Rural and urban disparities in the care of Canadian patients with inflammatory bowel disease: a population-based study

doi:10.2147/CLEP.S178056

. 2018 Nov 8:10:1613-1626.

doi: 10.2147/CLEP.S178056. eCollection 2018.

Rural and urban disparities in the care of Canadian patients with inflammatory bowel disease: a population-based study

Eric I Benchimol^{1

2

3

4

5}, M Ellen Kuenzig^{1

2

5}, Charles N Bernstein^{6

7}, Geoffrey C Nguyen^{5

8}, Astrid Guttmann^{5

9}, Jennifer L Jones¹⁰, Beth K Potter⁴, Laura E Targownik^{6

7}, Christina A Catley⁵, Zoann J Nugent^{6

11}, Divine Tanyingoh^{12

13}, Nassim Mojaverian⁵, Fox E Underwood^{12

13}, Shabnaz Siddiq^{1

2}, Anthony R Otley¹⁴, Alain Bitton¹⁵, Matthew W Carroll¹⁶, Jennifer C deBruyn¹⁷, Trevor Jb Dummer¹⁸, Wael El-Matary¹⁹, Anne M Griffiths⁹, Kevan Jacobson^{20

21}, Desmond Leddin¹⁰, Lisa M Lix²², David R Mack^{1

2

3}, Sanjay K Murthy^{4

23}, Juan Nicolás Peña-Sánchez²⁴, Harminder Singh^{6

7}, Gilaad G Kaplan^{12

13}; Canadian Gastro-Intestinal Epidemiology Consortium

Affiliations

¹ Children's Hospital of Eastern Ontario IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Canada, ebenchimol@cheo.on.ca.
² Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada, ebenchimol@cheo.on.ca.
³ Department of Pediatrics, University of Ottawa, Ottawa, Canada, ebenchimol@cheo.on.ca.
⁴ School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada, ebenchimol@cheo.on.ca.
⁵ ICES, Toronto, Canada, ebenchimol@cheo.on.ca.
⁶ University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Canada.
⁷ Department of Internal Medicine, University of Manitoba, Winnipeg, Canada.
⁸ Department of Medicine, Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, Canada.
⁹ Department of Paediatrics, University of Toronto, Toronto, Canada.
¹⁰ Department of Medicine, Dalhousie University, Halifax, Canada.
¹¹ CancerCare Manitoba, Winnipeg, Canada.
¹² Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
¹³ Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
¹⁴ Department of Pediatrics, Dalhousie University, Halifax, Canada.
¹⁵ Division of Gastroenterology, McGill University Health Centre, Montreal, Canada.
¹⁶ Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Canada.
¹⁷ Division of Gastroenterology, Department of Pediatrics, University of Calgary, Calgary, Canada.
¹⁸ School of Population and Public Health, University of British Columbia, British Columbia, Canada.
¹⁹ Department of Pediatrics, University of Manitoba, Winnipeg, Canada.
²⁰ Department of Pediatrics, The University of British Columbia, British Columbia, Canada.
²¹ Child and Family Research Institute, The University of British Columbia, British Columbia, Canada.
²² Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada.
²³ The Ottawa Hospital IBD Centre, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
²⁴ Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Canada.

PMID: 30519110
PMCID: PMC6233859
DOI: 10.2147/CLEP.S178056

Rural and urban disparities in the care of Canadian patients with inflammatory bowel disease: a population-based study

Eric I Benchimol et al. Clin Epidemiol. 2018.

. 2018 Nov 8:10:1613-1626.

doi: 10.2147/CLEP.S178056. eCollection 2018.

Authors

Affiliations

¹ Children's Hospital of Eastern Ontario IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Canada, ebenchimol@cheo.on.ca.
² Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada, ebenchimol@cheo.on.ca.
³ Department of Pediatrics, University of Ottawa, Ottawa, Canada, ebenchimol@cheo.on.ca.
⁴ School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada, ebenchimol@cheo.on.ca.
⁵ ICES, Toronto, Canada, ebenchimol@cheo.on.ca.
⁶ University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Canada.
⁷ Department of Internal Medicine, University of Manitoba, Winnipeg, Canada.
⁸ Department of Medicine, Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, Canada.
⁹ Department of Paediatrics, University of Toronto, Toronto, Canada.
¹⁰ Department of Medicine, Dalhousie University, Halifax, Canada.
¹¹ CancerCare Manitoba, Winnipeg, Canada.
¹² Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
¹³ Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
¹⁴ Department of Pediatrics, Dalhousie University, Halifax, Canada.
¹⁵ Division of Gastroenterology, McGill University Health Centre, Montreal, Canada.
¹⁶ Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Canada.
¹⁷ Division of Gastroenterology, Department of Pediatrics, University of Calgary, Calgary, Canada.
¹⁸ School of Population and Public Health, University of British Columbia, British Columbia, Canada.
¹⁹ Department of Pediatrics, University of Manitoba, Winnipeg, Canada.
²⁰ Department of Pediatrics, The University of British Columbia, British Columbia, Canada.
²¹ Child and Family Research Institute, The University of British Columbia, British Columbia, Canada.
²² Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada.
²³ The Ottawa Hospital IBD Centre, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
²⁴ Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Canada.

PMID: 30519110
PMCID: PMC6233859
DOI: 10.2147/CLEP.S178056

Abstract

Background and aims: Canada's large geographic area and low population density pose challenges in access to specialized health care for remote and rural residents. We compared health services use, surgical rate, and specialist gastroenterologist care in rural and urban inflammatory bowel disease (IBD) patients in Canada.

Methods: We used validated algorithms that were applied to population-based health administrative data to identify all people living with the following three Canadian provinces: Alberta, Manitoba, and Ontario (ON). We compared rural residents with urban residents for time to diagnosis, hospitalizations, outpatient visits, emergency department (ED) use, surgical rate, and gastroenterologist care. Multivariable regression compared the outcomes in rural/urban patients, controlling for confounders. Provincial results were meta-analyzed using random-effects models to produce overall estimates.

Results: A total of 36,656 urban and 5,223 rural residents with incident IBD were included. Outpatient physician visit rate was similar in rural and urban patients. IBD-specific and IBD-related hospitalization rates were higher in rural patients (incidence rate ratio [IRR] 1.17, 95% CI 1.02-1.34, and IRR 1.27, 95% CI 1.04-1.56, respectively). The rate of ED visits in ON were similarly elevated for rural patients (IRR 1.53, 95% CI 1.42-1.65, and IRR 1.33, 95% CI 1.25-1.40). There were no differences in surgical rates or prediagnosis lag time between rural and urban patients. Rural patients had fewer IBD-specific gastroenterologist visits (IRR 0.79, 95% CI 0.73-0.84) and a smaller proportion of their IBD-specific care was provided by gastroenterologists (28.3% vs 55.2%, P<0.0001). This was less pronounced in children <10 years at diagnosis (59.3% vs 65.0%, P<0.0001), and the gap was widest in patients >65 years (33.0% vs 59.2%, P<0.0001).

Conclusion: There were lower rates of gastroenterologist physician visits, more hospitalizations, and greater rates of ED visits in rural IBD patients. These disparities in health services use result in costlier care for rural patients. Innovative methods of delivering gastroenterology care to rural IBD patients (such as telehealth, online support, and remote clinics) should be explored, especially for communities lacking easy access to gastroenterologists.

Keywords: access to care; epidemiology; health administrative data; health services research; inflammatory bowel disease; routinely collected health data.

PubMed Disclaimer

Conflict of interest statement

Disclosure Eric I Benchimol and Geoffrey C Nguyen were supported by New Investigator Awards from CIHR, Crohn’s and Colitis Canada, and the Canadian Association of Gastroenterology. Eric I Benchimol was also supported by the Career Enhancement Program from the Canadian Child Health Clinician Scientist Program. M Ellen Kuenzig was supported by a Post-Doctoral Fellowship Award from CIHR, Crohn’s and Colitis Canada, and the Canadian Association of Gastroenterology. Charles N Bernstein was supported in part by the Bingham Chair in Gastroenterology. Geoffrey C Nguyen and Gilaad G Kaplan were CIHR Embedded Clinician Research Chairs. Astrid Guttmann was supported by a CIHR Applied Chair in Reproductive and Child Health Services and Policy Research. Lisa M Lix was supported by a Canada Research Chair (Tier I). The authors report no other conflicts of interest in this work.

Figures

**Figure 1**
Association between rural and urban (reference) residences and IBD-specific and IBD-related outpatient visit rates (multivariable Poisson regression models). **Abbreviations:** IBD, inflammatory bowel disease; IRR, incidence rate ratio; CI, confidence interval.

**Figure 2**
Association between rural and urban (reference) residences and IBD-specific and IBD-related hospitalization rates (multivariable negative binomial regression models). Bolded values represent meta-analysis results. **Abbreviations:** IBD, inflammatory bowel disease; IRR, incidence rate ratio; CI, confidence interval.

**Figure 3**
Association between rural and urban (reference) residences and risk of IBD-specific and IBD-related hospitalization (multivariable Cox proportional hazard models). Bolded values represent meta-analysis results. **Abbreviations:** IBD, inflammatory bowel disease; IRR, incidence rate ratio.

**Figure 4**
(A) Likelihood of resection or colectomy in rural and urban CD patients and (B) likelihood of colectomy in rural and urban UC patients. **Abbreviations:** CD, Crohn’s disease; UC, ulcerative colitis.

**Figure 5**
Association between rural and urban (reference) residences and prediagnostic lag time (multivariable Cox proportional hazard models). Bolded values represent meta-analysis results. **Abbreviation:** IBD, inflammatory bowel disease.

**Figure 6**
Association between rural and urban (reference) residences and likelihood of ever having seen a gastroenterologist for IBD-specific or IBD-related care (multivariable logistic regression models). Bolded values represent meta-analysis results. **Abbreviation:** IBD, inflammatory bowel disease.

**Figure 7**
Heat map demonstrating that higher proportion of IBD care provided by gastroenterologists (darker colors) was more likely to be located in urban regions (outlined boxes). **Abbreviation:** GI, gastroenterologist; IBD, inflammatory bowel disease.

See this image and copyright information in PMC

Cited by

Predictors of Unplanned Health Care Utilization Among Children with Inflammatory Bowel Disease in a Rural Region of the Southeastern US.
Gray C, Shakir R, Tumin D, Mandelia C. Gray C, et al. Dig Dis Sci. 2024 Dec;69(12):4347-4354. doi: 10.1007/s10620-024-08619-y. Epub 2024 Sep 3. Dig Dis Sci. 2024. PMID: 39225876 Free PMC article.
Advances in Mobile Health for Inflammatory Bowel Disease.
Spartz EJ, DeDecker L, Le D, Jalilian L, Limketkai BN. Spartz EJ, et al. Diagnostics (Basel). 2022 Dec 23;13(1):37. doi: 10.3390/diagnostics13010037. Diagnostics (Basel). 2022. PMID: 36611334 Free PMC article. Review.
Stakeholder Perspectives on Access to IBD Care: Proceedings From a National IBD Access Summit.
MacDonald S, Heisler C, Mathias H, Mirza R, MacMillan M, Borgaonkar M, Rohatinsky N, Jones JL. MacDonald S, et al. J Can Assoc Gastroenterol. 2022 Feb 4;5(4):153-160. doi: 10.1093/jcag/gwab048. eCollection 2022 Aug. J Can Assoc Gastroenterol. 2022. PMID: 35919759 Free PMC article.
Prescribing Patterns for Treatment of Mycobacterium avium Complex and M. xenopi Pulmonary Disease in Ontario, Canada, 2001-2013.
Brode SK, Chung H, Campitelli MA, Kwong JC, Marchand-Austin A, Winthrop KL, Jamieson FB, Marras TK. Brode SK, et al. Emerg Infect Dis. 2019 Jul;25(7):1271-80. doi: 10.3201/eid2507.181817. Emerg Infect Dis. 2019. PMID: 31215507 Free PMC article.
Factors Associated With Geographic Disparities in Gastrointestinal Cancer Mortality in the United States.
Ma C, Congly SE, Chyou DE, Ross-Driscoll K, Forbes N, Tsang ES, Sussman DA, Goldberg DS. Ma C, et al. Gastroenterology. 2022 Aug;163(2):437-448.e1. doi: 10.1053/j.gastro.2022.04.019. Epub 2022 Apr 25. Gastroenterology. 2022. PMID: 35483444 Free PMC article.

See all "Cited by" articles

References

1. Justice Laws Website [webpage on the Internet] Canada Health Act. R.S.C., 1985c. C-6; 1985. [AccessedJuly 8, 2017]. Available from: http://laws-lois.justice.gc.ca/eng/acts/C-6/
1. Benchimol EI, To T, Griffiths AM, Rabeneck L, Guttmann A. Outcomes of pediatric inflammatory bowel disease: socioeconomic status disparity in a universal-access healthcare system. J Pediatr. 2011;158(6):60, 967.e1–4. - PubMed
1. Rumman A, Candia R, Sam JJ, et al. Public versus Private Drug Insurance and Outcomes of Patients Requiring Biologic Therapies for Inflammatory Bowel Disease. Can J Gastroenterol Hepatol. 2017;2017:7365937. - PMC - PubMed
1. Benchimol E, Boualit M, Wong J, Colombel J-F, Gower-Rousseau C. Predictors of the need for second intestinal resection in children with Crohn’s disease. Inflamm Bowel Dis. 2011;17:S6.
1. Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA. 1998;280(11):1000–1005. - PubMed

LinkOut - more resources

Full Text Sources
Miscellaneous
- NCI CPTAC Assay Portal

[1] Justice Laws Website [webpage on the Internet] Canada Health Act. R.S.C., 1985c. C-6; 1985. [AccessedJuly 8, 2017]. Available from: http://laws-lois.justice.gc.ca/eng/acts/C-6/

[2] Justice Laws Website [webpage on the Internet] Canada Health Act. R.S.C., 1985c. C-6; 1985. [AccessedJuly 8, 2017]. Available from: http://laws-lois.justice.gc.ca/eng/acts/C-6/

[3] Benchimol EI, To T, Griffiths AM, Rabeneck L, Guttmann A. Outcomes of pediatric inflammatory bowel disease: socioeconomic status disparity in a universal-access healthcare system. J Pediatr. 2011;158(6):60, 967.e1–4. - PubMed

[4] Benchimol EI, To T, Griffiths AM, Rabeneck L, Guttmann A. Outcomes of pediatric inflammatory bowel disease: socioeconomic status disparity in a universal-access healthcare system. J Pediatr. 2011;158(6):60, 967.e1–4. - PubMed

[5] Rumman A, Candia R, Sam JJ, et al. Public versus Private Drug Insurance and Outcomes of Patients Requiring Biologic Therapies for Inflammatory Bowel Disease. Can J Gastroenterol Hepatol. 2017;2017:7365937. - PMC - PubMed

[6] Rumman A, Candia R, Sam JJ, et al. Public versus Private Drug Insurance and Outcomes of Patients Requiring Biologic Therapies for Inflammatory Bowel Disease. Can J Gastroenterol Hepatol. 2017;2017:7365937. - PMC - PubMed

[7] Benchimol E, Boualit M, Wong J, Colombel J-F, Gower-Rousseau C. Predictors of the need for second intestinal resection in children with Crohn’s disease. Inflamm Bowel Dis. 2011;17:S6.

[8] Benchimol E, Boualit M, Wong J, Colombel J-F, Gower-Rousseau C. Predictors of the need for second intestinal resection in children with Crohn’s disease. Inflamm Bowel Dis. 2011;17:S6.

[9] Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA. 1998;280(11):1000–1005. - PubMed

[10] Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA. 1998;280(11):1000–1005. - PubMed

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

Rural and urban disparities in the care of Canadian patients with inflammatory bowel disease: a population-based study

Affiliations

Rural and urban disparities in the care of Canadian patients with inflammatory bowel disease: a population-based study

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

Similar articles

Cited by

References

LinkOut - more resources

Full Text Sources

Miscellaneous

Abstract

Conflict of interest statement

Figures

Similar articles

Cited by

References

Related information

LinkOut - more resources

Full Text Sources

Miscellaneous