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Table 2 Health service utilization reported in uninsured population

From: Health outcomes, health services utilization, and costs consequences of medicare uninsurance among migrants in Canada: a systematic review

Author & year of publication

Service accessed

Main results

Ridde, Aho, Ndao, et al., (2020) [22]

-Private pharmacies

-Community organized health clinics

-Walk-in clinics

-Dental clinics

-Hospitals

-Unreported health care needs were reported by 69% of uninsured migrants in comparison to 26% of recent immigrants and 16% of citizens with insurance. Unmet health care needs were greatest among temporary workers and their descendants (73%)

-The association between unmet health care needs and migrant status was not statistically significant

-Reasons for unmet health care needs included not having enough money to pay fees (81%), fear of being overcharged (73%), potential negative impact of health consultation on migration status (22%), and fear of rejection by hospital (7%)

-Almost one fifth (19%) of all participants reported not knowing where to access health care

-Among those who used health care services, they accessed private pharmacies (60%), community organized health services (43%), walk-in-clinics (21%), dental clinics (16%), and hospitals (14%)

-Services such as osteopathy, chiropractic, and physiotherapy were used by less than 3%

Darling, Bennett, Burton, et al., (2019) [47]

-Antenatal services

-Intrapartum services

-Postpartum services

-Uninsured migrant women compared to insured women:

-Attended fewer antenatal appointments (mean 9.9 visits vs. 11.6 visits)

-Had more antenatal home visits (mean 1.9 visits vs. 0.6 visits)

-Were less likely to attend a prenatal visit in the first trimester (66.3% vs. 92.8%)

-Presented later to midwifery care (18.4 weeks gestation vs. 12.7 weeks gestation)

-Were less likely to attend prenatal class (33.2% vs. 65.2% for primiparous participants and 2.9% vs. 5.7% for multiparous participants)

-Had shorter hospital stays when they gave birth at the hospital (median 2 h vs. 3 h)

-Had more intrapartum consultations for fetal well-being and meconium while consultations for labour dystocia, oxytocin augmentation, and epidural were less common

-Received more postpartum home visits (mean 3.7 visits vs. 3.2 visits)

- Planned for home birth more (33.9% planned home birth and 28.7% gave birth at home whereas 19.6% insured planned home birth and 16.6% gave birth at home)

-Were less likely to have at least one postpartum consultation with a physician (5.5% vs. 6.8%)

-Were more likely to have a registered midwife (64.7% vs. 60.2%)

-Had lower transfer of care in labour (6.1% vs. 23.8%)

-Had lower newborn intensive care unit admissions (8.7% vs. 9.2%)

-Had lower newborn metabolic screening (90.9% vs. 92%)

-Had lower severity in care level. Level 1 hospitals were low-need and level 3 hospitals were high-need. (Level 1: 12.4% vs. 12.2%; Level 2: 77.3% vs. 74.5%; Level 3: 10.6% vs. 13.4%)

-The proportion of uninsured clients varied across the province, with midwifery clinics in the South West, Central, and Toronto Central Local Health Integration Networks caring for the highest percentage of uninsured clients

Hynie, Ardern, & Robertson (2016) [48]

-Emergency room

-Hospital

-The percentage of visits of uninsured increased from 0.23% in 2002/3 to 0.44% in 2010/11

-Within Ontario, the proportion of visits by the uninsured to the emergency room ranged from 0.07% in Erie St. Clair to 0.66% in Toronto

-Visit disposition differed by insurance status as those without insurance were less likely to be admitted (10.2% insured vs. 9.4% uninsured), more likely to leave without treatment (3.1% insured vs. 5.4% uninsured), and more likely to have died on arrival or in the emergency room (2.8% insured vs. 3.7% uninsured)

-Emergency room visits related to ambulatory care sensitive conditions were more common among the insured than uninsured (4.55% vs. 3.18%)

-A larger proportion of ambulatory care sensitive condition visits were accounted for by children (≤ 16 years), and youth (17–24 years) in the uninsured group

-Insured and uninsured were equally likely to be triaged into one of the severe categories if they arrived with ambulatory care sensitive conditions

-At hospital presentation, 15.6% of uninsured and 11.2% of insured individuals were triaged into one of the more severe categories (resuscitation or emergent)

-Compared to insured individuals (Odds Ratio (OR(1.00, referent), those who were uninsured were 43% more likely (OR 1.43; 95% Confidence Interval (CI): 1.39–1.46) to be classified as severe, even after adjustment for age and gender

Bunn, Fleming, Rzeznikiewiz, et al., (2013) [41]

-Prenatal care

-Pediatric care

-No significant difference between participants with Ontario Health Insurance Plan vs. participants utilizing the Compassionate Care Program in the proportion of patients seeking prenatal or routine pediatric care

-6% and 16% of insured and uninsured used prenatal care, respectively (p value (p) = 0.184)

-18% and 11% of insured and uninsured used routine pediatric care, respectively (p = 0.344)

Gagnon, Merry, & Haase (2013) [42]

-Newborn intensive care unit admission

-Hospital

-Significant differences in newborn intensive care unit admission were found among refugees (26.7%), asylum seekers (15.6%) and immigrants (7.0%), where p = 0.073

Rousseau, Laurin-Lamothe, Rummens, et al., (2013) [45]

-Emergency room

-1.3% of uninsured children compared to 0.3% of federally insured refugee children had the highest level of emergency (level 1) (chi-squared statistic (x2) = 15,290.01; p < 0.001) and 11.5% of uninsured children vs. 8.5% of federally insured refugee children had the second highest level of emergency (level 2) (x2 = 89,055.93; p < 0.001). For levels 3–5, there were no significant differences between groups

-In hospitals 2 (Montreal) (t = 4.81; p < 0.001) and 3 (Toronto) (t statistic (t) = 6.83; p < 0.001) the mean emergency rating at triage for uninsured immigrant and refugee claimant children was significantly higher (less urgent) than the mean emergency rating of the overall hospital populations

-In hospital 1 (Montreal), the refugee claimant and uninsured children status mean emergency rating was comparable with the overall hospital population mean emergency rating (t = -1.62; p = 0.105)

-Hospitalization of refugee claimants was more frequent in hospital 1 (25.1%) in Montreal compared to hospital 2 (2.5%) in Montreal and hospital 3 (9.2%) in Toronto [ p < 0.001]

-In hospital 2 (Montreal), 82.6% of children were prescribed medication, compared with 55.7% in hospital 3 (Toronto) and 34.3% in hospital 1 (Montreal) ( p < 0.001)

-In both hospital 1 and hospital 3, the overall number of children leaving with another follow-up plan documented in the file was approximately 20%; in contrast, it was 2.0% in hospital 2, where 10.6% of children also left before ever seeing a doctor

Wilson-Mitchell & Rummens, (2013) [43]

-Number of prenatal visits

-Provider type

-Length of stay in hospital for mother and baby

-Uninsured mothers had shorter hospital stays than insured mothers (1.7 days vs. 2.4 days) ( t =  − 6.110)

-No significant difference for baby length of stay between insured and uninsured mothers

-36.6% of uninsured saw a registered midwife vs. 4.0% of insured

-55.4% of uninsured saw an obstetrician vs. 94.1% of insured

-Number of prenatal visits for the uninsured group was significantly lower than the insured group (mean 6.04 vs. 8.70; t =  − 6.173)

-6.5% of uninsured women received no prenatal care whereas 100% of insured women received prenatal care. An equal proportion saw a general practitioner (1.8%)

-Using guidelines by the Society of Obstetricians and Gynaecologists of Canada, more than half (53.7%) of the uninsured women received inadequate prenatal care in comparison to one-in-five (19.6%) insured women

Wiedmeyer, Lofters, & Rashid, (2012) [44]

-Cervical cancer screening (Pap test)

-75% of insured women had a Pap test; 95% of refugee and uninsured women had a Pap test

-Univariate analysis: uninsured women were significantly more likely to have Pap tests compared to insured women (OR 6.65; p < 0.0001)

-Multivariate analysis: when controlling for confounders (language, region of origin, year of arrival, pregnancy, and age), there was no significant differences in receiving a Pap test between the insured women and uninsured women (adjusted hazard ratio 1.312; 95% CI: 0.922–2.058)

-In the cox proportional hazard model, insurance status was significantly associated with time to first Pap test (adjusted hazard ratio = 1.715; 95% CI: 1.156–2.545). Although uninsured patients were more likely to get a Pap test at any point in time in this model, after adjustment for all main regions of origin, rather than simply using the stratification of European versus non-European, this result became non-significant (adjusted hazard ratio 1.312; 95% CI: 0.922 to 2.058)

-English speakers had a higher likelihood of having a Pap test early compared to non-English speakers (adjusted hazard ratio 0.625 95%; CI: 0.462–0.854)

Jarvis, Munoz, Graves, et al., (2011) [46]

-Routine prenatal services (including blood tests, obstetric ultrasound, cervical swab for sexually transmitted infections, Pap tests and early genetic screening)

-Postpartum services

-Visits with health care professionals

-Uninsured women had fewer initial screening blood tests conducted (93.7% vs. 100%; p = 0.045), ultrasound screenings (82.5% vs. 98.4%; p = 0.003), cervical swabs (69.8% vs. 85.2%; p = 0.04), Pap tests (38.1% vs. 75.4%; p < 0.001), genetic screenings (12.7% vs. 44.3%; p < 0.001), lower mean total number of prenatal visits (6.6 visits; 3.4 SD vs. 10.7 visits; 3.0 SD; p = 0.05), and less physical examinations (6.6% vs. 10.7%; not statistically significant)

-Gestational age at first visit for uninsured women was 25.6 weeks vs. 12 weeks for insured women (p < 0.001)

-Using the Prenatal Care Utilization Index, the uninsured vs. insured experienced inadequate (61.9% vs. 11.7%), intermediate (12.7% vs. 13.3%), adequate (20.6% vs. 55%), and adequate care with prenatal care utilization (4.8% vs. 20%). The difference between the groups was significant (x2 = 36.3; p = 0.001)

-In terms of adequacy of received services, the uninsured vs. insured experienced inadequate (6.3% vs. 1.7%), intermediate (33.3% vs. 15%), adequate (44.4% vs. 58.3%), and adequate care plus (15.9% vs. 25%). The difference was statistically significant (x2 = 8.3; p = 0.04)

-Uninsured pregnant women presented for initial care 13.6 weeks later than insured women (25.6 weeks vs. 12.0 weeks; p < 0.001)

  1. OR  odds ratio, p p-value, x2 chi-squared statistic, t t-statistic