11

““Who are we Who are we serving?”serving?”

Dianne PatychukDianne PatychukAccess Alliance Multicultural Health and Community Access Alliance Multicultural Health and Community

Services, and Services, and Health Equity CouncilHealth Equity Council

April 6, 2009April 6, 2009

22

Health DisparitiesHealth Disparities

There are persistent, recurring There are persistent, recurring differences in health for most differences in health for most conditions, and causes of death conditions, and causes of death among population groupsamong population groups

How can hospitals influence and How can hospitals influence and reduce these disparities?reduce these disparities?

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Lowest Inc Med Low Middle Med High Highest Income

Ra

tes

of

de

ath

, d

ise

as

e,

po

or

he

ath

Premature Deaths (most Premature Deaths (most causes), Chronic Diseases, causes), Chronic Diseases, Self-rated Health all worse in Self-rated Health all worse in lower income groups lower income groups

Patychuk Steps to Equity/08

Neighbourhood Income Quintile

44

What if..?What if..?

Everyone had the same health as Everyone had the same health as the 20% of the population with the 20% of the population with the highest income or living in the the highest income or living in the highest income neighbourhoods?highest income neighbourhoods?

How many “excess” deaths, and How many “excess” deaths, and diseases can be attributed to diseases can be attributed to socio-economic inequlatitis?socio-economic inequlatitis?

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Income-gap attributable Income-gap attributable death and disease: # is death and disease: # is per year in Ontarioper year in Ontario

3,216 Excess deaths under age 75 (2001)3,216 Excess deaths under age 75 (2001) 61,909 Excess potential years of life lost 61,909 Excess potential years of life lost

<age 75<age 75 170,000 Excess cases of diabetes (2004/05)170,000 Excess cases of diabetes (2004/05) 16,000 Excess New cases of Diabetes16,000 Excess New cases of Diabetes 70,000 Excess cases of COPD (2006/07)70,000 Excess cases of COPD (2006/07) 42,000 Excess cases of IHD (2006/07)42,000 Excess cases of IHD (2006/07) 41,000 Excess cases of Osteoarthritis 41,000 Excess cases of Osteoarthritis

(2006/07)(2006/07)Calculations: deaths and PYLL is R Wilkins, Statistics Canada; others are prepared by D Patychuk using quintile data for diseases available on the ICES in-tool

Patychuk Steps to Equity/08

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Cost of Health Cost of Health DisparitiesDisparities Reducing “Excess” illness could Reducing “Excess” illness could

cut health care costs by up to cut health care costs by up to 20%20%

Health Disparities Task Group, Federal Territorial Health Disparities Task Group, Federal Territorial Provincial Advisory Committee on Population Health, Provincial Advisory Committee on Population Health, 20042004

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“ “The Subcommittee believes it is The Subcommittee believes it is unacceptable for a privileged country unacceptable for a privileged country like Canada to continue to tolerate like Canada to continue to tolerate such disparities in health. Our such disparities in health. Our challenge is to find ways to improve challenge is to find ways to improve the health of all Canadians to equal the health of all Canadians to equal that of those who experience the best that of those who experience the best regardless of their ethnicity, social or regardless of their ethnicity, social or economic position”.economic position”.

Fourth Report of the Subcommittee on Population Health of Fourth Report of the Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science the Standing Senate Committee on Social Affairs, Science and Technology April 2008and Technology April 2008

Patychuk Steps to Equity/08

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Health Care ShareHealth Care Share

But how much can hospitals But how much can hospitals and other health service and other health service providers influence and providers influence and reduce these disparities?reduce these disparities?

The health care system’s The health care system’s influence is often described as 20-influence is often described as 20-25%, with socio-economic 25%, with socio-economic conditions accounting for half.conditions accounting for half.

99

Health Care Share of Health Health Care Share of Health InequalitiesInequalities

Biology and genetics

15%

Physical environment

10%

Social and economic conditions

50%

Health care system

25%

Source: Canadian Institute for Advanced Research, cited by The Conference Board of Canada www.conferenceboard.ca

Public Health Agency of Canada http://www.phac-aspc.gc.ca/canada/regions/ab-nwt/resources/present/ppt_02-10-02_s47.htm

Includes: racism/discrimination, income, housing,

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Health Service EquityHealth Service Equity

Lower income, marginalized, ill or Lower income, marginalized, ill or disabled groups with greater disabled groups with greater health needs should receive health needs should receive equally good quality of care equally good quality of care without discrimination. It should without discrimination. It should be culturally appropriate and be culturally appropriate and linguistically accessible.linguistically accessible.

1111

Health Service EquityHealth Service Equity

Lower income, marginalized, ill or Lower income, marginalized, ill or disabled groups with greater health disabled groups with greater health needs should at least be receiving needs should at least be receiving equal benefit from prevention equal benefit from prevention services designed for the whole services designed for the whole population and should be receiving population and should be receiving MORE diagnostic and specialist MORE diagnostic and specialist services than people with better services than people with better health who need them less….health who need them less….

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Lowest Inc Med Low Middle Med High Highest Income

Ra

tes

of

MR

Is,

Sp

ec

ail

ist

Pro

ce

ud

ure

s

BUT THEY ARE RECEIVING LESS. Rates BUT THEY ARE RECEIVING LESS. Rates of MRIs, Hip Replacements, Specialist of MRIs, Hip Replacements, Specialist Procedures are Higher in high income Procedures are Higher in high income groupsgroups

Patychuk Steps to Equity/08

Neighbourhood Income Quintile

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Health Service Health Service InequitiesInequitiesWhen lower income, marginalized, ill or When lower income, marginalized, ill or

disabled groups with greater health needs disabled groups with greater health needs experience: experience: – Barriers to access to health careBarriers to access to health care– Lower rates of prevention and screeningLower rates of prevention and screening– Equal or Lower rates of specialist services, Equal or Lower rates of specialist services,

surgical procedures and diagnostic proceduressurgical procedures and diagnostic procedures– Different treatment, medication, referralsDifferent treatment, medication, referrals– Discrimination (unintentional, overt, embedded)Discrimination (unintentional, overt, embedded)– Discharge or follow-up care that doesn’t take Discharge or follow-up care that doesn’t take

circumstances/living situation into accountcircumstances/living situation into account– Lack of support to equally benefit from servicesLack of support to equally benefit from services

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Equity – Health ContinuumEquity – Health ContinuumHealth Equity Council Indicators Work Health Equity Council Indicators Work GroupGroup

Getting to Getting to CareCare

Service Service QualityQuality

DischargeDischarge//CommunitCommunityy

TransportationTransportation

LanguageLanguage

Child CareChild Care

TelephoneTelephone

Time off workTime off work

No OHIPNo OHIP

Fear/Lack of Fear/Lack of PowerPower

Past ExperiencePast Experience

Lack of supportLack of support

Preconceived Preconceived stereotypes stereotypes (staff)(staff)

Inflexible policies Inflexible policies and proceduresand procedures

Lack of culturally Lack of culturally and linguistically and linguistically appropriate careappropriate care

Wayfinding, Wayfinding, Consent, RightsConsent, Rights

Different QualityDifferent Quality

Hand-over to Hand-over to homecare, homecare, CCAC, CCAC, primary careprimary care

Supports Supports arranged arranged (transportatio(transportation, housing, n, housing, etc.)etc.)

Ensure Ensure follow-up follow-up carecare

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Results for Results for Clients/CommunityClients/Community

Being understoodBeing understood Being treated with respect, dignity,Being treated with respect, dignity, Receiving equally good care… Receiving equally good care…

without discriminationwithout discrimination Not having to wait to get help Not having to wait to get help

when you need itwhen you need it Getting thereGetting there

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Results for Health Results for Health ServicesServices Lower rates of Missed AppointmentsLower rates of Missed Appointments Reduced ReadmissionsReduced Readmissions Reduced complications that could Reduced complications that could

have been preventedhave been prevented Shorter Lengths of StayShorter Lengths of Stay Reduced ALCReduced ALC Costs SavedCosts Saved

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Can we use the quintile Can we use the quintile approach to measure approach to measure service equity across the service equity across the continuum?continuum? Given that most hospitals do not Given that most hospitals do not

currently collect patient social, currently collect patient social, income, housing, ethno-racial, income, housing, ethno-racial, language, etc. on patients, can we language, etc. on patients, can we group our patients into different group our patients into different population clusters by using their population clusters by using their postal codes which link to detailed postal codes which link to detailed census information?census information?

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First Step with Client First Step with Client DataData Geocode client 6-digit postal code Geocode client 6-digit postal code

to a census tractto a census tract Then match client census tract Then match client census tract

with the Statistics Canada data with the Statistics Canada data for that census tractfor that census tract

To make the tool shareble and To make the tool shareble and easy-to-use, Access Alliance easy-to-use, Access Alliance coded census tracts into quintiles coded census tracts into quintiles

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A Tool to Create A Tool to Create Comparison Comparison PopulationsPopulations At Access Alliance we ranked all 500 At Access Alliance we ranked all 500

Census Tracts in Toronto according to Census Tracts in Toronto according to income, no English language, disability, income, no English language, disability, recent immigrants, racialized groups, recent immigrants, racialized groups, education for all age groups and for education for all age groups and for seniors. A score of 1-5 was assigned to seniors. A score of 1-5 was assigned to each cluster of CTs representing 20% each cluster of CTs representing 20% of the population for each variable. 1 = of the population for each variable. 1 = highest need/highest access barrier highest need/highest access barrier and 5 = lowest need/barriersand 5 = lowest need/barriers

2020

Proportionately more Proportionately more clients live in low income clients live in low income CTsCTsDistribution of Clients: Access Alliance

43.8%

22.3%19.0%

10.5%

4.1%

0%

10%

20%

30%

40%

50%

Highest %Low

Income

High-Mid Mid Mid-Low Lowest %Low

Income

Toronto Neighbourhood Quintiles: % Low Income (Pre-Tax)

Pe

r c

en

t o

f A

cti

ve

Clie

nts

% of Pop is 20% in each

2121

Proportionately more clients Proportionately more clients live in CTs with no English or live in CTs with no English or FrenchFrench

Distribution of Clients: Access Alliance

28.2%

9.8%

34.4%

5.3%

22.1%

0%

10%

20%

30%

40%

50%

Highest20%

High-Mid Mid Mid-Low Lowest20%Toronto Neighbourhood Quintiles:

% Speaking Neither Official Language

Pe

r c

en

t o

f A

cti

ve

Clie

nts

% of Pop is 20% in each

2222

Proportionately more clients Proportionately more clients live in high recent live in high recent immigration CTsimmigration CTs

Distribution of Clients: Access Alliance

19.3%

12.0%15.6%16.1%

36.8%

0%

10%

20%

30%

40%

50%

Highest20%

High-Mid Mid Mid-Low Lowest20%

Toronto Neighbourhood Quintiles: % Recent Immigrants

Pe

r c

en

t o

f A

cti

ve

Clie

nts

% of Pop is 20% in each

2323

Adapting for service Adapting for service catchmentscatchments We tested this for other agencies We tested this for other agencies

who had catchment areas that who had catchment areas that were only part of the city, by were only part of the city, by distributing the catchment area distributing the catchment area population across the quintiles population across the quintiles and comparing actual clients to and comparing actual clients to catchment area population. It catchment area population. It worked.worked.

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Other WaysOther Ways

Some hospitals can geocode their Some hospitals can geocode their clients to Dissemination Areas (smaller clients to Dissemination Areas (smaller more homogeneous populations than more homogeneous populations than Census tracts); for others FSAs (postal Census tracts); for others FSAs (postal code forward sortation areas – first 3 code forward sortation areas – first 3 digits) may be enough to group clients digits) may be enough to group clients into two or more groups with different into two or more groups with different levels of disadvantage, need or access levels of disadvantage, need or access barriers as indicated by area they live barriers as indicated by area they live in compared to other areas of the city.in compared to other areas of the city.

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Next StepsNext Steps

Once client groups are created Once client groups are created their experience through the their experience through the continuum of care can be tracked continuum of care can be tracked and compared. Potential service and compared. Potential service inequities can be identified and inequities can be identified and potential impacts of changes in potential impacts of changes in practices can be tracked.practices can be tracked.

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Challenges and Challenges and SupportsSupports In the First Steps Tools and In the First Steps Tools and

Resources Section today, you will Resources Section today, you will hear more about how to access hear more about how to access geocoding, census and geocoding, census and community data.community data.

Please share your examples Please share your examples during the discussion after Ted during the discussion after Ted McNeill’s presentation.McNeill’s presentation.

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Equity LensEquity Lens

If we are ready to use an equity lens: to If we are ready to use an equity lens: to always ask if what we are doing, always ask if what we are doing, planning or deciding will benefit the planning or deciding will benefit the people who need it the most and who people who need it the most and who have existing barriers; and, to take have existing barriers; and, to take steps to mitigate consequences, reduce steps to mitigate consequences, reduce barriers, tailor strategies or make barriers, tailor strategies or make special effort;…. then we can measure special effort;…. then we can measure our efforts using this approach.our efforts using this approach.

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Looking Ahead: Equity is one of 13 Looking Ahead: Equity is one of 13 “Risk Categories” that Ministry, “Risk Categories” that Ministry, LHINs and HSPs should take into LHINs and HSPs should take into accountaccount

Ministry of Health and Long-Term Care. New Directions January 2009

Equity – Risk is uncertainty that services will have an equitable impact on the population.

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In 1995, I received a In 1995, I received a call..call..……from the Hospital for Sick Children. from the Hospital for Sick Children.

With recent cuts of 21.6% to social With recent cuts of 21.6% to social assistance rates, Sick Kids wanted to assistance rates, Sick Kids wanted to ensure it was adequately reaching ensure it was adequately reaching out to and serving low income out to and serving low income families whose children’s health was families whose children’s health was expected to be negatively affected expected to be negatively affected by the huge drop in income. This by the huge drop in income. This remains a concern today. Over to remains a concern today. Over to Ted.Ted.