Hospital Care for All - St. Michael's Hospital

Who should read this report? Health care administrators, health system planners, patients and patient advocates who are interested in equity in hospital care. What’s in this report? Key findings, discussion questions, charts and data tables documenting differences in household income and place of residence among patients admitted to major clinical services in TC LHIN hospitals, 2008-2010.

Hospital Care for All An equity report on differences in household income among patients at Toronto Central Local Health Integration Network (TC LHIN) hospitals, 2008-2010. Prepared May 2012

Not included in this report: Information about quality of care, patient outcomes or cost of care for different socioeconomic groups. Statistics on homeless patients treated at TC LHIN hospitals. Who developed this report? The Centre for Research on Inner City Health (St. Michael’s Hospital) and the Institute for Clinical Evaluative Sciences, in partnership with the Hospital Collaborative on Marginalized and Vulnerable Populations. This research was funded by the Ontario Ministry of Health and Long-Term Care. Download this report at www.crich.ca. 1

The Hospital Collaborative on Marginalized and Vulnerable Populations

HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

Contents About health equity........................... 3 About this report................................ 4 Methods................................................ 5 Toronto Central Local Health Integration Network: Income distribution and hospital locations............................................... 6 Findings................................................. 7 Discussion............................................ 10 HOSPITAL COMPARISONS Understanding the charts and ratios...................................................... 13 Household income............................. 14 Where patients lived.......................... 18 APPENDICES Hospital patient admissions: Household income............................. 21 Hospital patient admissions: Where patients lived.......................... 25 About the hospitals............................ 29

Prepared by: Kelly Murphy Rick Glazier Xuesong Wang Emily Holton Ghazal Fazli Minnie Ho Centre for Research on Inner City Health 30 Bond Street Toronto, Ontario M5B 1W8 crich.ca

This report has been generously funded by a grant to the Centre for Research on Inner City Health from the Government of Ontario. The views expressed are the views of the research team and do not necessarily reflect those of the Government of Ontario. How to cite this report: Murphy K., Glazier R., Wang X., Holton E., Fazli G., Ho M. (2012). Hospital care for all: An equity report on differences in household income among patients at Toronto Central Local Health Integration Network (TC LHIN) hospitals, 2008-2010. Toronto, ON.

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HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

About health equity Across the spectrum of health conditions, and everywhere that health and wealth have been compared, lower income and socially marginalized people have worse health status, die earlier and have greater unmet need for health care services, compared to those in higher socioeconomic positions. Health differences in the population that can be traced to social advantage/disadvantage are called health inequities. Health inequities in Ontario and in Toronto have been widely documented. For example, research conducted in the Toronto Central Local Health Integration Network (TC LHIN) has shown that people with low incomes are three times more likely to report poor or only fair health, twice as likely to develop diabetes and half as likely to receive hip replacements, compared to higher income groups. For more research findings on health inequities, visit www.crich.ca. Health equity means equal opportunity to be healthy, for all population groups. Achieving health equity will depend in large part on decisions made outside of the health care system, to address core social determinants of health, including income inequality and poverty, educational barriers and underemployment, unsafe working and living conditions, and systemic discrimination and racism.

Equity in health care Health inequities begin outside the health care system. However, a great deal can be done within health care to promote the health and well-being of disadvantaged groups, and to ensure that health inequities are not exacerbated, for example by unequal access to health care or unequal quality of care.

Equity in hospital care Equity in hospital care means designing and distributing hospital services, resources and processes in ways that will equalize patients’ opportunities to receive and benefit from excellent care, regardless of their socioeconomic status. In particular, it means ensuring that appropriate patient/family-centered care is accessible to and utilized by marginalized groups, so that their health chances can rise to match the health chances of more privileged groups. To plan and evaluate this work, an essential first step is to understand the sociodemographic and economic profile of hospital patients.

Health equity is a core value in Ontario’s health care system. For example, equity has been identified as a dimension of health care quality in Ontario’s Excellent Care for All Act (2010). In TC LHIN, health equity goals are incorporated into the 2010-2013 Integrated Health Service Plan. Health care provider organizations and networks, including the Hospital Collaborative on Marginalized and Vulnerable Populations, have taken important steps to plan, implement and evaluate equity-focused health care interventions and policies.

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HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

About this report What is in this report? This report documents differences in household income among patients admitted to hospitals in Toronto Central Local Health Integration Network (TC LHIN) during the period 2008-2010. To better understand the relationship between Toronto hospitals and the communities they serve, we also report on whether patients lived inside or outside the geographical boundaries of TC LHIN. The methods and data used are described on page 5.

Why did we produce this report? Understanding the socioeconomic status of our patients is an essential step toward ensuring that hospitals in TC LHIN provide excellent care for all patients, regardless of who they are, where they come from, where they live or what they earn. The Centre for Research on Inner City Health and Institute for Clinical Evaluative Sciences, in collaboration with the Hospital Collaborative on Marginalized and Vulnerable Populations, produced this report to establish standardized, baseline evidence about the socioeconomic status of patients receiving care in TC LHIN hospitals. This evidence will enable many hospitals and health care stakeholders in TC LHIN to see the socioeconomic profile of patients for the first time. It provides an empirical basis for planning, implementing and evaluating equity-focused health care services within and across hospitals. It is our aim for these data (and the methods for collecting them) to be incorporated into the TC LHIN Hospital Equity Reporting process.

The importance of collecting patients’ socioeconomic information Inadequate information about patients’ socioeconomic status is a major obstacle to planning and evaluating the outcomes of health care initiatives to advance health equity. Currently, most hospitals in TC LHIN do not have the data collection and analytical capacity to report on patient socioeconomic characteristics. Moreover, evidence from Canada and other jurisdictions has shown that patients are reluctant to share this information directly with health care providers. Recognizing this challenge, several TC LHIN hospitals and partner organizations are piloting new strategies to educate patients about health equity and to ask for socioeconomic information at the point of care. While these strategies are being developed for future use, it is possible now to make valid inferences about patients’ socioeconomic status using area-level census data. This is the primary way that diverse dimensions of population health and health inequities are currently measured in Ontario and many other jurisdictions. We linked area level census data to routinely collected administrative data about hospital utilization, in order to establish baseline information about socioeconomic differences among patients at TC LHIN hospitals.

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HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

Methods Data

Databases

We accessed data through a comprehensive research agreement between the Institute for Clinical Evaluative Sciences and the Ontario Ministry of Health and Long-Term Care. The hospitals included in this report are listed in the appendix of this document. Analyses were based on the hospital at which the service was performed and the number of individual patients - not number of services. Due to small cell sizes, data for the following hospitals were excluded from the analysis: •• Casey House •• Holland Bloorview Kids Rehabilitation Hospital •• Runnymede Healthcare Centre •• Sunnybrook Health Sciences Centre Rehabilitation

For acute hospital inpatient admissions, we used the Discharge Abstract Database (DAD) from the Canadian Institute for Health Information (CIHI). The SameDay Surgery Database from CIHI was used for sameday surgery. Mental health admissions were derived by combining admissions from the Ontario Mental Health Reporting System (OMHRS) with mental health admissions in the DAD. Emergency department and urgent care visits came from the National Ambulatory Care Reporting System which is maintained by CIHI. Complex continuing care and rehabilitation admissions were derived from the National Reporting System database.

Types of services We divided services into inpatient admissions, sameday surgery, emergency department and urgent care visits, and admissions to complex continuing care and rehabilitation. Inpatient admissions were further subdivided into mental health, alternate level of care (ALC), medical, surgical and obstetrical admissions. Emergency department visits were reported for less urgent and non-urgent visits (Canadian Triage and Acuity Scale 4 and 5). For complex continuing care hospitals and rehabilitation hospitals, no further service breakdown is provided; the broad range of unique programs offered at the different hospitals limit comparisons.

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Geographic location We further examined service use by place of residence and categorized these as within the boundaries of Toronto Central Local Health Integration Network (TC LHIN); within the boundaries of LHINs immediately surrounding TC LHIN (i.e. Central East LHIN, Central LHIN, Central West LHIN, Mississauga Halton LHIN) and within the rest of Ontario.

Patient income Hospital administrative data records contain information about patients’ age, sex and postal code of residence but do not routinely collect socioeconomic information such as income, education, employment, marital status, family composition, language, ethnicity or country of birth. In order to assess socioeconomic status, we linked census-derived income information to hospital administrative data. We used the Postal

Code Conversion File (PCCF+) from Statistics Canada to link postal codes to Census Dissemination Areas. Dissemination areas are the smallest census unit for which socioeconomic data are available in the Canadian census, each containing about 400-600 people. The measure used for income was the income quintile developed by Statistics Canada that is adjusted for household size and is specific to each community. It is therefore a measure of relative and not absolute income.

Patient income differences - within and across hospitals To assess income differences among hospital patients, we calculated the ratio of patients living in the lowest income dissemination areas (quintile 1) to patients living in the highest income areas (quintile 5). We used this ratio as an indicator of the magnitude of patients’ income differences, across hospital service categories and across hospitals.

Homeless patients Because this method relies on using patients’ home address to derive income information, it does not account for those patients who reported no fixed address at the time of hospitalization. During the reporting period, at least 543 homeless patients were hospitalized for acute care services and at least 4,817 had an emergency department visit in TC LHIN hospitals. Strategies to document homeless patients’ hospitalization patterns are essential for health equity planning and need to be standardized across all hospitals.

HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

Toronto Central Local Health Integration Network (TC LHIN): Income distribution (by Census Dissemination Area) and hospital locations Data sources: Statistics Canada Postal Code Conversion File (PCCF+); 2006 Census, Statistics Canada Produced by: Centre for Research on Inner City Health

Median household incomes across TC LHIN*: Lowest income quintile: $35,500 $49,500 $57,500 $66,000 Highest income quintile: $101,000 *Median incomes by quintile vary across Ontario. These amounts are valid only for residential areas within the geographical boundaries of TC LHIN.

TC LHIN Hospitals: 1. Baycrest 2. Bridgepoint Hospital 3. Centre for Addiction and Mental Health 4. The Hospital for Sick Children 5. Mount Sinai Hospital 6. Providence Healthcare 7. St. Joseph’s Health Centre 8. St. Michael’s Hospital 9. Sunnybrook Health Sciences Centre 10. Sunnybrook Holland Orthopaedic & Arthritic Centre 11. Toronto East General Hospital 12. Toronto Grace Health Centre 13. UHN: Princess Margaret Hospital 14. UHN: Toronto General Hospital 15. UHN: Toronto Rehab E.W. Bickle Centre for Complex Continuing Care 16. UHN: Toronto Rehab Hillcrest Centre 17. UHN: Toronto Rehab Lyndhurst Centre 18. UHN: Toronto Western Hospital 19. West Park Healthcare Centre 20. Women’s College Hospital

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HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

Findings All inpatients (acute care)

Mental health inpatients

Where patients lived: Altogether, TC LHIN hospitals admitted patients residing inside and outside of TC LHIN in roughly equal numbers. St. Joseph’s Health Centre and Toronto East General Hospital admitted more TC LHIN residents than non-residents; Sunnybrook Health Sciences Centre, University Health Network (UHN), and The Hospital for Sick Children (SickKids) admitted more non-residents. SickKids admitted the biggest share of patients from outside of TC LHIN (ratio of 4.2 to 1). Mount Sinai Hospital and St. Michael’s Hospital admitted TC LHIN residents and non-residents in about the same numbers.

Where patients lived: Mental health inpatients were nearly twice as likely to live inside, rather than outside of TC LHIN. SickKids was the only hospital where mental health inpatients were more likely to live outside of TC LHIN.

Household income:

•• Overall, high and low income patients were admitted to TC LHIN hospitals

in roughly the same numbers (ratio of about 1 to 1). Individuals in the middle income quintile were admitted the least.

•• The hospitals showed three different inpatient income profiles: ►► More low income than high income inpatients (St. Joseph’s, Toronto East General).

►► More high income than low income inpatients (Mount Sinai, Sunnybrook).

►► Similar numbers of high and low income inpatients (SickKids, St. Michael’s, UHN).

•• At Toronto East General, low income inpatients outnumbered high income

inpatients by a ratio of 3.5 to 1. This was the biggest inpatient income difference found in any of the hospitals. At Mount Sinai and Sunnybrook, high income inpatients outnumbered low income inpatients by about 1.5 to 1.

Household income:

•• In most hospitals, more low income patients were admitted than high income patients for mental health services. The exceptions were:

►► SickKids: half as many low income as high income patients admitted (ratio of 0.5 to 1)

►► Sunnybrook: more high income patients admitted than any other

group. The income profile for mental health inpatients (ratio of 0.7 to 1) resembled the hospital’s total inpatient population.

Alternate level of care (≥ 1 day ALC) The “ALC” designation is assigned when a patient occupies a bed in a hospital and does not require the intensity of resources/services provided in that setting. For this analysis, we reported on ALC wait times that were 1 day or longer. Where patients lived: Overall, ALC inpatients were more likely to live inside rather than outside of TC LHIN. Sunnybrook was the only hospital with more ALC patients residing outside of TC LHIN. Household income:

•• In most hospitals, low income ALC inpatients outnumbered high income ALC inpatients.

•• In most hospitals, the income profile for ALC inpatients was lower than the income profile for the hospital’s total inpatient population.

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HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

FINDINGS

Medical and surgical inpatients

Emergency (less/non-urgent conditions)

Where patients lived: Overall, medical inpatients at TC LHIN hospitals were equally likely to live inside and outside of TC LHIN. In contrast, surgical inpatients were twice as likely to live outside of TC LHIN. At Sunnybrook and SickKids, both medical and surgical inpatients were more likely to live outside of TC LHIN.

Where patients lived: Patients visiting TC LHIN hospital emergency departments for less/non-urgent conditions were twice as likely to live inside, rather than outside, of TC LHIN. The exception was SickKids, which saw slightly more emergency patients from outside of TC LHIN.

Household income:

Household income:

•• Overall, more low income than high income patients were admitted to

medical inpatient services (ratio of 1.2 to 1). Low and high income patients were admitted in close to the same numbers for surgical inpatient services (ratio of 0.9 to 1). While every hospital had a different patient income profile for medical and surgical inpatients, there were two notable trends:

►► In every hospital, income levels for medical inpatients resembled income levels for the hospital’s total inpatient population.

►► In every hospital, surgical inpatients had higher income profiles than

medical inpatients. The exception was Sunnybrook, where income ratios for medical and surgical inpatients were the same.

Same-day surgery Where patients lived: Overall, TC LHIN hospitals admitted more non-residents for same-day surgery than residents of TC LHIN. This resembled the pattern for surgical inpatient admissions. This was the case at every hospital except St. Joseph’s (equal numbers of residents and non-residents) and Toronto East General (slightly more residents than non-residents). Household income:

•• Most hospitals admitted more high income patients than low income patients for same-day surgery. The biggest patient income difference was at Women’s College Hospital, where half as many low income patients as high income patients were admitted (ratio of 0.5 to 1).

•• Overall, more low income patients visited emergency departments than high

income patients for less/non-urgent conditions (ratio of 1.3 to 1). This was the case at most hospitals. The biggest patient income difference was at Toronto East General (ratio of 2.6 to 1).

•• The exceptions were: ►► Mount Sinai and Sunnybrook: more high income patients than low income patients.

►► Toronto General Hospital: roughly equal numbers of high and low income patients.

Urgent care Where patients lived: Urgent care services are offered at two TC LHIN Hospitals (CAMH, Women’s College). Both hospitals saw more TC LHIN residents than nonresidents for urgent care visits. Household income:

•• At CAMH, more low income patients than high income patients visited urgent care.

•• At Women’s College, more high income patients than low income patients visited urgent care.

•• Toronto East General was the only hospital where low income patients outnumbered high income patients.

•• At Sick Kids and St. Joseph’s, low and high income patients were admitted in roughly the same numbers.

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HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

FINDINGS

Obstetrical (mothers only; excludes newborns)

Rehabilitation

Where patients lived: Obstetrical patients were more likely to live inside, rather than outside of TC LHIN. This was the case at all the hospitals, with the exception of Mount Sinai, where TC LHIN residents and non-residents were admitted in roughly the same numbers.

Where patients lived: Overall, rehabilitation patients at TC LHIN hospitals were more likely to live outside of TC LHIN than inside. This was the case at all the hospitals with the exception of Toronto East General (more TC LHIN residents), and Bridgepoint Hospital and Toronto Rehab Hillcrest Centre, where TC LHIN residents and nonresidents were treated in about equal numbers. Bridgepoint and Hillcrest were the two biggest rehabilitation hospitals in TC LHIN. At the Toronto Rehab Lyndhurst Centre, non-residents outnumbered TC LHIN residents by nearly 5 to 1.

Household income:

•• Overall, more low income than high income patients were admitted (ratio of 1.3 to 1). Patients in the middle income quintile were admitted the least.

•• The hospitals showed two distinct patient income profiles: ►► More low income and fewer high income patients (St. Joseph’s, St. Michael’s, Toronto East General).

►► More high income and fewer low income patients (Sunnybrook, Mount Sinai).

Complex continuing care Where patients lived: Overall, the hospitals showed two distinct two patterns: about half of the hospitals admitted more TC LHIN residents than non-residents, and half admitted more non-residents than TC LHIN residents. The exception was Baycrest, which admitted residents and non-residents in equal numbers.

Household income:

•• Overall, more low income patients were admitted for rehabilitation services, compared to high income patients (ratio 1.2 to 1).

•• Three patient income profiles were seen: ►► More low income than high income patients (Providence Healthcare, Toronto East General, West Park Healthcare Centre).

►► Similar numbers of high and low income patients (Baycrest, Bridgepoint, Toronto Rehab Hillcrest, Toronto Rehab Lyndhurst).

►► More high income than low income patients (Sunnybrook Holland Orthopaedic & Arthritic Centre).

Household income:

•• Overall, considerably more low income patients received complex continuing

care than high income patients (ratio of 1.8 to 1). At Baycrest and Toronto East General, low income patients outnumbered high income patients by a ratio of 3 to 1.

•• The exceptions were Sunnybrook and Sunnybrook Veterans Centre (more high income than low income patients) and Toronto Grace Health Centre (about equal numbers of low and high income patients).

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HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

Discussion It’s important to note that the information in this report does not describe patient outcomes, nor the quality of hospital care that was provided to different income groups. What the information does provide is an empirical starting point for asking questions about equity in health care quality and access in TC LHIN hospitals, in light of what is already known about income-related health needs and health care utilization patterns. The following observations and questions have emerged from this report.

1. Observation: TC LHIN hospitals admitted patients who lived both inside and outside of TC LHIN in equal numbers. For some services, the hospitals admitted more non-LHIN residents than local residents.

2. Observation: Although low income groups tend to have more health care needs, low and high income patients were admitted to TC LHIN hospitals in about the same numbers.



That TC LHIN provides health care to non-residents has been widely documented and is to be expected; Toronto is a major health care hub for the GTA and Ontario. Many Toronto teaching hospitals offer specialized services that are unavailable in some other areas.





Health equity questions: What are the health equity implications of serving patients from beyond the geographical boundaries of TC LHIN?

There is ample evidence to show that in Ontario, as in other jurisdictions, lower income groups are exposed to greater health risks, have more complex, co-morbid health conditions, and underutilize preventative health care compared to higher income groups. For these reasons, we can reasonably expect a greater need for hospital care among people with low incomes, compared to high income earners.



If levels of hospitalization matched patient need, we should expect to an inverse relationship between income and hospitalizations (i.e. higher income, lower hospitalizations). However, the income gradients for most TC LHIN hospitals and most admissions categories were distinctly U-shaped, rather than sloped, with fewest hospitalizations for middle income groups, and more hospitalizations for high and low income earners.



At least on the surface, these results suggest higher than expected hospital utilization for high income earners.



Health equity questions: Do high income earners enjoy better access to health care in TC LHIN, compared to other patients?

►► Was the likelihood of being referred into TC LHIN for specialized services related to patient income?

►► Did patients from outside of TC LHIN have higher, lower or similar household incomes as TC LHIN residents?

►► What was the influence of non-TC LHIN patients on

patient income profiles for individual hospitals and for hospitals overall in TC LHIN?

►► What was the influence of non-TC LHIN patients on

patient health profiles for individual hospitals and for hospitals overall in TC LHIN?

►► Did referrals into TC LHIN from outside affect access to hospital care for local residents?

►► Did low income patients have unmet needs for hospital care? What barriers did they face?

►► Did low income patients use other health care

providers/services (e.g. Community Health Centres), rather than hospitals?

►► If high income patients had better access to hospital care, what were the reasons for better access?

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HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

DISCUSSION 3. Observation: High and low income patients were hospitalized for different reasons.

4. Observation: Patients from different income groups were admitted to different hospitals in TC LHIN.







For many hospital services, low income patients were predominant (e.g. mental health, ALC, less/non urgent emergency and urgent care, and complex continuing care. In contrast, more high income patients were admitted for same-day surgery. In every hospital, the income profile of surgical inpatients was higher than the income of medical inpatients. The finding that low income patients were less often admitted for surgery compared to higher income patients is supported by the research literature describing upstream (i.e. socioeconomic) and downstream (i.e. health care system-related) barriers to surgical referrals. Health equity questions: Was income a barrier to receiving hospital services in TC LHIN?

►► Did patient income affect access to specialists and/or surgical referrals? ►► Was there a relationship between patient income and use of elective surgery?

►► Was income a barrier to discharging ALC patients to home and

TC LHIN hospitals showed three distinct patient income profiles, which may reflect the socioeconomic characteristics of the neighbourhoods in which they are situated and the referral patterns for communities and patient groups they have historically served.

►► More low income patients than high income patients. ►► More high income patients than low income patients. ►► Similar numbers of low and high income patients.

Health equity questions: Was there a relationship between quality of care and patient income?

►► Did patient income affect cost of care? ►► Did patient income affect resource utilization patterns? ►► Did patients experience income-related barriers to receiving care at TC LHIN hospitals?

community care?

►► How if at all did the course or quality of treatment differ for patients in different income quintiles?

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HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

Hospital comparisons Acute care:

Complex continuing care:

Rehabilitation:

Centre for Addiction and Mental Health (CAMH)

Baycrest

Baycrest

Bridgepoint Hospital

Bridgepoint Hospital

Providence Healthcare

Providence Healthcare

St. Joseph’s Health Centre

UHN: Toronto Rehab E.W. Bickle Centre for Complex Continuing Care

Sunnybrook Holland Orthopaedic & Arthritic Centre

St. Michael’s Hospital

Sunnybrook Health Sciences Centre

Toronto East General Hospital

Sunnybrook Health Sciences Centre

Sunnybrook Veterans Centre

UHN: Toronto Rehab Hillcrest Centre

Toronto East General Hospital

Toronto East General Hospital

UHN: Toronto Rehab Lyndhurst Centre

University Health Network (UHN: Princess Margaret Hospital, Toronto General Hospital, Toronto Western Hospital)

Toronto Grace Health Centre

West Park Healthcare Centre

The Hospital for Sick Children (SickKids) Mount Sinai Hospital

West Park Healthcare Centre

Women’s College Hospital

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HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

Understanding the charts and ratios household income

Number of patients in the lowest income quintile

Number of patients in the highest income quintile

NUMBER of PATIENTS

20000 15000 10000 5000 0

0.70

BLUE VALLEY HOSPITAL

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where patients lived

To assess income differences among hospital patients, we calculated the ratio of lowest income patients to highest income patients. We used this ratio as an indicator of the magnitude of patients’ income differences, across hospital service categories and across hospitals. A ratio that is: • Greater than 1 means more patients in the lowest income quintile were admitted, compared to patients in the highest income quintile (e.g. a ratio of 2 means that there were twice as many patients in the lowest income quintile). • Less than 1 means fewer patients in the lowest income quintile were admitted, compared to patients in the highest income quintile (e.g. a ratio of 0.5 means that there were half as many patients in the lowest quintile).

Number of patients from TC LHIN

BLUE VALLEY HOSPITAL

Number of patients from surrounding LHINs

Number of patients from the rest of Ontario

1.34 0

5000

10000

15000

20000

NUMBER of PATIENTS To assess the geographical reach of Toronto Central Local Health Integration Network (TC LHIN) hospital care, we calculated the ratio of non-residents to residents admitted to TC LHIN hospitals. A ratio that is: • Greater than 1 means more patients from outside of TC LHIN were admitted, compared to patients from TC LHIN. • Less than 1 means fewer patients from outside of TC LHIN were admitted, compared to patients from TC LHIN. If all patients lived inside TC LHIN, the ratio would be 0. If equal numbers of patients from inside and outside of TC LHIN were admitted, the ratio would be 1.

HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

Household income

Lowest income quintile Ratio of lowest income to highest income patients Highest income quintile

All inpatients (acute care)

1.10 ALL HOSPITALS

NUMBER of PATIENTS

20000

NUMBER of PATIENTS

1.64 ALL HOSPITALS

5000 0

1.17

0.70

1.79

SICK KIDS

MOUNT SINAI

ST. JOSEPH’S

0.48 SICK KIDS

1.02 MOUNT SINAI

2.69 ST. JOSEPH’S

0.87

1.22

MOUNT SINAI

ST. JOSEPH’S

1.15

0.65

3.51

0.95

ST. MICHAEL’S SUNNYBROOK

TORONTO EAST GENERAL

UHN

2.45 0.66 ST. MICHAEL’S SUNNYBROOK

3.12 TORONTO EAST GENERAL

1.37 UHN

3.62

1.28

TORONTO EAST GENERAL

UHN

800

1500

600

1000

400

500 0

10000

1000

2000

Mental health inpatients

15000

200

1.42 CAMH

0

Alternate level of care 1.28 ALL HOSPITALS

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NUMBER of PATIENTS

1500 1200 900 600 300 0

1.48

0.81

ST. MICHAEL’S SUNNYBROOK

HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

HOUSEHOLD INCOME

Lowest income quintile Ratio of lowest income to highest income patients Highest income quintile

Medical inpatients

1.19 ALL HOSPITALS

NUMBER of PATIENTS

8000 6000 4000 2000 0

1.29

0.77

1.60

SICK KIDS

MOUNT SINAI

ST. JOSEPH’S

1.18

0.71

ST. MICHAEL’S SUNNYBROOK

3.36

1.12

TORONTO EAST GENERAL

UHN

1.97

0.83

TORONTO EAST GENERAL

UHN

Surgical inpatients 0.88 ALL HOSPITALS

NUMBER of PATIENTS

10000 8000 6000 4000 2000 0

1.03

0.65

1.27

SICK KIDS

MOUNT SINAI

ST. JOSEPH’S

0.91

0.68

ST. MICHAEL’S SUNNYBROOK

Same-day surgery 0.80 ALL HOSPITALS

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NUMBER of PATIENTS

20000 15000 10000 5000 0

1.11

0.66

1.03

SICK KIDS

MOUNT SINAI

ST. JOSEPH’S

0.67

0.54

ST. MICHAEL’S SUNNYBROOK

1.54

0.81

0.45

TORONTO EAST GENERAL

UHN

WOMEN’S COLLEGE

HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

HOUSEHOLD INCOME

Lowest income quintile Ratio of lowest income to highest income patients

(less/non-urgent conditions) 1.33 ALL HOSPITALS

Urgent care

15000 12000 9000 6000 3000 0

NUMBER of PATIENTS

Emergency

NUMBER of PATIENTS

Highest income quintile

8000 7000 6000 5000 4000 3000 2000 1000 0

1.64

0.79

1.89

SICK KIDS

MOUNT SINAI

ST. JOSEPH’S

1.25

0.69

CAMH

WOMEN’S COLLEGE

0.70

2.44

MOUNT SINAI

ST. JOSEPH’S

1.43

0.44

ST. MICHAEL’S SUNNYBROOK

2.64

0.90

1.80

TORONTO EAST GENERAL

UHN: TORONTO GENERAL

UHN: TORONTO WESTERN

Obstetrical

(mothers only; excludes newborns) 1.25 ALL HOSPITALS

16

NUMBER of PATIENTS

6000 5000 4000 3000 2000 1000 0

1.51

0.56

ST. MICHAEL’S SUNNYBROOK

5.12 TORONTO EAST GENERAL

HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

HOUSEHOLD INCOME

Lowest income quintile Ratio of lowest income to highest income patients Highest income quintile

350

Complex continuing care

1.75 ALL HOSPITALS

NUMBER of PATIENTS

1000

300

800

250

600

200

400

150 100

200

50

0

3.19

1.55

BAYCREST

0

1.95

BRIDGEPOINT PROVIDENCE

1.46

0.87

0.64

3.04

UHN: TRI SUNNYBROOK SUNNYBROOK TORONTO E.W. BICKLE VETERANS EAST GENERAL

1.09

1.43

TORONTO GRACE

WEST PARK

Rehabilitation 1.19 ALL HOSPITALS

17

NUMBER of PATIENTS

1200 1000 800 600 400 200 0

0.91

1.11

1.92

0.60

2.97

1.01

1.11

1.55

BAYCREST

BRIDGEPOINT

PROVIDENCE

SUNNYBROOK ORTHOPAEDIC

TORONTO EAST GENERAL

UHN: TRI HILLCREST

UHN: TRI LYNDHURST

WEST PARK

HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

Where patients lived

Within TC LHIN Within surrounding LHINs Within rest of Ontario

Mental health inpatients

All inpatients (acute care)

Ratio of patients who lived outside of TC LHIN to patients from TC LHIN

0.56 ALL HOSPITALS

1.14

CAMH

ALL HOSPITALS

Alternate level of care

0.80 0

500

0.66

1000 1500 2000 2500 3000 3500

ALL HOSPITALS

SICK KIDS

4.22

SICK KIDS

2.08

MOUNT SINAI

1.05

MOUNT SINAI

0.60

MOUNT SINAI

0.39

ST. JOSEPH’S

0.67

ST. JOSEPH’S

0.38

ST. JOSEPH’S

0.38

ST. MICHAEL’S

1.12

ST. MICHAEL’S

0.21

ST. MICHAEL’S

0.69

SUNNYBROOK

1.63

SUNNYBROOK

0.98

SUNNYBROOK

1.69

TORONTO EAST GENERAL

0.47

TORONTO EAST GENERAL

0.29

TORONTO EAST GENERAL

0.22

UHN

1.45

UHN

0.50

UHN

0.66

0

10000

20000

30000

40000

50000

0

500

1000

1500

0

2000

NUMBER of PATIENTS

NUMBER of PATIENTS

Medical inpatients

Surgical inpatients

0.90

2.07

ALL HOSPITALS

ALL HOSPITALS

Same-day surgery SICK KIDS

4.05

5.50

MOUNT SINAI

1.33

MOUNT SINAI

0.63

MOUNT SINAI

1.67

ST. JOSEPH’S

1.00

ST. JOSEPH’S

0.44

ST. JOSEPH’S

0.97

ST. MICHAEL’S

1.33

ST. MICHAEL’S

0.82

ST. MICHAEL’S

2.12

SUNNYBROOK

2.17

TORONTO EAST GENERAL

0.84

1.73

SUNNYBROOK

3.01

TORONTO EAST GENERAL

0.30

TORONTO EAST GENERAL

0.72

UHN

1.54

UHN

0.91

UHN

2.20

WOMEN’S COLLEGE

1.14

10000

15000

NUMBER of PATIENTS

18

20000

0

5000

10000 15000 20000 25000 30000

NUMBER of PATIENTS

2000

2500

3000

ALL HOSPITALS

SICK KIDS

5000

1500

1.34

3.67

0

1000

NUMBER of PATIENTS

SICK KIDS

SUNNYBROOK

500

0

5000 10000 15000 20000 25000 30000 35000 40000

NUMBER of PATIENTS

HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

WHERE PATIENTS LIVED

Within TC LHIN Within surrounding LHINs Within rest of Ontario Ratio of patients who lived outside of TC LHIN to patients from TC LHIN

Emergency

(less/non-urgent conditions) 0.47 ALL HOSPITALS SICK KIDS

1.26

MOUNT SINAI

0.45

ST. JOSEPH’S

0.30

CAMH

0.56

ST. MICHAEL’S

0.41

WOMEN’S COLLEGE

0.38

SUNNYBROOK

0.76

TORONTO EAST GENERAL UHN: TORONTO GENERAL UHN: TORONTO WESTERN

Urgent care

0

5000

10000

15000

20000

NUMBER of PATIENTS

0.27

Complex continuing care

0.52 0.27

Rehabilitation

0.92 0

5000 10000 15000 20000 25000 30000 35000

ALL HOSPITALS

1.44

NUMBER of PATIENTS

Obstetrical

(mothers only; excludes newborns) 0.75 ALL HOSPITALS

1.00

BRIDGEPOINT

0.49

BAYCREST

1.28

PROVIDENCE

1.58

BRIDGEPOINT

0.86

UHN: TRI E.W. BICKLE

0.62

PROVIDENCE

1.65

SUNNYBROOK

2.01

2.39

1.95

SUNNYBROOK ORTHOPAEDIC TORONTO EAST GENERAL UHN: TRI HILLCREST UHN: TRI LYNDHURST

MOUNT SINAI

1.05

ST. JOSEPH’S

0.77

ST. MICHAEL’S

0.56

SUNNYBROOK VETERANS TORONTO EAST GENERAL

SUNNYBROOK

0.71

TORONTO GRACE

0.64

TORONTO EAST GENERAL

0.48

WEST PARK

1.29

0

2000

4000

6000

8000

NUMBER of PATIENTS

19

10000

ALL HOSPITALS

BAYCREST

0.21

WEST PARK 0

500

1000

1500

2000

0.51 0.99 4.84 3.57 0

NUMBER of PATIENTS

HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

500

1000

1500

2000

NUMBER of PATIENTS

2500

Appendices Hospital patient admissions: Household income Hospital patient admissions: Where patients lived About the hospitals

20

HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

Hospital patient admissions: Household income HOUSEHOLD INCOME: All inpatients (acute care) (number of patients, 2008-2010) Q1 HOSPITAL Total (lowest income) Q2 All hospitals 364776 87054 71323 The Hospital for Sick Children 25990 5811 4967 Mount Sinai Hospital 62443 11847 11346 St. Joseph’s Health Centre 44086 13245 9608 St. Michael’s Hospital 58065 14231 10880 Sunnybrook Health Sciences Centre 69761 12645 13062 Toronto East General Hospital 42781 16057 8702 University Health Network 61650 13218 12758

Q3 60659 4932 10196 6310 10617 11283 6557 10764

Q4 66228 5296 12165 7538 9959 13315 6891 11064

Q5 (highest income) 79512 4984 16889 7385 12378 19456 4574 13846

Q5:Q1 Ratio 0.91 0.86 1.43 0.56 0.87 1.54 0.28 1.05

Q1:Q5 Ratio 1.10 1.17 0.70 1.79 1.15 0.65 3.51 0.95

HOUSEHOLD INCOME: Mental health inpatients (number of patients, 2008-2010) Q1 HOSPITAL Total (lowest income) Q2 All hospitals 15111 4730 3035 Centre for Addiction and Mental Health 5987 1732 1163 The Hospital for Sick Children 277 45 49 Mount Sinai Hospital 496 133 87 St. Joseph’s Health Centre 2531 923 586 St. Michael’s Hospital 1030 375 169 Sunnybrook Health Sciences Centre 1326 286 239 Toronto East General Hospital 2540 969 542 University Health Network 924 267 200

Q3 2257 961 37 72 316 181 164 401 125

Q4 2213 913 52 74 363 152 205 317 137

Q5 (highest income) 2876 1218 94 130 343 153 432 311 195

Q5:Q1 Ratio 0.61 0.70 2.09 0.98 0.37 0.41 1.51 0.32 0.73

Q1:Q5 Ratio 1.64 1.42 0.48 1.02 2.69 2.45 0.66 3.12 1.37

HOUSEHOLD INCOME: Alternate level of care (number of patients, 2008-2010) Q1 HOSPITAL Total (lowest income) Q2 All hospitals 18768 5006 3907 Mount Sinai Hospital 1164 287 219 St. Joseph’s Health Centre 3179 864 669 St. Michael’s Hospital 2786 759 508 Sunnybrook Health Sciences Centre 4228 894 901 Toronto East General Hospital 2526 898 510 University Health Network 4785 1274 1082

Q3 2891 168 386 582 648 383 710

Q4 3055 159 554 423 684 487 725

Q5 (highest income) 3909 331 706 514 1101 248 994

Q5:Q1 Ratio 0.78 1.15 0.82 0.68 1.23 0.28 0.78

Q1:Q5 Ratio 1.28 0.87 1.22 1.48 0.81 3.62 1.28

21

HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

HOSPITAL PATIENT ADMISSIONS: HOUSEHOLD INCOME HOUSEHOLD INCOME: Medical inpatients (number of patients, 2008-2010) Q1 HOSPITAL Total (lowest income) All hospitals 125415 31638 The Hospital for Sick Children 13479 3194 Mount Sinai Hospital 11420 2528 St. Joseph’s Health Centre 16911 5084 St. Michael’s Hospital 17436 4387 Sunnybrook Health Sciences Centre 21300 4224 Toronto East General Hospital 14161 4957 University Health Network 30708 7264

Q2 25302 2596 2114 3716 3143 4120 3038 6575

Q3 20512 2556 1719 2226 3347 3201 2114 5349

Q4 21420 2665 1785 2710 2856 3773 2575 5056

Q5 (highest income) 26543 2468 3274 3175 3703 5982 1477 6464

Q5:Q1 Ratio 0.84 0.77 1.30 0.62 0.84 1.42 0.30 0.89

Q1:Q5 Ratio 1.19 1.29 0.77 1.60 1.18 0.71 3.36 1.12

HOUSEHOLD INCOME: Surgical inpatients (number of patients, 2008-2010) Q1 HOSPITAL Total (lowest income) All hospitals 146319 29891 The Hospital for Sick Children 12660 2625 Mount Sinai Hospital 13443 2418 St. Joseph’s Health Centre 11335 2852 St. Michael’s Hospital 27564 5688 Sunnybrook Health Sciences Centre 32696 5874 Toronto East General Hospital 10105 2908 University Health Network 38516 7526

Q2 28587 2388 2476 2337 5309 6174 2154 7749

Q3 25825 2398 2274 1818 5216 5613 1755 6751

Q4 28045 2703 2567 2090 5113 6377 1815 7380

Q5 (highest income) 33971 2546 3708 2238 6238 8658 1473 9110

Q5:Q1 Ratio 1.14 0.97 1.53 0.78 1.10 1.47 0.51 1.21

Q1:Q5 Ratio 0.88 1.03 0.65 1.27 0.91 0.68 1.97 0.83

Q2 60775 2390 5020 9770 9340 8202 9690 12202 4128

Q3 55024 2437 4815 7431 9423 7665 8330 10666 4226

Q4 62020 2656 5299 9819 10120 9045 8401 11543 5113

Q5 (highest income) 83116 2563 7967 10921 15237 14219 8018 15618 8526

Q5:Q1 Ratio 1.26 0.90 1.53 0.97 1.49 1.84 0.65 1.24 2.21

Q1:Q5 Ratio 0.81 1.11 0.66 1.03 0.67 0.54 1.54 0.81 0.45

HOUSEHOLD INCOME: Same-day surgery (number of patients, 2008-2010) HOSPITAL All hospitals The Hospital for Sick Children Mount Sinai Hospital St. Joseph’s Health Centre St. Michael’s Hospital Sunnybrook Health Sciences Centre Toronto East General Hospital University Health Network Women’s College Hospital

22

Total 327048 12892 28324 49205 54350 46858 46788 62616 25844

Q1 (lowest income) 66113 2846 5223 11264 10230 7727 12349 12587 3851

HOSPITAL CARE FOR ALL: AN EQUITY REPORT ON DIFFERENCES IN HOUSEHOLD INCOME AMONG PATIENTS AT TC LHIN HOSPITALS, 2008-2010

HOSPITAL PATIENT ADMISSIONS: HOUSEHOLD INCOME HOUSEHOLD INCOME: Emergency department (less/non-urgent conditions) (number of patients, 2008-2010) Q1 HOSPITAL Total (lowest income) Q2 Q3 All hospitals 270053 74800 55028 42144 The Hospital for Sick Children 40531 11748 8317 6740 Mount Sinai Hospital 39092 8808 7297 5844 St. Joseph’s Health Centre 35888 11471 8115 4429 St. Michael’s Hospital 34878 10051 6275 6428 Sunnybrook Health Sciences Centre 21161 3699 3418 2550 Toronto East General Hospital 42241 14195 8372 7106 UHN: Toronto General Hospital 22409 5162 4273 3698 UHN: Toronto Western Hospital 33853 9666 8961 5349

Q4 41861 6547 5990 5799 5108 3161 7197 3562 4497

Q5 (highest income) 56220 7179 11153 6074 7016 8333 5371 5714 5380

Q5:Q1 Ratio 0.75 0.61 1.27 0.53 0.70 2.25 0.38 1.11 0.56

Q1:Q5 Ratio 1.33 1.64 0.79 1.89 1.43 0.44 2.64 0.90 1.80

HOUSEHOLD INCOME: Urgent care (number of patients, 2008-2010) Q1 HOSPITAL Total (lowest income) Centre for Addiction and Mental Health 8471 2276 Women’s College Hospital 24979 4927

Q4 1363 4276

Q5 (highest income) Q5:Q1 Ratio 1827 0.80 7186 1.46

Q1:Q5 Ratio 1.25 0.69

Q4 9890 3961 1444 1221 1934 1330