Enhanced Health Services Equal Superior Health Outcomes

"In Canada, despite a universal health-care system, geographic variation in the supply of physician services is a policy concern and may contribute to regional disparities in health outcomes."
"Our study suggests that, even in a country with a universal health-insurance system, higher rates of preventive health care contribute to lower rates of cardiovascular disease events at a regional level."
"Ontario has long-standing challenges in recruiting and retaining primary care physicians to northern and more rural parts of the province, where wait times for urgent primary care visits are the longest and physician shortages the greatest."
Institute for Clinical Evaluative Sciences and Sunnybrook Schulich Heart Centre study

"There was a clear division between the healthiest and least-healthy LHINs [Local Health Integration Networks]."
"What we found were rather striking two-fold differences in the incidence of cardiovascular disease between Ontarians living in different parts of the province."
"Those living in the areas with the lowest burden of disease were the most likely to have received cardiovascular preventative services — such as having an annual physical, seeing their doctor to have their cholesterol and diabetes checked, and having their blood pressure controlled."
"The data suggests that there's a significant number of Ontarians who are not being fully assessed for cardiovascular risk in the middle-age range."  
"We think part of the difference is due to the availability and accessibility of primary care in different health regions across Ontario. I think part of it’s related to supply. In general, a lot of physicians prefer to live in the Toronto area and generally fewer physicians practise in rural areas of Ontario, paradoxically the areas where the need is the greatest."
"Almost all immigrant groups had lower cardiovascular disease... I don't think this is well recognized as an important contributor [to lower rates of cardiovascular disease]."
Dr. Jack Tu, cardiologist, senior scientist, Institute for Clinical Evaluative Sciences, Toronto

Toronto researchers found people in northern Ontario faced nearly double the levels of cardiovascular health issues of residents in and around Toronto.  (IStock)

This new study's conclusions -- which has been published in the Canadian Medical Association Journal -- were based data collected through researchers tracking 5.5 million middle-aged adults during the period of 2008 to 2012, specific to tracking heart attacks, strokes and deaths resulting from cardiovascular issues. The adults ranged in age from 40 to 79, and none had a history of cardiovascular disease at the onset of the study period.

The "striking variation" in heart attack, stroke and cardiovascular disease outcomes which were seen to be dependent on which LHIN people happened to be living in, was what impressed the study authors most particularly. Leading them to the conclusion that beyond genetic inheritance, lifestyle, including smoking and drinking, along with food choices, it was the issue of preventive medicine that was found to have a principal role in the differences.

Research undertaken previously had focused on smoking, obesity and other allied risk factors, including high blood pressure, seen to be more elevated in rural Ontario than what pertains in urban centres, linked to the variance in heart attack, stroke and cardiovascular disease rates. The current study, however, deviated from attributing outcomes to those key areas, to focus on what distinguished outcomes between rural northern areas of the province and centrally located cities.

What became clear as the study proceeded was that the geographic differences led to the reality that residents in the north had a diminished access to doctors, seeing them less frequently because of lack of availability. Leading to a situation where regions with the most elevated rates of cardiovascular disease were also the very regions where residents were least likely to receive preventive health care. These are regions known for the high rate of smoking and obesity along with the scarcest rates of fruits and vegetables consumption.


The key measure identified in the study was the frequency of people undergoing annual or periodic checkups; itself a subject of controversy given that where once annual medical checkups were routinely recommended, but latterly discouraged, as a result of provincial alterations in funding. While some research has found no compelling evidence to support yearly medical examinations, the finding of this study suggests those yearly events have needed significance in proactive, rather than reactive care.

The areas where people customarily receive the most annual physical checkups, according to Dr. Tu, the lead author of the study report, also happen to be the areas matching with the lowest rates of cardiovascular events. Improved screening for cardiovascular events is clearly required as a reaction to the study's conclusions, feels Dr. Tu. Emulating regular screening for some forms of cancer, for example.

He points out that in the United Kingdom and the United States there are national cardiovascular screening protocols. As well, the study pointed out that those parts of Ontario hosting the largest contingent of immigrants and the greatest non-white populations, also coincide with the lowest rates of cardiovascular disease. Dr. Tu labels this the 'healthy immigrant effect'. [Which appears to wear off, over time.]

The incidence of major cardiovascular events across health service regions, also known as Local Health Integration Networks, across Ontario throughout the five years of the study period. (CMAJ)