Linking Preventable Hospitalisation Rates to Neighbourhood Characteristics within Ottawa Geneviève Prud’homme Master Thesis in Science in Health Systems University of Ottawa Supervisor: Kevin Brand – Telfer School of Management Co-Supervisor: Elizabeth Kristjansson – School of Psychology © Geneviève Prud’homme, Ottawa, Canada, 2012 Library and Archives Bibliothèque et Canada Archives Canada Published Heritage Direction du Branch Patrimoine de l'édition 395 Wellington Street 395, rue Wellington Ottawa ON K1A 0N4 Ottawa ON K1A 0N4 Canada Canada Your file Votre référence ISBN: 978-0-494-86598-9 Our file Notre référence ISBN: 978-0-494-86598-9 NOTICE: AVIS: The author has granted a non- L'auteur a accordé une licence non exclusive exclusive license allowing Library and permettant à la Bibliothèque et Archives Archives Canada to reproduce, Canada de reproduire, publier, archiver, publish, archive, preserve, conserve, sauvegarder, conserver, transmettre au public communicate to the public by par télécommunication ou par l'Internet, prêter, telecommunication or on the Internet, distribuer et vendre des thèses partout dans le loan, distrbute and sell theses monde, à des fins commerciales ou autres, sur worldwide, for commercial or non- support microforme, papier, électronique et/ou commercial purposes, in microform, autres formats. paper, electronic and/or any other formats. The author retains copyright L'auteur conserve la propriété du droit d'auteur ownership and moral rights in this et des droits moraux qui protege cette thèse. Ni thesis. Neither the thesis nor la thèse ni des extraits substantiels de celle-ci substantial extracts from it may be ne doivent être imprimés ou autrement printed or otherwise reproduced reproduits sans son autorisation. without the author's permission. In compliance with the Canadian Conformément à la loi canadienne sur la Privacy Act some supporting forms protection de la vie privée, quelques may have been removed from this formulaires secondaires ont été enlevés de thesis. cette thèse. While these forms may be included Bien que ces formulaires aient inclus dans in the document page count, their la pagination, il n'y aura aucun contenu removal does not represent any loss manquant. of content from the thesis. Abstract Enhancing primary care is key to the Canadian health care reform. Considered as an indicator of primary care access and quality, hospitalisations for ambulatory care sensitive (ACS) conditions are commonly reported by Canadian organisations as sentinel events signaling problems with the delivery of primary care. However, the literature calls for further research to identify what lies behind ACS hospitalisation rates in regions with a predominantly urban population benefiting from universal access to health care. A theoretical model was built and, using an ecological design, multiple regressions were implemented to identify which neighbourhood characteristics explained the socio-economic gradient in ACS hospitalisation rates observed in Ottawa. Among these neighbourhoods, healthy behaviour and - to a certain extent - health status were significantly associated with ACS hospitalisation rates. Evidence of an association with primary care accessibility was also signaled for the more rural neighbourhoods. Smoking prevention and cessation campaigns may be the most relevant health care strategies to push forward by policy makers hoping to prevent ACS hospitalisations in Ottawa. From a health care equity perspective, targeting these campaigns to neighbourhoods of low socio-economic status may contribute to closing the gap in ACS hospitalisations described in this current study. Reducing the socio-economic inequalities of neighbourhoods would also contribute to health equity. ii Disclosure “The research and analysis are based on data from Statistics Canada and the opinions expressed do not represent the views of Statistics Canada.” “The research and analysis are also based on data from the Canadian Institute for Health Information - obtained from Ottawa Public Health - and the opinions expressed do not represent the views of these organisations.” iii Acknowledgments First and foremost, I offer my deepest gratitude to my two supervisors, Prof. Kevin Brand and Prof. Elizabeth Kristjansson from the University of Ottawa (UofO), who supported me throughout the process with their knowledge, expertise, patience and passion. Their encouragements and advices were more than crucial to the conception, analysis and writing of my thesis project, I am truly thankful for their contributions and I cherish the relationships we developed. I particularly enjoyed the on-going conversation with my supervisor Kevin, who continually pushed me further in my reflective and intellectual process. A special thank you goes to all, and in particular to Prof. Sawada from UofO, who were involved in the development of the Ottawa neighbourhoods and their health measures as part of the multidisciplinary research project of the Ottawa Neighbourhood Study, an initiative based at the Institute of Population Health of the UofO. I am more than pleased by having had the opportunity to be part of this project lead by my co-supervisor Elizabeth, thank you for having me as part of your team. The recommendations of Prof. Ted Schrecker from UofO in the early stages of my thesis were also most valuable to me and his recommendations as an external examiner were greatly appreciated. A special thank you goes to Eric Crighton from the Department of Geography of UofO for his thorough review of my thesis as an external examiner: his comments vastly improved the content of my work. Numerous other people were indispensable for the completion of this thesis. Starting with Katherine Russell, Epidemiologist at Ottawa Public Health (OPH), who initiated the study of ACS hospitalisations in Ottawa and accepted that I pursue it for my thesis project. Cameron McDermaid, Epidemiologist at OPH, embraced my research project, organised my data sharing agreement with the institution and provided me with the customised hospitalisation and ER visit counts that I needed. His knowledge and expertise of the DAD and NACRS databases as well as his on-going advices were really valuable. I am also grateful to Leigh Ann Butler, Epidemiologist at OPH, and Amira Ali, Senior Epidemiologist at OPH, who thoroughly explored with me the iv possibilities of using data from the Rapid Risk Factor Surveillance Survey to derive my neighbourhood compositional estimates. The two analysts of the COOL RDC - Jean-Michel Billette and Darcy Hango - with whom I collaborated over the course of my thesis project were great support to me. A special and heartfelt ‘merci’ goes to Jean-Michel for his precious intellectual input on the methodological aspects of this study. I am beholden to Jean-Michel’s expertise in statistics and infinite willingness to help. I am also really grateful for the valuable assistance received from senior staff at Statistics Canada who accepted to meet with me and share their expertise on the Canadian Community Health Survey: Georgia Roberts, Chief of the Data Analysis Resource Centre; Marie-Claude Duval, Senior Methodologist and Steven Thomas, Senior Methodologist. Similarly, I want to thank Paul Villeneuve, Senior Research Scientist at Health Canada, for his insights on standardisation methods. Goes without saying the valuable input from the following people who answered specific questions related to my thesis: Prof. Quon from Telfer Management School, Yanyan Gong from the Canadian Institute for Health Information, and Jackie Schultz and Dr. Hogg from the C.T. Lamont Primary Health Care Research Centre. My apologies if I am missing someone. I could not omit my beloved parents who were always behind me throughout my studies at University; their love, presence, encouragements, and patience were most valuable to me. To them and to my brothers, I want to say thank you for believing in me. And, thank you to my dear friends for your support and for making sure I still had a life during my studies! A special mention goes to my classmate and friend, Marie-Andrée Cadieux, to whom I wish the best success. v Table of Contents Chapter 1. Introduction ...................................................................................... 1 1.1. ACS Hospitalisations and Socio-economic Differences ............................. 2 1.1.1. Primary Care Access Hypothesis ........................................................ 5 1.1.2. Primary Care Utilisation Hypothesis .................................................... 7 1.1.3. Health Status Hypothesis .................................................................. 11 1.1.4. Healthy Behaviour Hypothesis ........................................................... 12 1.1.5. Other hypotheses .............................................................................. 13 1.2. Current Research Need ........................................................................... 13 1.3. Research Objectives and Questions ........................................................ 15 1.3.1. Research Objective 1 ........................................................................ 15 1.3.2. Research Objective 2 ........................................................................ 16 1.3.3. Research Objective 3 ........................................................................ 16 Chapter 2. Causal Model of Preventable Hospitalisation Rates ....................... 18 Chapter 3. Methodology ..................................................................................