PATIENT MARGINALIZATION AND COVID-19 EMERGENCY DEPARMENT (ED) VISITS DURING THE INITIAL WAVE OF THE PANDEMIC

Prepared by: HHS Integrated Decision Support BI (IDS), September, 2020

Data Sources: 1. ED Visit & Marginalization Information: IDS: National Ambulatory Care Reporting System (NACRS), 2016 Marginalization Index 2. Population Counts: Statistics Canada, 2016 Census of Population, Statistics Canada Catalogue no. 98-400-X2016003. Accessed July, 2020.

Purpose: To explore how the marginalization of a patient's community relates to the rate of adult COVID-19 ED visits (both suspected and confirmed cases) in the inital wave of the pandemic.

Data Time Period: January to June, 2020 > For context, this is the time period outlined in red as displayed in the Public Health Ontario chart to the right, which shows confirmed daily cases in Ontario.

IDS Patient Regions: Patients residing in the regions displayed below in blue are included in this report, accounting for about half the province of Ontario. For more details see Appendix A.

Chart Source: Ontario Agency for Health Protection and Promotion (Public Health Ontario). Epidemiologic summary: COVID-19 in Ontario – January 15, 2020 to September 20, 2020. , ON: Queen’s Printer for © 2020 Mapbox © OpenStreetMap Ontario; 2020. https://files.ontario.ca/moh-covid-19-report-en-2020-09-21.pdf. Accessed on Sept 21, 2020. Rate of COVID-19 ED Visits Per 10,000 Adult Population, by Ontario Marginalization Dimensions Summary Table All IDS Patient Regions, Adults Only, Jan to Jun 2020 IDS Patient Regions

Material Deprivation Residential Instability COVID-19 ED Visits 11,972

31.8 30 28.5 t t l l

u 30 u Adult Population 5,392,245 d d 23.3 A A 23.4 n 23.2 n 20.6 0 0 o o 0 0 i i Rate Per 10,000

t t 20

0 0 17.7 17.6 , , a 17.7 a 22.2 l 20 l 0 17.0 0 u u 1 1 Adult Population

p p r r o o e e P P P P

e e 10 2016 ON MARG INDEX:

t 10 t a a

R R 1 - Least Marginalized to 5 - Most 0 0 Marginalized 1 2 3 4 5 1 2 3 4 5 Material Deprivation Dependency Ethnic Concentration Closely connected to poverty and refers to 25.7 40 35.2 the inability for individuals and

t 24.6 t l l communities to access and attain basic u u

d 20.9 d

A A 30 material needs

n n 0 20 18.2 18.2 0 o o 0 0 i i 22.7 t t 0 0 , , a a

l l Residential Instability 0 0 18.3 u u

1 1 20

p p r r People who experience high rates of family o o e e 13.4

P P 12.3 P P 10 or housing instability e e

t t 10 a a R R Dependency 0 0 People who do not have income from 1 2 3 4 5 1 2 3 4 5 employment (including seniors, children, and adults whose work is not Observations: Looking across all IDS patient regions, the rate of COVID-19 ED visits per population increases compensated) considerably as the material deprivation, residential instability or ethnic concentration of the patient's neighbourhood increases. In addition, the rate appears to decrease as dependency increases. Ethnic Concentration High area-level concentrations of people However, this aggregate level can be misleading. Results by public health unit on the next several pages, show who are recent immigrants and/or people that within each area the trend is less pronounced, especially for dependency and ethnic concentration. belonging to a ‘visible minority’ group (defined by Statistics Canada as “persons, Part of the reason for this, is that not all cities have an equal distribution of marginalization across the other than aboriginal peoples, who are non-Caucasian in race or non-white in dimensions. For example, Peel & Toronto contribute 77% of the population within the 'Ethnic Concentration 5' colour”). bar on this page, but only 3% of the population within the 'Ethnic Concentration 1' bar. Peel & Toronto regions have some of the highest rates of COVID-19 ED visits per population overall (regardless of Ethnic ON-MARG Definition Source: Matheson, FI; Ontario Agency for Health Protection and Promotion Concentration), and this higher overall rate has a large impact on the 'Ethnic Concentration 5' column and a low (Public Health Ontario). 2016 Ontario impact on the 'Ethnic Concentration 1' column. marginalization index: user guide. Toronto, ON: Providence St. Joseph’s and St. Michael’s Similarily, Peel & Toronto contribute 58% of the 'Dependency 1' bar, but only 20% of the 'Dependency 5' bar. Healthcare; 2018. Joint publication with Public Health Ontario. Rate of COVID-19 ED Visits Per 10,000 Adult Population, by Material Deprivation & Public Health Unit Adults Only, Jan to Jun 2020

Material Deprivation 1 - Least Marginalized to 5 - Most Marginalized BRANT COUNTY CHATHAM-KENT CITY OF HAMILTON GREY BRUCE HALDIMAND-NORFOLK

16.0 3.6 2.9 2.7 3.5 5.7 6.9 3.9 10.5 7.3 4.7 6.4 9.4 6.5 6.6 7.9 6.7 4.8 6.5 5.4 4.7 7.1 9.3 4.2 10.2 HALTON REGION HURON COUNTY LAMBTON MIDDLESEX-LONDON NIAGARA REGION

25.6 26.7 21.0 20.9 16.0 15.9 10.0 10.4 6.7 12.6 13.1 12.3 8.0 5.2 7.5 11.4 6.2 10.9 7.7 7.0 10.0 6.9 5.0 8.4 8.9 PEEL PERTH DISTRICT REGION OF WATERLOO SOUTHWESTERN TORONTO*

67.2

43.9 43.0 45.5 32.0 35.1 33.1 30.0 30.2 26.8 31.1 26.3 23.2 20.6 24.2 20.2 14.6 16.8 15.3 15.3 14.5 12.9 8.7 13.4 12.9 WDG* WINDSOR-ESSEX

Observations: Within certain public health units such as Peel, Region of Waterloo, Toronto*, and Windsor-Essex, the rate of COVID-19 ED visits per population increases as the material deprivation of the patient's neighbourhood increases.

20.5 13.6 17.2 16.1 13.6 19.7 11.1 13.3 8.2 12.4 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

TORONTO*: This figure displays results for only the portion of Toronto Public Health (about half) that is contained in the TC LHIN, CW LHIN and MH LHIN regions. See Appendix A for more information. Wellington-Dufferin-Guelph (WDG)*: This figure only displays results for the Wellington & Guelph portions of this Public Health Region, not the Dufferin Region. See Appendix A for more information. Rate of COVID-19 ED Visits Per 10,000 Adult Population, by Residential Instability & Public Health Unit Adults Only, Jan to Jun 2020

Residential Instability 1 - Least Marginalized to 5 - Most Marginalized BRANT COUNTY CHATHAM-KENT CITY OF HAMILTON GREY BRUCE HALDIMAND-NORFOLK

17.2 14.6 10.5 3.6 3.5 1.2 4.4 6.4 6.1 4.7 4.1 7.0 6.3 7.0 5.8 9.2 8.4 6.0 7.7 5.2 4.7 4.1 6.3 4.4 6.2 HALTON REGION HURON COUNTY LAMBTON MIDDLESEX-LONDON NIAGARA REGION

31.5 24.7 16.4 19.9 20.8 12.4 11.1 11.4 12.9 10.7 9.2 9.1 8.1 9.7 7.8 0.0 7.7 7.6 10.0 7.1 7.3 8.9 1.3 4.4 8.6 PEEL PERTH DISTRICT REGION OF WATERLOO SOUTHWESTERN TORONTO*

49.7 46.6 40.5 42.4 39.4 34.9 33.0 32.0 30.2 26.4 25.4 29.1 30.0 21.2 23.0 17.3 20.9 19.0 17.6 19.2 11.9 14.2 11.9 3.8 9.1 WDG* WINDSOR-ESSEX

Observations: Within certain public health units such as the Region of Waterloo and Wellington Dufferin Guelph (WDG) the rate of COVID-19 ED visits per population increases as the residential instability of the patient's neighbourhood increases.

14.3 15.4 16.1 18.1 17.2 18.3 10.0 12.7 12.7 13.4

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

TORONTO*: This figure displays results for only the portion of Toronto Public Health (about half) that is contained in the TC LHIN, CW LHIN and MH LHIN regions. See Appendix A for more information. Wellington-Dufferin-Guelph (WDG)*: This figure only displays results for the Wellington & Guelph portions of this Public Health Region, not the Dufferin Region. See Appendix A for more information. Rate of COVID-19 ED Visits Per 10,000 Adult Population, by Dependency & Public Health Unit Adults Only, Jan to Jun 2020

Dependency 1 - Least Marginalized to 5 - Most Marginalized BRANT COUNTY CHATHAM-KENT CITY OF HAMILTON GREY BRUCE HALDIMAND-NORFOLK

19.6 20.0 18.9 13.3 4.8 4.0 2.8 4.3 3.6 0.0 0.0 3.5 4.2 5.6 7.2 7.8 8.3 8.2 3.6 4.5 5.1 6.2 7.5 4.5 4.1 HALTON REGION HURON COUNTY LAMBTON MIDDLESEX-LONDON NIAGARA REGION

37.0

17.3 19.6 21.8 11.5 11.6 10.8 10.7 13.1 9.4 5.9 8.7 10.2 10.0 5.3 10.2 6.2 9.8 7.1 6.2 7.4 6.4 5.8 7.1 8.1 PEEL PERTH DISTRICT REGION OF WATERLOO SOUTHWESTERN TORONTO*

51.2 44.6 41.8 37.7 40.0 30.3 28.0 31.8 28.5 31.9 29.0 29.7 27.3 27.5 24.1 27.7 18.7 19.3 16.4 16.3 13.0 11.8 12.0 14.7 4.9 WDG* WINDSOR-ESSEX Observations: Within certain public health units such as the City of Hamilton and Windsor-Essex, the rate of COVID-19 ED visits per population increases as the dependency of the patient's neighbourhood increases. In many public health units, there is not a clear relationship between dependency and COVID-19 ED visits. Across all IDS Patient Regions there was a decreasing trend in COVID-19 ED visits with

20.7 18.3 increased dependency of a patient's neighbourhood. However, this decreasing trend is not 12.8 16.8 13.5 13.3 16.5 11.6 11.3 8.1 apparent at the public health unit level.

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

TORONTO*: This figure displays results for only the portion of Toronto Public Health (about half) that is contained in the TC LHIN, CW LHIN and MH LHIN regions. See Appendix A for more information. Wellington-Dufferin-Guelph (WDG)*: This figure only displays results for the Wellington & Guelph portions of this Public Health Region, not the Dufferin Region. See Appendix A for more information. Rate of COVID-19 ED Visits Per 10,000 Adult Population, by Ethnic Concentration & Public Health Unit Adults Only, Jan to Jun 2020

Ethnic Concentration 1 - Least Marginalized to 5 - Most Marginalized BRANT COUNTY CHATHAM-KENT CITY OF HAMILTON GREY BRUCE HALDIMAND-NORFOLK 3 . 0 . 3 9 9 2 8 3 1 5 0 1 4 0 7 0 4 9 3 3 6 0 0 ...... 0 ...... 1 9 7 7 8 7 7 4 2 6 5 0 5 0 1 6 5 5 6 6 0 0 HALTON REGION HURON COUNTY LAMBTON MIDDLESEX-LONDON NIAGARA REGION 7 . 8 5 . 6 2 2 . 2 . 5 0 1 9 9 . . . . . 6 6 6 5 9 2 1 4 9 9 3 9 3 . . 2 0 0 0 8 3 3 2 . . 2 0 . . . 1 . . 1 ...... 1 9 9 1 1 8 9 1 1 8 7 7 6 7 0 0 0 5 6 6 PEEL PERTH DISTRICT REGION OF WATERLOO SOUTHWESTERN TORONTO* 6 . 8 5 7 6 7 . . . 7 1 5 3 1 . 1 0 9 . . 0 . . 4 . 4 4 3 3 3 4 6 2 2 3 . 0 1 . 3 . 3 3 . 3 3 9 3 4 3 3 . . 6 2 2 7 2 6 1 5 . . . . . 2 . 2 7 7 2 2 4 4 4 4 3 2 0 1 1 . 1 1 1 1 1 1 0 WDG* WINDSOR-ESSEX Observations: Peel is the only public health unit with a clear increase in the rate of COVID-19 ED visits per population as the ethnic concentration of the patient's neighbourhood increases. However for several public health units, such as Halton Region, Middlesex-London, Region of Waterloo, Toronto*, and WDG*, patients residing in the most ethnically diverse 1 . 2 6 1 9

. neighbourhoods (ON-MARG ethnic concentration index 5) have a higher rate than patients . . 2 8 . 1 6 7 5 . . . . 7 . 6 7 2 5 3 3 2 1 1 1 1 1 1 1

1 1 living in all other neighbourhoods. 1 1

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

TORONTO*: This figure displays results for only the portion of Toronto Public Health (about half) that is contained in the TC LHIN, CW LHIN and MH LHIN regions. See Appendix A for more information. Wellington-Dufferin-Guelph (WDG)*: This figure only displays results for the Wellington & Guelph portions of this Public Health Region, not the Dufferin Region. See Appendix A for more information. Overall Rate of COVID-19 ED Visits Per 10,000 Adult Population Results by Public Health Unit, Adults Only, Jan to Jun 2020

TORONTO* 1,202,110 [22%] 41.58 4,998

PEEL 1,030,380 [19%] 28.89 2,977

CITY OF HAMILTON 417,375 [8%] 7.40 309

REGION OF WATERLOO 405,455 [8%] 29.00 1,176

HALTON REGION 404,775 [8%] 9.93 402

NIAGARA REGION 355,565 [7%] 8.72 310

MIDDLESEX-LONDON 353,160 [7%] 8.30 293

WINDSOR-ESSEX 306,790 [6%] 14.73 452

WDG* 169,505 [3%] 14.69 249

SOUTHWESTERN 151,240 [3%] 15.41 233

GREY BRUCE 127,570 [2%] 5.64 72

BRANT COUNTY 102,375 [2%] 3.81 39

LAMBTON 97,535 [2%] 19.89 194

HALDIMAND-NORFOLK 85,690 [2%] 9.92 85

CHATHAM-KENT 78,785 [1%] 6.47 51

PERTH DISTRICT 58,100 [1%] 14.63 85

HURON COUNTY 45,835 [1%] 10.25 47

0K 500K 1000K 1500K 0 10 20 30 40 50 0 1,000 2,000 3,000 4,000 5,000

Rate of COVID-19 ED visits Per 10,000 Adult Population Population COVID-19 ED Visits > [%] shows the % of column total

TORONTO*: This figure displays results for only the portion of Toronto Public Health (about half) that is contained in the TC LHIN, CW LHIN and MH LHIN regions. See Appendix A for more information. Wellington-Dufferin-Guelph (WDG)*: This figure only displays results for the Wellington & Guelph portions of this Public Health Region, not the Dufferin Region. See Appendix A for more information. TORONTO* & PEEL SPOTLIGHT Background: Since Toronto and Peel Public Health Units (PHUs) cover such a large population, the following four pages break the two PHUs into smaller LHIN Subregions. The LHIN Subregion map below is provided for reference.

Toronto* & Peel LHIN Subregion Reference Map LHIN Subregion 05 Bolton-Caledon 05 Bramalea 05 05 North Malton* 06 East 06 North West Mississauga 06 South Etobicoke 06 South West Mississauga 07 07 Mid-East Toronto 07 Mid- 07 07 West Toronto

TORONTO*: The map displays results for only the portion of Toronto Public Health (about half) that is contained in the TC LHIN, CW LHIN and MH LHIN regions. See Appendix A for more information.

05 North Etobicoke Malton*: This LHIN subregion is typically named 05 North Etobicoke Malton West Woodbridge. However, the West Woodbridge portion of the LHIN subregion falls within the York Region PHU, which is not within the IDS Patient Region geography. Therefore West Woodbridge is not included in this analysis, and the LHIN subregion name has been revised accordingly.

© 2020 Mapbox © OpenStreetMap TORONTO* & PEEL SPOTLIGHT Rate of COVID-19 ED Visits Per 10,000 Adult Population, by Material Deprivation & LHIN Subregion Adults Only, Jan to Jun 2020 1 - Least Marginalized to 5 - Most Marginalized Material Deprivation 05 Bolton-Caledon 05 Bramalea 05 Brampton 05 North Etobicoke Malton* 1 . 7 3 . 9 8 0 . 7 9 . 0 5 2 0 4 1 . . 8 . 3 3 . . 8 6 . 4 2 3 . . 2 3 5 . . 3 . 0 8 8 4 . 6 9 . 4 3 4 4 . 0 1 9 4 3 3 5 3 5 2 3 3 3 . . 2 3 3 2 2 2 3 9 1 06 East Mississauga 06 North West Mississauga 06 South Etobicoke 06 South West Mississauga 7 8 1 3 9 . . 3 . 5 . . 1 . 4 . 9 2 . 1 9 1 9 . 8 0 2 4 4 . . 6 6 0 6 6 . . 3 . . . . 1 . . . 0 4 3 6 3 4 6 3 3 3 4 3 1 1 0 0 3 7 5 4 3 2 2 2 2 2 2 2 2 2 1 1 1 07 East Toronto 07 Mid-East Toronto 07 Mid-West Toronto 07 North Toronto 8 . 9 0 4 4 . 3 1 . . 4 9 7 0 0 8 . 9 . 7 9 7 . 7 . 1 . 8 3 0 0 8 6 5 5 . . 0 5 3 9 5 1 . 4 1 . . 8 2 9 4 . 3 2 . . . . . 7 5 5 2 3 3 0 1 8 6 8 2 2 2 2 2 2 1 1 1 07 West Toronto

Observations: Within certain LHIN Subregions such as Bolton-Caledon, North Etobicoke Malton, East Toronto, and Mid-East Toronto, there is a clear increase in the rate of COVID-19 ED visits per population as the material deprivation of the patient's neighbourhood increases. 5 1 4 2 1 . . . . . 6 6 3 4 4 2 2 2 2 2

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

TORONTO*: This figure displays results for only the portion of Toronto Public Health (about half) that is contained in the TC LHIN, CW LHIN and MH LHIN regions. See Appendix A for more information. 05 North Etobicoke Malton*: This LHIN subregion is typically named 05 North Etobicoke Malton West Woodbridge. However, the West Woodbridge portion of the LHIN subregion falls within the York Region PHU, which is not within the IDS Patient Region geography. Therefore West Woodbridge is not included in this analysis, and the LHIN subregion name has been revised accordingly. TORONTO* & PEEL SPOTLIGHT Rate of COVID-19 ED Visits Per 10,000 Adult Population, by Residential Instability & LHIN Subregion Adults Only, Jan to Jun 2020

Residential Instability 1 - Least Marginalized to 5 - Most Marginalized 05 Bolton-Caledon 05 Bramalea 05 Brampton 05 North Etobicoke Malton* 6 . 8 0 . 0 . 0 1 9 6 1 0 . 9 . 8 0 9 7 6 4 4 6 0 6 . . 0 6 . . . 8 . . 5 . 9 9 3 8 . 6 5 4 . 4 4 6 2 . 0 3 3 3 . . 7 3 3 4 3 3 2 0 3 . 3 1 2 2 2 9 1 1 06 East Mississauga 06 North West Mississauga 06 South Etobicoke 06 South West Mississauga 6 . 5 9 2 5 . 0 7 . . 9 9 . 2 1 6 . 3 . . . 2 2 . . 7 . 2 4 4 2 7 8 . . 2 4 9 5 1 . 9 . . . 7 8 . . 7 7 3 5 3 3 3 3 3 3 0 2 8 8 8 2 2 6 0 2 2 2 2 2 2 1 1 1 1 1 07 East Toronto 07 Mid-East Toronto 07 Mid-West Toronto 07 North Toronto 1 4 . 6 7 2 . . . . 8 3 0 9 0 3 7 . 7 8 7 6 7 . 4 6 7 5 . 1 0 6 3 . 4 7 . 1 0 2 . . 2 3 0 8 0 ...... 7 6 2 3 3 1 0 9 8 3 5 6 7 2 2 2 2 2 2 1 1 1 1 1 1 07 West Toronto

Observations: In most of the LHIN Subregions shown here, there is no clear relationship between the rate of COVID-19 ED visits per population and the residential instability of the patient's neighbourhood. 7 3 0 . . 5 . 1 . . 7 7 4 1 7 2 2 2 2 1 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

TORONTO*: This figure displays results for only the portion of Toronto Public Health (about half) that is contained in the TC LHIN, CW LHIN and MH LHIN regions. See Appendix A for more information. 05 North Etobicoke Malton*: This LHIN subregion is typically named 05 North Etobicoke Malton West Woodbridge. However, the West Woodbridge portion of the LHIN subregion falls within the York Region PHU, which is not within the IDS Patient Region geography. Therefore West Woodbridge is not included in this analysis, and the LHIN subregion name has been revised accordingly. TORONTO* & PEEL SPOTLIGHT Rate of COVID-19 ED Visits Per 10,000 Adult Population, by Dependency & LHIN Subregion Adults Only, Jan to Jun 2020 1 - Least Marginalized to 5 - Most Marginalized Dependency 05 Bolton-Caledon 05 Bramalea 05 Brampton 05 North Etobicoke Malton* 4 . 0 4 . 0 8 6 6 . . 1 0 9 . 1 8 2 8 7 7 4 5 . 9 8 1 . 9 1 3 . . . 4 . 5 . . 0 1 . 6 . 3 3 0 5 7 . 2 0 9 0 4 . . . 7 3 5 3 3 9 2 3 3 2 3 . 1 3 6 2 2 2 7 1 1 1 06 East Mississauga 06 North West Mississauga 06 South Etobicoke 06 South West Mississauga 0 . 0 1 3 4 3 8 7 . 5 5 . . . 7 . 7 5 5 . 5 . . 6 . . . . 4 0 0 3 1 4 3 . 2 2 2 1 . . . . . 0 . 8 8 6 5 5 5 3 2 3 3 3 3 9 9 0 9 0 3 4 2 2 2 2 2 2 2 1 1 2 1 2 1 07 East Toronto 07 Mid-East Toronto 07 Mid-West Toronto 07 North Toronto 4 4 . 0 . 9 9 6 . 9 . . 3 . . 8 4 1 2 8 9 7 7 7 7 7 6 6 8 5 . . 9 1 1 1 0 9 . 9 . . 6 4 . 7 2 1 0 . . . 4 . 3 . . . 7 7 7 5 2 0 0 9 8 5 6 2 2 2 2 2 2 2 1 1 1 1 07 West Toronto

Observations: In Bolton-Caledon, North West Mississauga and South Etobicoke, there is an increasing trend of COVID-19 ED visits per population as the dependency of a patient's neighbourhood increases. 1 7 . 4 . 2 4 . . . 2 8 5 3 0 3 2 2 2 2

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

TORONTO*: This figure displays results for only the portion of Toronto Public Health (about half) that is contained in the TC LHIN, CW LHIN and MH LHIN regions. See Appendix A for more information. 05 North Etobicoke Malton*: This LHIN subregion is typically named 05 North Etobicoke Malton West Woodbridge. However, the West Woodbridge portion of the LHIN subregion falls within the York Region PHU, which is not within the IDS Patient Region geography. Therefore West Woodbridge is not included in this analysis, and the LHIN subregion name has been revised accordingly. TORONTO* & PEEL SPOTLIGHT Rate of COVID-19 ED Visits Per 10,000 Adult Population, by Ethnic Concentration & LHIN SubRegion Adults Only, Jan to Jun 2020

Ethnic Concentration 1 - Least Marginalized to 5 - Most Marginalized 05 Bolton-Caledon 05 Bramalea 05 Brampton 05 North Etobicoke Malton* 3 . 1 8 9 . 0 7 3 . 6 . 7 2 4 7 . . 2 . 8 4 9 . 1 6 4 7 . 2 1 . 0 . 9 3 . . 7 . 2 3 3 1 0 0 5 9 2 8 8 2 . 0 . . 2 2 1 1 1 8 1 0 7 06 East Mississauga 06 North West Mississauga 06 South Etobicoke 06 South West Mississauga 5 . 4 6 1 7 5 0 . 8 . 9 8 . . 2 . 7 2 . . 0 . 7 . . 5 2 3 . 3 3 3 1 9 0 0 9 3 . . . 8 3 . 6 6 3 . . 4 3 3 3 3 3 0 0 0 8 2 7 2 2 2 . 5 2 2 2 1 1 1 0 1 07 East Toronto 07 Mid-East Toronto 07 Mid-West Toronto 07 North Toronto 6 . 5 6 . 4 7 9 2 8 . . . . 5 2 7 7 2 5 6 7 . . 6 6 6 6 5 3 5 9 5 5 8 . 5 2 7 . . . 9 6 . . 7 1 5 . . 4 1 . 8 7 . 6 . . 5 3 3 1 1 8 2 2 7 2 1 1 2 2 2 2 1 1 1 1 07 West Toronto Observations: Within certain LHIN Subregions such as Brampton, North Etobicoke Malton, East Mississauga, and North Toronto there is an increasing trend in the rate of COVID-19 ED visits per population as the ethnic concentration of the patient's neighbourhood increases. 2 .

5 In other regions such as West Toronto and South West Mississauga, the rate of COVID-19 ED visits per 2 . 7 6 . . 0 4 0 . 5 5 3 0 population decreases with ethnic concentration. 2 2 2

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

TORONTO*: This figure displays results for only the portion of Toronto Public Health (about half) that is contained in the TC LHIN, CW LHIN and MH LHIN regions. See Appendix A for more information. 05 North Etobicoke Malton*: This LHIN subregion is typically named 05 North Etobicoke Malton West Woodbridge. However, the West Woodbridge portion of the LHIN subregion falls within the York Region PHU, which is not within the IDS Patient Region geography. Therefore West Woodbridge is not included in this analysis, and the LHIN subregion name has been revised accordingly. Appendix A: IDS Patient Regions How much of Ontario is > IDS data includes all acute care hospitals within the ESC, SW, WW, HNHB, MH & TC LHINs, as well as single health service providers in other included? regions: William Osler Health System, Children's Hospital of Eastern Ontario & Health Sciences North. The adult (18+) > In order to calculate a rate per population, only regions where the majority of patient hospital activity from that region is captured within the population residing hospitals listed above can be used. in the 'IDS Patient > Therefore, only residents that live within the census divisions within the 6 LHIN regions above, as well as Peel (since William Osler accounts for the Regions' is 5.4 majority of ED visits for residents of Peel) have been included in the analysis, and are referred to as 'IDS Patient Regions'. million, which is 50% of the total > Toronto Census Division however, is only partially contained within these regions. Therefore, only the Dissemination Areas included within the TC, Ontario adult MH & CW LHINs are included in the analysis, displayed in dark green in the 'Toronto Census Division' map below. population of 10.8 > As noted throughout this report, the Dufferin portion of the Wellington-Dufferin-Guelph (WDG) Public Health Unit is not included. The majority of million as of the acute visits for residents of Dufferin take place at Headwaters Healthcare, which is not an IDS Participating Hospital. 2016 census.

IDS Patient Regions Census Divisions marked in blue below, as well as the dark green portion of the Toronto Census Division is included in this report.

Toronto Census Division

© 2020 Mapbox © OpenStreetMap © Mapbox © OSM Appendix B: Distribution of Public Health Unit Adult Population by Ontario Marginalization Dimension

Ontario Marginalization Quntiles [1 - Least Marginalized to 5 - Most Marginalized]: Sample Interpretation: 35% of the population of Chatham-Kent live in the most materially deprived areas in the province (quintile 5), while 9% live in the most 1 2 3 4 5 affluent (quintile 1) areas of the province.

Material Deprivation Residential Instability

BRANT COUNTY 19% 17% 22% 17% 26% BRANT COUNTY 19% 25% 17% 22% 17% CHATHAM-KENT 9% 13% 18% 24% 35% CHATHAM-KENT 14% 21% 24% 28% 13% CITY OF HAMILTON 20% 17% 15% 20% 28% CITY OF HAMILTON 18% 17% 20% 19% 25% GREY BRUCE 18% 24% 24% 19% 15% GREY BRUCE 9% 25% 33% 22% 11% HALDIMAND-NORFOLK 8% 24% 29% 25% 14% HALDIMAND-NORFOLK 20% 26% 27% 21% 6% HALTON REGION 56% 23% 12% HALTON REGION 38% 18% 18% 11% 15% HURON COUNTY 14% 20% 25% 30% 12% HURON COUNTY 18% 20% 23% 34% 5% LAMBTON 24% 24% 18% 14% 20% LAMBTON 12% 23% 23% 26% 17% MIDDLESEX-LONDON 26% 19% 13% 19% 24% MIDDLESEX-LONDON 14% 17% 21% 16% 32% NIAGARA REGION 18% 21% 16% 22% 23% NIAGARA REGION 8% 21% 23% 29% 19% PEEL 13% 22% 29% 24% 13% PEEL 42% 19% 13% 12% 15% PERTH DISTRICT 16% 27% 28% 21% 8% PERTH DISTRICT 18% 20% 17% 30% 15% REGION OF WATERLOO 29% 20% 18% 16% 16% REGION OF WATERLOO 25% 16% 16% 18% 25% SOUTHWESTERN 18% 23% 19% 18% 22% SOUTHWESTERN 18% 27% 22% 20% 13% TORONTO* 33% 16% 14% 16% 21% TORONTO* 6% 10% 20% 59% WDG* 35% 23% 21% 13% 8% WDG* 21% 22% 17% 20% 19% WINDSOR-ESSEX 16% 20% 19% 17% 28% WINDSOR-ESSEX 23% 19% 18% 20% 20%

Dependency Ethnic Concentration

BRANT COUNTY 14% 22% 24% 20% 19% BRANT COUNTY 24% 39% 21% 13% CHATHAM-KENT 8% 19% 36% 34% CHATHAM-KENT 45% 31% 19% 5% CITY OF HAMILTON 20% 22% 18% 21% 19% CITY OF HAMILTON 10% 22% 26% 29% 13% GREY BRUCE 9% 12% 32% 45% GREY BRUCE 67% 24% 9% HALDIMAND-NORFOLK 13% 21% 27% 34% HALDIMAND-NORFOLK 50% 39% 9% HALTON REGION 45% 17% 12% 13% 13% HALTON REGION 7% 14% 23% 28% 27% HURON COUNTY 14% 21% 25% 37% HURON COUNTY 67% 24% 7% LAMBTON 12% 24% 27% 34% LAMBTON 42% 34% 19% MIDDLESEX-LONDON 19% 23% 22% 20% 16% MIDDLESEX-LONDON 15% 23% 26% 22% 14% NIAGARA REGION 7% 15% 18% 25% 36% NIAGARA REGION 25% 32% 28% 13% PEEL 42% 27% 15% 11% 6% PEEL 9% 18% 70% PERTH DISTRICT 15% 26% 24% 18% 17% PERTH DISTRICT 42% 38% 18% REGION OF WATERLOO 37% 21% 17% 13% 12% REGION OF WATERLOO 10% 20% 24% 33% 13% SOUTHWESTERN 12% 22% 25% 21% 20% SOUTHWESTERN 34% 41% 20% 5% TORONTO* 38% 27% 16% 10% 9% TORONTO* 6% 24% 39% 30% WDG* 32% 25% 15% 14% 14% WDG* 19% 28% 24% 21% 8% WINDSOR-ESSEX 10% 19% 24% 22% 25% WINDSOR-ESSEX 19% 23% 24% 20% 13% Appendix C: Methodology & Considerations

METHODOLOGY

1. The following Census Divisions of patient residence are included in the analysis: Brant, Bruce, Chatham-Kent, Elgin, Essex, Grey, Haldimand-Norfolk, Halton, Hamilton, Huron, Lambton, Middlesex, Niagara, Oxford, Peel, Perth, Toronto, Waterloo, Wellington. In addition, any dissemination areas (DAs) of the Toronto Census Division outside of MH, CW & TC LHIN region boundaries were excluded.

2. The adult population (18+) of each DA were downloaded from Statistics Canada (source citation on page 1 of this report).

3. Adult COVID-19 ED visits were identified from NACRS data as follows: ED Visits (ED Visit Indicator = 1) with a registration date in January to June, 2020, patient age of 18 or older, and any diagnosis (not just main diagnosis) of “U071 - Confirmed COVID-19 Case” or “U072 - Suspected COVID-19 Case”.

4. Each patient was assigned an Ontario Marginalization (ON-MARG) Index Score using the dissemination area (DA) of patient residence (based on the patient's postal code of the ED visit). A DA is the smallest geography that the ON-MARG information is made available. Patients records that were not associated with an ON-MARG index score (either due to invalid patient geography, or because the region has not been attributed an ON-MARG score due to small cell counts) were excluded from the analysis. in addition, patients residing in a DA where the adult population count is deemed 'too unreliable to be published' by Statistics Canada are excluded from the analysis.

5. The rate of adult COVID-19 ED visits per 10,000 population is calculated as the number of ED visits within each ON-MARG quintile, divided by the total adult population within each ON-MARG quintile.

CONSIDERATIONS

1. The 2016 Ontario Marginalization Index (ON-MARG) is used here as a proxy for patient marginalization based on the dissemination area (DA) of patient residence, since this marginalization information is not available at an individual patient level. Therefore patients are assigned the marginalization score of their overall neighbourhood (a DA typically has a population of 400-700 people), and may not reflect that marginalization level as an individual. In addition, the 2016 Ontario Marginalization Index is based on the 2016 Statistics Canada census, while the ED visits in this report are from 2020. Therefore, population demographics within in each area that have changed since 2016 are not represented here.

2. As stated in Appendix A, not all hospitals in Ontario are participants of IDS. Therefore, patient activity for those who reside in the 'IDS patient regions' but attend a hospital outside of IDS will not be captured in this report.

3. Adult population counts from Statistics Canada are aggregated from counts by individual age at a DA level into an 18+ category. At the DA level, some of these individual age volumes are labelled as "too unreliable to be published' and are not available. In addition, populations of DAs that are not assigned an ON-MARG score are excluded from the analysis. Therefore aggregate population counts at the public health unit level posted by Statistic Canada may differ slightly from the population counts displayed in this report.

4. Results here are not adjusted for differences in age across regions or dimensions of marginalization. Age-adjustment could provide a more equitable look at the difference in rates. Public Health Ontario has released a document looking at ON-MARG ethnic concentration and COVID-19 infections across the province using age adjusted rates. This report is available here: > Ontario Agency for Health Protection and Promotion (Public Health Ontario). COVID-19 in Ontario - A Focus on Diversity: January 15, 2020 to May 14, 2020 Toronto, ON: Queen’s Printer for Ontario; 2020.