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May 2003, Vol 93, No. 5 | American Journal of Public Health 798-802
© 2003 American Public Health Association

RESEARCH AND PRACTICE

Markers of Access to and Quality of Primary Care for Aboriginal People in Ontario, Canada

Baiju R. Shah, MD, Nadia Gunraj, MPH and Janet E. Hux, MD, SM

The authors are with the Institute for Clinical Evaluative Sciences, Toronto, Ontario. Baiju R. Shah and Janet E. Hux are also with the Department of Medicine and the Clinical Epidemiology and Health Care Research Program, University of Toronto.

Correspondence: Requests for reprints should be sent to Janet E. Hux, MD, SM, Institute for Clinical Evaluative Sciences, Rm G1 06, 2075 Bayview Ave, Toronto, ON, Canada, M4N 3M5 (e-mail: jan{at}ices.on.ca).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 

Objectives. We evaluated primary care accessibility and quality for Ontario’s aboriginal population.

Methods. We compared a defined aboriginal cohort with nonaboriginal populations with analogous geographic isolation and low socioeconomic status. We determined rates of hospitalization for the following indicators of adequacy of primary care: ambulatory care–sensitive (ACS) conditions and utilization of referral care–sensitive (RCS) procedures from administrative databases.

Results. ACS hospitalization rates, relative to the general population, were 2.54, 1.50, and 1.14 for the aboriginal population, the geographic control populations, and the socioeconomic control populations, respectively. The relative RCS procedure utilization rates were 0.64, 0.91, and 1.00, respectively.

Conclusions. The increased ACS hospitalization rate and reduced RCS procedure utilization rate suggest that northern Ontario’s aboriginal residents have insufficient or ineffective primary care.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 References
 
Effective vertically integrated primary care is a cornerstone of health care delivery. Primary care plays a central role in delivering preventive services, in diagnosis, in long-term disease management, and in coordinating specialty services as a gatekeeper. Accordingly, access to primary care is an important quality indicator for a health care system. Unfortunately, measuring access is not straightforward—simple enumeration of services provided cannot be interpreted without information about a person’s or population’s needs and preferences for health care.

One approach for measuring access is to examine rates of hospital admission for certain medical conditions that could usually be effectively managed in an ambulatory setting. Such conditions are known as "ambulatory care–sensitive" (ACS) conditions,1 and hospitalizations for these diagnoses may indicate a potentially preventable complication resulting from inadequate access to or quality of primary care.

A number of demographic and sociological factors have been associated with admissions for ACS conditions. In the United States, the frequency of potentially preventable hospitalizations has been negatively correlated with income and having health insurance.2–6 In the United Kingdom, this correlation is less strong,7,8 and in Canada, where public health insurance coverage for physician fees and hospital expenses is available to all residents, the relationship is not found.9 Geography has also been associated with avoidable admissions. Rural Native Americans have higher hospitalization rates compared with their urban counterparts.10 Likewise, variations in admission rates for ACS conditions were found between rural districts and urban areas in Ontario.11 Race also affects preventable hospitalization, even when other predictive factors are controlled for.12

A second measure of access to primary care is utilization of tertiary care procedures. In addition to reflecting variability in access to specialists and referral centers, differences in the frequency of these procedures between populations may reflect variability in access to perceptive primary care providers who initiate and coordinate appropriate referrals.13 "Referral care–sensitive" (RCS) procedures such as renal transplantation and invasive cardiac procedures have been found to be related to many of the same sociodemographic factors predictive of ACS hospitalizations. Higher income has been correlated with increased frequency of specialist visits,14 renal transplantation,15,16 coronary artery bypass surgery,17 and coronary angiography.18

Because their delivery is often centralized, RCS procedures are particularly prone to variation based on geographic factors. Utilization of cardiac revascularization services has been shown to decrease with increasing distance from a patient’s residence to an institution offering these services in the United States,19 Canada,20 and the United Kingdom.21 Variation among racial groups has also been well documented.15,22

Limited research has examined access to primary care for aboriginal populations, particularly in Canada. Nonetheless, the reservation-dwelling aboriginal population of northern Ontario has several of the risk factors identified for inadequate primary care access: poverty, rural isolation, and minority ethnicity. We determined the frequencies of preventable hospitalizations and tertiary care procedures in this population to use as markers for its access to quality primary care.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 References
 
Data Sources
The Canadian Institute for Health Information maintains an administrative database containing abstracts of all hospitalizations; these include discharge diagnoses recorded with the International Classification of Diseases, Ninth Revision23 (ICD-9). The Ontario Health Insurance Plan database contains records of all physician billings to the provincial insurance program for consultations, assessments, and procedures. The Registered Persons Database includes a home address for every Ontario resident. We linked data between databases with a reproducibly scrambled unique identifier. We used data from fiscal years 1994/1995 to 1998/1999 in this study.

Study Populations
We defined the aboriginal population, as previously described,24 to include the entire population of a group of communities. A total of 104 communities in Ontario’s northern districts were identified as aboriginal reserves or settlements. We gathered population data for these communities from the 1996 Canadian census, because this year represented the midpoint of the data being evaluated. We excluded aboriginal communities that had response rates to the census of less than 75% (19 communities) and those too small to allow release of detailed population information (23 communities). We also excluded communities in which fewer than 95% of the population reported aboriginal ancestry (7 communities). The residents of the remaining 55 communities made up the aboriginal population (n = 22 806) of this study.

All of the aboriginal settlements in this study were small, geographically isolated northern communities. Because geographic barriers may influence access to care, we defined a geographic control population of similar small (but not necessarily isolated) northern communities. This population consisted of the residents of all communities with populations of less than 10 000 in Ontario’s northern districts (n = 354 915).

Low socioeconomic status may contribute to reduced access to medical care, even among people with health insurance. Because many aboriginal communities are economically disadvantaged, we also analyzed a socioeconomic control population. We ranked the average family income in each of the 503 postal service–designated "forward sortation areas" into which the province is divided, and defined the residents of the lowest quintile as the socioeconomic control population (n = 2 207 300).

Finally, we evaluated the entire population of Ontario (n = 10 753 573) as a reference population.

The 4 populations were not mutually exclusive.

Diagnoses Evaluated
We evaluated 3 categories of diagnoses. ACS conditions are those that could ideally be managed in the outpatient setting—for which admission to a hospital could reflect unavailable or inadequate primary care. RCS procedures are those that require access to specialists and tertiary care centers and also require adequate primary care to identify the need for referral. In Ontario, specialist services are available only by referral from another physician. Insensitive conditions are those for which hospitalization is usually considered obligatory and not directly preventable with outpatient care. The diagnoses and procedures considered within each category (Table 1Go) were determined by several expert panels of Ontario-based physicians and have been previously described.25


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  		TABLE 1— —Ambulatory Care–Sensitive Conditions, Referral Care–Sensitive Procedures, and Insensitive Conditions Evaluated
 
Rate Determination
We determined the hospitalization rates for ACS and insensitive conditions and the utilization rate for RCS procedures for each population. Numerators for hospitalizations were determined by searching the Canadian Institute for Health Information database for all hospitalizations recording a relevant ICD-9 code as the diagnosis responsible for the majority of the patient’s hospitalization. We excluded those cases for which the same diagnosis was also listed as a complication arising in the hospital. Numerators for procedures were determined by searching the Ontario Health Insurance Plan database for all claims with billing codes for the procedures under investigation. We attributed each hospitalization and procedure to the patient’s community of residence, independent of where the service was delivered, and included each event among those for all of the study populations to which the patient belonged. We counted all events for people with multiple events.

We used population counts obtained from 1996 census data as denominators. We age- and sex-adjusted crude rates to the provincial population and calculated rates relative to the general Ontario population. Under the null hypothesis that the admission and procedure rates for each population group did not differ from those of the general population, we generated multiple simulated populations with admission and procedure frequency distributions similar to those of the actual general population, but with random allocation to population groups.26 We then compared the observed relative rates (RRs) with the distribution of the simulated RRs to determine the probability that the observed rate is owing to chance alone.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 References
 
The aboriginal population had a significantly higher admission rate for ACS conditions than that of the general Ontario population (RR = 2.54; P < 0.001) (Figure 1Go). Part of this effect may be due to both isolation and poverty, because both the geographic and socioeconomic control populations had slightly higher rates of potentially preventable hospitalizations than that of the general population (RR = 1.50; P < 0.001; and RR = 1.14; P < .001, respectively).



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  		FIGURE 1— —Relative admission rates for ambulatory care–sensitive conditions for the aboriginal population and the geographic and socioeconomic control populations, compared with the general population: Ontario, Canada, 1994–1995 and 1998–1999.

 
In contrast, the aboriginal population had a lower utilization rate for specialist procedures (RR = 0.64; P < .001), compared with the general population (Figure 2Go). These procedures were also utilized less in the geographic control population (RR = 0.91; P < .001) than in the general population. However, the RR for the socioeconomic control population was 1.00 (P = .47).



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  		FIGURE 2— —Relative utilization rates for referral care–sensitive procedures for the aboriginal population and the geographic and socioeconomic control populations, compared with the general population: Ontario, Canada, 1994–1995 and 1998–1999.

 
The 3 comparison population groups also had higher admission rates for insensitive conditions compared with the general population (Figure 3Go). The RRs of admission were 1.39 (P < .001) for the aboriginal population, 1.23 (P < .001) for the geographic control population, and 1.03 (P < .001) for the socioeconomic control population.



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  		FIGURE 3— —Relative admission rates for insensitive conditions for the aboriginal population and the geographic and socioeconomic control populations, compared with the general population: Ontario, Canada, 1994–1995 and 1998–1999.

 
In addition to the aggregated analysis, we evaluated each disease and procedure within the 3 diagnosis categories individually. Although small numbers of events in some categories led to imprecise estimates of rates, in general each followed a pattern of admission or procedure utilization RRs similar to the overall category.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
References
 
Ontario’s northern, reservation-dwelling aboriginal population has a higher hospital admission rate for ACS conditions and a lower utilization rate for RCS procedures than that of the general population. These findings suggest that northern aboriginal communities have poorly accessible or ineffective primary care. In more remote communities, physician services may not be routinely available on-site; primary care may be delivered through nursing stations.

Differences in admissions or procedure utilization are not due simply to differences in disease prevalence. Although the Ontario aboriginal population has a higher prevalence of diabetes, hypertension, cigarette smoking, and coronary artery disease than the general population,24,27,28 potentially explaining higher hospitalization rates for some ACS conditions, such elevated prevalences should also lead to increased utilization of many RCS procedures. Moreover, the elevated overall admission RR for ACS conditions was mirrored in the RRs for most of the individual diseases considered, including those for which no evidence of a difference in disease prevalence exists.

The aboriginal and control populations did have higher admission rates for insensitive conditions than did the general population. However, the magnitudes of these differences were small and demonstrate that these populations do have access to nondiscretionary care when needed.

The barriers to quality primary care for vulnerable populations are numerous and complex. Some authors have postulated that financial obstacles are critical,29 but the Ontario aboriginal population has full public health insurance coverage for all physician and hospital fees. Geographic isolation and socioeconomic status are important variables that may explain the increased admission rate for ACS conditions and decreased utilization rate of RCS procedures. However, the relative magnitudes of the admission and procedure rates seen markedly exceeded those of both the geographic and socioeconomic control populations. Therefore, either the control populations did not adequately reflect the degree of poverty and rural isolation of aboriginal communities, or factors beyond these demographic characteristics affect primary care access in aboriginal communities.

For example, systemic barriers, such as the distribution of primary care physicians, may affect access to care in this population. Many aboriginal communities are in regions known to have a low density of family physicians and high rates of physician turnover,30 and some are quite remote from even basic medical facilities. The geographic control population may not have been adequate to assess this effect. Even in communities where consistent primary care is available, barriers to quality of care may persist. Many health care providers have large patient loads,31 minimizing the time and resources available to devote to individual patients. Onerous patient care demands and geographically dispersed practices may also have limited these physicians’ access to the continuous medical education activities and consultative advice from specialists needed to support high-quality care.

Population- and patient-specific factors may also contribute to the observed findings. The threshold for hospitalizing patients from aboriginal communities may be lower. Similarly, patients or practitioners may favor noninvasive management over tertiary care procedures. The biological presentation of disease in this population may differ from that anticipated by physicians, or symptoms and treatment options may be interpreted in a different cultural light. However, before differences in resource utilization are dismissed as being due to such factors, those who deliver health services must ensure that culturally sensitive care is being provided. Such care would include context-appropriate preventive interventions, development and use of tools to accurately elicit patient preferences, and required resource allocation to facilitate access to desired services.32

The patterns for hospitalizations for ACS conditions and utilization of RCS procedures among Ontario’s aboriginal population are consistent with inadequate primary care. Additional primary data collection in collaboration with the affected communities will be required to more precisely delineate the exact causes. Ultimately, both broad policy and local practice initiatives will be required to address these deficiencies across the spectrum of quantity, accessibility, continuity, and quality of primary care.


   Acknowledgments
 
The Physician Services Incorporated Foundation provided funding for this study.

We gratefully acknowledge the assistance of G. M. Anderson, A. D. Brown, and R. Croxford in completing this study, and of A. Laupacis in reviewing the article.

B. R. Shah and J. E. Hux planned the study, analyzed the data, and wrote the article. N. Gunraj assisted with study design, analyzed the data, and contributed to the writing of the article.

Human Participant Protection
No specific protocol approval was needed for this study, because only anonymous administrative data were used. However, the study was included under the general approval granted by the Sunnybrook and Women’s College Health Sciences Centre research ethics board for research at the Institute for Clinical Evaluative Sciences.


   Footnotes
 
Note. The opinions, results, and conclusions are those of the authors, and no endorsement by the Ontario Ministry of Health and Long-Term Care or by the Institute for Clinical Evaluative Sciences is intended or should be inferred.

Peer Reviewed

Accepted for publication November 25, 2002.


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