Month: April 2024

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 Assessing the Equity and Accessibility of Healthcare Service in British Columbia

Adam McNeice, Andrew Yan, Bosco Wong, and Michael Rohrwasser

 

Introduction

Canada lacks enough healthcare resources due to unrealistic expectations, limited support and resources, outdated compensation, and high clinic costs (Li et al., 2023). Long distances and inefficient routes make it harder for rural communities to access healthcare. COVID-19 worsened this issue, leading to ethical challenges and conflicts between fairness and autonomy. Staff shortages and service disruptions increase virus transmission risks among workers and communities.

Therefore, through cartography and geographic visualization methods, we aim to understand how the pressures exerted on the healthcare system during the COVID-19 pandemic have shaped its current landscape. We seek to explore how these effects vary across geographic regions, particularly in rural areas, and across important healthcare services.

 

Contextual framing

Understanding the reasons behind the imbalance and shortage of healthcare resources in Vancouver is crucial to understanding healthcare accessibility. Government decisions in the 1990s, driven by concerns about oversupply and high wages for family physicians, have shaped the current healthcare crisis in Canada (Li et al., 2023). Policies from that era reduced medical school seats, family medicine residency positions, and opportunities for international medical graduates (Li et al., 2023). Alongside stagnant wages and decreased government investment in primary care, these factors have contributed to the current shortage of family physicians and healthcare resources in Canada (Li et al., 2023).

In British Columbia (BC), despite its large population and medical school, there is a high number of residents without family doctors. BC offers only 5 medical school seats per 100,000 residents, planning to add 40 more in 2023 (Li et al., 2023). However, even with these additions, BC will still have the fewest seats per person compared to other provinces (Li et al., 2023). Additionally, BC has the fewest family medicine residency spots per person, which are highly sought after nationwide. In 2022, only one out of 122 family medicine residency spots in BC was not filled (Li et al., 2023).

The shortage of family physicians and a growing, aging population will make accessing healthcare harder, leading to poorer patient outcomes and increased pressure on the healthcare system. The COVID-19 pandemic exacerbates this with chronic understaffing, insufficient support, unpredictable schedules, and lack of control over working conditions making frontline work even more stressful (Olding et al., 2021), directly harming individuals. Outbreaks in long-term care facilities highlight how sick frontline workers might continue working due to lack of paid leave, spreading the virus. Part-time and casual staff, often working in multiple places, can also contribute to the spread of the virus (Olding et al., 2021).

Furthermore, ethical decisions must be made due to limited resources, considering concerns from both clinical ethics frameworks that prioritize individual patient needs and rights, alongside community safety and resource stewardship, and the public health ethics principle that focuses on efficiency and consistency in resource allocation. In situations with a big surge in patients, hospitals might run out of ventilators, leading health officials to potentially limit patient choices. Fairness in emergencies means attempting to treat everyone equally, but this may not always be possible due to limited resources.

The limited availability of healthcare resources is a structural problem. One solution is to adapt service models to reach people in their local communities through mobile, outreach, and housing-based approaches (Li et al., 2023). Our team created three maps at the levels of the individual, community, and province to assist people in finding the best route to healthcare resources and understanding their distribution. We hope these maps will aid the government in redistributing resources to make them more accessible to everyone.

 

Routing Visualization

How do people experience healthcare? Most would readily conjure up scenes within the confines of their local hospital: the discomfort of waiting in stiff chairs, the cacophony of children’s cries, or perhaps the unsettling sensation of sitting on crinkly paper atop examination tables. Yet, amidst these recollections, one crucial aspect often slips from memory—the journey to the hospital itself whether undertaken in an ambulance, aboard an emergency helicopter, or via a short drive. However, not all individuals have equitable access to these modes of transportation; for a young individual in Vancouver with a car—seeking a routine check-in with an oncologist is a straightforward affair. In contrast, a young child in Vanderhoof, whose parents must take time off work to embark on a four-hour drive to reach the nearest pediatrics department in Williams Lake. These disparities in access to healthcare transport are glaring, prompting us to visualize this disparity through a mapping tool. Drawing upon hospital data from Data BC and insights gathered from HealthLinkBC, we created a map that illuminates the shortest routes to hospitals for various services, allowing users to seamlessly interact with hospital markers, providing contact information and enabling filtering based on available services. We utilized Mapbox’s Directions API to enable users to plot points on the map, generating the shortest route to the nearest hospital, and provided estimates of distance and travel time to aid in informed decision-making during critical moments.

We designed this map as a platform for the stories of individuals navigating our healthcare system, who struggle not only to access hospitals but also to find ones equipped to offer the services they require. Although emergency rooms are prevalent throughout our province, specialized services like pediatrics, maternity, and oncology are notably lacking in rural areas, necessitating long journeys or even flights to urban centers for treatment. This map serves as a testament to these journeys, shedding light on the systemic barriers created by the allocation—or lack thereof—of healthcare resources. These barriers breed a landscape of inaccessibility that divides our province into two distinct medical tiers, one for urban dwellers and another for those in rural regions. This map also serves as an essential tool for BC residents, helping them understand their place within the healthcare system while also fostering empathy and understanding of others’ experiences. By bridging the geographical and informational gap between communities, this map empowers citizens to actively engage in shaping local and provincial policies that dictate healthcare outcomes. 

 

Community Visualization

To better understand the number of people that each hospital in BC serves, we created a community analysis map that would give us a more detailed, but not perfect, idea of the number of people that each hospital serves. The idea behind the community analysis is that when the user selects a particular hospital on the map, it will highlight the nearest census tracts or subdivisions, based upon a centroid assigned to each census unit, to said hospital compared to the other hospitals in the province, to give the user an idea of the amount of people that are served by a given hospital, shown through a pop-up on the map that can be reset in order to compare with other hospitals. Now obviously this is not going to be an entirely accurate display of the given statistics, however highlighting population is always going to be a challenge, and we felt using census subdivisions and tracts was the most effective way, as they are the smallest units of census data, and are therefore going to give the best results in these circumstances. In the end, the goal of the map is to show potential gaps or inequalities in the amount of people served by a particular, and see if there are any individual hospitals that could be overrun by a population that is too high for its capacity, or to see if a hospital could be used if others nearby are overfilled or above capacity.

The data used for the community analysis was derived entirely from governmental sources, with the census data all coming from Statistics Canada through the most recent Canadian Census, done in 2021. The census subdivision data was accessed through the BC Government’s Open Data Catalogue, with the data coming from Statistics Canada, while the census tracts for the more populated, urban areas were accessed directly from Statistics Canada. Census tracts were only drawn by Statistics Canada in large urban areas, which in BC was limited to Greater Vancouver, Victoria, Nanaimo, Kelowna, and Kamloops. Therefore, the smallest census geographic unit rest of BC was subdivisions, with the only exceptions being Indigenous reserves and lands, which are all their own separate census units. The census data was used in coordination with the hospital data that we have used throughout the project, in all our other cartographic analysis. The consensus that this map shows, is that despite the fact that many of the hospitals in the Interior and Northern BC have a lower number of people that they serve in terms of proximity to other hospitals, but have limited resources, as shown in our other maps, can only provide certain services and have lower patient capacities.

 

Health Authorities Visualization

Healthcare within BC is complex, with many factors and data from the provincial level affecting it. BC is divided into five health authorities, each with its own budget and population to support, creating disparities as residents from regions like Northern Health often need to travel to larger authorities like Vancouver Coastal Health to access specialized care not available in their area. We considered three key factors: budget, population density, and accessibility, focusing on emergency air transportation as it is the primary method of travel between health authorities. Utilizing data for air emergencies from BC Emergency Health Services, we calculated annual transported patient numbers for each authority. To visually depict emergency care accessibility, we discussed representing air transportation around hospitals on community-level maps using buffers. Our maps aim to illustrate the regional healthcare divide in BC, particularly highlighting the concentration of services in the Lower Mainland. In Metro Vancouver, numerous specialists cater to rural populations for specialized care, yet healthcare gaps persist. Emergency travel for healthcare presents significant disparities, ranging from journeys from the Gulf Islands to flights from Haida Gwaii. While an interactive map showcasing flight connections across BC communities is conceivable, air travel imposes a heavier financial burden on patients compared to local transportation options, such as buses for Vancouver residents accessing the same healthcare facility.

Population density was calculated using census data and provincial shapefiles which included the area in square kilometres. By considering population density, our group can assess the importance of both the geographic coverage of health authorities as well as the size of the populations they serve. Additionally, the budget information was obtained directly from the fiscal reports for each health authority for 2023. We observed during the production of the health authority map that higher population density correlates strongly with higher budgets. The only places where this relationship isn’t felt as strongly are Vancouver Coastal Health and Fraser Health. This is most likely due to the large remote regions included within these authorities, especially Vancouver Coastal Health. To take this choropleth map a step further, the inclusion of additional subregions within the analysis would be beneficial, providing insights into allocations of resources within each authority. This would serve to improve understanding of resource allocation within rural communities when compared with larger urban centres, such as Kitimat and Prince George.

 

Conclusion

In conclusion, our maps, influenced by Li’s reading, underscore the scarcity of family physicians and healthcare resources in Canada. Stagnant wages and reduced government investment in primary care exacerbate this issue. The Community Visualization and Health Authorities Visualization maps reveal these discrepancies. For instance, hospitals in the Interior and Northern BC serve fewer people but lack resources, while Metro Vancouver provides specialized care but still faces gaps. Disparities in emergency healthcare travel, from Gulf Islands journeys to Haida Gwaii flights, are evident in the Health Authorities Visualization. The Routing visualization identifies potential gaps in service coverage or uneven patient loads.

Despite some hospitals in the Interior and Northern BC serving fewer people, they struggle due to limited resources, as indicated in our other maps, specifying particular services and lower patient capacities. Therefore, concerns about ethical challenges and conflicts between fairness and autonomy are highly possible. Staff shortages and service disruptions increase virus transmission risks among workers and communities. To prevent and alleviate such situations, we hope that the information from the maps can be used for future city planning and resource distribution improvements.

Reference 

Chase, J. (2020). Caring for frail older adults during covid‐19: Integrating public health ethics into clinical practice. Journal of the American Geriatrics Society, 68(8), 1666–1670. https://doi.org/10.1111/jgs.16666

Li, K., Frumkin, A., Bi, W. G., Magrill, J., & Newton, C. (2023). Biopsy of Canada’s family physician shortage. Family Medicine and Community Health, 11(2). https://doi.org/10.1136/fmch-2023-002236

Olding, M., Barker, A., McNeil, R., & Boyd, J. (2021). Essential work, precarious labour: The need for safer and equitable harm reduction work in the era of covid-19. International Journal of Drug Policy, 90, 103076. https://doi.org/10.1016/j.drugpo.2020.103076