Provincial and Regional Differences in Self-reported Health and Health Service Use among Ontario Adults with Chronic Obstructive Pulmonary Disease (COPD)

This correlation comparative study extracted relevant data available through the Public Use Micro-data file of the 2017-2018 Canadian Community Health Survey (CCHS) (Statistics Canada, 2020). It is one of the largest population-based repository of health data gathered though national cross-sectional survey methods. The Public Use Micro-data file, which includes data collected over a two-year period, represents health status, healthcare utilization, and health determinants. As a credible health research data source, its availability for secondary analysis supports the examination of health surveillance at local, provincial, and national levels (Statistics Canada, 2020).

The CCHS survey uses multi-staged sampling method. The provinces are divided into clusters. Clusters are geographic regions of 100-600 dwellings. A sample of primary units, corresponding to geographic regions called clusters, are initially selected. In the second stage of sampling, dwelling lists are prepared for each selected cluster. Dwellings are then selected from these lists through systematic sampling. The total surveyed sample for 2017-2018 CCHS was 113, 289 Canadians, aged 12 and older, residing in one of 10 provinces and the three territories. The sample size of adult Ontarians was 33 510. Excluded from the survey's coverage are: persons living on reserves and other Aboriginal settlements in the provinces; full-time members of the Canadian Forces; the institutionalized population.

Data extraction

For this cohort, the following health-related and health service use variables were extracted.

Chronic obstructive pulmonary disease

Respondents were asked if they had a chronic condition. Those who responded "yes" to the question, "Do you have a chronic bronchitis, emphysema or chronic obstructive pulmonary disease or COPD?" were considered to have self-reported COPD.

Health

Respondents were asked, “In general, would you say your health is excellent, very good, good, fair, or poor?” Those who responded “excellent” or “very good” were grouped together and those who responded “fair or poor” were grouped together. The variable of poor health was created grouping those who responded excellent, very good, and good together and those who responded fair or poor together.

Mental health

Respondents were asked, “In general, would you say your mental health is excellent, very good, good, fair, or poor?” Those who responded “excellent” or “very good” were grouped together and those who responded “fair or poor” were grouped together. The variable of poor mental health was created grouping those who responded excellent, very good, and good together and those who responded fair or poor together.

Satisfaction with life

Respondents were asked, “Using a scale of 0 to 10, where 0 means ‘very dissatisfied’ and 10 means ‘very satisfied’, how do you feel about your life as a whole right now?” Those who responded “0, 1, 2, or 3” were grouped together, those who responded “4, 5, or 6” were grouped together, and those who responded “7, 8, 9, or 10” were grouped together.

Life stress

Respondents were asked, “Thinking about the amount of stress in your life, would you say that most of your days are not stressful at all, not very stressful, a bit stressful, quite a bit stressful, or extremely stressful?” Those who responded “quite a bit stressful” or “extremely stressful” were grouped together.

Level of coordination between regular HCP and other health professionals

Respondents were asked, “In general, how would you rate the level of coordination between your regular health care provider and other health professionals who provide you with regular care? Would you say the coordination is excellent, very good, good, fair, or poor?” Those who responded “excellent” or “very good” were grouped together and those who responded “fair or poor” were grouped together. The variable of poor coordination was created grouping those who responded excellent, very good, and good together and those who responded fair or poor together.

Health service use

In the CCHS, persons were asked if, in addition to their primary healthcare provider, they saw any other healthcare providers. A series of possible provider types was provided. We consider both these individual provider types and the total number of services accessed as proxies for the capacity to access health services as needed.

Geographic location

In the CCHS, there are variables for each of the health units in Ontario. Six health units are included within the northern Ontario region. A variable was created that indicates those living in the health units that fall within the northern Ontario region. The geographic boundaries are the eastern border of Ontario to the Quebec border, the northern border of Ontario at James and Hudson Bay, the western border of Ontario to the Manitoba border and southern border of the North Bay and Parry Sound Health Unit (NBPSHU) catchment area. Comparisons are made between those living within the northern Ontario region and those living in the rest of the province. The southern border of the NBPSHU is irregular, but captures part of the Muskoka region down to 45.17 degrees north. Covariates and demographic variables Age, gender, marital status, income, and education level were used to describe the sample and were used as covariates in adjusted models.

Ethics

This study was approved by the Laurentian University Research Ethics Board (Certificate 6018367).

A file of extracted data specific to Ontarians was created. A descriptive analysis was conducted to describe the self-reported overall health and health service usage between community dwelling adult Ontarians with and without a diagnosis of COPD. Cohort differences were examined relative to gender, marital status, age, highest level of education, household income and geographic location. Descriptive statistics were used to analyze the selected health and health service use variables. Differences between subjects with COPD and without COPD were tested with Chi-square tests. To determine factors associated with varying levels of health and age, logistic regression analyses were used. Poisson regression was used to determine the rate of health service use. In these analyses, adjustments were made for age, sex, marital status, income, and education level. A p-value of <0.05 was considered statistically significant,

All analyses were performed using Stata v16.1 statistical software (Stata Statistical Software, 2019). Population weights were applied according to Statistics Canada guidelines to ensure accurate measures of variance, and to eliminate the possibility of groups being over or under represented (Statistics Canada, 2020).

More females (58%) report having COPD than males (42%) and about half are between age of 50 and 69 (49 to 52%) (Table 1). They report being with a partner (43%) or widowed/divorced (42 to 44%). Fewer report being single (12 to 16%). Northern Ontario has the highest percentage of those who report being single (16%). The majority of those with COPD report having a secondary school diploma or less than secondary school as their highest level of education. Northern Ontario has the highest percentage of those with a less than secondary school education (36.7%) compared to those living elsewhere in Ontario (30.2%). Among those with COPD, persons living in northern Ontario also has the lowest percentage of those with post-secondary education, 40% compared to 43 % provincially. Higher levels of education, specifically post-secondary education, were reported for those who did not report having COPD, provincially, 57%, and in northern Ontario, 53%. About 45% of persons with COPD have an income of less than $39 999 while nearly 55 % have an annual income greater than $40 000. Overall, fewer persons with COPD have an annual income of greater than $80 000, approximately 22 % of the sample population. Those without COPD, whether they lived in northern Ontario or elsewhere in the province, were much more likely to report incomes greater than $80 000, 44% and 48%, respectively.

There were notable differences among the ratings persons with COPD and those without COPD assigned to their perception of their overall health. Persons with COPD were far less likely to rate their overall health as excellent or very good compared to those without COPD, 18.4% and 59.4%, respectively (Table 2). About the same percentage (31-30%) rate their health as good, across both groups. Provincially, the percentage of those who rate their health as fair or poor was 50.9%, however, those who live in Northern Ontario with COPD were the most likely with rate their health as fair or poor, 53.1%.

Differences were also noted among the ratings persons assigned to their mental health. Persons with COPD were less likely to rate their mental health as excellent or very good compared to those without COPD, 51.3% compared to 68.4%. Those living in Northern Ontario with COPD were the least likely (43.7%) to rate their mental health as excellent or very good. Similar percentages were noted between those with COPD and those without COPD who rated their mental health as good, ranging from 23.7% to 34.2%. Across both groups with COPD, those living in Northern Ontario were most likely to rate their mental health as fair or poor, 22.1% compared to 19.1% provincially.

Those living with COPD were more likely to rate their overall satisfaction with life with a lower score (0-3) than those without COPD, about 8% compared to about 2%, of those persons who do not live with COPD. The percentage of persons who rank their satisfaction with life highly (score of 7-10) also varies between those living with COPD and those without COPD. About 65% of those living with COPD ranked their satisfaction high (65.1%, and 62.3%, respectively) compared to about 87% of those who do not live with COPD (87.4%, and 86.6%, respectively).

Persons living with COPD and those without COPD ranked their perceived life stress similarly if they ranked their life stress as not at all, not very or a bit stressful, across both groups, provincially, and regionally. Differences between those living with or without COPD were noted among those who ranked their life as quite a bit or extremely stressful. Those living with COPD were more likely to rank their life stress as quite a bit or extremely stressful, 27.2% compared to 19.5%, provincially. Those living in Northern Ontario with COPD were most likely to rank their life stress as quite a bit or extremely stressful, 29.6%, compared to 19.4% of those living in Northern Ontario without COPD.

Similar trends were noted among the rankings of perceived stress at work among those living with COPD compared to those not living with COPD. Persons living with COPD and those without COPD ranked their perceived work stress similarly if they ranked their work stress as not at all, not very or a bit stressful, across both groups, provincially, and regionally. Differences between those living with or without COPD were noted among those who ranked their work stress as quite a bit or extremely stressful. Those living with COPD were more likely to rank their work stress as quite a bit or extremely stressful, 32.1% compared to 26.9%, provincially. Those living in Northern Ontario with COPD were most likely to rank their work stress as quite a bit or extremely stressful, 40.7%, compared to 27.4% of those living in Northern Ontario without COPD.

Persons living with COPD and those without COPD ranked their perceived sense of belonging to community similarly if they ranked their perceived belonging as very strong, somewhat strong or somewhat weak, across both groups, provincially, and regionally. Differences between those living with or without COPD were noted among those who ranked their perceived belonging to community as very weak. Those living with COPD were more likely to rank their perceived belonging to community as very weak, 14.2% compared to 7.3%, provincially. Those living in Northern Ontario with COPD were most likely to rank their perceived belonging to community as very weak, 21.4%, compared to only 6.4% of those living in Northern Ontario without COPD.

Provincially or regionally, approximately 90% of participants identified an accessible care service (Table 3). This was most commonly a doctor’s office followed by a walk-in clinic. The third most common service was a hospital emergency department. There were, however, significant differences in type of service identified between northern Ontario and the rest of Ontario. Northern Ontarians identify a hospital emergency room as the second most common place they seek care for a health issue. Approximately 1/5th of the northern partners, regardless if diagnosed with COPD (21.1%) or not (20.6%) access emergency services for a ‘minor issue.’ Provincially, only 15.6% of those living with COPD, and 12.1% living without COPD, identify a hospital emergency room as a source of care for a minor health issue. For those living in Northern Ontario, living with or without COPD, a community health centre was commonly identified as a place where persons sought care, 8.2 % and 9.0%, respectively. The highest percentages of community health centre use were reported in Northern Ontario, those living elsewhere in the province rarely identified a community health centre as a place to seek care for a minor health problem, 4.4% and 4.0% respectively. Hospital outpatient settings and other settings were the least common places persons sought care for a minor problem regardless of where persons resided.

Those living with COPD were more likely to report having a regular health care provider than their counterparts living without COPD. For those who do not have a regular health care provider, the most common reason identified was no one was available in the area. For those living in Northern Ontario with COPD, 48% of those without a health care provider identified this as the reason. The second most common reason identified was that their health care provider retired or left the area, and this was highest reason for those living in Northern Ontario with COPD with 40% citing this as the reason.

Provincially about 95% of persons living with or without COPD identified their regular health care provider as a family physician (Table 4). In northern Ontario, about 91% identified their regular health care provider as a family physician. In northern Ontario about 8% of those with self-reported COPD identified their regular care provider as a nurse practitioner compared to only 4% of persons with COPD living elsewhere in the province. Persons were also asked to identify their wait time to see their primary health care provider for a minor problem. Provincially, about one-quarter of persons, with or without COPD were able to see their primary health care provider on the same day, whereas only about 17% of those living in northern Ontario were able to do so. The amount of time persons living in northern Ontario, with or without COPD, reported waiting for an appointment were higher than those living elsewhere in the province. In northern Ontario, about 18% reported waiting 1-2 weeks before being seen compared to about 15% waiting 1-2 weeks elsewhere in the province. About 15% reported waiting 2 weeks to 1 month for an appointment in northern Ontario compared to 6% elsewhere in the province. Lastly, 11% reported waiting 1 month or more in northern Ontario and only 4% reported waiting 1 month or more elsewhere in the province.

An ordinal logistic regression were used to determine if the self-reported wait times were different for those with COPD living in Ontario and in Northern Ontario. This was not statistically significant indicating that persons with COPD did not wait longer for care than those without COPD.

Persons were also asked to report if, in addition to their primary care provider, they saw other health care providers. Provincially, 6% of those living with COPD reported seeing other health care providers and 8% of those living with COPD in northern Ontario reported seeing other health care providers. A specialist was identified most commonly by those living with COPD, 44.8% provincially and 39.8% regionally. About one-quarter of persons living with COPD, provincially and regionally, identified seeing a pharmacist. Only about 6% (6.3% to 7.6%) of persons, with and without COPD, living in northern Ontario or elsewhere in the province, reported seeing a physiotherapist. About 6% of those living with COPD, provincially and in northern Ontario reported seeing a psychologist or mental health professional.

Overall, the majority of persons with COPD were satisfied with the level of coordination between their regular health care provider and other health professionals as most, 62% provincially, and 56.8% regionally, reported the level of coordination to be excellent or very good. Conversely, those living with COPD in northern Ontario were more likely to report their level of coordination between their regular health care provider and other health professionals as fair or poor, compared to only 11.3% of those living with COPD elsewhere in the province.

In the CCHS, persons were asked if, in addition to their primary healthcare provider, they saw any other healthcare providers. A series of possible provider types was provided. We consider both these individual provider types and the total number of services accessed as proxies for the capacity to access health services as needed. Because a substantial proportion of respondents did not access any additional services, the number of total services was modelled using a poisson regression for this analysis.

Provincially, overall, persons with COPD reported using additional health care services beyond primary healthcare (1.26) than those persons without COPD. Those reporting their health as good were more likely to use more services than those reporting their health as excellent or very good (1.31) and those reporting their health as fair or poor were also more likely to use more services (1.99). Use of health services did vary by age, such that respondents aged 35 to 49 tended to use more (1.21) times more likely to access services than younger respondents (less than 35 years), this increased for those 50-69 (1.42) and again for those 70 or older (1.65). Female respondents tended to use more services (1.31) than males. There was also an effect of income such that those with higher incomes, $80 000 or higher, reported using the greatest number of services, and those with incomes from $40 000 to $79 000 used more services (1.14) than those reporting lower incomes of less than $39 000.

Regionally, those living in northern Ontario, persons with COPD reported using additional health care services beyond primary healthcare (1.01 but not statistically significant) than those persons without COPD. Those reporting their health as good were more likely to use more services than those reporting their health as excellent or very good (1.30) and those reporting their health as fair or poor were also more likely to use more services (1.84). Use of health services did vary by age, such that respondents aged 35 to 49 tended to use more (1.31) times more likely to access services than younger respondents (less than 35 years), this increased for those 50-69 (1.24) and again for those 70 or older (1.53). Female respondents tended to use more services (1.34) than males. However, in this region there was no statistically significant effect of income.

Provincially or regionally, the majority of persons, 86% to 94%, living with COPD or not, reported that they were able to receive health care when needed (Table 5). However, some persons identified that they needed health care but did not receive it. Those living with COPD in Northern Ontario were most likely to report needing heath care but not receiving care (13.5%), compared to 11.4% of those living with COPD provincially. Those without COPD living in the north, were also more likely to report needed care and not receiving it (6.7%) compared to those without COPD living elsewhere in the province (5.9%).

In the north, the most common reason identified as why someone did not receive care was that care was not available in the area, as 27.8% of persons with COPD and 15.1% of persons without COPD cited this reason. Provincially, percentages were lower and did not vary greatly between those with or without COPD, as 14.2% and 10.4%, respectively reported this as the reason why they did not receive care. In the north, the next most common reason cited as why someone did not receive care was that care was not available at the time, 25% for those with COPD, and 20.2% for those without COPD. Reported percentages were similar provincially, 23.7% for those with COPD and 20.3% for those without COPD.

Provincially, the most common reason identified as why they did not receive care when needed was that the wait time was too long, 24.3% for those with COPD, and 30.7% for those without COPD. In the north, only 11.1% of those with COPD identified wait time as the reason, and 37% of those without COPD identified wait time as the reason.

Those living with COPD in the north were the only group who did not identify cost as a possible reason for not getting care. All other groups, those living with and without COPD provincially and those without COPD living in the north, a small percentage identified cost as a reason, 6.5%, 9.8%, and 5.5%, respectively. Those living with COPD in the north reported transportation issues, 8.3%, compared to about 4% for those with or without COPD elsewhere in the province or in the north without COPD.

Most persons sought care for treatment of a chronic physical health condition. For those living with COPD provincially and regionally, almost half sought care for this reason, 48.0% and 44.4%, respectively. About 30% of persons without COPD stated they sought care for this reason, both provincially and regionally. Treatment of an acute physical, non-infectious condition was the second most common reason persons sought care, 12% to 20% of persons identified this reason across all groups.

Across all groups, about 80% stated they actively tried to obtain the health care needed. A doctor’s office was the most common place identified as 50% or more persons identified this as the place they sought care. Twenty-five percent of those living in the north with COPD identified a walk-in clinic as the place they tried to receive care. Comparatively, only 13.1% of those living with COPD elsewhere in the province tried to access a walk-in clinic. An emergency department was another place persons sought to receive care. Those with COPD provincially identified this location, 21.5%, compared to 17.9% in northern Ontario, and those living without COPD provincially, 21% compared to 28% of those in northern Ontario. In the north, about 10% those living with or without COPD identified a community health centre as the place they tried to seek care from, comparatively only about 5% of persons living with or without COPD elsewhere in the province identified a community health centre.

After controlling for gender, education, martial status, and education level, there was an association between their self reports of their level of health and having COPD and living in Northern Ontario [t=-35.15, p>0.001, CI:-0.70- -0.63] such that residents of Northern Ontario living with COPD were more likely rate their health lower than those without COPD. There was an association between their self reports of their level of mental health and having COPD and living in Northern Ontario [t=-11.93, p>0.001, CI:-0.26- -0.19] such that residents of Northern Ontario living with COPD were more likely rate their mental health lower than those without COPD. In addition, there was an association between rankings of general satisfaction with life and having COPD and living in Northern Ontario [t=14.32, p>0.001, CI:0.19- 0.25] such that residents of Northern Ontario living with COPD were more likely to rank their general satisfaction with life higher than those living elsewhere

After controlling for gender, education, martial status, and education level, there was an association between their self reports of their life stress and having COPD and living in Northern Ontario [t=-5.47, p>0.001, CI:-0.18- -0.08] such that residents of Northern Ontario living with COPD were more likely rate their life stress higher than those without COPD. There was an association between self reports of stress at work and having COPD and living in Northern Ontario [t=-3.06, p>0.001, CI:-0.22- -0.05] such that residents of Northern Ontario living with COPD were more likely to rate their stress at work higher than those without COPD.