Tomoko McGaughey, George Kephart, Utkarsh J. Dang, and Paul A. Peters

Abstract

Multiple definitions have been used to identify individuals who are high system users (HSUs), through economic costs, frequency of use, or length of stay for inpatient care users. However, no definition has been validated to be representative of those residing in rural communities, who face unique service accessibility. This paper identifies an HSU definition for rural Canada that is inclusive of various levels of rurality, longitudinal patient experiences, and types of hospitalizations experienced. This study utilized the 2011 Canadian Census Health and Environment Cohort (CanCHEC) linkage profile to assess hospitalization experiences between 1 January 2009 and 31 December 2013. A range of common HSU indicators were compared using Cox proportional hazards modelling for multiple periods of assessment and types of admissions. The preferred definition for rural HSUs was individuals who are in the 90th percentile of unplanned hospitalization episodes for 2 of 3 consecutive years. This approach is innovative in that it includes longitudinal hospital experiences and multiple types of hospitalizations and assesses an individual’s rurality as a point of context for analysis, rather than a characteristic. These differences provide an opportunity for community characteristic needs assessment and subsequent adjustments to policy development and resource allocation to meet each rural community’s specific needs.

Read the Article: .

Citation

McGaughey, T.; Kephart, G.; Dang, U.J.; Peters, P.A. Creating an Inclusive Definition for High Users of Inpatient Hospital Systems That Considers Different Levels of Rurality. Int. J. Environ. Res. Public Health 2025, 22, 381. https://doi.org/10.3390/ijerph22030381

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Addressing Health Inequities and Enhancing Population Health Management Strategies Through GeoAnalytics

The link between communities, places, and health is well established in the scientific and public health literature, and differences in the characteristics of places can help explain differences in health inequalities. Place-based analysis, as illustrated in this project, offers a lens to better understand the health needs of local communities, evaluate gaps in health service accessibility, and show where opportunities to intervene exist.

The Ontario health system has become more locally oriented with the introduction of , providing a vital link between health policy makers, health service providers, and local communities. OHTs are sources of expertise in data collection, analysis, and evidence-based approaches to improve population health and health equity. As such, there is tremendous potential for these organizations to conduct analyses that are relevant and impactful for local health services and health outcomes.

This project reviewed the potential role of geoanalytics for Ontario Health Teams via an examination of place-based analytic approaches at the local level, examination of use-case scenarios for emergency department visits and mammography screening, and an evaluation of the potential for geoanalytics within a population health framework.

Importantly, we are concerned here with how the analytic results can be used in health system planning and point-of-care, with the goal of improving the health of local populations. For this project, use-cases have been selected to make use of existing data available to and for those that can lead to impactful interventions and upstream engagement strategies in the short-term.

The final evaluation further discusses the potential for spread and scale of the analytic frameworks, data systems, and tools at the Provincial level. Looking towards future digital infrastructure, a geoanalytics approach has strong potential to integrate with existing health data systems and provide a much-needed link between often-inaccessible health administrative data and locally relevant population statistics.

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GeoAnalytics Project Evaluation

ArcGIS StoryMap

– this StoryMap presents the geoanalytic results for the emergency department and mammography screening use-case scenarios. This StoryMap was created as part of the Rural R:ISK project funded by the Social Sciences and Humanities Research Councile (SSHRC).

Health geoanalytics can support public health organizations such as OHTs in making informed decisions, optimizing resource allocation, and improving the efficiency of their operations. This may lead to cost savings by reducing waste, targeting interventions effectively, and improving overall health outcomes in the population.

Infographics of Health Indicators for Southlake Community OHT

Steering Committee Members

This project was guided with the expert input from a steering committee and contributing stakeholders.

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Characteristics of High-Resource Health System Users in Rural and Remote Regions: A Scoping Review

LeBlanc M, McGaughey T, & PA Peters. (2023) “Characteristics of High-Resource Health System Users in Rural and Remote Regions: A Scoping Review.” International Journal of Environmental Research and Public Health. 20(7): 5385. .

Abstract

A small proportion of health care users are recognized to use a significantly higher proportion of health system resources, largely due to systemic, inequitable access and disproportionate health burdens. These high-resource health system users are routinely characterized as older, with multiple comorbidities, and reduced access to adequate health care. Geographic trends also emerge, with more rural and isolated regions demonstrating higher rates of high-resource use than others. Despite known geographical discrepancies in health care access and outcomes, health policy and research initiatives remain focused on urban population centers. To alleviate mounting health system pressure from high-resource users, their characteristics must be better understood within the context in which i arises. To examine this, a scoping review was conducted to provide an overview of characteristics of high-resource users in rural and remote communities in Canada and Australia. In total, 21 papers were included in the review. Using qualitative thematic coding, primary findings characterized rural high-resource users as those of an older age; with increased comorbid conditions and condition severity; lower socioeconomic status; and elevated risk behaviors.

Keywords: health care; rural health; healthcare inequalities; public health systems research; health care costs; health services research

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Asad Fatima, Nur Fozia, Morris Julia, & Bobiak Julia. (2021). “Report: Defining Rural.” Spatial Determinants of Health Lab, ĐÓ°ÉÔ­´´ University: Ottawa ON.

A full PDF of this report is also available.

What does it mean to be rural?

Rurality is perceived as being a social constructed phenomenon.

The concept of rural found in the literature is often explained from a sociological perspective. For instance, rural can be further explained by the idea of “rurality” itself, or more a rurality alluded to as “extractive” or “northern” (Stark, Gravel, and Robinson 2014). Although varying definitions exist, rurality is generally perceived as being a socially constructed phenomenon that extends widely to agricultural or resource-dependent regions/communities (Williams and Kulig, 2012). Rurality is also commonly relational as it refers to proximity and spatial isolation from/to other places and services (Bourke et al., 2012).

The second concept of rural can be explained through the “identity” of a community or village (Dampier et al. 2014). However, this method is often linked to a set of myths related to living in small and isolated settlements (Peters, 2018) that often describe rural regions as “declining” regions. From this perspective, rural regions are viewed as being unable to withstand economic changes, endure declining population counts, higher poverty levels as well as a pleather of social problems including lagging behind urban areas in education and health status (Markey, Halseth, and Manson 2008). From a narrowed health perspective, rural areas are viewed using the deficit discourse, which refers to rural health as deficient, classifies urban health as the standard and compares rural health to urban health, acquainting rural health for what it lacks compared to urban, as opposed to what it accomplishes in its own context (Bourke et al., 2010).

The myths of rural decline are fought by various communities within rural regions using means such as “resilience,” “capital,” or “identity” (Buikstra et al. 2010). However, communities are often seen as singularities, with shared goals, spirit, leadership, and actions (Besser 2009). As such, overlap exists in the literature between community identity and rurality in “declining” regions. Although communities are now beginning to challenge the myth of singularity from a conceptual perspective, we believe researchers should avoid defining or describing rural regions using an urban-centric lens, referring to them as “declining” regions or view them from a deficit discourse perspective (Carson, Carson, and Lundmark 2014; Storey and Hall 2018; Markey, Halseth, and Manson 2008; Bourke et al., 2010).

Rural regions and communities have been subject to numerous independent definitions of “rural,” each with their strengths and weaknesses. Due to the absence of a standardized rural definition, a combination of both quantitative and qualitative rural definitions has formed.

In Canadian literature, quantitative definitions of rural primarily utilize secondary data sources, such as census data to define “rural.” This can allow for the geographical visualization of statistical data, but potentially reinforce the notion of “decline” (O’Hagan and Cecil 2007; Smailes, Griffin, and Argent 2014). Qualitative definitions of rural have the benefit of looking for resilience and social capital in communities where present, while withdrawing from the discourse of decline perspective, linked narrowly to population growth (Stark et al. 2014). However, disadvantages exist when applying qualitative rural definitions to analyze and visualize rural data. As such, disciplines across areas of health care professionals, policymakers, and health researchers lack consensus around which definition of “rural” is used to describe rurality across Canada and in particular, Ontario (Pitblado et al., 2005). Definitions found are often used for convenience rather than validity, where the need for data to easily merge is prioritized over consistency between theory, method, and practice. We recognize these challenges and believe research should avoid defining rural areas using an urban-centric lens.

For this report, a literature search of quantitative and qualitative definitions of “rural” was conducted to identify measures of defining rural areas in Ontario, Canada that can be subsequently used for data analysis and visualization. Analyzing both quantitative and qualitative definitions of rurality ensured that both social and statistical aspects of rural definitions were evaluated before determining which rural definition(s) is/are most appropriate to utilize for our project. On the one hand, it is necessary that geographically based statistical data can be represented consistently in both table and visual format; while on the other hand there are important qualitative considerations of what constitutes a “rural region.”

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Morris Julia, Bobiak Julia, Asad Fatima, & Fozia Nur. (2021) “Report: Accessibility of Health Data in Rural Canada.” Spatial Determinants of Health Lab, ĐÓ°ÉÔ­´´ University: Ottawa ON.

A full PDF of this report is also available.

Executive Summary 

The accessibility of rural health data in Canada is constrained by multiple structural and technical challenges. Survey, administrative, and census data collected in Canada are not easily accessible to health planners, policy analysts, or local health administrators, nor does the available data correspond to rurally relevant boundaries and rural places. Additionally, those data that are available only provide rudimentary indicators of population health and social determinants, ignoring important issues such as social inequity, rural poverty, and the health conditions of concern to residents in rural regions. One solution that has been proposed is the development of a web-based, openly accessible mapping and data visualization that is informed by and specific to the needs of rural health professionals.

To inform the development of an interactive web-based rural health atlas, the Rural Atlas team within the Spatial Determinants Lab at ĐÓ°ÉÔ­´´ University, Department of Health Sciences carried out two sets of informal interviews (User Needs Assessment and Tool Development). These interviews were conducted in order to obtain insight from key stakeholders that have been involved in rural health settings, rural health policy or advocacy, or the development of health mapping tools. Interviews took place via video-conferencing software with participants in the spring of 2020. These interviews have informed the development of our mapping tool for rural regions and health care system decision makers. The input from these interviews will aid us in creating a stronger evidence base for identifying health inequities and guide potential directions for policy development.

The following report provides a brief summary of the findings of both sets of interviews. Researchers took the semi structured interview notes and further analyzed them to pull out common themes introduced throughout the interviews. Using the information identified within these common themes, the Rural Atlas team is now able to tailor the health mapping tool to best fit the needs of the communities it will aid.

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Bobiak Julia, Morris Julia, Nur Fozia, & Asad Fatima. (2021). Rural Health Infrastructure in Ontario: A Rapid Review. Spatial Determinants of Health Lab, ĐÓ°ÉÔ­´´ University: Ottawa, ON. DOI:

A full PDF of this rapid review is also available.

Public Health Topic

The objective of this rapid review is to understand what types of evidence are used to identify and support policy development for rural health infrastructure.

Rural regions are composed of many unique and diverse communities where health behaviours, health literacy, perceived health, and health outcomes vary between widely. In general, rural populations in Canada are characterized as generally older, less affluent, and are faced with more health issues than their urban counterparts. While this may be the case in the aggregate, there are a diversity of communities across Canada with wide variation between and within rural places. Almost one-fifth of Canadians (18%) live in rural communities yet they are persistently faced with on-going challenges recruiting and retaining family physicians and other health-care professionals, maintaining infrastructure for health service provision, and adapting health policies developed for urban environments into rural settings. These challenges, among others, contribute to inequities in access to healthcare services for these individuals residing in rural Canada.

It is recognized that major systemic change is needed to improve health outcomes for communities in rural or remote areas, but that this cannot occur with addressing access inequities to health infrastructure such as hospitals, mental healthcare, and telehealth services.

Current Knowledge

Currently in Canada, there is a lack of systematic evidence-based rural health-care planning at national or provincial levels. The lack of this rural-focused planning proves challenging for the development of rural health infrastructure. As it is recognised that the needs of rural communities differ from their urban counterparts, rural communities need rural-based solutions. These solutions will allow rural communities to develop regional capacity to innovate, experiment, and discover what works for their needs.

Provincially, the recognizes the need for the renewal of health care infrastructure and facilitates the to address regional address renewal needs on a priority basis. However, such policies are often guided by urban health-care models which may be ill-suited or have negative impacts in rural communities.

Advocacy for the need for rural health research funding resulted in a pre-budget submission being made in August 2018 to the federal government to enable rural and remote communities to carry out rural health research through the use of infrastructure funding. In June 2019, the Canadian Institutes of Health Research (CIHR) announced that it is undertaking a strategic planning consultation with input from stakeholders across Canada. These investments are essential in order for rural health research funding to reflect the realities of rural healthcare.

It’s unclear exactly what kind of evidence, and exactly how and when it is used, to support the development of rural health care infrastructure. From initial research, it seems that a wide variety evidence is consulted; from personal anecdotes to in-depth and specific budget requirements. The objective of this rapid review is to understand what types of evidence are used to identify and support policy development for rural health infrastructure.

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