Disparities In Health Service Utilization Research Articles

Low income children with Inflammatory Bowel Disease have higher surgical and hospitalization rates in a Universal Health Care System

Canada's single-payer health system provides all residents of Ontario, Canada's largest province, with publicly-funded healthcare. Nonetheless, previous studies have demonstrated income-based disparities in health services utilization and outcomes in children with chronic diseases. To test whether there are important differences in healthcare utilization and outcomes based on household income in children with IBD. The Ontario Crohn's and Colitis Cohort uses a validated algorithm to identify all children <18 years diagnosed 1994-2004 with IBD within Ontario's health administrative databases. Children were followed until 2008. Patients were grouped into census-based mean neighborhood income quintiles groupings: the lowest two income quintiles (n= 944) and highest two income quintiles (n= 1286). Multivariable models tested the association between income group and physician and emergency department (ED) visits, hospitalizations, or surgery. Logistic, linear or Cox proportional hazard regression models were used. Covariates were determined a priori (sex, diagnosis age) or included if they changed the estimate of the income group variable by ≥10% (incidence date, rurality at birth and at diagnosis). 2230 IBD patients were included (age at diagnosis 14.4±3.9y, follow-up 8.4±3.2y [range 3-14y]). Care providers (adult/pediatric gastroenterologists, surgeons) were similar between groups. Lower income children were more likely to be hospitalized or visit the ED and had more physician IBD-related visits (see Table). Lower income children with Crohn's (not UC) were more likely to undergo surgery within 3y of diagnosis. IBD-RELATED HEALTH SERVICES UTILIZATION BY NEIGHBORHOOD INCOME QUINTILE GROUP. IBD-RELATED HEALTH SERVICES UTILIZATION BY NEIGHBORHOOD INCOME QUINTILE GROUP. In the context of higher overall physician visits in low income children with IBD, higher surgical rates in those with Crohn's disease, and higher hospitalization rates in all children with IBD are likely due to factors other than access to healthcare services. Further work should delineate whether there are potentially modifiable risk factors associated with these worse health outcomes in children of lower income families.

Racial Disparities in Access to Care for Men in a Public Assistance Program for Prostate Cancer

California's IMPACT program provides all its enrollees with health insurance and social service resources. We hypothesized that racial/ethnic disparities in access to care might be attenuated among men served by this program. Our objective was to evaluate racial/ethnic differences in health services utilization and patient-reported health care outcomes among disadvantaged men in a prostate cancer public-assistance program, and to identify modifiable factors that might explain persistent disparities in this health care setting. We performed a retrospective cohort study of 357 low-income men enrolled in IMPACT from 2001 through 2005. We evaluated realized access to care with two health services utilization measures: (1) use of emergency department care without hospitalization and, (2) frequency of prostate-specific antigen testing. We also measured two patient-experience outcomes: (1) satisfaction with care received from IMPACT, and (2) confidence in IMPACT care providers. We observed significant bivariate associations between race/ethnicity and patient-experience outcomes (P<0.05), but not utilization measures. In multivariable models, Hispanic men were more likely than white men to report complete satisfaction with health care received in IMPACT (adjusted OR=5.15, 95% CI 1.17-22.6); however, the association between race/ethnicity and satisfaction was not statistically significant (P=0.11). Language preference and self-efficacy in patient-physician interactions are potentially-modifiable predictors of patient-experience outcomes. We observed no racial/ethnic disparities in health services utilization among disadvantaged men served by a disease-specific public assistance program. The greater satisfaction and confidence among Hispanic men are explained by modifiable variables that suggest avenues for improvement.

Variation in health services utilization among ethnic populations

Although racial and ethnic disparities in health services utilization and outcomes have been extensively studied in several countries, this issue has received little attention in Canada. We therefore analyzed data from the 2001 Canadian Community Health Survey to compare the use of health services by members of visible minority groups and nonmembers (white people) in Canada. Logistic regression was used to compare physician contacts and hospital admissions during the 12 months before the survey and recent cancer screening tests. Explanatory variables recorded from the survey included visible minority status, sociodemographic factors and health measures. Respondents included 7057 members of visible minorities and 114,255 white people for analysis. After adjustments for sociodemographic and health characteristics, we found that minority members were more likely than white people to have had contact with a general practitioner (adjusted odds ratio [OR] 1.28, 95% confidence interval [CI] 1.14-1.42), but not specialist physicians (OR 1.01, 95% CI 0.93-1.10). Members of visible minorities were less likely to have been admitted to hospital (OR 0.83, 95% CI 0.70- 0.98), tested for prostate-specific antigen (OR 0.64, 95% CI 0.52-0.79), administered a mammogram (OR 0.68, 95% CI 0.59-0.80) or given a Pap test (OR 0.47, 95% CI 0.39-0.56). Use of health services in Canada varies considerably by ethnicity according to type of service. Although there is no evidence that members of visible minorities use general physician and specialist services less often than white people, their utilization of hospital and cancer screening services is significantly less.