GENDER EQUITY IN ACCESS TO
COMMUNITY CARE USING
AMBULATORY CARE SENSITIVE
CONDITIONS (ACSC) AS A PROXY
Academy Health Annual Research Meeting, Boston 2010
Levinton,
e o ,C
C.,, Abramson,
b a so , B.,, Bierman,
e a , A.,, Ca
Caku,E.,
u, , Mohamed,
o a ed, N.,,
Orlando, S., Stewart, D., Tipper, B.,Wilson, R., Brown, A.D.
1
Outline
Research question
Methods
Databases and linkage
Analytical method - equity model
Results
Discussion and implications for health policy
2
Research questions and Outcome of Interest
Research Questions
- To what extent do social factors contribute to inequities in access to
community care beyond that which can be explained by clinical or health
factors?
- Are there differences in the patterns of inequity between men and women?
• Outcome of interest: Hospitalization
p
for an ambulatoryy care sensitive
condition (ACSC)
- Hypertension, adult asthma, chronic obstructive pulmonary disorder,
congestive
ti hheartt ffailure,
il
diabetes,
di b t depressive
d
i disorders,
di d
alcohol
l h l andd ddrug
psychoses, neurotic disorders, alcohol and drug dependence, non-dependent
abuse of drugs
3
Databases
1 Hospital Person Oriented
1.
Information (HPOI)
- Administrative database of all acute
inpatient separations in Canada
(excluding Quebec)
g p
include: sex,, age,
g ,
- Basic demographics
postal code (region)
- Fiscal years 92/93 to 04/05 (13 years)
- Includes: diagnostic codes,
codes
surgical/procedure codes, accident
codes, admission and separation dates
- Mix of ICD-9
ICD 9 and ICD-10
ICD 10 coding
(change over time)
- Linkage variable: Health Insurance
Number (HIN)
2 CCHS (Canadian Community
2.
Health Survey)
- Four
ou cycles
cyc es ((2001,
00 , 2003,
003, 2005,
005, 2007)
00 )
- ~ 130,000 respondents/cycle
- Includes socio-economic and
d
demographic
hi variables,
i bl e.g.: age, sex,
education, income level, general
mental and physical health, work
status, geographic region, etc.
- Includes self-assessed mental and
physical health status
status, health service
utilization, behavioral risk factors
- Linkage variable: Health Insurance
N b (HIN)
Number
4
Analytical Method (Step 1- Use of CART)
5
Analytical Method (Step 2- Develop Lorenz
Curves)
Develop a Lorenz curve and resulting Gini coefficient to measure
(in)equity among the sub-groups
 CART generates the vector of coefficients used to calculating the Gini coefficient,
via
i a LLorenz curve – a cumulative
l ti measure off iinequality
lit
 Rank order the groups identified by the CART algorithm from lowest to highest
rates
 Plot the cumulative rates of ACSC vs. cumulative proportion of population
 The graph produced is the Lorenz curve
6
Equity model results : Examples of subgroups
Variable Type
Group 1
Group 2
Group 3
Group 4
Group 5
Group 6
Health +
Socio-Economic
Determinants
(Health Very
Good to
Excellent
Age < 50)
Middle to High
Income
Employed
(Health Very
Good to Excellent
Age < 50)
Lower to Middle
to Income
Not Employed
(Presence of
Chronic
Disease with
Mild effect on
Daily activities
Age >= 50)
Low Income
(Health Good
to Excellent
Age >=
> 50)
Low Income
(Health Poor to
Average
Age >=
> 50)
Working Part
Time
Household
Size 2 or less
Ethnicity-Non
English
(Health Poor
to Average
Age >=
> 50)
Working Part
Time
Household
Size 3 or
more
Ethnicity-Non
English
ACSC rate %(N)
5.25(1,416,991)
13.96(259,426)
26.90(253,406)
34.96(374,411)
43.79(311,729)
61.06(202,574)
8.21
4.11
16.03
12.66
35.08
34.99
42.46
45.20
7.06(12.82)
10.24(14.16)
10.47(11.9 1)
20.47(35.3 6)
9.47(10.62)
10.99(12.38)
10.51(13.15)
18.23(37.70)
12.60(15.81)
13.82(18.07)
18.24(51.7 3)
16.42(17.6 5)
2.65(0.97)
2.85(0.97)
2.98(1.02)
3.16(0.96)
2.88(0.80)
3.09(0.85)
2.91(1.14)
2.89(1.12)
2.74(1.01)
2.57(0.90)
2.24(0.71)
3.19(0.98)
Males (%)
Females (%)
Consultations With Medical
Doctors
M
Mean(SD)
F
Availability of health care
Services in Community
y
M
F
Mean(SD)
23.59
31.04
61.27
61.02
7
Results: Lorenz curves
1
Eastern Canada
0.9
0.8
Cumulative
e Proportion o
of Events
Fem ale
Males
0.7
06
0.6
0.5
0.4
0.3
0.2
0.1
0
0
0.2
0.4
0.6
Cumulative Proportion of the Population
0.8
1
8
Results: Lorenz curves
1
Eastern Canada
0.9
0.8
Cumulative
e Proportion o
of Events
Fem ale
Males
0.7
06
0.6
0.5
0.4
0.3
Gini = 0.375
((0.335,, 0.419))
0.2
0.1
0
0
0.2
0.4
0.6
Cumulative Proportion of the Population
0.8
1
9
Results: Lorenz curves
1
Eastern Canada
0.9
0.8
Cumulative
e Proportion o
of Events
Fem ale
Males
0.7
06
0.6
0.5
0.4
0.3
Gini= 0.525
(0 491 0.560)
(0.491,
0 560)
0.2
0.1
0
0
0.2
0.4
0.6
Cumulative Proportion of the Population
0.8
1
10
Conclusion and Discussion
 Females demonstrate greater disparity in ACSC hospitalizations based on health
or clinical variables.
 Lower
L
iincome, poor hhealth,
lth andd ethnicity
th i it may bbe contributing
t ib ti ffactors
t tto greater
t
inequity
 Implications
p
on the health care system:
y
Policies to reduce inequities
q
through
g
supporting improved access to high quality care in the community, focusing on
identified groups with high rates of ACSC hospitalizations may lead to:
 Shorter ED wait times as a result of reduced need for ED utilization
 Alleviation of high bed occupancy rates especially in large urban centers
 Resulting decrease in health care costs with potentially lower cost
community
it care replacing
l i hi
higher
h costt acute
t care
 Healthier individuals with better managed conditions
11
Appendix
12
Definitions of
Ambulatory Care
S iti
Sensitive
Conditions
13
Generalized Lorenz Curve
• Expressed as follows:


v 1

G v  v cov y, 1  F y   y


•  = 2 reduces to standard Gini index
• This “aversion” parameter simply permits weighting of
different socio-economic groups. Larger values of 
applies less weight to “higher” socio-economic groups.
14
Results: Differences in ACSC rates for some
SES variables
SES Variable
Marital Status
Schooling
Geography
Males
Females
Married
0.222
0.132
Unmarried
0.214
0.214
< Secondary
0.312
0.237
Secondary graduate
0.134
0.169
S
Some
post-secondary
t
d
0 199
0.199
0 138
0.138
Post-secondary graduate
0.171
0.130
Urban
0 225
0.225
0 165
0.165
Rural
0.201
0.177
15
Results: Differences in ACSC rates for some
household income
SES Variable
Household
Income Level
Males
Females
10,000 – 19,999
0.250
0.244
20,000 – 29,999
0.286
0.180
30,000 – 39,999
0.235
0.233
40,000 – 49,999
0.229
0.104
50 000 – 59,999
50,000
59 999
0 360
0.360
0 133
0.133
60,000 – 79,999
0.168
0.076
80 000 and over
80,000
0 159
0.159
0 095
0.095
16
Results: Lorenz curves
Western Canada
Model includes health + social factors
17
Equity model results: Gini coefficients
* Confidence Intervals
at P < 0.05
Model consists of:
((1)) Health factors – age,
g , ppresence of chronic disease,, health utilityy index,, mental health pphysical
y
health,, social support;
pp ;
(2) SES factors – education status, income (personal, household), barriers to health access, labor force participation,
race, immigration status, language, marital status, geographic region.
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