Chronic Diseases and Injuries in Canada

Volume 31 · Supplement 1 · Fall 2011
Patterns of Health Services Utilization in Rural Canada

Discussion and conclusion

In the previous sections of this report, we presented data concerning consultations with physicians and use of hospital and other health services by Canadians living in urban communities and in different types of rural settings. Here we discuss these findings and their implications by asking three questions:

• What do these findings mean from the perspective of rural health?
• Do the findings shed any new light on such issues as place of residence and health, health equity and the relationship between the Canadian health care system and rural health care?
• What are their implications for future rural health research?

This study has used multiple sources of information, including survey and administrative data from different sources, to examine patterns of health services utilization by rural Canadians. It has investigated the relationship between place of residence and health services utilization from the national and provincial perspectives, using national data and provincial data from Nova Scotia, Ontario and British Columbia, so as to ensure that the findings are not solely a methodological artefact attributable to a specific data source from a specific jurisdiction.

Given the massive amount of data used, there are some inevitable variations in the findings, depending on the dataset, jurisdiction, disease category, health service and population group under consideration; however, some broad trends have emerged, and the patterns are reasonably consistent. In addition, this study has gone beyond treating rural Canada as an undifferentiated entity. While many researchers and health care planners have looked at urban-rural differences, few have examined the heterogeneity of rural Canada, as reflected in the ways health services are used. To rectify this situation, this study has disaggregated rural Canada into finer categories based on the degree of rurality or remoteness to urban centres.

The summaries of findings presented earlier outlined some general patterns of rural health services utilization. Superficially, the relationships between place of residence and use of health services are quite variable and appear to reflect unique situations, individual preferences of patients, different styles of medical practice or special patterns of service provision associated with different diseases. But at the national and provincial level (at least in the three provinces examined in this study) and in terms of major disease categories, there are broad patterns of service utilization: rural residents tend to have lower physician consultation rates than their urban counterparts; on the other hand, they tend to have higher relative risks of hospitalization. These trends are particularly evident for people living in Weak and No MIZ areas. There are some exceptions in British Columbia, which may be due to the fact that the analysis of physician visits in that province focused on specific diseases, whereas the analysis for Nova Scotia and Ontario focused on broad disease categories.

We will discuss the significance and implications of the findings in the following sections.

"Rural" is not a unitary concept

All rural areas are not the same in terms of utilization of health services. In some cases, the differences between types of rural areas may be greater than between rural and urban communities. For instance, strong MIZ areas appear to be different from other rural areas with respect to health status and utilization of health services. People living in Strong MIZ areas tend to enjoy long life expectancy (men: 77.4 years; women: 81.5 years) and health-adjusted life expectancy (men: 68.7 years; women: 71.3 years)Footnote 1c1c compared with Canadians in general. This may manifest itself in lower relative risks of physician visits. From the point of view of access to health services, residents in Strong MIZ areas may have fewer health care needs, experience fewer access barriers or be in a better position to overcome barriers if they do arise.

Conversely, and perhaps understandably, people in No MIZ areas typically face the greatest challenges in terms of availability of health care resources and access to health services. Furthermore, residents of these areas tend to have poorer health status. They have the shortest life expectancy (men: 74.0 years; women: 81.4) and shortest health-adjusted life expectancy (men: 65.5 years; women: 69.9 years).Footnote 1d1d From a health care planning perspective, Canadians in No MIZ areas (and, to some extent, in Weak MIZ areas) may have the greatest need for support in order to overcome difficulties in accessing care and in improving health status. As the Romanow Commission has pointed out:

In fact, some would say that there is an "inverse care law" in operation. People in rural communities have poorer health status and greater needs for primary health care, yet they are not as well served and have more difficulty accessing health care services than people in urban centres (p. 162).^Footnote24

Different patterns of service delivery

Residents of urban and rural communities show marked differences in their access to and use of health services. For instance, hospitalization rates increase with increasing degree of rurality, but average lengths of hospital stay decrease. Also, greater proportions of rural residents report receiving care in emergency departments or outpatient clinics. These findings may reflect more than differences in health status or health care needs: they may reflect differences in how health services are organized or provided in non-urban areas and disparities in the availability of health care resources, including health human resources.

For example, Pong and Pitblado^Footnote3b described the differences in the practice profiles of rural- and urban-based FPs. The former tend to have a much broader scope of practice, are more inclined to work in different types of care setting and are more likely to provide clinical services and perform procedures that would typically be done by specialists in larger urban centres. In the relative absence of specialists in rural areas, some rural family doctors expand their scope of practice as a way to fill the gaps in the service. Similarly, the greater reliance on hospital care and emergency departments by rural residents could be due to the lack of community-based ambulatory care facilities, such as walk-in clinics or community health centres.

Consultations with a nurse are more frequent among rural residents. People living in Moderate, Weak and No MIZ areas are more likely than urban residents to have one or more consultations with a nurse, and those living in No MIZ areas are especially likely to have consulted a nurse. Some remote or very small communities have nursing stations staffed by out-post nurses or nurse practitioners who offer a broad range of health services, including diagnosis and treatment of minor diseases, with physicians providing backup and consultation at a distance or through periodic outreach visits.

Such divergent patterns of service utilization are not aberrations but, rather, are to be expected. It is important to distinguish between regional variations in health services utilization and regional disparities in health status or outcomes. The former are not necessarily undesirable, as long as they reflect different means to the same end and as long as the latter can be minimized. If substantial regional differences in health status persist over time, however, the appropriateness of the service delivery approach or the levels of service consumption may need to be questioned. Although this study has used CMA and CA as the reference group for comparison with rural categories, it does not necessarily endorse the utilization rates of urban areas as the standards or benchmarks for which rural areas should strive.

The health care system and rural health

While there are differences between rural and urban communities, such regional disparities should not be unduly exaggerated. Neither should it be assumed that the situation in rural areas is always poor or at least worse than in urban areas. While, in general, rural residents have less access to certain types of health services or they use certain types of services to a lesser extent, there are no differences between rural and urban areas in other respects. In a few cases, rural residents actually use certain types of services more often than their urban counterparts.

The Canadian Medicare system, which ensures universal access to necessary medical and hospital care, and the Canada Health Act, which specifies "accessibility" as one of its five principles, aim to eliminate financial means as a condition for accessing necessary medical and hospital care. Nonetheless, universal access is meaningless if practitioners and services are not available or are very difficult to find in certain regions of the country. As a result, nearly all provincial and territorial governments have established special programs (such as the Underserviced Area Program in Ontario, the Fly-In Program of the J.A. Hildes Northern Medical Unit in Manitoba and the Travel Assistance Program in British Columbia) to provide assistance to those who have to travel great distances to receive care. These and other programs help rural residents, particularly those living in more remote areas, gain better access to health services and reduce inequity. All this attests to the strength of the Canadian health care system.

However, this study has focused primarily on insured health services, such as those provided by physicians and in hospitals. Services not covered under the Medicare system, such as rehabilitation therapy, home care, dental care and community mental health, have not been examined extensively, primarily because data are not widely available. As a result, whether rural residents have more or less access to such services relative to urban residents, or whether they use such services at levels similar to those of urban residents, remains largely unknown at the national level. Further investigation is needed when data become available.

Whether urban and rural residents experience similar ease or difficulty in accessing health services is also unknown. While, in theory, all Canadians have access to needed medical and hospital care, some may achieve such access only with considerable inconvenience and hardship. For instance, although residents of remote communities have the same right to specialist care as those living in large urban centres, they may have to travel great distances to see a specialist. This may require individuals to take time off work, lose income, incur substantial travel costs and endure greater emotional distress. In other words, accessibility is one thing, but the costs entailed (both material and psychological) are another. Because of lack of data, such issues were not dealt with in this study.

Reasons for regional variations in utilization

Consistent with the Andersen model,^{Footnote 2e2e} regional variations in utilization of health services may be as a result of different health needs and availability of health care resources, among other things. For instance, we observed higher relative risks of physician visits and hospitalization due to injuries and poisoning in rural areas both nationally and in the three provinces examined. These higher risks may reflect the increased likelihood of accidents and injuries sustained because of the nature of many rural-based occupations such as farming, fishing, logging and mining. Similarly, the much higher relative risk of ambulatory visits in relation to diabetes in No MIZ areas in all three provinces could be due to the higher prevalence of diabetes among Aboriginal people, who make up a large proportion of the population in more remote regions.

Differences in availability of resources and service delivery models have a great impact on service utilization patterns. For instance, limited availability of community-based care, a heavier disease burden and other factors, such as distance to services, could create a greater reliance on hospital care among rural Canadians.

The role of "place" in health

Does where people live make a difference in terms of access to and utilization of health services? According to the findings of this study and results from the companion study, How Healthy Are Rural Canadians?,^{Footnote 1e1e} the answer to this question is: "Yes, place of residence does matter—in some cases." A series of multivariate regression analyses showed that, after various socio-demographic factors, selected diseases and health behaviours were controlled for, place of residence, whether urban or in different categories of rurality, still has an independent effect on some aspects of health services utilization.

But the importance of place of residence is also a function of the variables being examined. In some cases, it is an important factor; in others, less so. For instance, data from the HSAS show that place of residence has an independent effect on not having a family doctor only in No MIZ areas, after controlling for a number of other variables (Figure 2). On the other hand, place of residence has an independent effect on the likelihood of being hospitalized in all MIZ except Strong MIZ areas (Table 9).

But what is it about place of residence that makes it an important factor to consider in examining health behaviours and outcomes? This is an equally important and possibly a more difficult question to answer. As pointed out earlier, "place" embodies many things, including the physical environment, population, socio-economic conditions, occupational activities, culture, customs, community structure and social relationships. Thus, when we talk about the role of place of residence in health, we are in fact talking about how health is shaped by an aggregate of interacting factors encapsulated in specific geographic locations. Now that this study, as well as others, has established the fact that there is a place for "place" in our understanding of health, it behoves us to go beyond locality and look at how these interacting factors affect—and are affected by—health in the context of rural Canada.

Furthermore, "rural" is just one aspect of "place." In addition to rural health, there is a growing interest in other aspects of place of residence and their relationships to health, as exemplified by a growing body of literature on urban health, inner city health, circumpolar health, frontier health and border health (e.g. health issues in areas along the United States–Mexico border). Our understanding of rural health would be further enhanced if we become more aware of the research on the impact on health of neighbourhoods, inner city cores, suburbs, frontiers, isolated locations and other places.

Where do we go from here?

While this and its companion study^{Footnote 1f1f} have covered a lot of ground, there are still many unknowns about the health of rural Canadians and how they utilize health services. The following are some suggestions for additional work that needs to be done to further our understanding of rural health, particularly health services utilization.

• "Rural" is not a homogeneous entity. In terms of access to and use of health services, Strong MIZ areas are more like cities, No MIZ areas are at the other extreme, with Moderate and Weak MIZ areas somewhere in between. Should special attention and support be given to those living in No and Weak MIZ areas, since these residents may need help most and may not have as many alternatives? What kinds of support should be given and what additional evidence should be gathered to ascertain such needs and support?
• Differences in the way health services are delivered and used in rural and urban areas are not necessarily undesirable but, rather, may reflect divergent conditions and needs. What works in big cities may not work in remote communities; what is needed in urban areas may not be needed in rural ones. More research is needed to find out whether the service delivery approaches used in rural areas are appropriate in light of their health and social conditions. It might also be interesting to find out whether approaches adopted by rural communities may actually serve as a model for urban areas of the country.
• Regional variations in the delivery of health services are acceptable, but substantial and persistent discrepancies in population health status are not. Many rural health studies, including How Healthy Are Rural Canadians?,^{Footnote 1g1g} have documented poorer health status among rural Canadians. Substantial and persistent regional variations in population health status should be seen as signs that something may be problematic or that health care provision strategies are less than adequate. This calls for monitoring of rural health conditions over longer periods of time and longitudinal tracking of rural population health status.
• This study has focused mostly on insured health services since data on such services are more readily available. It is possible that differences between rural and urban Canadians with respect to access to and use of non-insured services like dental care, vision care and rehabilitation therapy are even greater because such services often require out-of-pocket payments, and some of these services are even less available in rural communities. Future research on rural health issues should not be restricted just to those services covered under national Medicare. Better and more systematic data collection for services other than physician and hospital services is urgently needed.
• Also as a result of the lack of data, this study has not paid much attention to such services as health promotion, disease prevention, early intervention and accident/injury/suicide deterrence. From a population health standpoint, these are just as important as curative care. While curative and remedial services are required, equally important are efforts to address adverse determinants that have a negative impact on the health of the population. But even less is known about non-curative care in rural areas, and the need to explore these issues is clearly a priority.
• Variations in access to and utilization of health services may be a function of many things, not just the unavailability of services or resources in local areas. For instance, lack of means of transportation could deter some rural residents from seeking care that is available only in distant urban centres. Thus, solutions to the problem of lack of access do not reside exclusively in the health care domain and improving transportation services could be just as important. As such, research on rural health issues should pay attention to factors that are not usually considered a health concern, but are nonetheless relevant to how rural Canadians access and use health care.
• The nature of the data and the methods used in this study does not allow the disentangling of the complex relationships between health care resources, health services delivery models and disease burden in order to determine their relative contributions to the patterns and extent of utilization. In addition, this study cannot estimate the extent to which health services utilization is a determinant of health status among rural Canadians. While it is safe to say that health services are important to the improvement of rural health status, particularly in light of the generally heavier disease burden in rural Canada, the more difficult question is: "To what extent?" These are important issues for rural health research and planning, and they require further investigation.
• Perfect equality with respect to the distribution of health care resources and access to care is probably unachievable, but we do not know what level of inequality is acceptable. This is as much a policy issue as a philosophical or ethical question. Society may have to seek a balance between convenience of access on the one hand and economic viability, practicality and quality of care on the other. Rural Canadians should be given a voice in this important discussion. In addition, there is a role for those interested in health ethics to be involved in this debate and to conduct research on ethical issues in rural health.
• As noted earlier, "rural" is just one aspect of "place." There is a growing interest in how different aspects of "place" influence health status and behaviours. Ultimately, we would like to know whether there are underlying principles or common theoretical frameworks that can guide research on rural health, inner city health, remote health, circumpolar health and so forth, and that can inform our understanding of the relationships between "place" and health. To this end, rural health researchers need to work with health researchers who are interested in other aspects of "place" with a view to achieving research synergy and theoretical breakthrough.

To enhance equity in health for Canadians living in different parts of the country, we need to better understand variations in health status and variations in utilization patterns of health services. To this end, this report has focused on the latter, while its companion report, How Healthy Are Rural Canadians?,^{Footnote 1h1h} sought to address the former subject. This study has examined in considerable detail how rural Canadians access and use a broad array of health services. It has used multiple sources of data and data of different types (survey and administrative data), and the analyses were conducted at the national and the provincial level. It has examined health services utilization patterns on a broad scale and in relation to selected disease categories. Moving beyond a simple rural-urban dichotomy, it has disaggregated rural into finer categories, with a view to understanding intra-rural variations in health care consumption. It is hoped that by shedding new light on utilization behaviours and answering previously unanswered questions, this study will lead to better provision of health care for rural Canadians and a better understanding of the role of place in health.