contacting a family physician in the previous 12 months.
More than 1 in 10 (12%) reported that their last visit to an emergency department was for a condition that they
perceived as being treatable by their usual provider of primary health care, and almost two-thirds (61%) did not
have access to after-hours care. Even though they rated their interactions with providers highly, many were not
receiving the recommended tests to monitor their chronic conditions (49%), appropriate management of their
medications (40% to 42%) or support to self-manage their chronic conditions, such as receiving help to make a
treatment plan or receiving a written list of things to do to improve their health (61% and 69%, respectively; see
tables 1 and 2 and Appendix C).
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
3
Results
The results in this report will highlight the barriers to and difficulties in accessing and receiving appropriate
primary health care for Canadians with ambulatory care sensitive conditions, by examining differences
according to sex, household income, rural or urban residence and presence of multiple chronic conditions.
Twenty primary health care measures were examined in the analyses; the results presented here are for
those measures where the largest population differences were observed:
•
Access to and use of primary health care services; and
•
Appropriateness of care, as measured by clinical management and support for the self-management
of chronic conditions.
For further information on each of the measures examined, see appendices C and D.
Access to and Use of Primary Health Care Services
Regular access to and use of primary health care is influenced by a range of factors, and some population
groups experience greater difficulties receiving the services they require. The results that follow show that
population differences exist in the use of primary health care services (as measured by visits to a family
physician, use of emergency departments for conditions perceived as being treatable by primary health care
physicians and having access to after-hours services) within the population diagnosed with ambulatory care
sensitive conditions.
Among adults with ambulatory care sensitive conditions:
Low-income individuals were higher users of primary health care and were more likely to visit
emergency departments for conditions perceived as being treatable by their primary health
care provider.
•
Individuals in the lowest income group were higher users of primary health care and had on average 6.2
annual contacts with a family physician, compared with 3.4 contacts, on average, for those in the highest
income group.
•
Individuals in the lowest income group were also more likely than those in the highest income group to
report that their last visit to an emergency department was for a condition that they perceived as being
treatable by their usual provider of primary health care (19% versus 10%). They were also more likely to
report not having access to after-hours care (78% versus 60%; see Table 1).
Rural residents and those with multiple chronic conditions were more likely to visit emergency
departments for conditions perceived as being treatable by their primary health care provider.
•
Rural residents were more likely than urban residents to report that their last visit to an emergency
department was for a condition that they perceived as being treatable by their usual provider of primary
health care (23% and 9%, respectively). Rural residents were also more likely than urban residents to
report not having access to after-hours care (69% versus 58%; see Table 1).
•
Compared to those with a single ambulatory care sensitive condition, individuals with three or more chronic
conditions were also more likely to report that their last visit to an emergency department was for a
condition that they perceived as being treatable by their usual provider of primary health care (16% versus
8%). Members of this group were also more likely to have contacted their family physician in the previous
year and were high users of primary health care—they had, on average, 6.5 annual contacts with a family
physician, compared with 2.6 contacts, on average, for those with a single ambulatory care
sensitive condition.
4
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
When controlling for factors such as age, sex, rural or urban residence, presence of multiple chronic conditions
and self-perceived health status in these measures of access to primary health care, many of the differences
observed in the bivariate analysis continued to be significant. In particular, when adjusting for the other factors
listed, having three or more chronic conditions appeared consistently as a significant predictor for many of
these access measures: having no contact with a family physician in the previous 12 months (odds of 0.5),
having a high frequency of contact (four or more contacts in the previous year; odds of 2.6) and visiting an
emergency department for a condition perceived as being treatable by the usual provider of primary health
care (odds of 2.3). Rural residence appeared as a significant factor only in the models for emergency
department visits and after-hours access (odds of 3.0 and 1.5, respectively), and low income was significant
for after-hours access only (odds of 2.1; see Table D1 in Appendix D).
The association between higher need and higher use of primary health care that is evident from this self-reported
survey is consistent with data registered by primary health care providers in their electronic medical record
systems. According to CIHI’s Primary Health Care Voluntary Reporting System, most patients with three or more
ambulatory care sensitive conditions had at least one visit with their primary health care provider in the last year
(98%), and 88% had four or more visits; this compares with 93% and 62% for patients with only one ambulatory
care sensitive condition. (See CIHI’s Primary Health Care Voluntary Reporting System for further information.)
Table 1: Reported Experiences With Access to and Use of Primary Health Care for Those With
Ambulatory Care Sensitive Conditions, Age 18 and Older, 2008
Average Number of
No Contact With
Contacts With
Family Physician in Family Physician in
Previous 12 Months Previous 12 Months
(%)
(#)
Overall
Last Visit to the
Emergency Department
Was for a Condition
Perceived as Being
Treatable by Usual
Provider of Health Care
(%)
No After-Hours
Access
(%)
20.8
4.1
11.8
61.0
Male†
22.2
3.9
11.3
61.5
Female
19.5
4.3
12.4
60.5
26.2
2.6
8.0
57.3
11.8*
6.5*
16.2*
63.5
3.4
10.1E
60.3
Sex
Number of Chronic Conditions
Single Ambulatory
Care Sensitive
Condition†
Three or More
Chronic
Conditions
Household Income (Adjusted for Household Size)
Highest Income†
14.9E
E
E
17.1
6.2 *
19.1 *
78.1*
Urban†
21.1
4.3
8.8
58.3
Rural
20.2
3.4*
23.0*
69.3*
Lowest Income
Geography
Notes
* Value is significantly different from reference group at p<0.05.
† Reference group.
E Interpret with caution (coefficient of variation between 16.6% and 33.3%).
Source
Canadian Survey of Experiences With Primary Health Care, 2008, Canadian Institute for Health Information, Health Council of
Canada and Statistics Canada.
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
5
Appropriateness of Primary Health Care Received
Not all Canadians with ambulatory care sensitive conditions receive an appropriate level of care in terms of the
clinical management of their conditions or support from their health care provider to independently manage
their conditions. Studies have shown that, for those with chronic illness, allowing enough time with a doctor,
having the doctor elicit concerns, patient-centred decision-making, whole-person care and satisfaction with
care are associated with patients actively engaging in health behaviours that will maintain or improve their
health.7 The results that follow show that population differences exist for many of these primary health care
experiences for Canadians with ambulatory care sensitive conditions. The largest disparities were seen
between the sexes and between the lowest and highest income groups.
Among adults with ambulatory care sensitive conditions:
Women were less likely to receive recommended tests for chronic disease monitoring or tools to
self-manage their conditions.
•
Females diagnosed with heart disease, diabetes or high blood pressure were less likely than their male
counterparts to report receiving all four recommended tests for disease monitoring—blood pressure, blood
cholesterol, body weight and blood sugar measurements—in the previous 12 months (46% and 56%,
respectively; see Table 2). Females who received regular or ongoing prescription medications were also
less likely to report that their doctors usually or always explained the side effects of medications (56%
versus 65%; see Table C2 in Appendix C).
•
Females were also more likely than males to report generally not or almost never being asked to talk about
their goals in caring for their condition, receiving help from their primary health care provider to make a
treatment plan, receiving a written list of things to do to improve their health or being shown ways to take
care of themselves (see Table 2).
These patterns remained significant for all of these measures when adjusting for other factors, such as age,
household income, rural or urban residence, presence of multiple chronic conditions and self-perceived health
status (see Table D3 in Appendix D).
Lower-income individuals were less likely to report that their physician involved them in clinical
decisions or helped them make a treatment plan to manage their conditions.
•
Individuals in the lowest income group were less likely to report that their primary health care physician
usually or always involved them in clinical decisions, compared with those in the highest income group
(47% versus 66%).
•
Individuals in the lowest income group were also more likely to report generally not or almost never
receiving help from their primary health care provider to make a treatment plan (71% versus 54%; see
Table 2).
When adjusting for other factors (age, sex, rural or urban residence, presence of multiple chronic conditions
and self-perceived health status), these measure continued to remain significant (odds of 0.4 and 1.8,
respectively; see tables D2 and D3 in Appendix D).
While females and those in the lowest income group may not be experiencing an optimal level of care to
manage their conditions, those in higher need, as measured by having three or more chronic conditions,
reported more positive experiences, both in the clinical management of their conditions and in support to selfmanage their chronic conditions—specifically in discussing goals in caring for their condition and receiving a
written list of things to do to improve their health from their primary health care physician (Table 2). These
differences persisted when controlling for other factors (see Table D3 in Appendix D).
6
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
Table 2: Reported Experiences With Disease Monitoring and Self-Management Support for Those With Ambulatory
Care Sensitive Conditions, Age 18 and Older, 2008
Patients
In Previous 12 Months, the Primary Health Care Physician
Received All
Generally Did Not or Almost Never
Four Monitoring Primary Health
Tests (for Those Care Physician
Helped Make a
Showed Patients
Diagnosed With
Usually or
Asked to Talk
Treatment Plan
Gave Patients a
What to Do to
Heart Disease, Always Involved About Patients’
That Patients
Written List of
Take Care of
High Blood
Patients in
Goals in Caring Could Implement Things to Do to
Themselves to
Pressure or
Clinical
for Their Chronic
in Their Daily
Improve Their
Influence Their
Diabetes)
Decisions
Conditions
Lives
Health
Condition
(%)
(%)
(%)
(%)
(%)
(%)
Overall
50.9
56.2
45.5
61.4
69.0
34.9
55.8
55.2
42.1
56.2
63.5
29.3
45.9*
57.2
48.9*
66.7*
74.6*
40.5*
45.1
52.9
49.6
65.7
74.3
34.7
57.8*
62.3*
37.7*
58.9
63.3*
31.1
Sex
Male†
Female
Number of Chronic Conditions
Single
Ambulatory Care
Sensitive
Condition†
Three or More
Chronic
Conditions
Household Income (Adjusted for Household Size)
Highest Income†
48.3
65.8
46.2
54.2
69.9
31.2
Lowest Income
44.4
46.7*
46.1
71.0*
69.3
42.4
Geography
Urban†
51.0
57.1
46.5
61.2
70.4
34.4
Rural
46.7
53.0
43.5
63.2
64.9
38.6
Notes
* Value is significantly different from reference group at p<0.05.
† Reference group.
Source
Canadian Survey of Experiences With Primary Health Care, 2008, Canadian Institute for Health Information, Health Council of Canada and
Statistics Canada.
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
7
Discussion
The results presented in this analysis highlight that not all Canadians are receiving optimal access to primary
health care services or an appropriate level of care according to their needs. The findings confirm that primary
health care management of ambulatory care sensitive conditions is influenced by an individual’s sex,
household income, and geographic and health factors.
Individuals in the lowest income group had a higher rate of using emergency departments for conditions that
they perceived as being treatable by their primary health care provider and experienced a lower availability of
after-hours care than those in the highest income group. Despite being higher users of primary health care
services than those in the highest income group, they were less likely to report that their primary health care
physician routinely involved them in clinical decisions or helped them make a treatment plan. This finding is
consistent with other Canadian studies that show that low-income individuals have higher use of primary health
care services and higher rates of hospitalizations for chronic conditions, and that low income is a driver of
primary health care use and/or need for hospitalization.3–5
Living in rural areas was associated with a lower availability of after-hours care and a higher rate of using
emergency departments for conditions patients perceived as being treatable through primary health care.
This finding is consistent with other research and may reflect the role that small rural hospitals play in
delivering primary health care services.8 Physicians in rural areas also tend to have multiple primary health
care locations, including emergency departments as primary health care offices. This may result in rural
physicians spending fewer hours in their clinics and being less available for walk-in care.9
In this analysis, those in higher need—as measured by having three or more chronic conditions—were higher
users of primary health care and were more likely to visit emergency departments for conditions that they
perceived as being treatable by their primary health care provider than those living with a single ambulatory
care sensitive condition. They were also more likely to report more positive experiences in the clinical
management of their conditions (such as receiving the recommended tests for chronic disease monitoring
and being involved in clinical decisions about their health) and receiving support to independently manage
their chronic condition. This suggests that those with multiple chronic conditions reported receiving a higher
level of care—potentially reflecting their higher need for care. Males were also more likely than females to
experience this higher level of clinical care.
Reducing hospitalizations and emergency department visits for all those with ambulatory care sensitive
conditions, by providing more timely and accessible primary health care, has the potential to result in
considerable savings to the health care system. The estimated average cost, excluding physician costs,
of an acute care stay for an ambulatory care sensitive condition was almost $5,700, and that for an emergency
department visit was approximately $280, in 2009–2010 (for 20- to 74-year-olds; see Table B2 in Appendix B).
This suggests that every 10% reduction in hospitalizations equates to around $34 million in savings in hospital
care each year.
The results presented in this Analysis in Brief highlight that there is considerable scope for further gains in the
use of and appropriateness of primary health care for all Canadians and that the primary health care sector
has an important role to play in ensuring equitable access to and quality of clinical care. These findings may
also shed further light on why Canada compares unfavorably with 10 other countries in The Commonwealth
Fund’s survey on many of the primary health care measures presented in this Analysis in Brief, particularly in
terms of after-hours access, emergency department use, availability and duplication of test results and access
to a doctor or nurse when sick.10
8
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
Strengthening Primary Health Care in Canada
The findings of this analysis suggest that more can be done in Canada to ensure that all Canadians can
access the primary health care services they require and to strengthen programs that ensure quality of clinical
delivery and support for self-management of chronic conditions.
A number of strategies and models have been introduced to strengthen primary health care in Canada and
internationally, which could influence health disparities. These focus on the quality of patient–clinician
interactions, care delivery and records management, as well as supporting patients to self-manage their
chronic conditions as a means of supplementing health care services and improving individuals’ sense of
control over their condition.6, 11, 12 For example, the World Health Organization suggests several ways of
addressing gendered disparities in health system access, including training health system staff on gendered
differences in patient needs, underpinned by sustained financial and human resources.13 Nurse-practitioner-led
clinics, which provide an interdisciplinary and comprehensive approach to primary health care, are also being
implemented in Canada and Europe and have been shown to improve health outcomes.14, 15
A number of studies have also identified specific activities to address the shortfalls in high-quality primary health
care, such as the implementation of electronic health records, electronic monitoring and tele-monitoring systems,
the provision of financial incentives for primary health care providers and the expansion of interprofessional
collaborative teams.6, 16 Case studies of 10 electronic health record systems in Europe indicated a net benefit
to the health care system 6 to 11 years after implementation, with the benefits tending to be in the reduction
of duplicate procedures, improved timeliness and improved health information to support decision-makers.17
A review of evaluations from financial incentive programs in the United Kingdom and the United States yielded
mixed results, with few significant impacts reported.18
A preliminary scan of activities at the health region level suggests that there are a number of initiatives
currently under way in Canada that address disparities in access to primary health care for vulnerable groups,
such as those outlined in this Analysis in Brief. For instance, information and communication technologies are
being used in some regions to reduce barriers of time and distance for Canadians in rural and northern areas
by helping them connect remotely with staff in hospitals from urban areas.19 Some rural and northern areas are
also reorienting service delivery, employing nurse-led clinics to deliver primary health care in underserviced
areas.20 Beyond service delivery, initiatives are in place to address shortages in health human resources
through training and retention efforts for underserviced rural and isolated areas.21 Initiatives are also under way
to address financial barriers that low-income populations face to maintain health and when accessing services.
In some areas, programs are being implemented to provide low-income populations with subsidies for
prescription drugs, food supplements, prostheses and other equipment necessary for the management of
certain conditions,22 transportation options to medical appointments and child care services.23
An essential part of developing programs to address health inequalities is having in place effective monitoring
practices to ascertain whether new and existing programs are having an impact on reducing disparities.24
Collecting and reporting on the demographic and socio-economic information of patients and linking this
information to medical information could better support decision-makers in evaluating the success of programs
aimed at mitigating disparities in health system experiences. Further exploration of intervention options in
primary health care settings and the impacts of these initiatives on vulnerable groups and health disparities
could also contribute to the knowledge base.
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
9
Conclusion
This Analysis in Brief has shown that population differences exist in access to, use of and appropriateness of
primary health care for Canadians with ambulatory care sensitive conditions. It highlights that there is room for
improvement in providing more equitable access to and use of primary health care, clinical management of
chronic conditions and support for patients to self-manage their conditions. While many of these factors can be
addressed by the primary health care system, such as by providing more timely, accessible, comprehensive
and coordinated health care, other factors lie beyond primary health care and are influenced by the wider
social, economic, environmental and health system contexts. Further qualitative and quantitative research
is required to more fully understand and address these factors and to further explore the impact of primary
health care initiatives on disadvantaged populations. Building better information has the potential to ensure
accountable, efficient and sustainable delivery of accessible health care for Canadians, foster the spread of
best practices in primary health care that reduce health inequalities and promote the health of all Canadians.
10
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
Acknowledgements
The Canadian Population Health Initiative (CPHI), a part of the Canadian Institute for Health Information (CIHI)
acknowledges with appreciation the contributions of many individuals and organizations to the development of
this Analysis in Brief. In particular, we would like to express our appreciation to the following individuals who
peer-reviewed the Analysis in Brief and provided feedback to improve its content:
Dr. Rick Glazier, MD, University of Western Ontario; MPH, Johns Hopkins University School of Public Health
Dr. Michel Grignon, PhD, Director, Centre for Health Economics and Policy Analysis, and Associate
Professor, McMaster University
CPHI also thanks CIHI’s Board of Directors and the CPHI Council for their support and guidance in setting the
strategic direction of this Analysis in Brief.
A number of people and teams were involved in the development of this Analysis in Brief. In particular, we wish
to acknowledge the CPHI staff members who made up the core project team: Anne Markhauser, Yiwen Chen,
Diana Ridgeway and Sushma Mathur. We would also like to acknowledge and thank the CPHI/CIHI staff
members who provided generous and ongoing support and assistance to the core team throughout the
production of this Analysis in Brief: Lisa Corscadden, Sadiq Raji, Mélanie Josée Davidson, Catherine Fraser,
Andrew Clairmont, Jean Harvey, Jeremy Veillard and staff from the Primary Health Care Information and
Patient Costing teams.
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
11
Appendix A: Data Source, Definitions and Methods
Data Source
The 2008 Canadian Survey of Experiences With Primary Health Care (CSE-PHC), a subsample of the
Canadian Community Health Survey, was the primary data source used in this project. The CSE-PHC was
co-sponsored by CIHI and the Health Council of Canada and conducted by Statistics Canada. The survey
collected information on the use of, access to and experiences with primary health care services, as well as
primary health care support for the self-management of chronic conditions. Information was collected from
individuals living in private dwellings in the 10 provinces and 3 territories, excluding residents on Indian
Reserves or Crown lands and in institutions, full-time members of the Canadian Forces and residents of certain
remote regions. Further details about the CSE-PHC’s design and sampling methodology are available from
Statistics Canada.
Study Population
Adults age 18 and older who reported having been diagnosed with an ambulatory care sensitive condition
that lasted, or was expected to last, six months or more were included in the study population (n = 4,138).
The ambulatory care sensitive conditions included in this analysis were asthma, chronic obstructive pulmonary
disease (including emphysema), diabetes, high blood pressure and heart disease. The inclusion of these
conditions is consistent with other studies that have examined populations with ambulatory care sensitive
conditions; however, there are slight variations in the conditions included due to the information collected on
health conditions in the CSE-PHC.6 Analyses of ambulatory care sensitive conditions are commonly restricted
to the population age younger than 75; however, in this analysis, those age 75 and older were included due to
the small sample of adults in the CSE-PHC who reported having an ambulatory care sensitive condition.
The results presented in this analysis include only individuals with self-reported diagnosed ambulatory care
sensitive conditions; however, this information was not independently clinically validated, nor was the severity
of the condition evaluated. Given that undiagnosed chronic conditions, such as high blood pressure and
diabetes, are more likely to occur among the socio-economically disadvantaged, there is the potential for
under-reporting in this analysis, particularly among the more disadvantaged groups.25
Populations Compared in the Analyses
Twenty primary health care measures were examined across different population groups by sex, adjusted
household income, rural or urban residence and presence of multiple chronic conditions.
Income Groups
Income quintiles were derived from gross household income that was adjusted for household size. For
example, an annual household income of less than $25,000 for a two-person household or less than $41,071
for a five-person household was categorized as falling within the lowest income quintile. Records with missing
income were not included in the bivariate analysis but were included separately as an income category in the
multiple logistic regression analysis (missing income category is not reported in the results).
Rural or Urban Residence
Urban and rural residence was defined using Statistics Canada’s statistical area classification. Residents of
census metropolitan areas or census agglomerations were considered urban, while residents of all other areas
(strong, moderate, weak and no metropolitan influence zones, as well as the territories) were classified as rural.
12
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
Multiple Chronic Conditions
To evaluate whether experiences with primary health care within the population that has been diagnosed with
an ambulatory care sensitive condition vary according to need, the study population was grouped according to
the number of chronic conditions.
•
One ambulatory care sensitive condition: individuals who reported being diagnosed with only one
ambulatory care sensitive condition—that is, asthma, chronic obstructive pulmonary disease (including
emphysema), diabetes, high blood pressure or heart disease—and no other chronic conditions.
•
Three or more chronic conditions: individuals who reported having three or more chronic conditions,
including at least one ambulatory care sensitive condition. Other chronic conditions could also include
arthritis, cancer, stroke, mood disorders (including depression) and/or chronic pain.
Statistical Methods
Descriptive analyses were undertaken using SAS software (version 9.1) to estimate the prevalence of
demographic, socio-economic, geographical, health condition and primary health care measures. The
calculation of the prevalence estimates excludes cases with “don’t know,” “not stated,” “refusal” and missing
responses. These cases generally account for less than 2.5% of respondents, except for the after-hours
access question, where 14% of respondents did not know whether their primary health care provider had afterhours access.
Multiple logistic regression analysis was used to assess whether subgroup differences persisted in primary
health care experiences after controlling for age, sex, household income (adjusted for household size), rural or
urban residence, presence of multiple chronic conditions and self-perceived health status. Only primary health
care measures that were significantly different for the subgroups studied in the bivariate analyses were
considered (see Appendix D for further details).
The bootstrap technique, which takes into account the complex survey design, was used to estimate variance
and 95% confidence intervals.
Study Limitations
There are several limitations to this study. The study examines individuals’ reported experiences with primary
health care services and does not measure the quality of the care received, the types of services received,
whether sufficient care was received according to individual needs or health care choices. It is also unknown
whether individuals reported experiences with their primary health care provider related to the management
of their ambulatory care sensitive condition or to other conditions. The inability to link primary health care
experiences to emergency department visits, hospitalizations or mortality for individuals with ambulatory care
sensitive conditions is a major limitation of this study. Such information would provide greater insight into the
relationship between primary health care use and adverse health outcomes. Despite these limitations, this
study provides valuable new information on reported experiences with primary health care for those with
diagnosed ambulatory care sensitive conditions and the role of factors such as sex, household income,
geography and the presence of multiple chronic conditions.
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
13
Appendix B: Health and Economic Burden of Ambulatory
Care Sensitive Conditions
Table B1: Age-Standardized Prevalence, Hospitalization and Mortality Rates for
Those With Ambulatory Care Sensitive Conditions, Age 20 to 74, 2008
Prevalence
(%)
Overall Ambulatory
Care Sensitive
Conditions
Hospitalization Rate
(per 100,000
Population)
Mortality Rate
(per 100,000
Population)
25
390
52
Male†
26
438
72
Female
24
345*
33*
Relative Difference
(Females/Males)
0.9
0.8
0.5
Sex
Area-Level Socio-Economic Status (SES)‡
Highest SES†
21
206
N/A§
Lowest SES
29*
389*
N/A
Relative Difference
(Low/High Area SES)
1.4
1.9
Urban†
25
349
Rural
27
541*
Relative Difference
(Rural/Urban)
1.1
1.5
Geography
N/A
§
N/A
Notes
*
Value is significantly different from reference group at p<0.05.
†
Reference group.
‡
The Institut national de santé publique du Québec’s Deprivation Index was used as a summary measure
of area-level socio-economic status. It is based on a range of socio-economic variables from the 2006
26
census, including education, employment, income and family structure. Quebec data was excluded from
the area-level socio-economic status analysis because of the lack of six-digit postal codes on Quebec’s
hospitalization records in the Discharge Abstract Database, which are necessary to identify a patient’s
place of residence.
§
Mortality rates by area-level socio-economic status or geography are not available from Statistics
Canada’s Vital Statistics Database. However, studies have documented that death rates among those
living in less-populated areas and in the most disadvantaged areas are 25% to 50% higher than those
27–29
in other areas.
N/A Not available.
All estimates have been age-standardized to the 1991 Canadian population.
The definition of ambulatory care sensitive conditions differs slightly between prevalence, hospitalization and
mortality data because of the information collected in the Canadian Survey of Experiences With Primary Health
Care. For hospitalization rates, the following conditions were included: angina, asthma, chronic obstructive
pulmonary diseases, diabetes, epilepsy, heart failure and pulmonary edema, and hypertension. For mortality
rates, other acute/chronic ischemic heart disease was included rather than angina, and epilepsy was not
included, as these causes of death were not available from Statistics Canada’s Vital Statistics Database.
Sources
Prevalence: Canadian Survey of Experiences With Primary Health Care, 2008, Canadian Institute for Health
Information, Health Council of Canada and Statistics Canada.
Hospitalization rates: Deprivation Index, 2006, Institute national de santé publique du Québec; Discharge
Abstract Database, 2008–2009, Canadian Institute for Health Information.
Mortality rates: Vital Statistics Database, 2008, Statistics Canada.
14
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
Table B2: Emergency Department and Acute Care Inpatient Cost per Visit for
Patients Presenting With Ambulatory Care Sensitive Conditions,
Age 20 to 74, 2009–2010
Estimated Average
Emergency
Department
Cost per Visit ($)
Weighted Average for All Ambulatory Care
Sensitive Conditions Combined
Estimated Average
Acute Care Inpatient
Cost per Visit ($)
281
5,679
Angina
504
3,854
Asthma
205
2,938
Chronic Obstructive Pulmonary Disease
275
6,514
Diabetes
284
4,745
Epilepsy
311
5,511
Heart Failure and Pulmonary Edema
430
7,258
Hypertension
298
3,670
Individual Ambulatory Care Sensitive Conditions
Notes
Cost estimates represent the estimated average cost of services provided to the average patient. They include
the costs incurred by the hospital in providing services and exclude physician fees.
The estimated average cost for services provided to a hospital patient is generated by multiplying the cost per
weighted case by the average Resource Intensity Weight for each patient group. Cost estimates for inpatients
are calculated using typical cases only (see the Patient Cost Estimator for further information).
Estimated average emergency department visit cost is calculated excluding patients in Saskatchewan, Quebec,
New Brunswick, Newfoundland and Labrador, the Northwest Territories and Nunavut.
Estimated average acute care inpatient cost is calculated excluding patients in Quebec.
Inpatient cases were grouped using the Case Mix Group+ 2011 grouping methodology, Canadian Institute for
Health Information.
Emergency patient cases were grouped using the Comprehensive Ambulatory Classification System, 2011,
Canadian Institute for Health Information.
Sources
Emergency patients: Canadian MIS Database, 2008–2009 and 2009–2010, and National Ambulatory Care
Reporting System, 2009–2010, Canadian Institute for Health Information; Alberta Ambulatory Care Database,
2008–2009, Alberta Health and Wellness.
Inpatients: Canadian MIS Database, 2009–2010, and Discharge Abstract Database, 2009–2010, Canadian
Institute for Health Information.
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
15
Appendix C: Prevalence Estimates of Selected
Experiences With Primary Health Care for Individuals
With Ambulatory Care Sensitive Conditions
Table C1: Prevalence of Reported Primary Health Care Access Measures for Those
With Ambulatory Care Sensitive Conditions, Age 18 and Older, 2008
Have a Regular
Medical Doctor
(%)
Overall
Difficulties Obtaining Difficulties Obtaining
Routine/Ongoing
Health Information or
Care in Previous
Advice in Previous
12 Months
12 Months
(%)
(%)
93.9
10.9
13.3
Male†
94.2
10.3E
11.9
Female
93.5
11.5
14.8
Single Ambulatory
Care Sensitive
Condition†
93.4
7.9E
7.6E
Three or More
Chronic Conditions
96.1
12.6E
17.2*
Sex
Number of Chronic Conditions
Household Income (Adjusted for Household Size)
Highest Income†
93.7
17.9
E
18.4E
Lowest Income
93.2
14.7E
19.9E
94.0
11.7
14.2
92.2
E
10.2*
Geography
Urban†
Rural
10.2
Notes
* Value is significantly different from reference group at p<0.05.
† Reference group.
E Interpret with caution (coefficient of variation between 16.6% and 33.3%).
Source
Canadian Survey of Experiences With Primary Health Care, 2008, Canadian Institute for Health Information,
Health Council of Canada and Statistics Canada.
16
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
Table C2: Prevalence of Reported Experiences Interacting With Primary Health Care Provider for Those With
Ambulatory Care Sensitive Conditions, Age 18 and Older, 2008
In Previous 12 Months, the Primary Health Care Physician Usually or Always
Allowed
Patients
Enough Time
to Discuss
Their
Concerns
(%)
Took Patients’
Health
Concerns Very
Seriously
(%)
Explained Test
Results in a
Way Patients
Could
Understand
(%)
Coordinated
Care From
Other Doctors
and Places
When Needed
(%)
64.9
70.3
62.9
74.2
Male†
65.0
70.4
63.6
Female
64.8
70.3
Overall
Reviewed and
Discussed
Prescription
‡
Medications
(%)
Did Not Have Test
Results Available, Had
Tests Repeated
Unnecessarily or Gave
Conflicting Information
(%)
60.2
58.1
5.4
75.1
64.6
59.9
4.2
62.2
73.3
56.1*
56.3
6.6
Explained the Side
Effects of
Prescription
‡
Medications
(%)
Sex
Number of Chronic Conditions
Single
Ambulatory
Care Sensitive
Condition†
59.1
67.1
59.5
67.7
56.8
60.1
3.6E
Three or More
Chronic
Conditions
74.1*
78.0*
70.3*
81.8*
61.5
59.6
7.9*
Household Income (Adjusted for Household Size)
Highest
Income†
70.2
75.5
65.1
76.2
65.4
53.2
3.2
Lowest
Income
60.2
66.7
56.2
68.2
61.5
53.0
E
9.5 *
Urban†
64.3
70.6
63.4
74.6
57.5
57.2
5.2
Rural
66.2
71.8
62.0
71.1
62.6
59.1
6.0E
E
Geography
Notes
* Value is significantly different from reference group at p<0.05.
† Reference group.
‡ These measures relate only to respondents who received regular or ongoing prescription medications. The prevalence estimates exclude
respondents with a long-term use of the same medication, as these questions were not asked during the survey (28% and 23% of
respondents, respectively).
E Interpret with caution (coefficient of variation between 16.6% and 33.3%).
Source
Canadian Survey of Experiences With Primary Health Care, 2008, Canadian Institute for Health Information, Health Council of Canada and
Statistics Canada.
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
17
Appendix D: Adjusted Odds of Selected Primary Health Care
Measures and Characteristics, for Individuals With Ambulatory
Care Sensitive Conditions
Table D1: Adjusted Odds of Reported Primary Health Care Access Measures for Those With
Ambulatory Care Sensitive Conditions, Age 18 and Older, 2008
Four or More
Last Visit to Emergency
No Contact With
Contacts With
Department Was for a
Family Physician Family Physician Condition Perceived as
in Previous
in Previous
Being Treatable by Usual
12 Months
12 Months
Provider of Health Care
No After-Hours
Access
Sex
Male†
1.00
1.00
1.00
1.00
Female
0.84
1.30*
0.98
0.91
18–44†
1.00
1.00
1.00
1.00
45–64
0.52*
1.39
0.65
0.77
65+
0.63*
1.70*
0.36*
0.78
Age
Household Income (Adjusted for Household Size)
High Income†
1.00
1.00
1.00
1.00
Middle Income
2.08*
0.92
1.13
0.94
1.64
1.20
1.72
2.05*
Low Income
Geography
Urban†
1.00
1.00
1.00
1.00
Rural
1.00
0.79
2.98*
1.52*
Number of Chronic Conditions
Single
Ambulatory
Care Sensitive
Condition†
1.00
1.00
1.00
1.00
Two Chronic
Conditions
0.95
1.96*
1.84*
1.23
0.49*
2.64*
2.30*
1.05
1.00
1.00
1.00
1.00
0.67*
2.14*
1.15
1.56*
Three or More
Chronic
Conditions
Self-Perceived Health Status
Excellent, Very
Good or Good†
Fair or Poor
Notes
* Value is significantly different from reference group at p<0.05.
† Reference group.
Source
Canadian Survey of Experiences With Primary Health Care, 2008, Canadian Institute for Health Information, Health Council of
Canada and Statistics Canada.
18
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
Table D2: Adjusted Odds of Reported Experiences Interacting With Primary Health Care Provider for Those With
Ambulatory Care Sensitive Conditions, Age 18 and Older, 2008
In Previous 12 Months, the Primary Health Care Physician Usually or Always
Allowed Enough
Took Patients’
Time to Discuss Health Concerns
Patients’ Concerns Very Seriously
Explained Test
Results in a Way
Patients Could
Understand
Involved Patients
in Clinical
Decisions
Coordinated Care
From Other Doctors
and Places When
Needed
Explained the Side
Effects of Prescription
‡
Medications
Sex
†
Male
1.00
1.00
1.00
1.00
1.00
1.00
Female
1.02
1.01
0.96
1.16
0.91
0.69*
18–44†
1.00
1.00
1.00
1.00
1.00
1.00
45–64
2.20*
2.13*
1.68*
2.01*
1.61*
0.95
65+
2.14*
1.94*
1.70*
1.28
1.07
1.03
Age
Household Income (Adjusted for Household Size)
High Income†
1.00
1.00
1.00
1.00
1.00
1.00
Middle Income
0.71
0.67
0.87
0.66*
0.91
0.72
0.50*
0.54*
0.58*
0.42*
0.60
0.86
Urban†
1.00
1.00
1.00
1.00
1.00
1.00
Rural
1.05
1.08
0.94
0.86
0.82
1.15
Low Income
Geography
Number of Chronic Conditions
Single
Ambulatory
Care Sensitive
Condition†
1.00
1.00
1.00
1.00
1.00
1.00
Two Chronic
Conditions
1.05
0.90
0.93
1.02
1.37
1.27
1.75*
1.57*
1.45*
1.60*
2.08*
1.17
Three or More
Chronic
Conditions
Self-Perceived Health Status
Excellent, Very
Good or Good†
1.00
1.00
1.00
1.00
1.00
1.00
Fair or Poor
1.09
1.04
1.15
0.87
1.21
1.15
Notes
* Value is significantly different from reference group at p<0.05.
† Reference group.
‡ This measure relates only to respondents who received regular or ongoing prescription medications. The prevalence estimate excludes respondents
with a long-term use of same medication (28% of respondents).
Source
Canadian Survey of Experiences With Primary Health Care, 2008, Canadian Institute for Health Information, Health Council of Canada and
Statistics Canada.
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
19
Table D3: Adjusted Odds of Reported Experiences With Clinical Management and Self-Management Support
From Primary Health Care Provider for Those With Ambulatory Care Sensitive Conditions, Age 18
and Older, 2008
Patients Received
In Previous 12 Months, the Primary Health Care Physician
All Four
Generally Did Not or Almost Never
Monitoring Tests
(for Those
Diagnosed With
Helped Make a
Showed Patients
Heart Disease,
Asked to Talk About Treatment Plan That
What to Do to Take
High Blood
Patients’ Goals in
the Patients Could Gave a Written List Care of Themselves
Pressure or
Caring for Their
Implement in Their
of Things to Do to
to Influence
Diabetes)
Chronic Conditions
Daily Lives
Improve Health
Their Condition
Sex
Male†
1.00
1.00
1.00
1.00
1.00
0.62*
1.38*
1.48*
1.77*
1.62*
18–44†
1.00
1.00
1.00
1.00
1.00
45–64
4.84*
0.50*
0.97
0.61*
0.65*
65+
4.68*
0.68
1.67*
0.94
0.78
Female
Age
Household Income (Adjusted for Household Size)
High Income†
1.00
1.00
1.00
1.00
1.00
Middle Income
1.30
0.91
1.07
0.81
1.06
Low Income
0.91
0.99
1.79*
0.91
1.40
1.00
1.00
1.00
1.00
1.00
0.75*
0.93
1.06
0.80
1.20
Geography
Urban†
Rural
Number of Chronic Conditions
Single Ambulatory
Care Sensitive
Condition†
1.00
1.00
1.00
1.00
1.00
Two Chronic
Conditions
1.06
1.02
0.70*
0.79
1.23
1.40*
0.69*
0.61*
0.65*
0.80
Three or More
Chronic
Conditions
Self-Perceived Health Status
Excellent, Very
Good or Good†
1.00
1.00
1.00
1.00
1.00
Fair or Poor
0.93
0.88
0.97
0.78
1.05
Notes
* Value is significantly different from reference group at p<0.05.
† Reference group.
Source
Canadian Survey of Experiences With Primary Health Care, 2008, Canadian Institute for Health Information, Health Council of Canada and
Statistics Canada.
20
Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
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Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions
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