Inequities in Ambulatory Care and the Relationship Between Socioeconomic Status and Respiratory Hospitalizations: A Population-Based Study of a Canadian City

Abstract

PURPOSE Individuals of lower socioeconomic status have higher rates of hospitalization due to ambulatory care-sensitive conditions, particularly chronic obstructive pulmonary disease and asthma. We examined whether differences in patient demographics, ambulatory care use, or physician characteristics could explain this disparity in avoidable hospitalizations.METHODS Using administrative data from the city of Winnipeg, Manitoba, Canada, we identified all adults aged 18 to 70 years with chronic obstructive pulmonary disease or asthma, grouped together as obstructive airway disease. We divided patients into census-derived income quintiles using average household income. We performed a series of multivariate logistic regression analyses to determine how the association of socioeconomic status with the risk of obstructive airway disease-related hospitalizations changed after controlling for blocks of covariates related to patient demographics (socioeconomic status, age, sex, and comorbidity), ambulatory care use (continuity influenza vaccination and specialist referral), and characteristics of the patient's usual physician (eg, payment mechanism, sex, years in practice). RESULTSWe included 34,741 patients with obstructive airway disease, 729 (2.1%) of whom were hospitalized with a related diagnosis during a 2-year period. Patients having a lower income were more likely to be hospitalized than peers having the highest income, and this effect of socioeconomic status remained virtually unchanged after controlling for every other variable studied. In a fully adjusted model, patients in the lowest income quintile had approximately 3 times the odds of hospitalization relative to counterparts in the highest income quintile (odds ratio = 2.93; 95% confidence limits: 2.19, 3.93). CONCLUSIONSIn the setting of universal health care, the income-based disparity in hospitalizations for respiratory ambulatory care-sensitive conditions cannot be explained by factors directly related to the use of ambulatory services that can be measured using administrative data. Our findings suggest that we look beyond the health care system at the broader social determinants of health to reduce the number of avoidable hospitalizations among the poor.

Clinical Population Medicine: Integrating Clinical Medicine and Population Health in Practice

“…We categorized these papers as they apply to the Centers for Disease Control core functions of public health (health assessment, policy development, and assurance) and the Public Health Agency of Canada's essential functions of public health (health protection, health promotion, population health assessment, disease and injury prevention, and health surveillance) in clinical settings ( Table 2). [9][10][11][12][13][14][15][16][17][18] We curated this virtual issue by selecting 10 papers to showcase the breadth of CPM practice. These papers might have been developed and presented as research initiatives or commentary, but this virtual issue is an opportunity to consider them together as CPM in practice.…”

“…10 Williamson et al validated the use of electronic health record systems for chronic disease surveillance through the Canadian Primary Care Sentinel Surveillance Network. 9 In continuing practice, CPM could translate these research findings into ongoing assessment and surveillance systems to guide health care planning and implementation.…”

Contextual, Ecological, and Organizational Variations in Risk-Adjusted COPD and Asthma Hospitalization Rates of Rural Medicare Beneficiaries

“…Hospitalizations associated with COPD and asthma are often cited as an ambulatory care sensitive condition or potentially avoidable hospitalization. Empirical research suggests that personal attributes (Kabir et al, 2010; Ong, Earnest, & Lu, 2005), socioeconomic status (Trachtenberg, Dik, Chateau, & Katz, 2014), health care system or provider factors (Casalino et al, 2014; O’Malley, Pham, Schrag, Wu, & Bach, 2015;), health education for self-care management (Gadoury et al, 2005), and access to primary care (Caminal, Starfield, Sanchez, Casanova, & Morales, 2005) are potential predictor variables for COPD hospitalizations. However, little is known about how these factors contribute to the variability in COPD hospitalization rates when the influence of patient characteristics is being simultaneously considered by applying a risk adjustment method.…”

Does socio-economic status or having a chronic condition affect whether family physicians accept a new patient? A Nova Scotia population study

“…24 Notably, low SES is associated with higher rates of hospitalization for chronic conditions that could be managed through outpatient care. [25][26][27] A qualitative investigation of unattached patients with low SES and chronic disease highlighted themes of participants feeling like undesirable patients because of unsuccessful attempts to find a regular provider and concerns about lack of access to preventive services and discontinuous medical records.…”