Rich-poor divide in Toronto’s hospitals

Posted on June 13, 2012 in Health Delivery System, Health Policy Context

Source: — Authors: – opinion/editorialopinion
Posted on June 13, 2012.   By Carol Goar, Editorial Board

A missing piece of Ontario’s health-care puzzle has fallen into place. It is a perfect fit for the whole, but a mismatch for public perceptions.

Those “bed blockers” who take up acute care space in Ontario’s hospitals? Probably not your frail grandmother — unless she’s poor, has no family support and no place to receive home care.

Those walk-in patients who clog emergency departments with non-urgent ailments? Probably not your middle-class neighbours with their coughing, feverish children. The majority are low-income Torontonians with nowhere else to go.

These are two of the findings in a groundbreaking study just released by theCentre for Research on Inner City Health at St. Michael’s Hospital. Its analysts linked hospital use to the socio-economic status of patients. Without this information, says team leader Dr. Rick Glazier, “it’s impossible to say if hospital care is equitable or if hospitals have the proper resources to respond to the patients they serve.”

Because hospitals don’t ask patients their income, the researchers had to come up with an approximation. To do this, they cross-referenced their postal codes with the household income figures in the census. (Unfortunately, their method excluded the homeless, 4,817 of whom visited hospital emergency departments.)

Using admission data for all 20 of the city’s hospitals, Glazier and his team picked out distinct differences.

They began by dividing Toronto’s hospitals into three categories:

• Those that serve a disproportionate share of the city’s low-income patients (St. Joseph’s and East General).

• Those that serve predominantly high-income patients (Mount Sinai andSunnybrook).

• And those with a socio-economic mix of patients ( the University Health Network and St. Michael’s).

Then they examined the ways rich and poor people use Toronto’s hospitals. Here is what they found:

Wealthy patients went to hospitals chiefly for surgery and outpatient procedures. Poor patients used them for basic medical care, mental health services, chronic care, emergencies and end-of-life care.

High-income mothers-to-be gravitated toward Sunnybrook and Mount Sinai. Their low-income counterparts gave birth at St. Michael’s, St. Joseph’s and Toronto East General.

In theory, any Ontarian can go to any public hospital. In fact, that doesn’t happen. People’s choices are shaped by where they live, where their doctor practises (if they have one), what kind of treatment they need and whether they have a car.

It makes sense that St. Joseph’s (in Parkdale) and Toronto East General (whose catchment area includes Flemingdon Park, Crescent Town, Dorset Park and Eglinton East-Kennedy Park) have a large percentage of low-income patients. It is likewise understandable that the big teaching/research hospitals along University Ave. cater to surgical patients with life-threatening conditions.

But neither geography nor type of treatment explains the anomalies in the study.

Unlike Toronto’s other large university-affiliated hospitals, St. Michael’s plays a dual role. It is a province-wide centre for neurosurgery, cardiovascular surgery and trauma care, while caring for the inner-city poor.

Sunnybrook is an outlier among Toronto’s chronic care hospitals. Most of its patients come from the highest income quintile. Baycrest, Bridgepoint Health, Grace and the E.W. Bickle Centre of the University Health Network draw their patients from across the socio-economic spectrum.

Women’s College Hospital, which served women of all income levels as a full-service hospital, became an ambulatory care centre in 2010. Now its clientele is skewed toward higher-income women.

The researchers did not attempt to compare the quality or cost of care at various hospitals. That is for a future study.

But Glazier draws two lessons from Hospital Care for All. The first is that “very low-income people are using the parts of the health-care system that are in greatest crisis.” The second is that to reduce hospital use “people need the ability to pay for healthy foods, buy medicine and live in a healthy place where they can receive home care.”

There is a third lesson, which he lets readers draw for themselves: Don’t believe everything health bureaucrats, hospital executives and politicians tell you.

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